In this prospective cohort, patients who were diagnosed as esophageal varices as well as complicated with liver cirrhosis and portal hypertension were enrolled during the period from January 2012 to December 2014. Of these, a total of 206 patients met the inclusion and exclusion criteria. During follow-up period, 53 individuals were ruled out. Of them, lost or less than 3-year follow-up 23, received TIPS or surgery 9, and died 21. Total 153 patients were enrolled for study. The inclusion criteria were as follows: (1) Age from 18 to 75 years old cirrhotic patients without any treatemt history for portal hypertension, including oral non-selective beta blockers, interventional radiology (such as TIPS), or surgical therapy (splenectomy and devascularization); (2) Esophageal varices were caused by liver cirrhosis with portal hypertension, (3) Esophageal varices were diagnosed by endosopy according to the guidelines , (4) The esophageal varices were individually treated by EVL, EIS, or EVL plus EIS. The following exclusion criteria were used in this study: (1) Endoscopic treatment failed to achieve eradication of esophageal varices, (2) TIPS, surgery or death were identified during the 3-year follow-up period, (3) Gastric varices (type GOV2, GOV3) or isolated gastric varices (IGV), (4) Child-Pugh score more than 14, (5) The function failures in the renal, brain, and heart, (6) Esophageal varices caused by no-cirrhotic portal hypertension.
The flexible GI endoscope (GIF-CV290, Olympus, Japan) was used for diagnosis and treatment for esophageal varices. The methods of endoscopic treatment for esophageal varices included EIS, EVL, and EVL plus EIS. 30–40 mL of 1% lauromacrogol(Xian, China) or 5% sodium morrhuate(Shanghai, China) were used for one course of EIS. The super 7 multiple band ligator (Speedband superview,Boston science, USA) was used for one course of EVL. The endoscopic therapies were carried out by the experienced chief physician. As we known, the superficial varices of the esophageal mucosa are the most important risk factors for bleeding. Therefore, the variceal eradication were defined as endoscopic normal esophageal mucosa or lesions lack a varicose appearance of the esophageal mucosa after one or more courses of endoscopic treatments (Fig. 1a-c).
Endoscopic ultrasound probe examinations(EUP)
In the course of EUP, the endoscopy used for EUP was GIF-CV290 (Olympus, Japan). A EU-ME1 Ultrasound endoscopy host with UM-3R,20-MHz catheter probe (Olympus, Japan) was also used. EUP was performed in one month after variceal eradication confirmed by endoscopy. EUP was not performed again during follow-up. The criteria for the EUP diagnosis were as follows: the multilayer structure stratification of the esophageal wall can be clearly visualized, including mucosa layer, mucosal muscle layer, submucosal layer, intrinsic muscle layer, and outer layer. The varicose veins around the esophagus aren’t connected to the intrinsic muscle layer, which is defined as para-esophageal collateral veins (para-ECVs); varicose veins is located in submucosal layer and no link with the intrinsic muscle layer, which is defined as peri-esophageal collateral veins (peri-ECVs), Penetrating the intrinsic muscle layer, The vein connects para-ECVs and submucosal vein, which is defined as perforating veins (PFV). The diameter of varicose vein was also measured. The results were recorded on EUP images, which were independently reviewed and interpreted by two senior endoscopists to reduce bias. The EUP images were shown in Fig. 2a-d.
4-phase multidetector computed tomography (CT) scan (GE HISPEED DXI; GE Company) with three-dimensional vascular reconstruction for the liver was routinely performed. The portal thrombosis, spontaneous spleno-renal shunts and portosystemic collateral veins were observed by 4-phase multidetector CT in the patients (Fig. 3a-c).
Clinical and laboratory data
Symptoms, signs, and adverse events were recorded in the medical record. Serum markers for hepatitis B and C viruses were detected by electrochemiluminescence immunoassay (Roche E170 modular immunoassay analyzer, Roche Diagnostics, Mannheim, Germany). Serum biomarkers for the liver and renal function, including serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), albumin, creatinine, and urea nitrogen, were measured on an automatic biochemical analyzer (AU5400, Olympus Company, Tokyo, Japan). Child-Pugh scores was calculated11; MELD (Model for-stage liver disease) is 3.8 × ln[TBiL(mg/dL)] + 11.2 × ln(INR) + 9.6 × ln[creatinine (mg/d1) + 6.4 × (cause of disease: biliary or alcoholic 0; other 1).
The end-points and follow-up protocol
During the follow-up period, endoscopy and clinical data were collected once every six months, while CT images were reviewed once a year. The endpoints of follow-up were recurrence of esophageal varices, or rebleeding from esophageal varices or follow-ups to 3 years, liver transplantion or TIPS, and death. The criteria of recurrence of esophageal varices were defined as moderate esophageal varices, or mild varicose vein with red sign needed to be treated by endoscopy (Fig. 1d-e). The cirrhotic etiology and complications of portal hypertension were treated following the guidelines. Non-selective beta-blockers, however, were not used during follow-up period. Observation period was defined as the time interval between the end of the endoscopic treatment and the time of the endpoint.
IBM SPSS 22 statistical software was used to statistical analysis. The quantitative data were presented as mean ± standard deviation (SD). The student t test and ANOVA for unpaired data were applied to compare differences between groups. The qualitative data were analyzed by the chi-square test or the Fisher’s exact probability test. Multivariate linear regression analysis was conducted to evaluate the correlation between multiple variables. The Kaplan–Meier estimator and log-rank test was used to analyze the survival. A P value less than 0.05 (two-way) was considered statistically significant.