| BackgroundEsophageal gastric variceal bleeding(EGVB)is one of the most serious complications of decompensation of cirrhosis,as well as gastric variceal bleeding(GVB)is one of the most serious complications during decompensation of cirrhosis.Compared with esophageal variceal bleeding(EVB),the incidence of GVB was lower,and the cumulative bleeding rate in 5 years was about 24%-44%.However,compared with EVB,GVB hemorrhages rapidly,which has a large amount of bleeding and a high rebleeding rate and can occur immediately under low portal pressure,which is also associated with higher mortality.Therefore,endoscopic diagnosis and treatment of gastric varicose veins are very important.for the treatment of gastric varices(GVs),due to the complex anatomical structure and blood flow of GVs,the current treatment strategy has not been uniformly concluded.Especially for Type 2 gastroesophageal varices(GOV2)in Sarin classification,different guidelines have different therapeutic tendencies.These include endoscopic tissue glue injection,transjugular intrahepatic portosystemic shunt(TIPS),balloon-occluded retrograde transvenous obliteration(BRTO)under balloon catheter occlusion,Our center has conducted long-term exploration in the endoscopic treatment of GVs,and the research results are presented in the first part of the article.However,in the diagnosis of gastroscopic varices,white light endoscopy can observe the location,size,and shape of the varices and whether there is a red sign on the surface,while endoscopic ultrasound can obtain real-time ultrasound images,which can help us to judge the size of blood vessels and the source of perforating blood vessels more accurately.And endoscopy-guided tissue glue and coil spring therapy are also recommended.Therefore,for gastroesophageal varices(GOV),which have the highest incidence,especially for GOV2 varices,it is still necessary to further explore how to select appropriate endoscopic treatment.Aims1.Through retrospective analysis,the efficacy,safety,and complications of different endoscopic treatment methods for GOV2 gastric varices under the Hashizume classification(F1,F2,F3)and gastric varices ligation and tissue gel therapy were discussed and compared.2.To investigate the endoscopic ultrasonography(EUS)guided by the India ink markers and directly under endoscopy in the diagnosis of gastric varices consistency,evaluation of EUS in the diagnosis of GVs value,and further understanding of traditional endoscopic features of GVs.3.EUS-guided injection of tissue glue combined with the balloon-compressed esophageal injection sclerosant(EUS-CYA+bc-EIS)is a novel technique compared with the transjugular intrahepatic portosystemic shunt(TIPS),efficacy,safety,and cost of TIPS in the treatment of cirrhotic portal hypertension GOV type gastric varicose hemorrhage.Materials and methods1.Patients with cirrhosis who received endoscopic treatment in the Department of Gastroenterology,the First Affiliated Hospital of Anhui Medical University from January 2016 to March 2022 were selected as retrospective objects,and GOV2 cases of esophageal and gastric varices treated with tissue gel or ligation were selected.A total of 324 subjects were selected and divided into the F1 group(94 cases,29.0%),F2 group(161 cases,49.7%),and F3 group(69 cases,21.3%)according to Hashizume gastric vein type.The F1 and F2 groups were further divided into two groups:gastric fundus ligation treatment or gastric fundus tissue glue injection treatment.The efficacy of different treatment methods,rebleeding,and other complications in the F1 and F2 groups were compared respectively.Then the treatment of gastric fundus glue in the F3 group was observed and analyzed,and compared with the injection amount and number of tissue glue in F1 and F2,therapeutic effect,postoperative rebleeding,and complications.2.From April 2022 to October 2022,34 patients diagnosed with GVs requiring endoscopic tissue treatment in the First Affiliated Hospital of Anhui Medical University were included.First,the GVs were observed with a white light microscope,and the size was measured to determine the injection site.Then EUS was used to probe the blood vessels,and the source vein of the perforating branch was detected.India ink was used to mark the injection point of the target blood vessel,and tissue glue was given for treatment.Finally,the post-treatment situation was observed under a white light microscope to find the mark points.To observe whether the marks were clear,compare whether the injection sites under the white light microscope were consistent with those marked with India ink,explore the characteristics of gastric varicose veins under the white light microscope,and calculate the therapeutic efficacy and postoperative adverse events.3.A total of 68 patients with cirrhotic portal hypertension complicated with gastric varicose of type GOV were selected from the First Affiliated Hospital of Anhui Medical University from August 2021 to March 2023 for retrospective evaluation.All patients gave informed consent and received ethical approval.The two groups were treated with EUS-guided injection of tissue glue for GVs,and balloon-compressed esophageal injection sclerosant(28 cases in the EUS-CYA+bc-EIS group)and TIPS(38 cases in the TIPS group),respectively.Postoperative adverse events,rebleeding,survival rate,and cost were compared between the two groups.Results1.(1)There was no statistical difference in the basic information of F1 GOV2 gastric varices between the EVL group(33 cases)and GVO group(61 cases),such as age,sex,cause of cirrhosis,Child-Pugh grade,and the GVs between the two groups.For example,there were no statistical differences in the size of gastric varices,red signs,and esophageal varices(EVs).There was no significant difference in the rates of effect(81.8%vs.80.3%,P=0.861)and rebleeding(12.1%vs.8.2%,P=0.537)between the EVL and GVO groups.(2)For GOV2 gastric varices of F2,there were no statistically significant differences in basic information and gastric varices between the EVL group(46 cases)and GVO group(115 cases),and there was no statistically significant difference in the effective rate between EVL group and GVO group(80.4%vs.73.9%,P=0.383).The rate of early rebleeding in the EVL group was significantly higher than that in the GVO group(15.2%vs.4.3%,P=0.041).(3)All the types of F3 proved GOV2 gastric varicose veins were treated with tissue gel injection(69 cases),compared with the type of F2(115 cases)and the type of F1(61 cases)according to the GVO treatment,there was no statistical difference in the general data of F3 group,such as age,sex and cause of cirrhosis.The diameter of F3 is 1.95±0.782cm,the diameter of F2 is 0.99±0.186cm and F1 is 0.47±0.134cm(P<0.001).The number of injection points for gastric varicose veins in F3 was 2.03 ± 1.260,higher than that in F2(1.25 ± 0.736)and F1(1.18 ± 0.533)(P<0.001).The efficacy of F3 was lower than that of F2 and F1(60.9%vs.73.9%vs.80.3%,P=0.038).The rate of rebleeding in the treatment of F3 tissue glue was much higher than that of F2 and F1(31.9%vs.13.9%vs.8.2%,P=0.001).2.Endoscopic ultrasonography combined with Indian ink to mark GVs were compared with conventional white-light endoscopy,and the process was smooth without complications,including 29 cases with one marker,4 cases with 2 markers,and 1 case with 3 markers,with a total of 40 markers.and the distribution difference between the markers the injection sites under the endoscopic ultrasonography and under the white light microscope was statistically significant(P<0.05).they were divided into anastomosis group(25 cases)and non-anastomosis group(15 cases),the vessel diameter of anastomosis group was 10.84±4.02mm,and that of non-anastomosis group was 10.53±2.42mm,with no statistical significance(P=0.756).The incidence of red sign on vascular surface was not statistically significant in anastomosis group and non-anastomosis group(80.0%vs.52.0%,P=0.691).The incidence of erosion anastomosis group and non-anastomosis group(64.0%vs.26.7%,P=0.022)was statistically significant.3.(1)There were no statistical differences in the basic information of the two groups,such as age,sex,cause of cirrhosis,and Child-Pugh grade.(2)The average diameter of the gastric vein was 10(10-15)mm,and the diameter of the perforating branch vein was 10(8-11)mm.Each patient received 1.1 ± 0.4 treatments on average.The average injection volume of tissue glue was 1.4 ± 1.3ml,and the average injection volume of lauryl alcohol was 18.2±8.9ml.In the TIPS group,38 cases were operated and 35 cases were embolized with varicose veins.The mean preoperative portal vein pressure gradient was 37.8±8.3mmHg,and the mean postoperative portal vein pressure gradient was 25.7 ± 6.2mmHg,with an average decrease of 12.2 ± 5.3mm Hg(P<0.001).(3)In the EUS-CYA+bc-EIS and TIPS groups,patients were treated at 48h(35.7%vs.21.1%,P=0.504),1 month(21.4%vs.7.9%,P=0.504),3 months(10.7%vs.5.3%,P=0.153),6 months or more(3.5%vs.2.6%,P=1.000)had no significant difference in the rate of gastric varicose rebleeding.(4)The incidence of hepatic encephalopathy in the TIPS group was significantly higher than that in the EUS-CYA+bc-EIS group(15.8%vs.0%,P=0.035).(5)There was no difference in survival rate between the two groups(100%vs.92.1%,P=0.256).(6)The length of hospitalization in the EUS-CYA+bc-EIS group was 8(7-11)days,which was less than that in the TIPS group 13(9-18)days(P=0.010);The average hospitalization cost in the EUS-CYA+bc-EIS group was 16200.5(12597.8-20590.7)yuan,which was lower than that in TIPS group 99357.3(72545.6-126981.0)yuan(P<0.001).Conclusion1.For patients with GOV2 gastric varicose veins,there were no significant differences in effectiveness,bleeding,and other complications between the F1-type tissue glue treatment group and the ligation treatment.For F2 GOV2 gastric varicose patients,there was no significant difference in efficacy between the tissue glue treatment group and the ligation treatment group,but the rate of early rebleeding in the ligation group was higher than that in the tissue glue group.For F3 GOV2 gastric varicose patients,the effective rate of tissue gel treatment was lower than that of F1 and F2,and the rebleeding rate was significantly higher than that of F1 and F2.2.Endoscopic ultrasonography combined with Indian ink labeling technology has proved that endoscopic ultrasonography is different from white light microscopes in locating injection points,and endoscopic ultrasonography can more accurately select target vessels and injection points.However,white light endoscopy can help us better judge the blood vessels with obvious surface eminence,erosion,and thrombus head.3.For patients with GOV gastric varicose veins,EUS-guided injection of tissue gel combined with balloon-compressed esophageal injection sclerosant has the same hemostatic effect as TIPS,and there is no significant difference in survival rate between the two groups.However,the incidence of hepatic encephalopathy in the EUS group is lower than that in the TIPS group,and the length of hospitalization and cost are lower. |
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