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内镜下静脉曲张套扎术

Author
John S Goff, MD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Anne C Travis, MD, MSc, FACG, AGAF
Translators
高建, 主任医师，教授

引言

为了找到一种能在内镜下治疗食管静脉曲张，且并发症少于内镜下硬化疗法(endoscopic sclerotherapy, ES)的有效方法，人们研发出了内镜下静脉曲张套扎术(endoscopic variceal ligation, EVL)[1-4]。这个概念来源于对有或没有门静脉高压症的患者采用胶圈套扎治疗痔的多年经验。EVL的原理是通过结扎所有或部分曲张静脉，从而使血栓形成引起静脉闭塞。这些组织会在随后的数日到数周内坏死并脱落，留下一个能迅速愈合的浅表黏膜溃疡。EVL可避免使用组织硬化剂，从而避免ES后发生的食管壁深层损伤。贲门附近的侧支血管在EVL后会减少，而EVL可能促进胃深部侧支血管的生长。这些因素也可能参与EVL防止进一步静脉曲张破裂出血的效果[5,6]。另一个有趣的发现是，急性静脉曲张破裂出血期间，肝静脉压力梯度(与静脉曲张破裂出血的风险相关)在ES后增加，但在EVL后不增加[7]。

1986年报道了首例接受EVL治疗的患者。从那以后，技术进展使得EVL已常规用于治疗食管静脉曲张患者。最大的进步之一是研发了多环套扎器(Saeed Six-Shooter和Speedbander)，其简化了EVL并提高了EVL的安全性。

本文将总结EVL的相关技术和支持其有效性的资料。EVL在静脉曲张患者治疗中的作用将单独讨论。 (参见“急性静脉曲张出血患者实现止血的方法”和“肝硬化患者复发性静脉曲张出血的预防”)

技术

内镜下静脉曲张套扎装置被置于标准内镜的顶端。该装置有一个安装在内镜顶端的软罩，以及一个坚硬的塑料部分。橡皮圈被拉伸跨过装置远端的硬质部分，用于随后套扎曲张的静脉。目前可用的装置是针对标准内镜和治疗用内镜的尺寸而设计的。

开始该手术前，先进行一次彻底的上消化道内镜检查以确定需治疗的食管静脉曲张部位。有活动性出血或近期出血迹象(如，纤维蛋白栓子或“红色鞭痕”征)的静脉曲张都应被作为主要目标，即使其并不位于胃食管连接处(图片 1A-B)。EVL的进行不会受到凝血参数的绝对限制，然而，在活动性出血的患者中，应尝试改善凝血状态[8]。

                       

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Literature review current through: 2017-06 . | This topic last updated: 2015-11-20.
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