| Objectives:Gastroesophageal variceal bleeding(GEVB)is a severe complication of portal hypertension(PH)mainly caused by liver cirrhosis.Recurrent GEVB contributes to the high morbidity and mortality of patients with liver cirrhosis,ranging from 15%to 25%at 6 weeks,leading to simultaneous pain and economic pressure.Thus,secondary prophylaxis is one of the most important management strategies.The first line therapy for preventing recurrent variceal hemorrhage among all patients is the therapeutic combination of endoscopic variceal therapy+nonselective ?-receptor blocker(NSBB),which is more effective than either treatment alone.However,studies showed that the rate of rebleeding of treatment is still not satisfactory.Current clinical guidelines recommend that transjugular intrahepatic portosystemic shunt(TIPS)can be considered as a secondary prevention plan for cases of repeated bleeding or clinical intolerance to NSBB after endoscopic treatment.As we all know,rebleeding of variceal rebleeding is very harmful to cirrhotic patients.If it can be prevented in advance and reduce the occurrence of bleeding in the clinical process of patients,it may be beneficial for the survival of patients.Therefore,how to choose the appropriate population for TIPS and endoscopic treatment in secondary prevention has always been a clinical concern.In recent years,our center has used hepatic venous pressure gradient(HVPG)as an important method to guide the selection of clinical programs and evaluate the efficacy of treatment.Previous study found that for patients with variceal hemorrhage and an HVPG greater than 20 mmHg,TIPS placement displayed a higher successful rate and a higher six-week survival rate than endoscopic therapy did.However,there is no stratified study comparing the efficacy of TIPS with endoscopic therapy for secondary prophylaxis of variceal bleeding in cirrhotic patients with HVPG?20 mmHg.This study retrospectively analyzed the clinical cases of TIPS and endoscopic treatment in the secondary prophylaxis of cirrhotic patients with HVPG less than 20mmHg,aiming to evaluate the clinical efficacy of TIPS and endoscopic treatment+NSBB for secondary prophylaxis of gastroesophageal variceal bleeding in cirrhotic patients with HVPG value less than 20 mmHg and exploring the influential factor of the outcomes.Methods:In this retrospective study,all consecutive liver cirrhosis patients with a history of GEVB in Shandong Provincial Hospital Affiliated with Shandong University from April 2010 to November 2019 were collected.After the inclusion criteria and the exclusion criteria,we finally concluded 204 patients with HVPG less than 20 mmHg who performed TIPS or endoscopic therapy+NSBB for secondary prophylaxis(TIPS,51;Endoscopic,153).Main clinical parameter items:(1)Basic data:age,gender;(2)Past medical history:etiology of cirrhosis,previous bleeding history,past splenectomy or splenic embolism;(3)Related laboratory data:liver and kidney function,White blood cell count(WBC),hemoglobin(Hb),platelet count(PLT),prothrombin time(PT),international normalized ratio of prothrombin(INR)and ascites,etc.,and calculate Child-Pugh grading and MELD score which can reflect liver function;(3)gastroscopy data:record the type of varicose veins of the patient;(4)postoperative follow-up:postoperative outpatient or telephone follow-up,the follow-up content is mainly whether there is rebleeding,survival,and whether hepatic encephalopathy(HE)occurs after treatment and postoperative complications.The primary end point was the recurrence of variceal bleeding.The secondary end points were the occurrence of death.All patients were followed up every 3 months until the end of the follow-up event or the end of the study.Statistical analysis was performed using SPSS 25.0 software.Continuous variables are described as the meanąstandard deviation or the median(interquartile range),and the groups were compared using t-tests or the Wilcoxon rank sum test.The categorical variables are described by frequency(percent)and were tested using the Wilcoxon rank sum test,and the nonhierarchical variables were assessed by chi-square or Fisher's exact tests.The rebleeding rate,survival rate,and HE incidence rate of the two groups during follow-up were determined using the Kaplan-Meier method and the log-rank test.Cox proportional hazard analyses were used for univariate and multivariate analyses of the end points.A two-sided p-value<0.05 was considered statistically significant.Results:1.This study finally included 204 cirrhotic patients with HVPG less than 20 mmHg and a history of variceal bleeding(51 in TIPS group and 153 in Endoscopic group).There were no differences in baseline data between two groups including age,gender,etiology,ascites,laboratory tests,liver function Child-Pugh classification,types of varices,but HVPG,TBIL,MELD score were different in two groups.What's more,TBIL and MELD score were higher in the TIPS group than in the endoscopic group,suggesting that TIPS-treated patients with hepatic cirrhosis had higher portal hypertension and worse liver function reserve in this retrospective group,but the results showed that the rebleeding rate in the TIPS group was still lower than that in the endoscopic group.2.Rebleeding:During the follow-up period,recurrent bleeding occurred in 59 patients:54 patients in the Endoscopic group and 4 in the TIPS group.The rebleeding rate of patients in the Endoscopic group was 35.3%,while the rebleeding rate of patients in the TIPS group was 9.8%.The Kaplan-Meier curves for rebleeding in the Endoscopic group and TIPS group showed that the rebleeding rate in TIPS group was significantly lower than that in Endoscopic group(p=0.02).The 3-year probability of remaining free of recurrent variceal bleeding was 86%in the TIPS group and 83.3%in the Endoscopic group.Specifically,multivariate analysis was performed to evaluate factors that might influence the rebleeding rate,showing that treatment way was an independent predictors of rebleeding.Seventeen of 54 patients in the Endoscopic group received additional endoscopic therapy,and fifteen patients received rescue TIPS,whereas five of 22 patients who chose conservative treatment in the local hospital died before TIPS placement could be carried out.Three of five patients in the TIPS group who showed dysfunctional TIPS had another stent graft placed,and two patients accepted drug therapy.3.HE:A total of 21 patients suffered from HE after operation:6 patients in the Endoscopic group and 15 patients in the TIPS group.The incidence of HE in the Endoscopic group was 3.9%,while that in the TIPS group was 29.4%.The Kaplan-Meier curves for HE showed that the occurrence of HE in the TIPS groups was higher than that in Endoscopic group(p=0).The 3-year probability of remaining free of HE occurrence was 96.6%in the Endoscopic group and 66.8%in the TIPS group.A Cox regression analysis was performed for factors that might influence the HE rates after the operation,and the results showed that treatment methods,GGT and Na+were independent predictors of HE.After drug therapy,all patients cured.4.Death:During the follow-up period,mortality occurred in 18 patients:17 patients in the Endoscopic group and 1 in the TIPS group.The survival rate of patients in the Endoscopic group was 88.9%,while the survival rate of patients in the TIPS group was 98.0%.The Kaplan-Meier curves for survival showed no significant differences were observed between the Endoscopic and TIPS groups(p=0.089).The 3-year probability of survival was 96.3%in the Endoscopic group and 95.2%in the TIPS group.After Cox regression analysis,GGT,Na+and MELD score were found to be independent predictors of survival.Six patients in the Endoscopic group and 1 in the TIPS group died from liver failure.In the endoscopic group,4 patients died from hepatocellular carcinoma,5 patients died from uncontrolled rebleeding,1 patient died due to multiorgan dysfunction syndrome,and the other patient died from unknown reasons.5.Complications:After the operation,complications including portal vein thromsis,infection,fever,spontaneous peritonitis,severe abdominal pain and ascites were followed up,none of which were fatal.There were no significant differences in these complications between the two groups.Conclusions:In conclusion,for cirrhotic patients with HVPG less than 20mmHg and gastroesophageal variceal bleeding,the rebleeding rate of TIPS treatment is lower than that of endoscopic combined drug therapy,and the incidence of HE with TIPS treatment is higher than that of endoscopic combined drug therapy,the survival rate and postoperative complications were not different.Therefore,this study considered that TIPS has a better effect of reducing rebleeding in the patients for secondary prophylaxis of variceal bleeding with HVPG less than 20 mmHg,but has no clinical survival benefit. |
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