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伴门静脉栓子的食管胃静脉曲张破裂出血急诊胃镜下硬化术联合组织胶注射术止血失败的危险因素分析
DOI: 10.3969/j.issn.1001-5256.2021.01.014
利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突，特此声明。
作者贡献声明：丁鹏鹏、陈建宏负责课题设计，资料分析，撰写论文；李莉、祁小宝、王艳玲参与收集数据，修改论文；王沧海、路筝、张文辉、刘红负责拟定写作思路，指导撰写文章，并最后定稿。
Risk factors for hemostatic failure in emergency gastroscopic sclerotherapy combined with tissue adhesive injection for esophagogastric variceal bleeding with portal vein embolus
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摘要:
目的 探讨急诊胃镜下硬化术(EIS)序贯联合组织胶注射术(HI)在合并门静脉栓子(PVE)的肝硬化食管胃静脉曲张破裂出血(EGVB)治疗中失败的危险因素。 方法 选取2018年1月—2019年12月首都医科大学附属北京世纪坛医院和解放军总医院第五医学中心急诊胃镜治疗的合并PVE的EGVB患者共109例，按照急诊胃镜下止血疗效分为止血失败组(n=28)和止血成功组(n=81)，比较两组间的一般资料、胃镜下静脉曲张及出血表现、血液生化指标、Child-Pugh分级及MELD评分，分析其止血失败的危险因素。计量资料两组间比较采用t检验或Mann-Whitney U秩和检验，计数资料两组间比较采用χ2检验，多因素分析采用logisitc回归分析。 结果 止血失败组外周血WBC、TBil、Child-Pugh分级、MELD评分均显著高于止血成功组(统计值分别为Z=3.794、Z=4.751、χ2=40.104、Z=6.412，P值均＜0.001)，而PTA、Alb、CHE均显著低于止血成功组(统计值分别为t=9.653、Z=3.093、Z=4.092，P值分别为＜0.001、0.002、＜0.001)；其中WBC、PTA、TBil、Alb、Child-Pugh分级为其止血治疗失败的独立危险因素[OR(95%CI)分别为：28.543(1.285~634.113)、0.194(0.045~0.835)、2.197(1.004~4.810)、0.448(0.209~0.961)、5.164(1.307~20.406)，P值均＜0.05]。 结论 WBC、PTA、TBil、Alb、Child-Pugh分级为急诊EIS序贯联合HI治疗合并PVE的EGVB失败的独立危险因素，术前充分评估并纠正有助于提高止血成功率。 Abstract:Objective To investigate the risk factors for failure in emergency endoscopic injection sclerotherapy (EIS) combined with sequential histoacryl injection (HI) for esophagogastric variceal bleeding (EGVB) with portal vein embolus (PVE). Methods A total of 109 EGVB patients with PVE who underwent emergency gastroscopy in Beijing Shijitan Hospital, Capital Medical University, and The Fifth Medical Center of Chinese PLA General Hospital from January 2018 to December 2019 were enrolled, and according to the outcome of hemostatic treatment under emergency gastroscopy, the patients were divided into hemostatic failure group with 28 patients and hemostatic success group with 81 patients. The two groups were compared in terms of general information, varices and bleeding manifestations under gastroscopy, blood biochemical parameters, Child-Pugh class, and Model for End-Stage Liver Disease (MELD) score, and the risk factors for hemostatic failure were analyzed. The t-test or the Mann-Whitney U test was used for comparison of continuous data between groups, and the chi-square test was used for comparison of categorical data between groups; a logistic regression analysis was used for multivariate analysis. Results Compared with the hemostatic success group, the hemostatic failure group had significantly higher peripheral white blood cell count (WBC), total bilirubin (TBil), Child-Pugh class, and MELD score (Z=3.794, Z=4.751, χ2=40.104, Z=6.412, all P < 0.001) and significantly lower prothrombin time activity (PTA), albumin (Alb), and cholinesterase (CHE) (t=9.653, Z=3.093, Z=4.092, P < 0.001, P=0.002, and P < 0.001). WBC (odds ratio [OR]=28.543, 95% confidence interval [CI]: 1.285-634.113, P < 0.05), PTA(OR=0.194, 95%CI: 0.045-0.835, P < 0.05), TBil (OR=2.197, 95%CI: 1.004-4.810, P < 0.05), Alb (OR=0.448, 95%CI: 0.209-0.961, P < 0.05), and Child-Pugh class (OR=5.164, 95%CI: 1.307-20.406, P < 0.05) were independent risk factors for hemostatic failure. Conclusion WBC, PTA, TBil, Alb, and Child-Pugh class are independent risk factors for failure in emergency EIS combined with sequential HI in the treatment of EGVB with PVE, and adequate preoperative evaluation and correction may help to improve the success rate of hemostasis. -
表 1 两组一般资料比较
项目 成功组(n=81) 失败组(n=28) 统计值 P值 男[例(%)] 55(67.9) 23(82.1) χ2=2.074 0.150 年龄(岁) 57.44±9.63 55.04±9.00 t=1.160 0.249 肝硬化病因[例(%)] χ2=2.531 0.112 病毒性肝炎 71(87.7) 21(75.0) 非病毒性肝炎 10(12.3) 7(25.0) 肝硬化病程(年) 7.44(2.00~9.00) 4.39(1.00~6.75) Z=1.894 0.058 合并肝癌[例(%)] 28(34.6) 14(50.0) χ2=2.092 0.148 首次出血[例(%)] 35(43.2) 8(28.6) χ2=1.867 0.172 
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表 2 两组静脉曲张情况比较
胃镜下表现 成功组(n=81) 失败组(n=28) χ2值 P值 静脉曲张程度[例(%)] 2.771 0.096 重度
中度64(79.0)
17(21.0)26(92.9)
2(7.1)静脉曲张出血部位[例(%)] 4.773 0.092 食管
贲门
胃底54(66.7)
19(23.5)
8(9.9)17(60.7)
11(39.3)
0胃镜下出血表现[例(%)] 0.131 0.717 活动性出血1) 46(56.8) 17(60.7) 其他2) 35(43.2) 11(39.3) 注：1)活动性出血指静脉曲张喷血、涌血或渗血; 2)其他指曲张静脉有糜烂、血栓及镜下能够见到新鲜血液，并能排除非静脉曲张出血因素。
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表 3 两组血液生化指标比较
项目 成功组(n=81) 失败组(n=28) 统计值 P值 WBC(109/L) 4.29(1.51~5.88) 8.10(3.75~11.03) Z=3.794 ＜0.001 Hb(g/L) 92.78(83.50~102.50) 88.50(71.25~99.75) Z=1.467 0.142 PLT(109/L) 125.44(80.50~131.00) 91.89(50.50~135.75) Z=1.876 0.061 PTA(%) 76.62±7.40 53.60±17.51 t=9.653 ＜0.001 ALT(U/L) 28.05(19.00~35.00) 53.50(20.75~70.50) Z=1.657 0.098 AST(U/L) 51.11(31.50~57.00) 139.50(32.00~177.50) Z=1.758 0.079 TBil(μmol/L) 18.83(10.65~19.25) 69.49(19.00~79.80) Z=4.751 ＜0.001 Alb(g/L) 32.33(29.00~36.50) 28.11(24.00~33.75) Z=3.093 0.002 ChE(U/L) 3445(2487~4260) 2327(1579~2772) Z=4.092 ＜0.001 Child-Pugh分级[例(%)] χ2=40.104 ＜0.001 A级
B级
C级33(40.7)
42(51.9)
6(7.4)011(39.3)
17(60.7)MELD评分 8.59(7~8) 14.68(10~17) Z=6.412 P＜0.001
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表 4 止血疗效影响因素的logistics回归分析
变量 B值 SE Wald值 P值 OR(95%CI) WBC 3.351 1.582 4.487 0.034 28.543(1.285~634.113) PTA 1.641 0.746 4.846 0.028 0.194(0.045~0.835) TBil 0.787 0.400 3.880 0.049 2.197(1.004~4.810) Alb 0.802 0.389 4.261 0.039 0.448(0.209~0.961) ChE 0.002 0.002 2.180 0.140 0.998(0.994~1.001) MELD评分 0.066 0.909 0.005 0.942 1.068(0.180~6.329) Child-Pugh分级1)(B级=0，C级=1) 1.642 0.701 5.483 0.019 5.164(1.307~20.406) 注：1)因止血失败组Child-Pugh A级为0例，仅纳入两组间Child-Pugh B级C级进行比较。
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