【作者】 孙爱涛；

【导师】 张春清；

【作者基本信息】 山东大学 ， 内科学（专业学位）， 2013， 博士

【摘要】 研究背景和目的肝硬化门静脉高压常并发食管胃底静脉曲张破裂出血(EVB),出血率及病死率极高。目前对食管胃底静脉曲张出血的防治共识,指出要预防食管胃底静脉曲张首次出血(一级预防)与再次出血(二级预防)。内科药物、外科手术及内镜下套扎、硬化等是目前临床上常采用的治疗手段。内科药物在静脉曲张出血方面,治疗效果有限,重复出血率和死亡率均比较高；对肝功能损害严重患者,外科手术视为禁忌症；由于不能降低门脉高压,内镜下治疗后易复发,再出血率较高,故术后需长期反复治疗。所以在食道胃底静脉曲张出血的防治方面,选择其他的一些治疗手段,这时就显得及其重要。近年以来,对门脉高压介入治疗手段的研究日益迅猛,渐渐成熟。作为一种微创治疗方法,介入治疗具有很多特点,如：手术创伤小、术后并发症少、恢复快、治疗效果好等,这在临床工作中发挥着及其重要的意义。(percutaneous transhepatic varicral embolization,PTVE)经皮肝穿胃食管静脉曲张栓塞术作为其中一种常见的介入方法,近年来研究日益增多。传统PTVE没有做到曲张静脉的完全栓塞,术后静脉曲张复发出血率很高,改良的PTVE技术以永久性栓塞剂组织胶(TH tissue histoacryl)进行栓塞,在预防食道胃底静脉曲张再出血和复发方面取得了较好的疗效。PTVE治疗效果和门脉系统侧枝循环血流动力学改变间关系密切,因此术前仔细评估门脉侧枝循环非常重要。门静脉病变的清晰显示长期以来一直是困扰临床医生的难题,门静脉高压侧支循环的评价方法,现包括上消化道钡餐、常规CT扫描、B超和胃镜等,但均仅能显示间接征象或仅部分显示侧支循环。传统的门静脉造影在临床应用中得到限制,因为门静脉造影是一种有创的检查,而且不能一次性多角度、全面立体的显示侧支循环血管。多层螺旋CT及门静脉成像作为-种无创检查近年来已显示出很高的临床应用价值。多层螺旋CT具有高分辨率成像及强大的后期3D图像处理功能的优势,操作中,以其快速的扫描速度及超薄层扫描,可实现各个方向的同性扫描,实践中利用后期的计算机工作站,可进行图像薄层重建以及三维重建,可以获得高质量的门静脉图像及清晰观察食管胃静脉曲张及其供血交通支的空间解剖关系。多层螺旋CT及门静脉成像在门静脉高压的临床应用中有越来越广阔的空间。我们此项研究的目的即为探讨应用多层螺旋CT门静脉成像评估PTVE术后食道胃静脉曲张患者门脉侧枝循环血流动力学变化及其远期疗效。方法：经皮经肝组织胶介入栓塞(PTVE)治疗食管胃底静脉曲张患者156例。应用多层螺旋CT门静脉成像观察PTVE术前及术后食道胃底曲张静脉及门脉侧枝循环。根据组织胶在食道胃底曲张静脉及供血侧枝中的分布范围将患者分为三组：食管-胃底组,胃底-贲门组及冠状静脉主干组。运用多层螺旋CT门静脉成像及胃镜动态随访食道胃底曲张静脉的消失、复发及残存情况。分析门脉侧枝血流动力学变化和临床预后的关系。结果：1.术前食管胃曲张静脉及相关侧支血管在螺旋CT及门静脉成像中得到很好的显示。研究发现单独胃冠状静脉供血128例,胃冠状静脉合并胃短静脉13例,胃冠状静脉、胃后静脉合并胃短静脉15例,并观察到141例食管旁静脉,与PTVE术中所见相同。2.据TH胶在血管内的分布情况将研究资料分为三组：(1)食管-胃底组：TH胶持久充填在胃冠状静脉前后支、胃底贲门周围血管以及至少5cm以上的食道曲张静脉内；(2)胃底-贲门组：TH胶持久栓塞在胃冠状静脉和胃底贲门的曲张静脉内,但没有到达食管下端的曲张静脉内；(3)冠状静脉主干组：TH胶仅仅栓塞在胃冠状静脉主要分支。3.食管-胃底组：螺旋CT平扫随访显示在食管旁静脉、食管贲门及胃底周围静脉、壁内穿支静脉内的TH胶持续滞留,填充良好。胃底-贲门组：螺旋CT平扫观察显示贲门胃底周围静脉和壁内穿支静脉内的TH胶持续沉积、填充较好,未见TH胶脱失情况。冠状静脉主干组：CT平扫显示胃冠状静脉的主要分支内组织胶未见脱失、持续存在。结合CT强化显示食管-胃底组静脉曲张消失77例,残存5例,随访期内66例静脉曲张持续消失,复发11例。胃底-贲门组静脉曲张残存11例,其中无明显变化6例,随访期内20例静脉曲张持续消失,复发18例。冠状静脉主干组静脉曲张缓解3例,25例静脉曲张全部残存,无明显变化22例,随访期内曲张静脉全部复发。三组静脉曲张消失率分别为80.4%、40.8%、0%,复发率分别为13.4%、41.9%、100%。组间静脉曲张消失率、复发率存在明显差异,食管-胃底组、胃底-贲门组静脉曲张消失率明显高于冠状静脉主干组,而复发率明显低于冠状静脉主干组(P<0.01)；食管-胃底组及胃底-贲门组两者间比较消失率、复发率存在明显差异,P值分别为0.000,0.001。门静脉成像显示三组新生血管形成、曲张静脉复发率分别为10.98%、30.6%及100%(P<0.01)。4.胃镜下观察显示三组随访期内静脉曲张消失率分别为90.2%、42.9%、0,静脉曲张未复发率分别为81.7%、51.1%、0。三组总的静脉曲张消失率为56.4%(88/156),静脉曲张复发率为31.3%(41/131)。与螺旋CT下观察所见基本一致。组间静脉曲张消失及复发的Kaplan-Meier值均为p=0.000,OR值为3.824及3.603,差异有统计学意义。5.三组PTVE栓塞术后再出血率分别为8.5%、22.4%、72%(Kaplan-Meier值P=0.000,OR3.560),病死率分别为17%、30.6%及76%(Kaplan-Meier值P=0.02,OR2.822)。我们对可能影响术后再出血率及生存率的因子进行了Cox回归分析,研究结果表明,Child分级和栓塞范围是栓塞术后评估计患者再出血率及生存率的独立因子。结论：1.无创性螺旋CT扫描及成像观察食道胃底静脉曲张与胃镜相比无明显差异,能准确预测食道胃底曲张静脉的复发,对静脉曲张再发严重的病人,我们发现后都给予了胃镜下曲张静脉套扎治疗或者胃镜下硬化剂注射,这可以有效的指导临床中的治疗。2.螺旋CT扫描及门静脉成像能清晰显示术前食道胃底曲张静脉的供血侧枝循环,与PTVE术中所见相同。PTVE栓塞术后随访期内CT能清晰观察TH胶在血管内的分布范围,是评价栓塞是否彻底的有用工具。3.不同栓塞类型间临床转归存在差异,有效的栓塞可减少静脉曲张患者的复发率及死亡率。更多还原

【Abstract】 Background&aim:Esophageal varices bleeding is very commen in Liver cirrhosis portal vein high pressure; The rate of bleeding and mortality is also high. In the Consensus on prevention and treatment of EVB, It is necessary to Stop the bleeding in the first time (primary prevention)and reblooding(secondary prevention). Interventional therapy is very important in clinical treatment because of the merit of fewer traumas, less complication,rapid recuperation and high effective. Percutaneous transhepatic varicral embolization(PTVE) as a method of interventional therapy has been applied and studied deeply. Traditional PTVE can not embolize vessel well and the rate of bleeding is also high in polstoperation. Permanent Embolic agents (HE glue) is applied in reformative PTVE.It has good curative effect in preventing rebleeding and recurrence. The effect of PTVE is closely related with hemodynamics of Collateral circulation of portal system.So it is important to evaluate Collateral circulation of portal system. Traditional portal phlebography is invasive and it is limited to Stereovision. Multi slice spiral CT and Portal vein imaging as an non-invasive method has been extensive used in clinic. Multi slice spiral CT allows isotropic scanning because of quick scan and thin layer scanning. High definition imagery and3D image postprocessing are superior function. After Image reconstruction and three-dimensional reconstruction via computers,we can obtain high quality images of portal vein, clear observation of esophageal and gastric varices and communicating branch of spatial anatomical relationship of blood. So our purpose of this study is to explore the long-term curative effect and changes of gastroesophageal varices in patients with portal collateral circulation hemodynamics after PTVE application of multi-slice spiral CT portography.Methods:The subjects of this prospective study were156patients who underwent percutaneous transhepatic variceal embolization for esophageal varices.We observe PTVE before and after operation of esophageal and gastric varices and portal vein branch according multi-slice spiral CT portography.Patients were divided into three groups according to the filling range of cyanoacrylate in esophageal varices and their feeding vessels:Esophageal gastric fundus group, gastric cardia group and coronary vein group.We performed chart reviews and prospective follow-up using multi-detector row computed tomography images, angiography, and gastrointestinal endoscopy.Results:Preoperative esophageal and gastric varices and collateral vessels in spiral CT and portal imaging was been shown very well.Paraesophageal varices, esophageal gastric fundus and cardia peripheral vein and perforating vein wall in Esophageal gastric fundus group (82cases) was filled well and continued detention by TH gel according follow-up of spiral CT dynamic.BUT the gel decreased in the patients of esophageal and gastric fundus esophageal varices after the operation of reformative PTVE. Spiral CT scan showed that gastric cardia peripheral vein and perforating vein wall within the TH glue was filling good and continuous deposition in the Gastric cardia group (49cases), and no tissue was glued depigmentation. esophagus seen scattered in a small amount of tissue adhesive deposition, but TH adhesive deposition disappeared in the stomach mucosa half a year after operation.According CT scan Coronary vein group (25cases)showed that the main branch of gastric coronary vein was embolized well in TH gel.There was no loss. It showed that variceal disappearance rates in three groups of were80.4%,40.8%,0%, recurrence rates were13.4%,41.9%,100%respectively ((P<0.01) combined with enhanced-CT. Portal vein imaging shows that three groups of neovascularization, variceal recurrence rates were10.98%,30.6%and100%(P<0.01) respectively.Three groups of PTVE after embolization, rebleeding rate were8.5%,22.4%,72%respectively (Kaplan-Meier=P=0.000, OR3.560), the mortality rates were17%,30.6%and76%(Kaplan-Meier=P=0.02, OR2.822).Cox regression analysis showed the embolization area and Child grading are independent factors of rebleeding and survival rate.Conclusion:Spiral CT scanning and imaging evaluation is very useful to evaluate completeness of Embolism. It can predict the esophageal and gastric variceal recurrence accurately, and effective embolization can reduce recurrence.更多还原