| Objectives:Gastroesophageal varices is a common complication of liver cirrhosis.The incidence of gastric varices bleeding(GVB)is lower than that of esophageal varices bleeding(EVB),which accounts for 10-30%of all varices bleeding.However,gastric varices bleeding is more frequent.It is dangerous and the mortality is higher.60%-85%of patients with gastric varices are accompanied by gastro-renal shunt(GRS),which puts the risk of ectopic embolism in traditional endoscopic tissue glue injection.Due to the complex anatomy and hemodynamic characteristics of gastric varices,its treatment methods are also more complicated.Endoscopic titanium clip combined with tissue glue injection is a new and improved technique for endoscopic treatment of gastric varices that has been clinically reported in recent years.Firstly,the branches of gastric varices are clipped by titanium clips under gastroscopy to slow or block the varicose.Intravenous blood flow,then intravenous tissue glue injection for varicose veins.This technique uses titanium clips to slow or interrupt the blood flow of gastric varices(GV)to facilitate the retention of tissue glue in the varicose veins,which may reduce the risk of ectopic embolism caused by simple endoscopic tissue glue injection in GV with large GRS.Whether this modified endoscopic tissue glue embolization really has a clinical advantage over traditional endoscopic tissue glue treatment is still difficult to determine due to the lack of comparative studies.In order to explore the clinical value of titanium clips in the treatment of gastric varices,this study observed the effects of titanium clips combined with endoscopic tissue glue injection therapy and traditional endoscopic gastric tissue glue injection on solitary gastric patients with gastric-renal shunt through retrospective analysis,comparing the safety and effectiveness of the two treatment methods.Methods:A collection of patients with liver cirrhosis from the Eastern Hospital of Shandong Provincial Hospital from January 2017 to July 2020 and Beijing Ditan Hospital from January 2016 to December 2018 who underwent endoscopic treatment of liver cirrhosis.228 patients with gastric varices(GOV2 or IGV1)combined with gastric-renal shunt were included.Divide the patients into two groups:titanium clip combined group(titanium clip combined with endoscopic tissue glue injection therapy),tissue glue group(only endoscopic tissue glue injection therapy).Among them,74 cases were in the combined titanium clip group and 154 cases were in the tissue glue injection group.Main baseline data collection:(1)Basic information:age,gender,etiology of liver cirrhosis,endoscopic examination confirmed the presence of isolated gastric varices,active bleeding from gastric varices or previous bleeding from gastric varices,etc.;(2)related laboratories Indicators:white blood cells(WBC),hemoglobin(Hb),platelets(PLT),prothrombin time(PT),alanine aminotransferase(ALT),aspartate aminotransferase(AST),albumin(ALB),creatinine(Scr),coagulation The zymogen international normalized ratio(INR),and Child-Pugh classification and score of liver function and calculation of MELD score according to laboratory indicators;(3)Imaging examination:gastro-renal shunt diameter and ascites condition,etc.;(4)Gastroscopy:Record the type of varices of the patient and whether combined with esophageal varices;(5)Postoperative follow-up:Postoperative follow-up is mainly outpatient and telephone,the content of follow-up includes whether there is ectopic embolism,rebleeding,survival and other postoperative complications disease.The main outcome measures were ectopic embolism,rebleeding and death.Statistical analysis was performed with SPSS 25.0 software,in which measurement data obeyed normal distribution was described by the mean ± standard deviation,and non-normal distribution was expressed by the median(interquartile range),and the two groups were compared by t-test or Wilcoxon rank sum test.Count data is described by frequency(percentage),graded variables are used by Wilcoxon rank sum test,and non-ranked variables are used by chi-square test or Fisher’s exact test.The Kaplan-Meier method was used to draw the rebleeding rate and survival rate curves of the two groups of patients,and the log-rank test was further used for comparison.The Cox proportional hazard regression model was used for univariate and multivariate analysis.Significance level p<0.05.Results:1.Baseline data:This study included 228 patients with solitary gastric varices(GOV2 or IGV1)cirrhosis treated by endoscopy(74 cases in the titanium clip combined group,154 cases in the tissue glue group).The baseline data between the two groups,including age,gender,etiology,treatment purposes,hepatic encephalopathy,liver cancer,laboratory indicators,liver function Child-Pugh classification,Child-Pugh score,and Meld score,there were no statistical difference between the two groups about these data.There are statistical differences in the diameter of the gastric-renal shunt and ascites between the two groups,suggesting a selection offset.Most of the baseline data between the two groups are comparable.The follow-up time of the titanium clip combined group was 10.42±8.68 months,and the follow-up time of the tissue glue group was 16.41±15.06 months.2.Ectopic embolism and other complications:There was no statistically significant difference in the incidence of postoperative ectopic embolism between the two groups(P=1.000).There was no statistical difference in the incidence of ectopic embolism between the two groups when GRS>1cm and GRS≤1cm.Among them,there was 1 case of pulmonary embolism in the titanium clip combined group,1 case of pulmonary embolism and 1 case of cerebral embolism in the tissue glue group,both of which were related Changes in symptoms and signs did not lead to death.Other complications include postoperative fever and bleeding(within 72 hours after surgery).The results of the study showed that there was no significant statistical difference in the incidence of postoperative fever between the two groups(P=0.130);There was no significant difference in the incidence of postoperative bleeding(within 72 hours)between the two groups(P=0.553).3.Dosage of tissue glue and treatment times:Compare the dose of tissue glue used in this treatment and the number of endoscopic treatments received after surgery(including this treatment).The results showed that there was no statistical difference in the number of endoscopic treatments(including this treatment)between the two groups after surgery.There was a statistical difference in the amount of tissue glue applied during the operation(P=0.041).The amount of tissue glue in the tissue glue group was compared with that of titanium.The combined group is bigger.When GRS>1cm and GRS≤1cm,there was no statistical difference in the amount of tissue glue and the number of endoscopic treatments between the two groups.4.Rebleeding:The follow-up results showed that 91 patients had rebleeding,including 23 cases in the titanium clip group and 68 cases in the tissue glue group.The rebleeding rate of patients in the titanium clip group was 31.9%,while the rebleeding rate of patients in the tissue glue group of the injection group was 45.9%.The Kaplan-Meier curve of rebleeding in the two groups showed that there was no significant difference in rebleeding rate(log-rank test,P=0.630).Multivariate analysis showed that INR(HR=9.275,95%CI(1.948,44.163),P=0.005),liver cancer(HR=2.725,95%CI(1.387,5.354),P=0.004),hepatic encephalopathy grade 3-4(HR=62.273,95%CI(3.860,1004.718),P=0.004)are independent factors affecting rebleeding.Separate multivariate analysis of the two groups showed that creatinine(HR=1.019,95%CI(1.001,1.037),P=0.033)was an independent factor influencing rebleeding in the titanium clip group;hepatic encephalopathy 3-4 Grade(HR=77.300,95%CI(5.317,1123.840),P=0.001)and INR(HR=8.161,95%CI(1.731,38.484),P=0.008)are independent factor of rebleeding in the tissue glue group.According to the diameter of the gastric-renal shunt,it is divided into the large gastric-renal shunt group(GRS>1cm)and the small gastric-renal shunt group(GRS<lcm).When GRS>1cm,A total of 32 patients in the group had rebleeding,of which 14 were in the titanium clip combined group,18 were in the tissue glue group,and the titanium clip combined group had a rebleeding rate of 32.6%.The rebleeding rate of patients in the tissue glue group was 36.7%.The Kaplan-Meier curve of rebleeding between the two groups showed that the rebleeding rate of the two groups was not significantly different(log-rank test,P=0.601).When GRS ≤1cm,58 patients in the titanium clip combined group and the glue injection group tissue glue group had rebleeding.Among them,there were 9 cases in the titanium clip group and 49 cases in the tissue glue group.The rebleeding rate of the titanium clip combined group was 31%,and the rebleeding rate of the tissue glue group was 47.1%.The Kaplan-Meier curve of the rebleeding of the two groups of patients showed the rebleeding rate of the two groups.There was no significant difference in bleeding rate(log-rank test,P=0.447).In summary,there is no significant difference in the rebleeding rate between the titanium clip combined group and the tissue glue group.Liver cancer,hepatic encephalopathy grade 3-4,and INR are independent risk factors for rebleeding.Creatinine is the independent risk factor for rebleeding in the titanium clip combined group.Hepatic encephalopathy grade 3-4 and INR were independent risk factors for rebleeding in the tissue glue group.5.About death:Follow-up results showed that a total of 24 patients died,including 6 in the titanium clip combined group and 18 in the tissue glue group.The survival rate of the titanium clip combined group was 91.9%,and the survival rate of the tissue glue group was 88.3%.The Kaplan-Meier curve of the survival of the two groups of patients showed that there was no significant difference in survival between the titanium clip combined group and the tissue glue group(log-rank test,P=0.378).Among them,3 patients in the titanium clip combined group died of liver cancer,2 died of gastrointestinal hemorrhage,and 1 died of unknown cause;in the tissue glue group,8 died of liver failure,3 died of liver cancer,and 3 died of gastrointestinal hemorrhage,1 case died of hepatic encephalopathy,1 case died of multiple organ failure(MODS),and 2 cases died of unknown causes.The results showed that liver cancer(HR=4.856,95%CI(1.402,16.817),P=0.013)and MELD score(HR=1.280,95%CI(1.012,1.618),P=0.040)were independent influence factors of patient death.Multivariate analysis of the two groups separately showed that liver cancer(HR=13.933,95%CI(2.141,90.661),P=0.006)was an independent factor influencing the death of patients in the titanium clip group;Child-Pugh score(HR=2.287,95%CI(0.887,5.897),P<0.001)is an independent factor influencing the death of patients in the tissue glue group.When GRS>1cm,7 patients in the titanium clip combined group and tissue glue group died,including 5 in the titanium clip combined group and 2 in the tissue glue group.The survival rate of the titanium clip combined group was 88.6%,and the survival rate of the tissue glue group was 95.9%.The Kaplan-Meier curve of the survival of the two groups of patients showed that there was no significant difference in survival between the two groups(log-rank test,P=0.091).Among them,3 patients in the titanium clip combined group died of liver cancer,1 died of gastrointestinal hemorrhage,and 1 died of unknown cause;2 patients in the tissue glue group died of liver failure;when GRS≤1 cm,a total of 15 patients died,including 1 in the titanium clip combined group and 14 in the tissue glue group.The survival rate of the titanium clip combined group was 96.7%,and the survival rate of the tissue glue group was 86.4%.The Kaplan-Meier curve of the survival of the two groups of patients showed that there was no significant difference in survival between the two groups(log-rank test,P=0.554).Among them,1 patient in the titanium clip group died of gastrointestinal hemorrhage;in the tissue glue group,5 patients died of liver failure,3 patients died of gastrointestinal bleeding,2 patients died of liver cancer,and 1 patient died of hepatic encephalopathy,1 patient died of multiple organ failure,and the cause of death in two cases was unknown.In summary,there is no significant difference in the survival rate between the titanium clip group and the tissue glue group.Liver cancer is an independent risk factor for patient survival,liver cancer is an independent risk factor for survival in the titanium clip combination group,and Child-Pugh score is the independent risk factor for patient survival in the tissue glue group.Conclusions:This retrospective study found that the combination of titanium clips with endoscopic tissue glue injection for the treatment of gastric varices with gastro-renal shunts is technically feasible,clinically effective and safe.It has not been confirmed that titanium clips combined with tissue glues are used to treat g isolated gastric varices with gastric-renal shunts can reduce the incidence of ectopic embolism,but it does not increase the risk of surgical bleeding.Titanium clips combined with endoscopic tissue glue injection can reduce the amount of tissue glue,which is likely to reduce the risk of ectopic embolism.Considering that this study is a retrospective study,and the sample size is small,it needs to be further confirmed by future prospective studies and multi-center studies. |
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