Prevention for rebleeding of esophageal varices under the guidance of hepatic venous pressure gradient

Abstract

Objective Hepatic venous pressure gradient(HVPG)is an important indicator for the evaluation and prognosis of liver cirrhosis.This study explores the value of different procedures according to HVPG for reducing the rate of rebleeding in cirrhotic patients with esophageal varices. Methods A total of 270 cirrhotic patients with esophageal varices who had a history of variceal bleeding and HVPG performance from April 2010 to October 2019 were enrolled.Among them, 130 patients(HVPG guided group)underwent individualized treatment according to HVPG value: patients with 10 mmHg≤HVPG≤16 mmHg accepted endoscopic esophageal variceal ligation(EVL)combined with non-selectiveβreceptor blocker(NSBB)treatment; patients with 16 mmHg 20 mmHg, transjugular intrahepatic portosystemic shunt(TIPS)was used.Another 140 patients(non-HVPG guided group)were treated with EVL plus NSBB.The primary end point was rebleeding associated with portal hypertension, and the secondary end point was death. Results The median follow-up time was 26 months.The rate of rebleeding in the HVPG guided group was lower than that in the non-HVPG guided group(12.31% vs.30.00%, P=0.000 88), but there was no significant difference in survival between the two groups(93.08% vs.91.43%, P=0.71). Further subgroup analysis showed that for patients with 16 mmHg 20 mmHg, the rebleeding rate of patients with TIPS was lower than that of patients with EVL+ NSBB(6.12% vs.36.36%, P=0.000 88), but there was no significant difference in survival between the two groups. Conclusion Individualized therapy based on HVPG has important theoretical and clinical significance.According to the risk stratification of HVPG, individualized choice of secondary prevention of esophageal variceal bleeding(EVL+ NSBB, PTVE or TIPS)can reduce the risk of rebleeding, which is worthy of further clinical research for individualized therapy of cirrhotic patients. Key words: Liver cirrhosis; Individualized treatment; Hepatic vein pressure gradient; Percutaneous transhepatic variceal embolization; Transjugular intrahepatic portosystemic shunt