| Objective:Endoscopic ligation is a first-line method to prevent and treat partial cirrhosis with bleeding of esophageal and gastric fundus varices.However,the efficacy of treatment in different patient types remains to be determined.In addition,there is still a risk of rebleeding after endoscopic ligation,and the related risk factors also need to be explored.This study aims to analyze the related factors affecting the efficacy and bleeding after endoscopic ligation treatment for cirrhosis of esophageal varicose veins,so as to provide reference for individualized clinical diagnosis and treatment decisions for patients with cirrhosis of esophageal varicose veins,with a view to reducing the incidence of bleeding after treatment and improving the prognosis.Methods:Retrospectively collected datas for patients with cirrhosis and esophageal varices who received EVL treatment from December 2017 to December 2019.The data contains detailed demographic,laboratory,imaging,and clinical data,including age,gender,etiology of liver cirrhosis(including viral hepatitis,autoimmune liver disease,cholestasis liver disease,alcoholic liver disease and other reasons,etc.),hepatic encephalopathy stratification,laboratory tests: Total cholesterol(TC),alanine aminotransferase(ALT),aspartate aminotransferase(AST),gamma-glutamyltransferase(gamma GGT),albumin(Alb),creatinine(Cr),urea nitrogen(BUN),international standardization ratio(INR),platelet count(PLT),total bilirubin(TB),combined bilirubin(CB).Imaging examination(portal vein width,spleen size),other treatment measures(splenectomy,non-selectiveβ-blocker,combined with gastric variceal ligation),etc.The t test was used at measurement data conforming to the normal distribution and homogeneity of variance.The measurement data which did not satisfy used non-parametric test.Classified variables were represented by N(%),and chi-square test or Fisher’s exact test was used.Logistic regression was used to evaluate the correlation between related factors and outcome indicators.Results:A total of 241 patients with esophageal varicose veins with cirrhosis were enrolled in this study.During the follow-up period,185 patients received one EVL treatment,43 received two EVL treatments,12 received three EVL treatments and one received four EVL treatments.The Child-Pugh grade of liver function reserve before ligation was performed in all patients,including 142 cases(45.7%)in grade A,115 cases(37.0%)in grade B,and 54(17.4%)in grade C.71 patients(22.8%)were treated with an oral beta-blocker combine with intravenous ligation.About 11.3% of patients(35)underwent splenectomy to improve portal hypertension.43 cases(13.8%)underwent gastric vein ligation at the same time as esophagus vein ligation.244 cases(78.5%)received ligation alone,8 cases(2.6%)received sclerosing agent injection simultaneously,and 59 cases(19.0%)received tissue glue occlusion simultaneously.During the follow-up,52 patients suffered post-treatment(re)bleeding,and most of the patients did not(re)bleeding(259cases,83.3%).Baseline clinical characteristics of the two groups were compared,we find that the splenectomy proportion in the non-bleeding group was significantly lower than that in bleeding group(9.7% vs.19.2%,P=0.046),other factors were not statistical different.The majority(270,86.8%)of varicose veins were classified as severe,while only a few(20,6.4%)were classified as moderate.No thrombosis was found in 252 patients and thrombosis was found in 59 patients(19.0%).Microscopically active bleeding occurred in 39 patients(12.5%).During the follow-up,the endoscopic indicators of the two groups(bleeding and non-bleeding)were compared,and the differences in red sign,thrombosis and active bleeding between these two groups showed statistical significance(P=0.009,0.006,0.040).Single factor regression analysis showed that splenectomy(OR=0.449,95%CI0.201-1.002,P=0.051)and high platelet count(OR=0.997,95%CI 0.993-1.000,P=0.072)had close P values of 0.05 in the analysis of reducing(re)bleeding after ligation,but neither reached < 0.05.Thrombosis(OR=2.510,95%CI 1.288-4.890,P=0.007)and microscopic discovery of active bleeding(OR=2.213,95%CI 1.022-4.792,P=0.044)were risk factors for post-ligation(re-ligation)bleeding.Multivariate logistic regression analysis showed similar results:thrombosis(OR=2.364,95% CI 1.196-4.676,P=0.013),microscopic discovery of active bleeding(OR=2.265,95% CI 1.021-5.021,P=0.044).Logistic regression analysis was performed on clinical factors for grade relief of varicose veins after venous ligation.Univariate logistic regression analysis showed that active bleeding(OR=4.888,95%CI 1.677-14.252,P=0.004)and portal hypertensive gastropathy(OR=0.368,95%CI 0.180-0.753,P=0.006)were strongly correlated with grade relief of varicose veins.Multivariate logistic regression analysis showed that active bleeding and portal hypertensive gastropathy were still significant influencing factors for the remission of varicose vein grade.Taking secondary prevention as a reference,primary prevention(OR=2.815,95%CI 1.086-7.296,P=0.033)was more likely to obtain follow-up varicose relief,indicating that early venous ligation was more conducive to the relief of varicose veins.Statistical analysis of postoperative complications showed that the main adverse events included fever,retrosternal pain,swallowing obstruction,nausea,and abdominal pain.Among 311 cases,fever was found in 28 cases(9.0%),retrosternal pain in 29 cases(9.3%),swallowing obstruction in 55 cases(17.7%),nausea in 6.4% and abdominal pain in 2.9%,respectively.The incidence of swallowing obstruction was the highest,nearly20%,followed by fever,retrosternal pain and discomfort.Adverse reactions after EVL mostly appeared 24-72 hours after treatment,and lasted for a short time.Most of the adverse reactions could be relieved and disappeared after close observation and symptomatic treatment.Conclusion:EVL showed similar therapeutic effect in preventing subsequent(re)bleeding in the primary prevention,acute bleeding and secondary prevention of esophageal varices in cirrhosis,and postoperative complications were controllable.Thrombus formation and endoscopic detection of active bleeding are risk factors for post-EVL(re)bleeding,which can increase the risk of subsequent bleeding.Active bleeding and portal hypertensive gastropathy were significant influencing factors for the remission of varicose veins.Compared with secondary prevention,patients with primary prevention are more likely to get varicose relief.Therefore,early venous ligation is recommended to achieve varicose relief. |
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