超声内镜引导下贲门周围穿通支阻断术治疗食管胃静脉曲张3型的临床应用价值

Clinical value of endoscopic ultrasound-guided targeted occlusion of perforating veins around the cardia for type 3 gastroesophageal varices

摘要:

目的 评价超声内镜引导下贲门周围穿通支靶向闭塞治疗食管胃静脉曲张3型（GOV3）的临床疗效与安全性。方法 前瞻性纳入2024年1月1日－2024年10月31日于该院因急性出血或二级预防接受超声内镜引导下贲门上下5.0 cm范围内穿通支靶向闭塞治疗的GOV3患者32例，设为贲门周围超声内镜组（C组）；回顾性纳入2021年全年和2022年3月1日－12月31日于该院接受经典直视内镜治疗的患者40例，设为经典直视组（A组），接受经典直视+贲门上下5.0 cm范围内追加硬化剂联合组织胶治疗的患者35例，设为贲门追加组（B组）。比较3组患者的治疗相关指标、术后再出血情况及治疗相关不良事件。结果 在调整年龄、性别、蔡尔德-皮尤评分及门静脉血栓等混杂因素影响后，贲门周围超声内镜组的穿刺点数和组织胶用量少于经典直视组和贲门追加组，差异均有统计学意义（P = 0.005，0.002），但经典直视组与贲门追加组比较，差异无统计学意义（P = 0.279，0.312）。术后3个月内，贲门周围超声内镜组再出血率低于经典直视组，差异有统计学意义（P = 0.012），贲门追加组再出血率低于经典直视组，但差异无统计学意义（P = 0.124）。术后6和12个月内，贲门周围超声内镜组再出血率均低于另外两组，但组间比较，差异均无统计学意义（P = 0.396，0.632）。3组术后均未发生异位栓塞。经典直视组和贲门追加组均有患者发生术后食管狭窄，经内镜下行食管支架置入术后症状缓解。随访期间，3组均无患者因再出血追加介入或外科手术治疗，亦无死亡病例。结论 超声内镜引导下贲门周围穿通支靶向闭塞治疗GOV3，可减少穿刺点数及组织胶用量，并降低术后短期再出血风险，具有一定的临床应用价值。但其中期和长期疗效仍需进一步研究验证。

Abstract:

Objective To evaluate the clinical efficacy and safety of endoscopic ultrasound (EUS)-guided targeted occlusion of paracardial perforating veins for the treatment of type 3 gastroesophageal varices (GOV3).Methods We prospectively enrolled 32 GOV3 patients who received EUS-guided targeted occlusion of paracardial perforating veins within 5.0 cm above or below the cardia due to acute hemorrhage or for secondary prevention at our hospital between January 1, 2024, and October 31, 2024; this cohort was designated the paracardial EUS group (Group C). Retrospectively, we enrolled 40 patients who received conventional direct-vision endoscopic therapy at our hospital during the full year of 2021 and from March 1, 2022, to December 31, 2022, as the conventional direct group (Group A); additionally, 35 patients who received conventional direct therapy supplemented with sclerotherapy combined with tissue glue injection within 5.0 cm above or below the cardia were designated as the cardial supplementary group (Group B). Treatment-related indicators, postoperative rebleeding rates, and treatment-related adverse events were compared among the three groups.Results After adjusting for confounding factors including age, sex, Child-Pugh score, and portal vein thrombosis, the number of puncture points and the dosage of tissue glue in the paracardial EUS group were significantly lower than those in the conventional direct group and the cardial supplementary group (P = 0.005 and P = 0.002, respectively); however, there was no statistically significant difference between the conventional direct group and the cardial supplementary group (P = 0.279 and P = 0.312, respectively). Within 3 months postoperatively, the rebleeding rate in the paracardial EUS group was significantly lower than that in the conventional direct group (P = 0.012); the rebleeding rate in the cardial supplementary group was also lower than that in the conventional direct group, but the difference was not statistically significant (P = 0.124). Within 6 and 12 months postoperatively, the rebleeding rate in the paracardial EUS group was lower than that in the other two groups, although the intergroup differences were not statistically significant (P = 0.396 and P = 0.632, respectively). No cases of ectopic embolization occurred in any of the three groups postoperatively. Postoperative esophageal stenosis occurred in patients within both the conventional direct group and the cardial supplementary group, with symptoms resolving after endoscopic esophageal stent placement. During the follow-up period, no patient in any of the three groups required additional interventional radiology or surgical treatment due to rebleeding, and no mortalities occurred.Conclusion EUS-guided targeted occlusion of paracardial perforating veins for GOV3 can reduce the number of puncture points and the volume of tissue glue, and decrease the risk of short-term postoperative rebleeding, suggesting definitive clinical utility. However, its medium- and long-term efficacy requires further validation through additional research.