In the last 20 years, there have been significant advances in the management of esophageal variceal bleeding in portal hypertension, including resuscitation techniques, pharmacotherapy, endoscopic ligation and sclerosis, transjugular intrahepatic portosystemic shunts and advances in liver transplantation, resulting in a 20-30% reduction in in-hospital mortality in patients with esophageal variceal bleeding in cirrhosis. Endoscopic variceal ligation (EVL) is a revolutionary change in the treatment of esophageal variceal bleeding in portal hypertension and has been widely used in clinical practice. I. Endoscopic ligation is the first-line treatment for variceal bleeding and prevention of rebleeding Since 1991, we have performed endoscopic ligation on 1253 patients with esophagogastric varices in portal hypertension in cirrhosis, including 302 cases with emergency ligation, and the rate of emergency hemostasis reached 92.7%, and the rate of occlusion of varices reached 91% with multiple consecutive ligations. Not only the acute bleeding state was terminated as soon as possible, but also the recurrence rate of recent bleeding was greatly reduced. After more than 10 years of clinical practice, the endoscopic ligation-based therapy for rescuing esophageal variceal haemorrhage is more mature and perfect, which is mainly manifested as follows: 1. The resuscitation time after bleeding is shortening, and the time for emergency gastroscopy and ligation is shortened from 24 hours to 4-6 hours after admission, and the bleeding state is aborted and recent rebleeding is prevented due to decisive and effective hemostatic measures. 2.For patients in serious danger, more bedside ligatures are carried out, and ligatures after prophylactic tracheal tube placement in the operating room under anesthesia have improved the level of resuscitation. We believe that prophylactic tracheal tube placement should be carried out in the following cases: severe and persistent variceal bleeding, combined with hepatic encephalopathy, oxygen saturation below 90%, and existing aspiration pneumonia. 3.About 20% of patients with upper gastrointestinal hemorrhage in cirrhosis have bacterial infection within 48 hours after admission, and its incidence increases to 35-66% within two weeks. Infection is a major cause of death, and routine prophylactic application of antibiotics significantly reduces the incidence of bacteremia and spontaneous bacterial peritonitis. 4, for patients whose bleeding has stopped should be promptly endoscopic ligation to prevent near-term and long-term re-bleeding. Generally, each case should be ligated 3-4 times consecutively and ligated 38-40 points to achieve varicose vein occlusion, which should be reviewed 3, 6, months after discharge, and then once a year. If new varicose veins are found, they should be treated again so that the patient can keep the varicose veins in an occluded state. 5.The combination of ligature and drug to reduce portal pressure was gradually introduced. 1990 the use rate of Octerotide was 10%, in 2000 it was 54%, after using the drug the recent recurrence bleeding rate was greatly reduced if the ligature was performed but the varicose vein was not completely occluded. Due to the continuous maturation and improvement of the technique, the use of balloon tamponade has decreased from 18% to 8% since 1990-2000, the rate of emergency surgery has decreased from 25% to 3%, the rate of early rebleeding has decreased from 54% to 3%, and the rate of in-hospital mortality has decreased from 35% to 13%. 1253 recurrent bleeding cases 15.6% and 5.6% recurrent bleeding after variceal occlusion, thanks to the long-term Follow-up review kept the patient’s variceal vein occluded for a long time. For cirrhotic patients with poor liver reserve function long-term endoscopic ligation is a bridge to liver transplantation. Endoscopic ligation is an important measure to prevent first bleeding The annual incidence of esophageal variceal bleeding in cirrhotic patients is about 5%, which increases to 15% in patients with existing varices, and can even reach 30% in patients with severe varices. The mortality rate of first variceal bleeding is 50% and the mortality rate of subsequent hospitalization for recurrent bleeding is 30%, so the best way to reduce the mortality rate of variceal bleeding is to prevent the first bleeding (primary prophylaxis). What kind of cirrhotic patients should be treated with primary prophylaxis? The first step in whether a patient with cirrhosis should be treated for primary prophylaxis is gastroscopy to determine the presence or absence of varices. 1.When should a patient with cirrhosis undergo gastroscopy? ① All patients diagnosed with cirrhosis should undergo gastroscopy promptly. ②Patients whose first gastroscopy did not find varicose veins should have a repeat gastroscopy at an interval of three years. ③If small varices are found in the first gastroscopy, gastroscopy should be performed once a year. 2.What kind of cirrhotic patients should have the first bleeding prevention? ①Patients with severe varices and erythema sign, especially if the ratio of erythema sign area (erythema sign area/ variceal area) ≥ (19.91±5.3%). The larger the ratio of erythema sign, the more extensive the damage to the variceal wall and the greater the possibility of bleeding. ②Hepatic venous pressure gradient HVPG >12 mmHg, there is variceal hemorrhage and ascites. Since this test is invasive, it is not routinely performed in many hospitals. In recent years, it has been found that esophageal variceal pressure plays an important role in the pathology of variceal hemorrhage and its value is positively correlated with HVPG, which is an independent predictor of hemorrhage, as long as it is measured transmurally against the variceal vessel wall during gastroscopy. When esophageal variceal pressure is >15.2 mmHg, the likelihood of bleeding is 78% and should be intervened earlier (7,8). (iii) If a moderate esophageal variceal is diagnosed and liver function is child grade C, prophylactic treatment should be performed. (iv) Gastric varices should be treated prophylactically with or without accompanying esophageal varices. Although propranlol is the best prophylactic treatment, nearly 15% of patients have a counter indication for beta blockers, such as asthma, insulin-dependent diabetic patients, and a further 15% are unable to adhere to clinical dosing. For these patients, the best option is endoscopic ligation therapy. Endoscopic ligature therapy with a controlled study of insulin has not only reduced the rate of first bleeding, but also has several significant advantages: ① no counter-indications for endoscopic therapy; ② short treatment time, easy for patients to accept; ③ no need for indefinite oral medication. It has become an important measure to prevent the first bleeding. Endoscopic ligation has a new idea for the treatment of gastric varices. 20% of patients with portal hypertension have gastric varices. Once ruptured, gastric varices may be a fatal complication of portal hypertension. According to a prospective study of 568 cirrhotic patients, GoV1 (Gastroesophageal varices) was the common type, accounting for 74%; GoV2, IGV1 (Isolated gastric varices) and IGV2 accounted for 16%, 8% and 2%, respectively. The risk of two-year bleeding from gastric varices is 25%, and the fundic varices are independent with unique pathological features, and the incidence of bleeding is up to 78%, and once the gastric varices rupture, it is very difficult to deal with them, and although there are several options for endoscopic treatment, none of them are widely used. Some people abroad have ligated gastric variceal bleeding only when the diameter of the gastric variceal vein is not greater than the diameter of the ligature sleeve and have argued that attempting to ligate a large diameter variceal vein will result in devastating bleeding. Gastric variceal rupture has been considered a contraindication to endoscopic treatment in this country. Longitudinal or cross-sectional studies have confirmed that a decrease in the hepatic venous pressure gradient HVPG to less than 12 mmHg or 20% from baseline is the currently accepted goal for satisfactory treatment of portal hypertension, and that achieving this goal greatly reduces the risk of ascites, idiopathic bacterial peritonitis, hepatorenal syndrome, and even mortality . This provides a theoretical basis for the development of new drugs to reduce portal pressure with the help of visceral vasoconstrictors such as vasopressin and its derivative growth inhibitor and its analogue growth hormone releasing inhibitor (Somatostatin), which are widely used in clinical practice, whereas endoscopic treatment with elastic rubber band ligation of varicose veins does not reduce portal pressure, and therefore Therefore, the combination of endoscopy and drugs to reduce portal pressure greatly improves the efficacy and proposes a new idea for the treatment of ruptured gastric variceal bleeding. From 2003 to 2005, we used a combination of drugs and ligation to treat ruptured gastric variceal bleeding, specifically: 50ug of growth inhibitor and its analogue Octreotide were given intravenously rapidly after admission, followed by 50ug/h, given intravenously for 3 to 5 d. Endoscopic ligation was performed 4 to 5 h after the administration, usually 4 to 6 points at a time. A total of 29 cases were treated, including 10 cases of GoV1, 4 cases of GoV2, and 15 cases of IGVI, with 100% hemostasis and 89% reduction or occlusion of varicose veins, followed for 1 year. In one case, the bleeding recurred after one month, and the bleeding was stopped by ligation of the gastric varicose vein; in one case, the patient requested surgery 15 d after hemostasis, and a peanut-millet-sized moderately hard node could be found at the bottom of the stomach intraoperatively, and the varicose vein about 0.7 cm thick on the side of the greater curvature was ligated, and a black thrombus was seen in all the vessels, and a small amount of thrombus came out from the ligated end by squeezing the hard node in the stomach, indicating that most of the gastric varicose vein was embolized and hemostasis was stopped after ligation. . The regression of gastric variceal vein ligation treatment is different from esophageal variceal vein. 1, the trauma healing period of gastric variceal vein ligation is longer than that of esophageal vein, generally it should be extended to 3 weeks before the second ligation, otherwise either the ligature ring is not dislodged or the trauma in the stomach is not healed, so it is difficult to repeat the ligation. 2, ligation technology to overcome the “blind spot”, operation amplitude than esophageal varices, therefore, if allowed, generally to be combined with painless gastroscopy as the best. However, the number of cases is small, the observation time is short, and a large number of long-term studies are needed. The use of a-cyanoacrylate alkyl (a-cyanoacrylate alkyl) injection for the treatment of gastric varices is emerging in China, and its recent efficacy is still good, and its long-term efficacy and complications are under close observation. Fourth, there is a new method for the treatment of variceal vein recurrence after endoscopic ligation After variceal eradication, some regenerative small veins gradually appear in the esophagus, which are the root cause of rebleeding and the key to prevent rebleeding; another reason is the residual variceal vein recanalization. Therefore, there are three goals in principle to prevent recurrent bleeding: ①prevent the re-formation of varices; ②prevent the development of small varices to large varices; ③prevent the rupture and bleeding of large varices. For large varicose veins elective repeat treatment can be taken to make them re-root, but there is no more approach for the first two. Because after repeated ligation, local scarring is evident and re-suction ligation is difficult, and because of the continued development of cirrhosis and further elevation of portal vein pressure, residual varices will refill, re enlarge, thin the walls, and the risk of rebleeding will greatly increase, for this reason, we envision the use of laser light energy to mechanize small vessels. We first produced a canine model of portal hypertension by ligating the inferior vena cava and performing a lateral portal vena cava anastomosis below the ligation, then ligating the portal vein in stages, with 100% incidence of esophageal varices after 6 to 8 weeks. After the mold was formed, 5-6 ml of iudo cyanine green ICG was injected into the lower 5 cm of the esophagus under gastroscopy, and then connected to quartz fiber with a power of 10 W. The quartz fiber was irradiated through the biopsy hole to the injected ICG site until it became white and degenerate locally. It was confirmed that after laser irradiation of esophageal mucosa, small vessels were extensively mechanized and the treatment process was safe. 184 patients were treated and found that: 1, the esophageal mucosa was fibrotic as an island-like fibrotic plaque after ligature treatment. 2, After laser irradiation, the mucosa and surrounding small blood vessels were directly destroyed, the local vessel wall was damaged, internal thrombosis was formed, and the vessels were occluded. 3.Two weeks after the treatment, the residual varicose veins completely disappeared, which greatly improved the efficacy of EVL. 4.After laser treatment, the local nerve endings are destroyed due to the thermal effect, so there is no pain and no fever after the operation, and the diet recovers quickly. EVL+laser treatment for esophageal varicose veins will have a good future in terms of preventing varicose vein recurrence. V. Endoscopic ligation with traditional surgery can improve the efficacy In about 8-10% of patients, ligation treatment cannot control acute variceal bleeding or prevent early recurrent variceal bleeding effectively, according to our experience, early surgical treatment should be performed in one of the following cases 1.After more than two times of ligation treatment, the acute variceal bleeding still cannot be controlled. 2.Gastric variceal bleeding cannot be controlled by ligation treatment. 3.Gastric bleeding from portal hypertension that cannot be controlled by non-surgical treatment. 4.Recurrent hemorrhage in variceal vein within a short period of time by endoscopic treatment, which cannot be controlled by endoscopic ligation. For patients who fail endoscopy, TIPSS (Transjugular intrahepatic portosystemic shunt), the preferred option in China is peripancreatic vascular dissection, which effectively blocks the portal shunt and reduces the bleeding rate of variceal vein. However, it has been found clinically that peripancreatic vascular dissection also has some recurrent bleeding in the near and distant future. We have conducted a prospective study on 115 patients, randomly divided into three groups according to the treatment, namely 54 patients in the endoscopic ligation group, 30 patients in the peripancreatic vascular dissection group, and 31 patients in the peripancreatic vascular dissection + endoscopic ligation group, using microprobe ultrasound to examine the condition of the venous structures in the lower esophagus. Color Doppler ultrasound was used to check the hemodynamic indices of the odd vein, and a comparative study was performed before and after the surgery. After treatment, the submucosal varices disappeared in the ligature group and the periesophageal veins still existed, the varices in the lumen of the esophagus were reduced and the periesophageal plexus disappeared in the dissection group, and both the submucosal and periesophageal plexus disappeared in the combined group, and the blood flow in the odd vein decreased by 31%, 32% and 43% in the three groups, respectively. It indicates that the combined intraluminal and extraluminal dissection of peripancreatic vascular dissection + endoscopic ligation can block the portal odd shunt better than the single treatment method (10). This approach is simple, easily accepted by patients, and does not cause intolerable complications, and also indicates that the best choice for recurrent bleeding in the near and distant future after perivascular dissection of the cardia is endoscopic ligation.