| Background and purposePortal hypertension(PH)is a group of clinical syndromes caused by the continuous increase in pressure in the portal vein system.It is often secondary to liver cirrhosis caused by various reasons,such as post-hepatic cirrhosis and alcoholic cirrhosis.Gastroesophageal varices(GOV)is the most important clinical event caused by portal hypertension.Once bleeding,the prognosis is poor,it has a high morbidity and mortality,and it is one of the emergency of digestive system.However,at the time of diagnosis of cirrhosis,almost 50% of patients already have gastroesophageal varices,and about 5% to 15% of patients with gastroesophageal varices develop acute varices bleeding each year.Although there has been great progress in diagnosis and treatment,the mortality rate after 6 weeks after varices bleeding is still as high as 20%.Even with aggressive treatment,rebleeding rates can be as high as 60% to 70% and mortality as high as 33% within 1 to 2 years after the patient’s first varicose vein bleeding stops.With the improvement of endoscopic treatment technology,the hemostasis effect under endoscope is better,which has become the first-line treatment plan for varicose veins.Endoscopic treatment mainly includes endoscopic injection sclerotherapy(EIS),endoscopic variceal ligation(EVL),and endoscopic tissue adhesive(ETA).However,there are shortcomings such as high complications,poor one-time treatment,repeated treatment many times,long course of treatment,great patient suffering,high medical costs,and difficulty in promotion and application.In recent years,in order to improve the curative effect of esophagogastric varices bleeding,reduce surgery-related complications,reduce patient suffering,and reduce medical costs,a new surgical method,namely endoscopic selective varices devascularization(ESVD),that is,the combined injection of embolic agents into the cardia gastric fundus varicose veins under gastroscopy,and repeated mucosal puncture to explore the source of deep varicose veins,and finally to achieve the purpose of eliminating varicose veins at one time.It has the advantages of prospectiveness,individualization and accuracy.However,considering gastroscopy,it is impossible to observe and identify the submucosal small blood vessels,deeper source veins,and thickened wrinkles of the gastric fundus.It is blind in the process of exploring the source branch,and it is easy to missed diagnosis and misdiagnosis,which makes the diagnosis and treatment effect unsatisfactory,which leads to the increase in the number of treatments and the incidence of complications.Endoscopic ultrasound(EUS),by means of high-frequency ultrasound probes,can not only observe the varicose vessels on the mucosal surface,but also examine the vessels in the deep mucosa,collateral circulation and surrounding tissue structure,thus improving the diagnosis rate of varicose veins and differentiating the varicose veins from submucosal lesions of the gastric fundus.Moreover,color Doppler technology can also be used for real-time monitoring,if necessary,the incomplete occlusion of varicose veins and no found varicose vessels for supplementary treatment,improve the treatment effect,reduce recurrence.Therefore,endoscopic ultrasound-guided selective varices devascularization is more advantageous.This article mainly explores the application of EUS in the selective varices devascularization,observes the effectiveness of varicose veins blood flow blocking,and records the rebleeding,improvement of varicose veins and complications of patients through gastroscopy Situation,to understand the value of EUS in devascularization,to provide new approaches for clinical diagnosis and treatment.Methods43 patients with esophagogastric varices bleeding(EGVB)caused by portal hypertension received from Department of Gastroenterology,First Affiliated Hospital of Henan University from June 2018 to August 2019 were included.According to the treatment methods,they were randomly divided into two groups using a random data table.The control group 23 cases were treated with gastroscopy-guided selective varices devascularization.The treatment group 20 cases were firstly treated with gastroscopy-guided selective varices devascularization,and then endoscopic ultrasonography was used to explore the situation of varices embolization in the lower esophagus and gastric fundus of the cardia,and precision treatment under gastroscope guidance was performed when necessary.Record and analyze clinical data and general conditions of patients,including age,sex,etiology,Child-Pugh classification of liver function,Sarin classification,esophageal varices classification,etc.A review of the gastroscope was performed 1 weeks after the operation.If the varicose veins did not improve significantly,a selective varices devascularization was performed again at the cardia and the gastric fundus with the same method as before.The rebleeding status of the patients was recorded at 3 months after the operation,and the clinical improvement and complications of varicose veins were recorded at 6 months after the operation.The success rate of hemostasis,rebleeding rate,total improvement rate of clinical varicose veins,incidence of complications and treatment times of the two groups of patients were compared and discussed.Results1.A total of 43 patients were included in the study,including 23 in the control group and 20 in the treatment group.The general clinical data of the patients,such as gender,age,etiology of cirrhosis,Child-Pugh grade,and varices classification were not significantly different.2.The average number of treatments for each patient in the control group was(1.83 ± 0.49)times,the average dosage of sclerosing agent(40.30 ± 14.23)ml,and the average dosage of tissue adhesive(3.27 ± 0.65)ml.The average number of treatments for each patient in the treatment group was(1.40 ± 0.50)times,the average dosage of sclerosing agent(43.65 ± 15.15)ml,and the average dosage of tissue adhesive(3.36 ± 0.76)ml.The total number of treatments in the treatment group was lower than that in the control group,and the difference was statistically significant(P<0.05),while the total dosage of sclerosing agent and tissue adhesive in the two groups showed no statistically significant difference(P>0.05).3.Within 72 hours after operation,the hemostatic success rate of both groups was 100%,which was not statistically significant(P>0.05).4.The rebleeding rate within 3 months after operation was 26.09%(6/23)and 0.00%(0/20)in the control group and the treatment group.The treatment group was significantly lower than the control group,and the difference was statistically significant(P<0.05).5.After 6 months of follow-up,the total clinical improvement rate of varicose veins was 65.22%(15/23)and 95.00%(19/20)in the control group and treatment group,respectively.The treatment group was higher than the control group,and the difference was statistically significant(P<0.05).A total of 13 cases(56.52%)of complications occurred in the control group and 4 cases(20.00%)of complications occurred in the treatment group.There was a statistically significant difference in postoperative complications between the two groups(P<0.05).Ectopic embolism and death did not occur in either group after operation.ConclusionGastroscopy-guided selective varices devascularization and endoscopic ultrasound-guided selective varices devascularization have good effects on varices bleeding.The postoperative complications are mild,and most of them can be effectively relieved after symptomatic treatment.However,in contrast,endoscopic ultrasound-guided selective varices devascularization has greater advantages and provides a better option for the diagnosis and treatment of esophagogastric varices bleeding. |
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