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Singh J, Ebaid M, Saab S. Advances in the management of complications from cirrhosis. Gastroenterol Rep (Oxf) 2024; 12:goae072. [PMID: 39104730 PMCID: PMC11299547 DOI: 10.1093/gastro/goae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/29/2024] [Accepted: 06/15/2024] [Indexed: 08/07/2024] Open
Abstract
Cirrhosis with complications of liver decompensation and hepatocellular carcinoma (HCC) constitute a leading cause of morbidity and mortality worldwide. Portal hypertension is central to the progression of liver disease and decompensation. The most recent Baveno VII guidance included revision of the nomenclature for chronic liver disease, termed compensated advanced chronic liver disease, and leveraged the use of liver stiffness measurement to categorize the degree of portal hypertension. Additionally, non-selective beta blockers, especially carvedilol, can improve portal hypertension and may even have a survival benefit. Procedural techniques with interventional radiology have become more advanced in the management of refractory ascites and variceal bleeding, leading to improved prognosis in patients with decompensated liver disease. While lactulose and rifaximin are the preferred treatments for hepatic encephalopathy, many alternative treatment options may be used in refractory cases and even procedural interventions such as shunt embolization may be of benefit. The approval of terlipressin for the treatment of hepatorenal syndrome (HRS) in the USA has improved the way in which HRS is managed and will be discussed in detail. Malnutrition, frailty, and sarcopenia lead to poorer outcomes in patients with decompensated liver disease and should be addressed in this patient population. Palliative care interventions can lead to improved quality of life and clinical outcomes. Lastly, the investigation of systemic therapies, in particular immunotherapy, has revolutionized the management of HCC. These topics will be discussed in detail in this review.
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Affiliation(s)
- Jasleen Singh
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Mark Ebaid
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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2
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Huang X, Zou D, Wang H, Chen W, Zhang L, Li F, Ma L, Zhang C, Chen Y, Chen S. Gastric variceal obstruction improves the efficacy of endoscopic management of esophageal variceal bleeding in GOV type I. Endosc Int Open 2024; 12:E940-E946. [PMID: 39131733 PMCID: PMC11309793 DOI: 10.1055/a-2360-4490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/27/2024] [Indexed: 08/13/2024] Open
Abstract
Background and study aims Limited data exist regarding endoscopic obstruction of type I gastroesophageal (GOV I) in managing bleeding from esophageal varices. In this multicenter retrospective cohort study, we aimed to access the efficacy of blocking gastric varices in management of bleeding from esophageal varices in patients with GOV1. Patients and methods Cirrhotic patients experiencing bleeding from esophageal varices and having GOV I gastric varices in four centers were screened. All included patients were followed up for 180 days, or until death. Results A total of 93 cirrhotic patients with GOV I and bleeding esophageal varices were included. Among them, 58 patients underwent endoscopic cyanoacrylate injection (ECI) for gastric varices in addition to treatment for esophageal varices (EV), while the remaining 35 patients received treatment for EV only. Kaplan-Meier analysis demonstrated that the cumulative 180-day rebleeding rate was significantly lower in the ECI plus EV treatment group (7.9%) compared with the EV treatment group (30.7%) ( P = 0.0031). The cumulative incidence of 180-day mortality was 1.9% in the ECI plus EV treatment group and 23.9% in the EV treatment group ( P = 0.0010). Multivariable Cox regression analysis revealed that concomitant ECI treatment was an independent protective factor against 180-day rebleeding and overall mortality. Conclusions In conclusion, obstruction of gastric varices in addition to endoscopic treatment for bleeding from esophageal varices in patients with GOV 1 proved superior to endoscopic treatment alone for esophageal variceal bleeding.
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Affiliation(s)
- Xiaoquan Huang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R.China
- Center of Evidence-Based Medicine, Fudan University,
| | - Detong Zou
- Department of Gastroenterology, Xinghua Renming Hospital, Jiangsu, P.R. China
| | - Huishan Wang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R.China
| | - Wei Chen
- Department of Gastroenterology and Hepatology, Minhang Hospital, Fudan University, Shanghai, P.R. China
| | - Lili Zhang
- Department of Gastroenterology, Xinghua Renming Hospital, Jiangsu, P.R. China
| | - Feng Li
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R.China
| | - Lili Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, P.R. China
| | - Ying Chen
- Department of Gastroenterology and Hepatology, Minhang Hospital, Fudan University, Shanghai, P.R. China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, P.R.China
- Center of Evidence-Based Medicine, Fudan University,
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
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Biswas S, Vaishnav M, Gamanagatti S, Swaroop S, Arora U, Aggarwal A, Elhence A, Gunjan D, Kedia S, Mahapatra SJ, Mishra AK, Shalimar. Endoscopic Glue Injection vs Glue Plus BRTO or TIPSS for Preventing Gastric Variceal Bleeding: A Randomized Controlled Trial. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00593-7. [PMID: 38969074 DOI: 10.1016/j.cgh.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND AND AIMS The study sought to compare the efficacy of endoscopic injection sclerotherapy with cyanoacrylate glue (EIS-CYA) vs EIS-CYA plus a radiologic intervention (RI) (either transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration) for secondary prophylaxis in patients with liver cirrhosis who presented with acute variceal bleeding from cardiofundal varices. Primary outcome measure was gastric varix (GV) rebleed rates at 1 year. METHODS Consecutive cirrhosis patients with acute variceal bleeding from cardiofundal varices were randomized into 2 arms (45 in each) after primary hemostasis by EIS-CYA. In the endoscopic intervention (EI) arm, EIS-CYA was repeated at regular intervals (1, 3, 6, and 12 months), while in the RI arm, patients underwent transjugular intrahepatic portosystemic shunt or balloon-occluded retrograde transvenous obliteration followed by endoscopic surveillance. RESULTS GV rebleed rates at 1 year were higher in the EI arm compared with the RI arm: 11 (24.4%; 95% confidence interval [CI], 12.9%-39.5%) vs 1 (2.2%; 95% CI, 0.1%-11.8%) (P = .004; absolute risk difference: 22.2%; 95% CI, 8.4%-36.6%). GV rebleed-related mortality in the EI arm (8 [17.8%; 95% CI, 8.0%-32.1%]) was significantly higher than in the RI arm (1 [2.2%; 0.1%-11.8%]) (P = .030; absolute risk difference: 15.6; 95% CI, 2.9%-29.2%); however, there was no difference in all-cause mortality between the 2 groups (12 [26.7%; 95% CI, 14.6%-41.9%] vs 7 [15.6%; 95% CI, 6.5%-29.5%]). The number needed to treat to prevent 1 GV-related rebleed at 1 year was 4.5. CONCLUSIONS RI for secondary prophylaxis reduces rebleeding from GV and GV rebleeding-related mortality in patients with GV hemorrhage. (CTRI/2021/02/031396).
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shivanand Gamanagatti
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ashwani Kumar Mishra
- National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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4
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Sarkis Y, Masuoka H, Ghabril M, Gutta A, Al-Haddad MA, Stainko S, Cohen L, Perkins A, DeWitt JM. Comparison of endoscopic ultrasound-guided primary and secondary prophylaxis for gastric variceal bleeding. Dig Endosc 2024; 36:710-718. [PMID: 37886793 DOI: 10.1111/den.14713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/24/2023] [Indexed: 10/28/2023]
Abstract
OBJECTIVES Endoscopic ultrasound (EUS)-guided injection of cyanoacrylate (CYA) for primary prophylaxis (PP) of gastric varices (GV) is controversial. This study evaluates the safety and efficacy of this intervention. METHODS Patients treated for PP of GV bleeding by EUS injection of CYA with or without coils were identified. Endoscopic techniques, outcomes, and adverse events (AEs) were reviewed and compared with a group treated for secondary prophylaxis (SP). Patients were followed until: (i) loss to follow-up; (ii) GV bleeding; (iii) interventional radiology or surgery decompression; (iv) liver transplant; or (v) death or comfort care. RESULTS One hundred and nineteen patients (61 men; mean 59 ± 12 years) underwent EUS for PP (n = 24) or SP (n = 95). The PP group was treated with CYA alone (n = 18) or with coils (n = 4). Eight (33%) mild (n = 6) or moderate (n = 2) AEs and no index GV bleeding occurred during a mean of 6.1 ± 5.9 months follow-up. Repeat EUS in 22 (92%) PP patients showed 7 (32%) residual GVs, which were retreated with CYA alone (n = 6) or with coils (n = 1). Two (29%) mild (n = 1) or moderate (n = 1) AEs occurred after repeat EUS and 1/22 (5%) index GV bleed occurred during a mean 23 ± 25 months follow-up. Compared to the SP group, the PP group had lower Model for End-stage Liver Disease (MELD) score (P = 0.03), fewer GV stigmata (P < 0.001), required less CYA (P = 0.019) during index EUS, and had a longer time between index and surveillance EUS (P = 0.014). The incidence of AEs and GV bleeding between the two groups were similar. CONCLUSION Posttreatment GV bleeding and AEs are similar following EUS-guided primary and secondary GV prophylaxis.
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Affiliation(s)
- Yara Sarkis
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Howard Masuoka
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Marwan Ghabril
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Aditya Gutta
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Mohammad A Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Sarah Stainko
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Lainna Cohen
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
| | - Anthony Perkins
- Department of Biostatistics and Health Data Science, Indiana University Health Medical Center, Indianapolis, USA
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, USA
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Patel RK, Tripathy T, Panigrahi MK, Nayak HK, Samal SC, Pattnaik B, Dutta T, Gupta S, Mohakud S, Naik S, Deep Bag N. Is salvage Plug-Assisted Retrograde Transvenous Obliteration (PARTO) safe and effective for bleeding gastric varices ?- A preliminary single-center experience. Emerg Radiol 2024; 31:359-365. [PMID: 38664278 DOI: 10.1007/s10140-024-02232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.
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Affiliation(s)
- Ranjan Kumar Patel
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Taraprasad Tripathy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India.
| | - Manas Kumar Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Hemant Kumar Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Subash Chandra Samal
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Bramhadatta Pattnaik
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Tanmay Dutta
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Sunita Gupta
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Sudipta Mohakud
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Suprava Naik
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Nerbadyeswari Deep Bag
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
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6
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
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Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
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Ma AS, Thuluvath PJ. The Role of Endoscopy for Primary and Secondary Prophylaxis of Variceal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:231-248. [PMID: 38395481 DOI: 10.1016/j.giec.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Cirrhosis is associated with a high morbidity and mortality. One of the most serious and unpredictable complication of cirrhosis, with a high mortality rate, is bleeding from esophagogastric varices. Endoscopic screening of varices followed by primary prophylactic treatment with beta blockers or band ligation in the presence of large esophageal varices will reduce the variceal bleeding rates and thereby reduce mortality risks in those with advanced cirrhosis. There is a paucity of data on primary prophylaxis of gastric varices but secondary prophylaxis includes glue injection, balloon-occluded retrograde transvenous obliteration, or transjugular intrahepatic portosystemic shunting with coil embolization.
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Affiliation(s)
- Andrew S Ma
- Institute for Digestive Health and Liver Disease Mercy Medical Center, Professional Office Building, 7th Floor 345 St. Paul Place, Baltimore, MD 21202, USA
| | - Paul J Thuluvath
- Institute for Digestive Health and Liver Disease Mercy Medical Center, Professional Office Building, 7th Floor 345 St. Paul Place, Baltimore, MD 21202, USA.
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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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10
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Jobe K, Henry Z. Endoscopic Treatment of Acute Esophageal and Gastric Variceal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:249-261. [PMID: 38395482 DOI: 10.1016/j.giec.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Acute variceal bleeding is a serious complication of portal hypertension. This most often manifests as bleeding from esophageal varices. Although less likely to occur, bleeding from gastric varices is usually more severe. The best endoscopic management for acute esophageal variceal bleeding is band ligation and this often proves to be definitive therapy for these patients. For gastric variceal bleeding, the best endoscopic therapy is endoscopic cyanoacrylate injection but this can be cumbersome to perform and is not a readily available resource at most centers in the United States.
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Affiliation(s)
- Kendra Jobe
- Department of Medicine, University of Virginia School of Medicine, 1215 Lee Street, PO Box 800708, Charlottesville, VA 22908-0708, USA
| | - Zachary Henry
- Division of Gastroenterology & Hepatology, University of Virginia School of Medicine, 1215 Lee Street, PO Box 800708, Charlottesville, VA 22908-0708, USA.
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11
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Gralnek IM, Garcia-Pagan JC, Hernández-Gea V. Challenges in the Management of Esophagogastric Varices and Variceal Hemorrhage in Cirrhosis - A Narrative Review. Am J Med 2024; 137:210-217. [PMID: 38128860 DOI: 10.1016/j.amjmed.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
Over the past decade, significant advancements in pharmacological, endoscopic, and radiographic treatments have emerged in the management of patients with cirrhosis and esophagogastric varices or variceal hemorrhage. These advances have been in several areas, including the role of screening and primary prophylaxis (preventing an initial variceal bleed), evaluation and management of acute esophagogastric variceal hemorrhage, and in preventing variceal rebleeding. Therefore, we believe there is a need for an updated, evidence-based "narrative review" on this important clinical topic that will be relevant for internists, hospitalists, intensive care unit physicians, and those in training. We believe the guidance presented in this narrative review will enhance daily medical practice of health care professionals and has the potential to improve quality of care for these complex patients.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel; Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel.
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
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12
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Lee EW, Eghtesad B, Garcia-Tsao G, Haskal ZJ, Hernandez-Gea V, Jalaeian H, Kalva SP, Mohanty A, Thabut D, Abraldes JG. AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage. Hepatology 2024; 79:224-250. [PMID: 37390489 DOI: 10.1097/hep.0000000000000530] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Edward Wolfgang Lee
- Department of Radiology and Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Bijan Eghtesad
- Department of General Surgery, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Department of Internal Medicine, Section of Digestive Diseases, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging/Interventional Radiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Universitat de Barcelona (UB). CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Arpan Mohanty
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Juan G Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
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13
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DeWitt JM. Endoscopic treatment of gastric variceal bleeding: Where have we come from, and where are we going? Gastrointest Endosc 2024; 99:38-40. [PMID: 37978964 DOI: 10.1016/j.gie.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 11/19/2023]
Affiliation(s)
- John M DeWitt
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Health Medical Center, Indianapolis, Indiana, USA
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14
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Xu X, Tang C, Linghu E, Ding H. Guidelines for the Management of Esophagogastric Variceal Bleeding in Cirrhotic Portal Hypertension. J Clin Transl Hepatol 2023; 11:1565-1579. [PMID: 38161497 PMCID: PMC10752807 DOI: 10.14218/jcth.2023.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 07/11/2023] [Accepted: 09/07/2023] [Indexed: 01/03/2024] Open
Abstract
To standardize the diagnosis, treatment, and management of esophagogastric variceal bleeding (EVB) in patients with cirrhotic portal hypertension, the Chinese Society of Hepatology, the Chinese Society of Gastroenterology, and the Chinese Society of Digestive Endoscopy of the Chinese Medical Association brought together relevant experts, reviewed the latest national and international progress in clinical research on EVB in cirrhotic portal hypertension, and followed evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guidelines provide recommendations for the diagnosis, treatment, and management of EVB in cirrhotic portal hypertension and with the aim to improve the level of clinical treatment of EVB in patients with cirrhotic portal hypertension.
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Affiliation(s)
- Xiaoyuan Xu
- Department of Gastroenterology, Peking University First Hospital, Beijing, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Enqiang Linghu
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated to Capital Medical University, Beijing, China
| | - Chinese Society of Hepatology, Chinese Medical Association; Chinese Society of Gastroenterology, Chinese Medical Association; Chinese Society of Digestive Endoscopy, Chinese Medical Association
- Department of Gastroenterology, Peking University First Hospital, Beijing, China
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Gastroenterology and Hepatology, Beijing You’an Hospital Affiliated to Capital Medical University, Beijing, China
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15
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Ilyas F, Ali H, Patel P, Shah N, Ishtiaq R, Giammarino A, Satapathy SK. Comparison of the management of gastric variceal bleeding techniques. JGH Open 2023; 7:908-915. [PMID: 38162851 PMCID: PMC10757495 DOI: 10.1002/jgh3.13001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 01/03/2024]
Abstract
Background and Aim Managing gastric variceal (GV) hemorrhage is more complicated than managing esophageal variceal (EV) bleeding, resulting in significantly higher morbidity and mortality. We aim to compare the outcomes of endoscopic variceal ligation (EVL), transhepatic intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (BRTO) in the management of GV bleeding. Methods We utilized the National Inpatient Sample (NIS) database from January 2016 to December 2019 to include adult patients with GV hemorrhage. Results Our study identified 7160 hospitalizations with a primary diagnosis of GV hemorrhage who underwent the interventions of interest. EVL was performed in 69.83%, TIPS in 8.72%, and BRTO in 4.88%. Patients with liver cirrhosis had a higher frequency of undergoing BRTO (68.6%), followed by TIPS (64.0%) and esophagogastroduodenoscopy (EGD) + TIPS (63.7%) (P < 0.001). Patients with cirrhosis secondary to alcoholism had a higher prevalence of TIPS (62.4%), followed by EGD + TIPS (69.4%) and BRTO (52.9%) (P < 0.001). Overall, the inpatient mortality was 6.5%. Overall inpatient mortality was highest in the TIPS cohort (8.8%), followed by BRTO (7.1%), EGD + TIPS (6.5%), EVL (6.2%), and EGD + BRTO (2.8%) (P < 0.001); However, the Kaplan-Meier graph showed endoscopy with BRTO had the most favorable 30-day survival, trailed by TIPS alone and BRTO alone. Conclusion EVL remains a prominent therapeutic strategy. Remarkably, the combination of endoscopy with BRTO shows promising 30-day survival outcomes. Considering these observations, although EVL holds its primacy, it is essential to further explore the potential benefits of combined therapies in larger studies to ascertain the best treatment strategies.
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Affiliation(s)
- Fariha Ilyas
- Department of Internal MedicineECU Health Medical CenterGreenvilleNorth CarolinaUSA
| | - Hassam Ali
- Department of Internal MedicineECU Health Medical CenterGreenvilleNorth CarolinaUSA
| | - Pratik Patel
- Department of GastroenterologyMather Hospital/Zucker School of Medicine at Hofstra UniversityPort JeffersonNew YorkUSA
| | - Nairuti Shah
- Department of Internal MedicineNYU Langone Hospital Long Island/NYU Long Island School of MedicineMineolaNew YorkUSA
| | - Rizwan Ishtiaq
- Department of Internal MedicineUniversity of Connecticut Health CenterFarmingtonConnecticutUSA
| | - Alexa Giammarino
- Department of Internal MedicineNorth Shore University Hospital/Zucker School of Medicine at Hofstra UniversityManhassetNew YorkUSA
| | - Sanjaya K Satapathy
- Department of HepatologyNorth Shore University Hospital/Zucker School of Medicine at Hofstra UniversityManhassetNew YorkUSA
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16
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Jogo A, Yamamoto A, Kageyama K, Sasaki F, Oura T, Mitsuyama Y, Terayama E, Matsushita K, Asano K, Sakai Y, Ozaki M, Harada S, Murai K, Nakano M, Sohgawa E, Kita R, Kaminou T, Miki Y. Afferent vein embolization via retrograde approach as a potential treatment strategy for bleeding duodenal varices. Radiol Case Rep 2023; 18:4327-4330. [PMID: 37789920 PMCID: PMC10542599 DOI: 10.1016/j.radcr.2023.08.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/13/2023] [Accepted: 08/21/2023] [Indexed: 10/05/2023] Open
Abstract
The standard treatment for ruptured duodenal varices remains to be established. Emergency balloon-occluded retrograde transvenous obliteration is challenging in patients with bleeding because re-rupture of varices can occur due to increased pressure when using the retrograde approach. Herein, we describe a case in which a catheter was retrogradely advanced to the afferent vein beyond bleeding duodenal varices; however, the varices re-ruptured during coil embolization, and a part of the catheter was deviated into the intestinal tract. The rupture site was embolized by liquid embolic materials from the microcatheter. Embolization via retrograde approach needs to be carefully performed.
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Affiliation(s)
- Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Fumi Sasaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Tatsushi Oura
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Yasuhito Mitsuyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Eisaku Terayama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Kazuki Matsushita
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Kazuo Asano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Yuki Sakai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Masanori Ozaki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Shohei Harada
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Mariko Nakano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | | | - Toshio Kaminou
- Advanced Imaging and Minimally Invasive Therapy Center, Himeji, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
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17
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Choi WM, Yoo SY, Chang JI, Han S, Kim YS, Sinn DH, Choi SH, Gwon DI, Lim YS. A model for predicting poor survival in patients with cirrhosis undergoing portosystemic shunt embolization. J Gastroenterol Hepatol 2023; 38:1629-1636. [PMID: 37417652 DOI: 10.1111/jgh.16280] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND AND AIM Portosystemic shunt embolization (PSSE) is a promising treatment for hepatic encephalopathy (HEP) and gastric varix (GV) in cirrhotic patients with a spontaneous portosystemic shunt. However, PSSE may worsen portal hypertension causing hepatorenal syndrome, liver failure, and mortality. This study aimed to develop and validate a prognostic model that helps identify patients with a risk of poor short-term survival after PSSE. METHODS We included 188 patients who underwent PSSE for recurrent HEP or GV at a tertiary center in Korea. To develop a prediction model for 6-month survival after PSSE, Cox proportional-hazard model was used. The developed model was validated in a separate cohort of 184 patients from two other tertiary centers. RESULTS In multivariable analysis, the 1-year overall survival after PSSE was significantly associated with baseline levels of serum albumin, total bilirubin, and international normalized ratio (INR). We therefore developed the albumin-bilirubin-INR (ABI) score by assigning 1 point each for albumin < 3.0 g/dL, total bilirubin ≥ 1.5 mg/dL, and INR ≥ 1.5. Time-dependent areas under the curve of the ABI score for predicting 3-month and 6-month survival were 0.85 and 0.85 in the development cohort and 0.83 and 0.78 in the validation cohort, indicating good discrimination performance. The ABI score showed a better discrimination and calibration performance than the model for end-stage liver disease and the Child-Pugh scores, especially in high-risk patients. CONCLUSIONS The ABI score is a simple prognostic model that helps decide whether to proceed with PSSE for the prevention of HEP or GV bleeding in patients with spontaneous portosystemic shunt.
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Affiliation(s)
- Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seo Yeon Yoo
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-In Chang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Gastroenterology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
| | - Seungbong Han
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young Seok Kim
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Hyun Choi
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Il Gwon
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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18
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Abraldes JG, Caraceni P, Ghabril M, Garcia-Tsao G. Update in the Treatment of the Complications of Cirrhosis. Clin Gastroenterol Hepatol 2023; 21:2100-2109. [PMID: 36972759 PMCID: PMC11097249 DOI: 10.1016/j.cgh.2023.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/17/2023] [Accepted: 03/07/2023] [Indexed: 03/29/2023]
Abstract
Cirrhosis consists of 2 main stages: compensated and decompensated, the latter defined by the development/presence of ascites, variceal hemorrhage, and hepatic encephalopathy. The survival rate is entirely different, depending on the stage. Treatment with nonselective β-blockers prevents decompensation in patients with clinically significant portal hypertension, changing the previous paradigm based on the presence of varices. In patients with acute variceal hemorrhage at high risk of failure with standard treatment (defined as those with a Child-Pugh score of 10-13 or those with a Child-Pugh score of 8-9 with active bleeding at endoscopy), a pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) improves the mortality rate and has become the standard of care in many centers. In patients with bleeding from gastrofundal varices, retrograde transvenous obliteration (in those with a gastrorenal shunt) and/or variceal cyanoacrylate injection have emerged as alternatives to TIPS. In patients with ascites, emerging evidence suggests that TIPS might be used earlier, before strict criteria for refractory ascites are met. Long-term albumin use is under assessment for improving the prognosis of patients with uncomplicated ascites and confirmatory studies are ongoing. Hepatorenal syndrome is the least common cause of acute kidney injury in cirrhosis, and first-line treatment is the combination of terlipressin and albumin. Hepatic encephalopathy has a profound impact on the quality of life of patients with cirrhosis. Lactulose and rifaximin are first- and second-line treatments for hepatic encephalopathy, respectively. Newer therapies such as L-ornithine L-aspartate and albumin require further assessment.
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Affiliation(s)
- Juan G Abraldes
- Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Paolo Caraceni
- Istituto di Ricerca e Cura a Carattere Scientifico Azienda Ospedaliera-Universitaria di Bologna, Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Guadalupe Garcia-Tsao
- Yale University School of Medicine, Veterans Administration - Connecticut Healthcare System, West Haven, Connecticut.
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19
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Zhang M, Mou H, Wang G, Li P, Kong D, Li S, Feng Q, Sun R, Yan J, Huang G, Shi Y, Tuo B, Zhang C. Clinical outcomes of clip-assisted endoscopic cyanoacrylate injection versus conventional endoscopic cyanoacrylate injection in treating gastric varices with a gastrorenal shunt. Scand J Gastroenterol 2023; 58:1173-1179. [PMID: 37128690 DOI: 10.1080/00365521.2023.2204388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/13/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND AND STUDY AIMS The optimal treatment for gastric varices (GVs) is a topic that remains definite for this study. This study compared the clinical outcomes of clip-assisted endoscopic cyanoacrylate injection (clip-ECI) to conventional endoscopic cyanoacrylate injection (con-ECI) for the treatment of GVs with a gastrorenal shunt. PATIENTS AND METHODS Data were collected retrospectively in five medical centers from 2015 to 2020. The patients were treated with con-ECI (n = 126) or clip-ECI (n = 148). Clinical characteristics and procedural outcomes were compared. Patients were followed until death, liver transplantation or 6 months after the treatment. The primary outcome was rebleeding, and the secondary outcome was survival. RESULTS There were no significant differences in age, sex, etiology, shunt diameter and Child-Pugh classification between the two groups. Fewer GVs obliteration sessions were required in the clip-ECI group than in the con-ECI group (p = 0.015). The cumulative 6-month rebleeding-free rates were 88.6% in the clip-ECI group and 73.7% in the con-ECI group (p = 0.002). The cumulative 6-month survival rates were 97.1% in the clip-ECI group and 94.8% in the con-ECI group (p = 0.378). CONCLUSIONS Compared with con-ECI, clip-ECI appears more effective for the treatment of GVs with a gastrorenal shunt, which required less sessions and achieved a higher 6-month rebleeding-free rate.
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Affiliation(s)
- Mingyan Zhang
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Haijun Mou
- Department of Gastroenterology, The Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Guangchuan Wang
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Ping Li
- Department of Gastroenterology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Derun Kong
- Department of Gastroenterology, Anhui Geriatric Institute, The First Affiliated Hospital of Anhui Medical University, Anhui, China
| | - Senlin Li
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
| | - Qian Feng
- Department of Gastroenterology, Liaocheng People's Hospital, Liaocheng, China
| | - Ruonan Sun
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jinming Yan
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Guangjun Huang
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yongjun Shi
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Biguang Tuo
- Department of Gastroenterology, The Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Chunqing Zhang
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Gastroenterology and Hepatology, Shandong Provincial Hospital, Shandong University, Jinan, China
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20
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Stoleru G, Henry Z. Balloon-occluded retrograde transvenous obliteration for treatment of portal hypertensive related varices. Curr Opin Gastroenterol 2023; 39:140-145. [PMID: 36976877 DOI: 10.1097/mog.0000000000000915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
PURPOSE OF REVIEW Balloon-occluded retrograde transvenous obliteration (BRTO) is becoming a more commonly used procedure to manage various complications of liver disease. It is important to understand the technique of the procedure, the indications for its use, and also potential associated complications. RECENT FINDINGS BRTO is superior to endoscopic cyanoacrylate injection and transjugular intrahepatic portosystemic shunt for bleeding gastric varices associated with a portosystemic shunt and should be considered a first line therapy in these patients. In addition, it has been shown to be useful in controlling ectopic variceal bleeding, improving portosystemic encephalopathy, and also in modulating blood flow in the post liver transplant setting. Modified versions of BRTO, plug assisted retrograde transvenous obliteration and coil assisted retrograde transvenous obliteration, have been developed to reduce procedure time and improve complication rates. SUMMARY As the use of BRTO expands in clinical practice it will be important for gastroenterologists and hepatologists to better understand the procedure. There are still many research questions left to answer regarding the use of BRTO in specific situations and for specific patient populations.
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Affiliation(s)
- Gianna Stoleru
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Virginia, Charlottesville, Virginia, USA
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21
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Chooklin S, Chuklin S. Transvenous obliteration of gastric varices. EMERGENCY MEDICINE 2023; 19:2-13. [DOI: 10.22141/2224-0586.19.1.2023.1549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Gastric varices on the background of portal hypertension occur less frequently than esophageal varices but they develop at lower portal pressure and are associated with more massive bleedings and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) has been well documented as an effective therapy for gastric varices caused by portal hypertension. However, BRTO requires long-term, higher-level post-procedural monitoring and can have complications related to balloon rupture and adverse effects of sclerosing agents. Several modified BRTO techniques have been developed, including vascular plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, and balloon-occluded antegrade transvenous obliteration. This article provides an overview of BRTO various and modified BRTO techniques.
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22
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Zeng HT, Zhang ZL, Lin XM, Peng MS, Wang LS, Xu ZL. Aluminum phosphate gel reduces early rebleeding in cirrhotic patients with gastric variceal bleeding treated with histoacryl injection therapy. World J Gastrointest Endosc 2023; 15:153-162. [PMID: 37034972 PMCID: PMC10080557 DOI: 10.4253/wjge.v15.i3.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/26/2022] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Esophageal-gastro varices bleeding (EGVB) is the most widely known cause of mortality in individuals with cirrhosis, with an occurrence rate of 5% to 15%. Among them, gastric varices bleeding (GVB) is less frequent than esophageal varices bleeding (EVB), but the former is a more critical illness and has a higher mortality rate. At present, endoscopic variceal histoacryl injection therapy (EVHT) is safe and effective, and it has been recommended by relevant guidelines as the primary method for the treatment of GVB. However, gastric varices after endoscopic treatment still have a high rate of early rebleeding, which is mainly related to complications of its treatment, such as bleeding from drained ulcers, rebleeding of varices etc. Therefore, preventing early postoperative rebleeding is very important to improve the quality of patient survival and outcomes.
AIM To assess the efficacy of aluminium phosphate gel (APG) combined with proton pump inhibitor (PPI) in preventing early rebleeding after EVHT in individuals with GVB.
METHODS Medical history of 196 individuals with GVB was obtained who were diagnosed using endoscopy and treated with EVHT in Shenzhen People's Hospital from January 2016 to December 2021. Based on the selection criteria, 101 patients were sorted into the PPI alone treatment group, and 95 patients were sorted into the PPI combined with the APG treatment group. The incidences of early rebleeding and corresponding complications within 6 wk after treatment were compared between both groups. Statistical methods were performed by two-sample t-test, Wilcoxon rank sum test and χ2 test.
RESULTS No major variations were noted between the individuals of the two groups in terms of age, gender, Model for End-Stage Liver Disease score, coagulation function, serum albumin, hemoglobin, type of gastric varices, the dose of tissue glue injection and EV that needed to be treated simultaneously. The early rebleeding rate in PPI + APG group was 3.16% (3/95), which was much lower than that in the PPI group (12.87%, 13/101) (P = 0.013). Causes of early rebleeding: the incidence of gastric ulcer bleeding in the PPI + APG group was 2.11% (2/95), which was reduced in comparison to that in the PPI group (11.88%, 12/101) (P = 0.008); the incidence of venous bleeding in PPI + APG group and PPI group was 1. 05% (1/95) and 0.99% (1/101), respectively, and there was no significant difference between them (0.999). The early mortality rate was 0 in both groups within 6 wk after the operation, and the low mortality rate was related to the timely hospitalization and active treatment of all patients with rebleeding. The overall incidence of complications in the PPI + APG group was 12.63% (12/95), which was not significantly different from 13.86% (14/101) in the PPI group (P = 0.800). of abdominal pain in the PPI + APG group was 3.16% (3/95), which was lower than that in the PPI group (11.88%, 12/101) (P = 0.022). However, due to aluminum phosphate gel usage, the incidence of constipation in the PPI + APG group was 9.47% (9/95), which was higher than that in the PPI group (1.98%, 2/101) (P = 0.023), but the health of the patients could be improved by increasing drinking water or oral lactulose. No patients in either group developed spontaneous peritonitis after taking PPI, and none developed hepatic encephalopathy and ectopic embolism within 6 wk of EVHT treatment.
CONCLUSION PPI combined with APG can significantly reduce the incidence of early rebleeding and postoperative abdominal pain in cirrhotic patients with GVB after taking EVHT.
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Affiliation(s)
- Hao-Tian Zeng
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Zhu-Liang Zhang
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Xi-Min Lin
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Min-Si Peng
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
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Huang Z, Zhang W, Lv F, Ma L, Xiao Y, Gao S, Zhang M, Wang Y, Li P, Zhao H, Yu H, Cao J, Ke G, Wang Y, Chen M. Efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration for gastric varices with high-risk ectopic embolism: A multicenter and retrospective cohort study. Endosc Ultrasound 2023; 12:74-83. [PMID: 36510863 PMCID: PMC10134943 DOI: 10.4103/eus-d-21-00260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives Gastric varices (GV) with spontaneous portosystemic shunt (SPSS) are associated with ectopic embolism in endoscopic cyanoacrylate. This study targeted to assess the efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration (BRTO) for GV with high-risk ectopic embolism. Materials and Methods We retrospectively analyzed six tertiary hospitals' 104 patients with GV at high-risk ectopic embolism (the narrowest diameter of SPSS was greater than or equal to 5 mm and the maximum diameter usually >8 mm) who underwent EUS-guided coil embolization combined with endoscopic cyanoacrylate injection or BRTO from January 2014 to December 2020. The outcomes included rebleeding, survival, and complications. Results The EUS group and BRTO group contained 59 and 45 patients, respectively. The technical success rate between the two groups was similar (96.6% vs. 95.6%, P = 1.000). During the follow-up, both groups' 5-day rebleeding rate and 6-week mortality rate were 0%. One-year all-cause rebleeding rate (20.0% vs. 18.9%, P = 0.900) and 1-year mortality rate (2.0% vs. 0%, P = 1.000) in the EUS group were similar to the BRTO group. One patient experienced ectopic embolism in the EUS group, while the BRTO group did not. Both groups had similar mean days (16.0 [interquartile range (IQR), 12.0-19.0] vs. 16.5 [IQR, 11.8-26.0], P = 0.165) and cost of hospitalization (¥ 45950.6 [IQR, 39330.2-55768.2] vs. ¥ 51205.8 [IQR, 31628.8-74251.5], P = 0.680). Multivariate analysis showed that the narrowest diameter of the shunt (odds ratio [OR] = 1.86; 95% confidence interval [CI]: 1.062-3.258; P = 0.03) and content of hemoglobin (OR = 0.941; 95% CI: 0.892-0.992; P = 0.025) were the prognostic factors for survival. Conclusions The efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection for GV with high-risk ectopic embolism are comparable to BRTO.
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Affiliation(s)
- Ziyin Huang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Wenhui Zhang
- Department of Digestive System, Affiliated Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Fujing Lv
- Department of Gastroenterology, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lili Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong Xiao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Shan Gao
- Department of Gastroenterology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Ming Zhang
- Department of Gastroenterology, Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Yanling Wang
- Endoscopy Center, Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Peng Li
- Department of Gastroenterology, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Haiying Zhao
- Department of Gastroenterology, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Honggang Yu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Jiwang Cao
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Ge Ke
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Yang Wang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
| | - Mingkai Chen
- Department of Gastroenterology, Renmin Hospital of Wuhan University, Hubei, China
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Chooklin S, Chuklin S. Comprehensive treatment of patients with gastric variceal bleeding. EMERGENCY MEDICINE 2022; 18:14-21. [DOI: 10.22141/2224-0586.18.8.2022.1539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Bleeding from gastric varices is usually severe and is associated with higher mortality and a higher risk of rebleeding than from esophageal varices. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiological interventions. In terms of treatment, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires prompt intervention to stop it and achieve long-term hemostasis. This review describes the features of pharmacological, endoscopic and interventional radiological prophylactic and treatment options in gastric variceal bleeding. We searched the literature in the MedLine database on the PubMed platform.
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25
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Luo X, Yang L. Letter to the editor: Is it time to change the standard TIPS procedure? Hepatology 2022; 76:E92. [PMID: 35698737 DOI: 10.1002/hep.32605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Xuefeng Luo
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Li Yang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
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26
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Tan YY, Gong J, Liu DL. Endoscopic tissue adhesive injection for gastric varices secondary to hepatic cirrhosis: Complications and management strategies. Shijie Huaren Xiaohua Zazhi 2022; 30:775-782. [DOI: 10.11569/wcjd.v30.i17.775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Gastric varices is a common clinical presentation of portal hypertension induced by hepatic cirrhosis, and gastric variceal bleeding is an emergency with high mortality. Endoscopic tissue adhesive injection plays an important role in the primary and secondary prophylaxis of gastric variceal bleeding, and acute bleeding control. However, this is a technique-demanding operation with nonnegligible complications, of which some may be fatal, such as ectopic embolism. Therefore, the prevention and treatment of such complications are of great importance. Herein, we present a review summarizing the complications and treatment strategies of endoscopic tissue adhesive injection for gastric varices secondary to hepatic cirrhosis.
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Affiliation(s)
- Yu-Yong Tan
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Research Center of Digestive Diseases of Central South University, Changsha 410011, Hunan Province, China
| | - Jian Gong
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Research Center of Digestive Diseases of Central South University, Changsha 410011, Hunan Province, China
| | - De-Liang Liu
- Department of Gastroenterology, The Second Xiangya Hospital of Central South University, Research Center of Digestive Diseases of Central South University, Changsha 410011, Hunan Province, China
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27
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Wu Z, Wu W, Tao C, Liu Q, Li W, Wang Q, Huang W, Gu J, Fei X, Wang Z, Ding X. Balloon-occluded retrograde transvenous obliteration with lauromacrogol sclerosant foam for gastric varices. J Interv Med 2022; 5:138-142. [PMID: 36317150 PMCID: PMC9617148 DOI: 10.1016/j.jimed.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/23/2022] [Accepted: 06/06/2022] [Indexed: 11/26/2022] Open
Abstract
Objectives To evaluate the safety and efficacy of balloon-occluded retrograde transvenous obliteration (BRTO) using lauromacrogol sclerosant foam for gastric varices (GVs) with gastrorenal venous shunts. Methods Data of GV patients treated with BRTO using lauromacrogol sclerosant foam in 2016–2020 were retrospectively analyzed along with procedural success rate, complications, and follow-up efficacy. Results A total of 31 patients were treated with BRTO. The sclerosant foam was prepared by mixing iodinated oil, lauromacrogol, and air at a 1:2:3 ratio. The BRTO procedure was successfully completed in 93.5% of patients. One patient was allergic to the lauromacrogol injection. A mild postoperative fever occurred in three patients. One patient experienced grand mal seizures after the procedure. There was no significant difference in the median Child-Turcotte-Pugh scores before versus after BRTO. Complete GV resolution was observed in 93.1% of patients. One patient underwent endoscopic treatment for the development of high-risk esophageal varices. Another patient underwent transjugular intrahepatic portosystemic shunt placement for the aggravation of ascites. Conclusions Lauromacrogol sclerosant foam is safe and effective in patients undergoing BRTO for GV.
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Affiliation(s)
- Zhiyang Wu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Clinical Research Center Member for Interventional Medicine, China
| | - Wei Wu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Cheng Tao
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, 15213, Pennsylvania, USA
| | - Qin Liu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Clinical Research Center Member for Interventional Medicine, China
| | - Wenchang Li
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Clinical Research Center Member for Interventional Medicine, China
| | - Qinbing Wang
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Clinical Research Center Member for Interventional Medicine, China
| | - Wei Huang
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Clinical Research Center Member for Interventional Medicine, China
| | - Junwei Gu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Clinical Research Center Member for Interventional Medicine, China
| | - Xiaoyan Fei
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Clinical Research Center Member for Interventional Medicine, China
| | - Zhongmin Wang
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Clinical Research Center Member for Interventional Medicine, China
- Corresponding author. Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Xiaoyi Ding
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
- Shanghai Clinical Research Center Member for Interventional Medicine, China
- Corresponding author. Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Lee HA, Kwak J, Cho SB, Lee YS, Jung YK, Kim JH, Kim SU, An H, Yim HJ, Yeon JE, Seo YS. Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding in liver cirrhosis. BMC Gastroenterol 2022; 22:355. [PMID: 35883035 PMCID: PMC9317208 DOI: 10.1186/s12876-022-02428-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND/AIMS We retrospectively compared the effect of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding. METHODS Patients with acute cardiofundal variceal bleeding treated with EVO or RTO at two hospitals were included. RESULTS Ninety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P = 0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, P = 0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, P = 0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P < 0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, P = 0.005). The mortality rates were similar between two groups (P = 0.597). CONCLUSIONS Both EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes.
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Affiliation(s)
- Han Ah Lee
- Departments of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jungwon Kwak
- Department of Radiology, Korea University College of Medicine, Seoul, Korea
| | - Sung Bum Cho
- Department of Radiology, Korea University College of Medicine, Seoul, Korea
| | - Young-Sun Lee
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea. .,Yonsei Liver Center, Severance Hospital, Seoul, Korea.
| | - Hyonggin An
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jong Eun Yeon
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.
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Shinkai K, Sakamori R, Yamada R, Tahata Y, Nozaki Y, Matsumoto K, Tawara S, Fukuda K, Yoshida Y, Tanaka S, Ito T, Doi Y, Iio S, Sakakibara M, Nakanishi F, Kodama T, Hikita H, Tatsumi T, Takehara T. Prognostic impact of worsening of esophageal varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 2022; 37:1148-1155. [PMID: 35430734 DOI: 10.1111/jgh.15853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Balloon-occluded retrograde transvenous obliteration (BRTO) is widely performed for treating gastric varices (GVs). However, worsening of esophageal varices (EVs) can be observed after BRTO. This study aimed to investigate the impact of EV worsening on prognosis after BRTO. METHODS Overall, 258 patients who underwent initial BRTO for GV treatment between January 2004 and May 2019 at 12 institutions were retrospectively registered. RESULTS Technical success was achieved in 235 patients (91.1%). Based on the exclusion criteria, 37 patients were excluded, and 198 were evaluated. The cumulative worsening rates of EVs at 1, 2, and 3 years were 39.0%, 59.4%, and 68.4%, respectively. In the univariate Cox proportional hazards model, sex, EV size, history of EV treatment, left gastric vein dilatation, platelet count, aspartate transaminase (AST), alanine aminotransferase (ALT), total bilirubin, albumin, albumin-bilirubin score, prothrombin time-international normalized ratio, fibrosis-4 index, AST to platelet ratio index, and spleen width were significantly associated with worsening of EV after BRTO. Multivariate analysis showed that sex (adjusted hazard ratio [aHR] 1.72; 95% confidence interval [CI] 1.03-2.86; P = 0.04), left gastric vein dilatation (aHR 1.90; 95% CI 1.17-3.10; P = 0.01), ALT (aHR 1.01; 95% CI 1.00-1.03; P = 0.02), albumin (aHR 0.61; 95% CI 0.43-0.87; P < 0.01), and spleen width (aHR 1.02; 95% CI 1.01-1.03; P < 0.01) were independent risk factors for worsening of EV after BRTO. Patients with EV worsening within 1 year after BRTO had a significantly worse prognosis than the other patients (P = 0.007). CONCLUSIONS Early worsening of EV after BRTO was associated with poor prognosis after BRTO.
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Affiliation(s)
- Kazuma Shinkai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ryoko Yamada
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuki Tahata
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | | | | | | | | | | | - Satoshi Tanaka
- National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Toshifumi Ito
- Japan Community Health Care Organization Osaka Hospital, Osaka, Japan
| | | | - Sadaharu Iio
- Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan
| | | | - Fumihiko Nakanishi
- National Hospital Organization Osaka Minami Medical Center, Kawachinagano, Japan
| | - Takahiro Kodama
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hayato Hikita
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
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30
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Luo X, Hernández-Gea V. Update on the management of gastric varices. Liver Int 2022; 42:1250-1258. [PMID: 35129288 DOI: 10.1111/liv.15181] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 02/13/2023]
Abstract
Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Although less frequent than oesophageal varices (EV), bleeding from gastric varices (GV) is generally more severe and associated with higher mortality and a greater risk to rebleed. According to Sarin's classification, GVs are categorized into four types based on their location within the stomach and relationship with EV. Currently, treatment options for the management of GV include beta-blockers, endoscopic band ligation, endoscopic cyanoacrylate injection, EUS-guided coil/cyanoacrylate injection, transjugular intrahepatic portosystemic shunts and balloon-occluded retrograde transvenous obliteration. The best treatment strategy of GV remains controversial because of the heterogeneity of GV, lack of high-quality data and suboptimal trial design of the studies available. The proper treatment algorithm may require adequate endoscopic and imaging evaluation by a multidisciplinary team with multiple treatment options available. This review describes the hemodynamic features of GV, pharmacological, endoscopic and interventional radiological treatment options for GV.
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Affiliation(s)
- Xuefeng Luo
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS, CIBEREHD, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
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Osman KT, Nayfeh T, Abdelfattah AM, Alabdallah K, Hasan B, Firwana M, Alabaji H, Elkhabiry L, Mousa J, Prokop LJ, Murad MH, Gordon F. Secondary Prophylaxis of Gastric Variceal Bleeding: A Systematic Review and Network Meta-Analysis. Liver Transpl 2022; 28:945-958. [PMID: 34860458 DOI: 10.1002/lt.26383] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/21/2021] [Accepted: 11/26/2021] [Indexed: 12/12/2022]
Abstract
There is no clear consensus regarding the optimal approach for secondary prophylaxis of gastric variceal bleeding (GVB) in patients with cirrhosis. We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of available treatments. A comprehensive search of several databases from each database's inception to March 23, 2021, was conducted to identify relevant randomized controlled trials (RCTs). Outcomes of interest were rebleeding and mortality. Results were expressed as relative risk (RR) and 95% confidence interval (CI). We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to rate the certainty of evidence. We included 9 RCTs with 647 patients who had histories of GVB and follow-ups >6 weeks. A total of 9 interventions were included in the NMA. Balloon-occluded retrograde transvenous obliteration (BRTO) was associated with a lower risk of rebleeding when compared with β-blockers (RR, 0.04; 95% CI, 0.01-0.26; low certainty), and endoscopic injection sclerotherapy (EIS)-cyanoacrylate (CYA) (RR, 0.18; 95% CI, 0.04-0.77; low certainty). β-blockers were associated with a higher risk of rebleeding compared with most interventions and with increased mortality compared with EIS-CYA (RR, 4.12, 95% CI, 1.50-11.36; low certainty), and EIS-CYA + nonselective β-blockers (RR, 5.61; 95% CI, 1.91-16.43; low certainty). Analysis based on indirect comparisons suggests that BRTO may be the best intervention in preventing rebleeding, whereas β-blocker monotherapy is likely the worst in preventing rebleeding and mortality. Head-to-head RCTs are needed to validate these results.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Ahmed M Abdelfattah
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA
| | | | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | | | - Homam Alabaji
- Department of Internal Medicine, Wertachklinik Schwabmünchen, Bavaria, Germany
| | - Lina Elkhabiry
- Department of Internal Medicine, University of Alexandria, Alexandria, Egypt
| | - Jehan Mousa
- Department of Internal Medicine, Damascus University, Damascus, Syria
| | - Larry J Prokop
- Department of Library Services, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Fredric Gordon
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA
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32
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Furuichi Y, Abe M, Yoshimasu Y, Takeuchi H, Itoi T. Liver and spleen stiffness on ultrasound elastography are predictors of the occurrence of esophagogastric varices after balloon-occluded retrograde transvenous obliteration. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:713-722. [PMID: 35301809 DOI: 10.1002/jhbp.1136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/19/2022] [Accepted: 01/22/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Balloon-occluded retrograde transvenous obliteration (BRTO) is an effective treatment for gastric varices, but predictors associated with overall survival rate (OS) and occurrence of esophagogastric varices (EGV) have not yet been clarified. In this study, we clarified these predictors by performing ultrasound elastography and blood tests at various time points. METHODS A total of 34 patients were enrolled. The primary endpoint was to identify predictors associated with OS and EGV occurrence by univariate and multivariate analyses. Secondary endpoints were to extract the cutoff values for OS and EGV occurrence, and to clarify chronological changes in liver stiffness (LS), spleen stiffness (SS), spleen index (SI), and portal vein flow volume (PVF). Time points were set as before BRTO (Bf), and 1 day (D1), 7 days (D7), 1 month (1M), 3 months (3M), and 6 months (6M) after BRTO. RESULTS Albumin-bilirubin score Bf, fibrin-4 index change 6M, and branched chain amino acids tyrosine molar ratio (BTR) 1M were predictors of OS on univariate analysis (p = 0.021, 0.033, and 0.019, respectively) but were not extracted by multivariate analysis. The factors of LS 6M > 19.9 kPa and SS D7 > 21.7 kPa were predictors of the occurrence of EGV on multivariate analysis (p = 0.029 and 0.025, respectively). PVF significantly increased with time after BRTO. CONCLUSION Albumin-bilirubin score and BTR had the possibility to associated with OS, and the predictors of reduced occurrence of EGV were LS < 19.9 and SS < 21.7.
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Affiliation(s)
- Yoshihiro Furuichi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.,Department of Gastroenterology, Niiza Shiki Central General Hospital, Saitama, Japan
| | - Masakazu Abe
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yuu Yoshimasu
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Hirohito Takeuchi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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33
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Tatsumi A, Maekawa S, Osawa L, Katoh R, Komiyama Y, Nakakuki N, Takada H, Matsuda S, Muraoka M, Suzuki Y, Sato M, Takahashi E, Miura M, Amemiya F, Takano S, Fukasawa M, Yamaguchi T, Nakayama Y, Inoue T, Okada H, Araki T, Onishi H, Enomoto N. Spontaneous portosystemic shunt diameter predicts liver function after balloon‐occluded retrograde transvenous obliteration. JGH Open 2022; 6:139-147. [PMID: 35155824 PMCID: PMC8829100 DOI: 10.1002/jgh3.12712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 12/14/2022]
Abstract
Background and Aim Recently, balloon‐occluded retrograde transvenous obliteration (BRTO), performed for spontaneous portosystemic shunts (SPSS), has been receiving attention as a measure to improve liver function in cirrhotic patients with portal hypertension. However, it is unclear whether SPSS diameter is associated with changes in hepatic venous pressure gradient (HVPG) and liver function after BRTO. Methods In 34 cirrhotic patients receiving BRTO for hepatic encephalopathy/gastric varices, the association of SPSS diameter with liver function at baseline and 6 months after BRTO and the accompanying changes in HVPG were investigated. Results Patients had Child–Pugh (CP) scores of A/B/C (7/19/8), SPSS diameters of ≤10 mm/11–20 mm/<20 mm (8/21/5), and an average observation period of 3.2 (0.3–8.5) years. SPSS diameter was significantly associated with male sex, alcohol use, and values of albumin, prothrombin time (PT%), and NH3 at baseline. Moreover, the SPSS diameter was significantly correlated with the changes in HVPG observed upon BRTO (r = 0.55, P = 0.005), and a large shunt diameter was significantly associated with a greater increase in HVPG. At 6 months, significant improvements in albumin, PT%, bilirubin, and NH3 were observed overall, but the improvement was marked in those with larger shunt diameters if they had CP A/B. Conclusion SPSS diameter was strongly associated with liver function at baseline and after BRTO and also with changes in HVPG, indicating that SPSS diameter is an important predictor of BRTO outcome.
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Affiliation(s)
- Akihisa Tatsumi
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Shinya Maekawa
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Leona Osawa
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Ryo Katoh
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Yasuyuki Komiyama
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Natsuko Nakakuki
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Hitomi Takada
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Shuya Matsuda
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Masaru Muraoka
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Yuichiro Suzuki
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Mitsuaki Sato
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Ei Takahashi
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Mika Miura
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Fumitake Amemiya
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Shinichi Takano
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Mitsuharu Fukasawa
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Tatsuya Yamaguchi
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Yasuhiro Nakayama
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Taisuke Inoue
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Hiroki Okada
- Department of Radiology, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Takuji Araki
- Department of Radiology, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Hiroshi Onishi
- Department of Radiology, Faculty of Medicine University of Yamanashi Yamanashi Japan
| | - Nobuyuki Enomoto
- First Department of Internal Medicine, Faculty of Medicine University of Yamanashi Yamanashi Japan
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34
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Tamai Y, Tanaka H, Fujimori M, Iwasa M, Nakagawa H. Successful endoscopic cyanoacrylate injection therapy for ruptured duodenal varices immediately after balloon-occluded retrograde transvenous obliteration. JGH Open 2021; 5:1401-1403. [PMID: 34950785 PMCID: PMC8674538 DOI: 10.1002/jgh3.12683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/11/2022]
Abstract
We present a rare case of acute duodenal variceal rupture after B-RTO that was successfully treated with endoscopic CA injection therapy. A 74-year-old Japanese woman was transferred to our hospital due to progressive general malaise and hematemesis. Gastroduodenoscopy (GDS) showed duodenal varices without active bleeding in the second portion of duodenum. Balloon-occluded retrograde transvenous obliteration (B-RTO) was carried out to prevent duodenal variceal rebleeding. Good pooling of ethanolamine oleate with iopamidol (EOI) was observed in duodenal varices using balloon catheters. However, massive melena was observed immediately after B-RTO. Emergent GDS revealed a white plug on the treated varix, thus endoscopic cyanoacrylate (CA) injection therapy was performed. We speculated that the injection of EOI increased the pressure in the duodenal varices which resulted in rupture of duodenal varices. B-RTO was effective therapy to prevent duodenal variceal rebleeding, but postprocedural monitoring is required as illustrated by this case. We suggest that careful monitoring and backup system for endoscopy are required during or after B-RTO.
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Affiliation(s)
- Yasuyuki Tamai
- Department of Gastroenterology and Hepatology Mie University Graduate School of Medicine Tsu Mie Japan
| | - Hideaki Tanaka
- Department of Gastroenterology and Hepatology Mie University Graduate School of Medicine Tsu Mie Japan
| | - Masashi Fujimori
- Department of Radiology Mie University Graduate School of Medicine Tsu Mie Japan
| | - Motoh Iwasa
- Department of Gastroenterology and Hepatology Mie University Graduate School of Medicine Tsu Mie Japan
| | - Hayato Nakagawa
- Department of Gastroenterology and Hepatology Mie University Graduate School of Medicine Tsu Mie Japan
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35
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Xiang T, Yang L, Luo X. REPLY. Hepatology 2021; 74:2915. [PMID: 34101883 DOI: 10.1002/hep.32001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Tong Xiang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Li Yang
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
| | - Xuefeng Luo
- Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, Chengdu, China
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36
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Chinnadurai KK, De A, Duseja A, Singh V. Letter to the Editor: Is Balloon-Occluded Retrograde Transvenous Obliteration Superior to Endoscopic Cyanoacrylate in Gastric Varices? Hepatology 2021; 74:2907-2908. [PMID: 33830506 DOI: 10.1002/hep.31853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Krishna Kumar Chinnadurai
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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37
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Bazarbashi AN, Li M, Ryou M. Letter to the Editor: Endoscopic Ultrasound-Guided Coil Therapy for Secondary Prevention After Gastric Variceal Bleeding: A Promising Alternative. Hepatology 2021; 74:2914. [PMID: 34105790 DOI: 10.1002/hep.31997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA
| | - Michael Li
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA
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38
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Renzulli M, Dajti E, Ierardi AM, Brandi N, Berzigotti A, Milandri M, Rossini B, Clemente A, Ravaioli F, Marasco G, Azzaroli F, Carrafiello G, Festi D, Colecchia A, Golfieri R. Validation of a standardized CT protocol for the evaluation of varices and porto-systemic shunts in cirrhotic patients. Eur J Radiol 2021; 147:110010. [PMID: 34801322 DOI: 10.1016/j.ejrad.2021.110010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of the present study was to propose and validate a standardized CT protocol for evaluating all the types of portosystemic collaterals (P-SC), including gastroesophageal varices and spontaneous portosystemic shunts (SPSS), and to evaluate the prognostic role of portal hypertension CT features for the prediction of the hepatic decompensation risk in cirrhotic patients. METHODS A retrospective cohort study of 184 advanced chronic liver disease who underwent CT scan between January 2014 and December 2017. Patients with an interval > 6 months between the imaging, elastometric, endoscopic and biochemical evaluation were excluded, as well as patients with previous transjugular intrahepatic portosystemic shunt (TIPS), liver transplantation (LT) or terminal medical conditions. Data on liver disease history, co-morbidities, endoscopic and radiologic findings were collected. The incidence of hepatic decompensation and other events, such as portal vein thrombosis, HCC, TIPS placement, LT, death, and its cause, were also recorded. The procedure was performed at baseline and after the administration of contrast agent using a multiphasic technique and bolus tracking. Two senior radiologists working in different centres and a non-expert radiologist reviewed all CT examinations, to evaluate both intra-observer and inter-observer variability of the CT protocol and to obtain an external validation. The radiological variables were evaluated using both univariate and adjusted multivariate competing risk regression models. RESULTS Both intra-observer and inter-observer agreement were excellent in detection and measurement of almost all types of P-SC. The presence of SPSS, a spleen diameter > 16 cm, a portal vein diameter > 17 mm and the presence of ascites resulted independent predictors of decompensation-free survival for cirrhotic patients and were incorporated in an easy-to-use score (AUROC = 0.799, p-value = 0.732) which can the risk of decompensation at 5 years, ranking it as low (11.3%), moderate (35.6%) or high (70.8%). CONCLUSIONS The CT protocol commonly performed during the HCC surveillance program for cirrhotic patients is valid for detecting all types of P-SC. The radiological score identified to predict the decompensation-free survival for cirrhotic patients could be an easy-to-use clinical tool.
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Affiliation(s)
- Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy.
| | - Elton Dajti
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Anna Maria Ierardi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano Milan, Italy
| | - Nicolò Brandi
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Annalisa Berzigotti
- Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Matteo Milandri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
| | - Benedetta Rossini
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Alfredo Clemente
- Radiology and Radiotherapy Unit, Department of Precision Medicine, University of Campania "L. Vanvitelli", 80138 Naples, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Francesco Azzaroli
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Gianpaolo Carrafiello
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano Milan, Italy
| | - Davide Festi
- Department of Medical and Surgical Sciences (DIMEC), IRCCS, University of Bologna, Via Massarenti 9, Bologna 40138, Italy
| | - Antonio Colecchia
- Unit of Gastroenterology, Borgo Trento University Hospital of Verona, Verona, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, Bologna, Italy
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Lee HL, Lee SW. The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: advantages and pitfalls. Clin Mol Hepatol 2021; 28:121-134. [PMID: 34571587 PMCID: PMC9013617 DOI: 10.3350/cmh.2021.0239] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/25/2021] [Indexed: 12/31/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.
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Affiliation(s)
- Hae Lim Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Deliwala SS, Hussain M, Ponnapalli A, Igbinedion SO, Bachuwa G, Bansal A. Accelerated balloon-retrograde transvenous obliteration (BRTO): an effective tool in the Arsenal against isolated gastric varices (IGV). BMJ Case Rep 2021; 14:e244405. [PMID: 34489255 PMCID: PMC8422294 DOI: 10.1136/bcr-2021-244405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2021] [Indexed: 12/20/2022] Open
Abstract
Gastric and oesophageal variceal bleeding poses high morbidity and mortality in cirrhosis. Amongst all types, isolated gastric varices (IGV) carry the highest propensity to bleed. Successful outcomes combine endoscopic and interventional radiology approaches using ligation, coils, glue or sclerosants. Transjugular intrahepatic portosystemic shunt success is only seen in a subset of patients, while balloon-retrograde transvenous obliteration (BRTO) has demonstrated high efficacy in preventing rebleeding and morbidity in patients with a myriad of anatomies and shunts. The American Association for the Study of Liver disease guidelines do not favour any particular modality; however, recent trials and meta-analyses support BRTO as the first-line therapy. Despite promising results, BRTO adoption is limited by procedural time, patient length-of-stay and equipment compatibilities hindering scalability in academic and community settings. To address these concerns, we present a successfully treated case of IGV with a revised technique called accelerated BRTO.
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Affiliation(s)
| | - Murtaza Hussain
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | | | - Samuel O Igbinedion
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Ghassan Bachuwa
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | - Anish Bansal
- Department of Interventional Radiology, Michigan State University at Hurley Medical Center, Flint, Michigan, USA
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Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis-Current Understanding and Future Prospects. Can J Gastroenterol Hepatol 2021; 2021:8795115. [PMID: 34422711 PMCID: PMC8376437 DOI: 10.1155/2021/8795115] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023] Open
Abstract
Portal hypertension (PHT) in cirrhosis results from increased resistance to splanchnic blood flow secondary to parenchymal and vascular changes within the liver. In an attempt to counteract the increased portal pressure, two mechanisms simultaneously occur: splanchnic vasodilatation and formation of spontaneous portosystemic shunts (SPSS). Long considered to be a compensatory mechanism to decompress the portal venous system, it is now well established that SPSS are not only inefficient in decreasing the portal pressure but also contribute to reduced hepatocyte perfusion and increased splanchnic blood flow and resistance, associated with worsening PHT. Recent studies have described a high prevalence of SPSS in cirrhosis patients, increasing with liver dysfunction, and observed an association between the presence of SPSS and worse clinical outcomes. In cirrhosis patients with preserved liver functions, the presence of SPSS independently increases the risk of hepatic encephalopathy, variceal bleeding, and ascites, and reduces transplant-free survival. Moreover, the presence of SPSS in patients undergoing transjugular intrahepatic portosystemic shunting and liver transplant has been shown to variably affect the postprocedural outcome. This article provides an overview of the current understanding of the role of SPSS in the natural history of liver cirrhosis and their status as a therapeutic target and an imaging biomarker to identify patients at higher risk of developing complications of PHT.
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42
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Primary prophylaxis of gastric variceal bleeding: the choices need to be tested!! Hepatol Int 2021; 15:863-867. [PMID: 34374928 DOI: 10.1007/s12072-021-10227-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
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Chevallier O, Guillen K, Comby PO, Mouillot T, Falvo N, Bardou M, Midulla M, Aho-Glélé LS, Loffroy R. Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10112298. [PMID: 34070534 PMCID: PMC8198169 DOI: 10.3390/jcm10112298] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/17/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
We performed a systematic review and meta-analysis of published studies to assess the efficacy, safety, and outcomes of N-butyl cyanoacrylate (NBCA) injection for the treatment of variceal gastrointestinal bleeding (GIB). The MEDLINE/PubMed, EMBASE, and SCOPUS databases were searched for English-language studies published from January 1980 to December 2019 and including patients who had injection of NBCA for variceal GIB. Two independent reviewers extracted and evaluated the data from eligible studies. Exclusion criteria were sample size < 5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. NBCA was injected during endoscopy in 42 studies and through a direct percutaneous approach for stomal varices in 1 study. The study’s endpoints were: Technical success, 30-day rebleeding, and 30-day overall and major complications. The estimated overall rates were computed with 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. In total, 43 studies with 3484 patients were included. The technical success rate was 94.1% (95% CI: 91.6–96.1%), the 30-day rebleeding rate was 24.2% (18.9–29.9%), and 30-day overall and major complications occurred in 15.9% (11.2–21.3%) and 5.3% (3.3–7.8%) of patients, respectively. For treating variceal GIB, NBCA injection is a safe and effective method that demonstrates high technical success rate and very low major complication rate.
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Affiliation(s)
- Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Kévin Guillen
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Pierre-Olivier Comby
- Department of Neuroradiology and Emergency Radiology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France;
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (T.M.); (M.B.)
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (T.M.); (M.B.)
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Ludwig-Serge Aho-Glélé
- Department of Biostatistics and Epidemiology, François-Mitterrand University Hospital, 14 Rue Paul, Gaffarel, BP 77908, 21079 Dijon, France;
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
- Correspondence: ; Tel.: +33-380-293-358
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