门静脉高压症上消化道出血不同指南诊治共识外科部分的比较分析
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摘要
目的门静脉高压症不同诊治指南外科手术部分论述有许多不同,比较其中的差异并分析原因。方法通过检索找出7篇公认度高的指南:BavenoⅥ共识、美国肝病协会指导(AASLD)、英国指南(UK)、奥地利指南(Austrain)、巴西共识(Brazil)、我国肝病指南和我国外科指南。精读筛选出外科手术部分论述,追溯参与制订专家及相关参考文献进行对比分析。另外对Baveno不同版本共识进行对比分析。结果不同指南中参与外科专业人员:AASLD、奥地利、巴西、我国肝病指南各1名;参考外科文献比例:BavenoⅥ、美国、奥地利、巴西、我国肝病指南及我国外科指南分别为0、1. 4%、5. 7%、3. 2%、6. 1%、6. 7%、25. 0%。Baveno出血共识中外科部分论述,第Ⅰ、Ⅱ版提及分流、断流术是内镜治疗失败后合适的手段,第Ⅲ、Ⅳ、Ⅴ版为仅推荐分流术,第Ⅵ版非肝外血管病变部分外科内容消失。结论药物、内镜、TIPS的快速发展、参与指南制订的外科专家较少,忽略引用外科手术相关的文献,是权威指南缺失外科声音的原因。英国指南具有一定程度的包容性和客观性。医生是指南最终的决策者。
Objective There are many differences in the surgical contents of guidelines or consensuses for upper gastrointestinal bleeding in patients with portal hypertension. Comparing and analyzing the causes can promote understanding and recognizing. Methods Seven high-profile guidelines were selected by searching: Baveno Ⅵ consensus,AASLD guidance,UK guideline,Austrian consensus,Brazil consensus,Chinese guideline from Liver Diseases/Digestive Disease/Endoscopy Branch of Medical Association( abbr. Chinese hepatopathy guideline) and Chinese surgery guidelines from Portal Hypertension Group of Surgery Branch,Medical Association( abbr. Chinese surgery guideline). Surgery parts in contents were selected to analyze by comparing the participants and tracing the relevant references after intensive reading the documents. Besides,different editions of Baveno consensus were compared and analyzed. Results In different guidelines: AASLD,Austrian,Brazil and Chinese hepatopathy guideline enrolled 1 surgery professionals respectively; The ratio of referenced surgery articles in Baveno VI,AASLD,Austrian,Brazil,Chinese hepatopathy guideline and Chinese surgery guideline,is 0,1. 4% 、5. 7% 、3. 2% 、6. 1% 、6. 7% 、25. 0%,respectively. The surgery parts of the Baveno consensus,showed that shunts and devascularizations are the appropriate means when endoscopic therapy failed on hemostatic treatment in Ⅰ,Ⅱ edition,only shunts are recommended in Ⅲ,Ⅳ,Ⅴ edition,and none surgery approaches recommended except extrahepatic vessel disease in Ⅵ edition. Conclusion The rapid progress of drugs,the advanced skills of endoscopy and Transjugular intrahepatic portosystemic shunt( abbr. TIPS),the lack of surgery professionals involved,and the lack of citing surgery articles,were one of the reasons for lacking voices of surgery in leading guidelines. The UK Guideline is relatively comprehensive and objective. Doctors is the final decision-maker on the application to practice of guidelines and consensuses.
Objective There are many differences in the surgical contents of guidelines or consensuses for upper gastrointestinal bleeding in patients with portal hypertension. Comparing and analyzing the causes can promote understanding and recognizing. Methods Seven high-profile guidelines were selected by searching: Baveno Ⅵ consensus,AASLD guidance,UK guideline,Austrian consensus,Brazil consensus,Chinese guideline from Liver Diseases/Digestive Disease/Endoscopy Branch of Medical Association( abbr. Chinese hepatopathy guideline) and Chinese surgery guidelines from Portal Hypertension Group of Surgery Branch,Medical Association( abbr. Chinese surgery guideline). Surgery parts in contents were selected to analyze by comparing the participants and tracing the relevant references after intensive reading the documents. Besides,different editions of Baveno consensus were compared and analyzed. Results In different guidelines: AASLD,Austrian,Brazil and Chinese hepatopathy guideline enrolled 1 surgery professionals respectively; The ratio of referenced surgery articles in Baveno VI,AASLD,Austrian,Brazil,Chinese hepatopathy guideline and Chinese surgery guideline,is 0,1. 4% 、5. 7% 、3. 2% 、6. 1% 、6. 7% 、25. 0%,respectively. The surgery parts of the Baveno consensus,showed that shunts and devascularizations are the appropriate means when endoscopic therapy failed on hemostatic treatment in Ⅰ,Ⅱ edition,only shunts are recommended in Ⅲ,Ⅳ,Ⅴ edition,and none surgery approaches recommended except extrahepatic vessel disease in Ⅵ edition. Conclusion The rapid progress of drugs,the advanced skills of endoscopy and Transjugular intrahepatic portosystemic shunt( abbr. TIPS),the lack of surgery professionals involved,and the lack of citing surgery articles,were one of the reasons for lacking voices of surgery in leading guidelines. The UK Guideline is relatively comprehensive and objective. Doctors is the final decision-maker on the application to practice of guidelines and consensuses.
引文
[1]de Franchis R,Baveno VI Faculty.Expanding consensus in portal hypertension Report of the Baveno VI Consensus Workshop:Stratifying risk and individualizing care for portal hypertension[J].J Hepatol,2015,63(3):743-752.
[2]Garcia-Tsao G,Abraldes JG,Berzigotti A,et al.Portal hypertensive bleeding in cirrhosis:Risk stratification,diagnosis,and management:2016 practice guidance by the American Association for the study of liver diseases[J].Hepatology,2017,65(1):310-335.
[3]Jalan R,Hayes PC.UK guidelines on the management of variceal haemorrhage in cirrhotic patients[J].Gut,2000,46 Suppl 3-4:III1-III15.
[4]Thomas Reiberger,Andreas Puspok,Maria Schoder.et al.Austrian consensus guidelines on the management and treatment of portal hypertension(BillrothⅢ)[J].Wien Klin Wochenschr,2017,129(Suppl 3):135-158.
[5]Bittencourt PL,Strauss E,Farias AQ,et al.Variceal bleeding:update of recommendations from the Brazilian Association of Hepatology[J].Arq Gastroenterol,2017,54(4):349-355.
[6]中华医学会肝病学分会,中华医学会消化病学分会,中华医学会内镜学分会.肝硬化门静脉高压食管胃静脉曲张出血的防治指南[J].临床肝胆病杂志,2016,32(2):203-219.
[7]中华医学会外科学分会门静脉高压症学组.肝硬化门静脉高压症食管、胃底静脉曲张破裂出血诊治专家共识(2015)[J].中国实用外科杂志,2015,35(10):1086-1090.
[8]Orozco H,Mercado MA.The evolution of portal hypertension surgery:lessons from 1000 operations and 50 years’experience[J].Arch Surg,2000,135(12):1389-1393.
[9]Orloff MJ,Isenberg JI,Wheeler HO,et al.Liver transplantation in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis[J].Transplant Proc,2010,42(10):4101-4108.
[10]Khan S,Tudur SC,Williamson P,et al.Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis[J].Cochrane Database Syst Rev,2006,(4):CD000553.
[11]Inokuchi K.Improved survival after prophylactic portal nondecompression surgery for esophageal varices:a randomized clinical trial.Cooperative Study Group of Portal Hypertension of Japan[J].Hepatology,1990,12(1):1-6.
[12]Riemenschneider T,Bermel RE,Hirner A.Results of devascularization surgery of the gastroesophageal junction in recurrent hemorrhage of esophageal and fundus varices[J].Zentralbl Chir,1994,119(5):291-297.
[13]Zhou J,Wu Z,Wu J,et al.Transjugular intrahepatic portosystemic shunt(TIPS)versus laparoscopic splenectomy(LS)plus preoperative endoscopic varices ligation(EVL)in the treatment of recurrent variceal bleeding[J].Surg Endosc,2013,27(8):2712-2720.
[14]Orloff MJ,Hye RJ,Wheeler HO,et al.Randomized trials of endoscopic therapy and transjugular intrahepatic porto systemic shunt versus portacaval shunt for emergency and elective treatment of bleeding gastric varices in cirrhosis[J].Surgery,2015,157(6):1028-1045.
[15]Bruix J,Castells A,Bosch J,et al.Surgical resection of hepatocellular carcinoma in cirrhotic patients.Prognostic value of preoperative portal pressure[J].Gastroenterology,1996,111(4):1018-1022.
[16]D’Amico G,Pagliaro L,Bosch J.The treatment of portal hypertension:a Meta-analytic review[J].Hepatology,1995,22(1):332-354.
[17]Fuccio L,Mussetto A,Laterza L,et al.Diagnosis and management of gastric antral vascular ectasia[J].World J Gastrointest Endosc,2013,5(1):6-13.
[18]Costa Lacet CM,Neto JB,Ribeiro LT,et al.Schistosomal portal hypertension:Randomized trial comparing endoscopic therapy alone or preceded by esophagogastric devascularization and splenectomy[J].Ann Hepatol,2016,15(5):738-744.
[19]de Franchis R,Pascal JP,Ancona E,et al.Definitions,methodology and therapeutic strategies in portal hypertension.A consensus development workshop[J].J Hepatol,1992,15(1-2):256-261.
[20]de Franchis R.Developing consensus in portal hypertension[J].JHepatol,1996,25(1-2):390-394.
[21]de Franchis R.Updating consensus in portal hypertension:report of the Baveno III consensus workshop on definitions,methodology and therapeutic strategies in portal hypertension[J].J Hepatol,2000,33(5):846-852.
[22]de Franchis R.Evolving consensus in portal hypertension.Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension[J].J Hepatol,2005,43(1):167-176.
[23]de Franchis R,Baveno V Faculty.Revising consensus in portal hypertension:report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension[J].J Hepatol,2010,53(4):762-768.
[24]李志伟,张培瑞,张绍庚.门静脉高压症断流术的争议[J].中华消化外科杂志,2013,12(11):823-826.
[25]宋思凯,丛鹏,吐尔洪江·吐逊.腹腔镜与开腹脾切除联合贲门血管阻断治疗门脉高压症的Meta分析[J].中华肝胆外科杂志,2016,22(3):172-175.
[26]孙勇伟,吴志勇,陈治平,等.肝硬化门静脉高压脾切除后免疫功能状况[J].中华肝胆外科杂志,2000,6(5):344-345.
[27]Bolognesi M,Merkel C,Sacerdoti D,et al.Role of spleen enlargement in cirrhosis with portal hypertension[J].Dig Liver Dis,2002,34(2):144-150.
[28]Pocock SJ,Stone GW.The Primary Outcome Is Positive-Is That Good Enough[J]?N Engl J Med,375(10):971-979.
[2]Garcia-Tsao G,Abraldes JG,Berzigotti A,et al.Portal hypertensive bleeding in cirrhosis:Risk stratification,diagnosis,and management:2016 practice guidance by the American Association for the study of liver diseases[J].Hepatology,2017,65(1):310-335.
[3]Jalan R,Hayes PC.UK guidelines on the management of variceal haemorrhage in cirrhotic patients[J].Gut,2000,46 Suppl 3-4:III1-III15.
[4]Thomas Reiberger,Andreas Puspok,Maria Schoder.et al.Austrian consensus guidelines on the management and treatment of portal hypertension(BillrothⅢ)[J].Wien Klin Wochenschr,2017,129(Suppl 3):135-158.
[5]Bittencourt PL,Strauss E,Farias AQ,et al.Variceal bleeding:update of recommendations from the Brazilian Association of Hepatology[J].Arq Gastroenterol,2017,54(4):349-355.
[6]中华医学会肝病学分会,中华医学会消化病学分会,中华医学会内镜学分会.肝硬化门静脉高压食管胃静脉曲张出血的防治指南[J].临床肝胆病杂志,2016,32(2):203-219.
[7]中华医学会外科学分会门静脉高压症学组.肝硬化门静脉高压症食管、胃底静脉曲张破裂出血诊治专家共识(2015)[J].中国实用外科杂志,2015,35(10):1086-1090.
[8]Orozco H,Mercado MA.The evolution of portal hypertension surgery:lessons from 1000 operations and 50 years’experience[J].Arch Surg,2000,135(12):1389-1393.
[9]Orloff MJ,Isenberg JI,Wheeler HO,et al.Liver transplantation in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis[J].Transplant Proc,2010,42(10):4101-4108.
[10]Khan S,Tudur SC,Williamson P,et al.Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis[J].Cochrane Database Syst Rev,2006,(4):CD000553.
[11]Inokuchi K.Improved survival after prophylactic portal nondecompression surgery for esophageal varices:a randomized clinical trial.Cooperative Study Group of Portal Hypertension of Japan[J].Hepatology,1990,12(1):1-6.
[12]Riemenschneider T,Bermel RE,Hirner A.Results of devascularization surgery of the gastroesophageal junction in recurrent hemorrhage of esophageal and fundus varices[J].Zentralbl Chir,1994,119(5):291-297.
[13]Zhou J,Wu Z,Wu J,et al.Transjugular intrahepatic portosystemic shunt(TIPS)versus laparoscopic splenectomy(LS)plus preoperative endoscopic varices ligation(EVL)in the treatment of recurrent variceal bleeding[J].Surg Endosc,2013,27(8):2712-2720.
[14]Orloff MJ,Hye RJ,Wheeler HO,et al.Randomized trials of endoscopic therapy and transjugular intrahepatic porto systemic shunt versus portacaval shunt for emergency and elective treatment of bleeding gastric varices in cirrhosis[J].Surgery,2015,157(6):1028-1045.
[15]Bruix J,Castells A,Bosch J,et al.Surgical resection of hepatocellular carcinoma in cirrhotic patients.Prognostic value of preoperative portal pressure[J].Gastroenterology,1996,111(4):1018-1022.
[16]D’Amico G,Pagliaro L,Bosch J.The treatment of portal hypertension:a Meta-analytic review[J].Hepatology,1995,22(1):332-354.
[17]Fuccio L,Mussetto A,Laterza L,et al.Diagnosis and management of gastric antral vascular ectasia[J].World J Gastrointest Endosc,2013,5(1):6-13.
[18]Costa Lacet CM,Neto JB,Ribeiro LT,et al.Schistosomal portal hypertension:Randomized trial comparing endoscopic therapy alone or preceded by esophagogastric devascularization and splenectomy[J].Ann Hepatol,2016,15(5):738-744.
[19]de Franchis R,Pascal JP,Ancona E,et al.Definitions,methodology and therapeutic strategies in portal hypertension.A consensus development workshop[J].J Hepatol,1992,15(1-2):256-261.
[20]de Franchis R.Developing consensus in portal hypertension[J].JHepatol,1996,25(1-2):390-394.
[21]de Franchis R.Updating consensus in portal hypertension:report of the Baveno III consensus workshop on definitions,methodology and therapeutic strategies in portal hypertension[J].J Hepatol,2000,33(5):846-852.
[22]de Franchis R.Evolving consensus in portal hypertension.Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension[J].J Hepatol,2005,43(1):167-176.
[23]de Franchis R,Baveno V Faculty.Revising consensus in portal hypertension:report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension[J].J Hepatol,2010,53(4):762-768.
[24]李志伟,张培瑞,张绍庚.门静脉高压症断流术的争议[J].中华消化外科杂志,2013,12(11):823-826.
[25]宋思凯,丛鹏,吐尔洪江·吐逊.腹腔镜与开腹脾切除联合贲门血管阻断治疗门脉高压症的Meta分析[J].中华肝胆外科杂志,2016,22(3):172-175.
[26]孙勇伟,吴志勇,陈治平,等.肝硬化门静脉高压脾切除后免疫功能状况[J].中华肝胆外科杂志,2000,6(5):344-345.
[27]Bolognesi M,Merkel C,Sacerdoti D,et al.Role of spleen enlargement in cirrhosis with portal hypertension[J].Dig Liver Dis,2002,34(2):144-150.
[28]Pocock SJ,Stone GW.The Primary Outcome Is Positive-Is That Good Enough[J]?N Engl J Med,375(10):971-979.