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Tada F, Hiraoka A, Tada T, Hirooka M, Kariyama K, Tani J, Atsukawa M, Takaguchi K, Itobayashi E, Fukunishi S, Tsuji K, Ishikawa T, Tajiri K, Ochi H, Toyoda H, Ogawa C, Nishimura T, Hatanaka T, Kakizaki S, Shimada N, Kawata K, Naganuma A, Kosaka H, Matono T, Kuroda H, Yata Y, Ohama H, Nouso K, Morishita A, Tsutsui A, Nagano T, Itokawa N, Okubo T, Arai T, Yokohama K, Nishikawa H, Imai M, Koizumi Y, Nakamura S, Iijima H, Kaibori M, Hiasa Y, Kumada T. Efficacy and safety of atezolizumab plus bevacizumab treatment for unresectable hepatocellular carcinoma patients with esophageal-gastric varices. J Gastroenterol 2023; 58:1134-1143. [PMID: 37528255 DOI: 10.1007/s00535-023-02026-2] [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: 03/18/2023] [Accepted: 07/11/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Bevacizumab inhibits vascular endothelial growth factor-A (VEGF-A), though is known to increase bleeding risk as an adverse event (AE). This study examined whether atezolizumab/bevacizumab (Atez/Bev) for unresectable hepatocellular carcinoma (uHCC) can be used for patients with esophageal-gastric varices (EGV). METHODS From October 2020 to December 2022, 506 uHCC patients (median 74 years) underwent an upper gastrointestinal endoscopy examination were enrolled, after exclusion of those with portal vein tumor thrombus (PVTT). Patients with EGV (≧ F1) were defined as EGV positive, and the cohort was divided into non-EGV (n = 355) and EGV (n = 151). Before introducing Atez/Bev, endoscopic treatment was performed, when necessary. Prognosis was evaluated, retrospectively. RESULTS The EGV group had significantly worse hepatic function, lower platelet count, elevated alpha-fetoprotein, and lower rate of extrahepatic metastasis, and lower rate of first-line use (each P < 0.05) than the other. However, progression-free survival (PFS) was also not a significantly difference between the EGV and non-EGV groups in analyses with (PFS rate at 6/12/18 months: 60%/38%/30% vs. 65%/46%/34%, P = 0.29) or without inverse probability weighting adjustment [median: 10.6 months (95% CI 8.3-14.0) vs. 10.5 months (95% CI 7.8-13.7), P = 0.79]. As for AEs, diarrhea was more frequent in the EGV group (≧ G3: 2.0% vs. 0.3%, P = 0.036), while no significant difference was noted for EGV hemorrhage (≧ G3: 1.3% vs. 0.6%, P = 0.345). Of 28 patients who underwent endoscopic treatments before introducing Atez/Bev, none showed EGV-associated hemorrhage. CONCLUSIONS Atez/Bev might be an effective therapeutic option in patients with EGV, when appropriate endoscopic treatment for EGV is performed.
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Affiliation(s)
- Fujimasa Tada
- Gastroenterology Center, Ehime Prefectural Central Hospital, 83 Kasuga-cho, Matsuyama, Ehime, 790-0024, Japan
| | - Atsushi Hiraoka
- Gastroenterology Center, Ehime Prefectural Central Hospital, 83 Kasuga-cho, Matsuyama, Ehime, 790-0024, Japan.
| | - Toshifumi Tada
- Department of Internal Medicine, Japanese Red Cross Himeji Hospital, Himeji, Japan
| | - Masashi Hirooka
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kazuya Kariyama
- Department of Hepatology, Okayama City Hospital, Okayama, Japan
| | - Joji Tani
- Department of Gastroenterology and Hepatology, Kagawa University, Takamatsu, Kagawa, Japan
| | - Masanori Atsukawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Koichi Takaguchi
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Ei Itobayashi
- Department of Gastroenterology, Asahi General Hospital, Asahi, Japan
| | - Shinya Fukunishi
- Department of Gastroenterology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kunihiko Tsuji
- Center of Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Toru Ishikawa
- Department of Gastroenterology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Kazuto Tajiri
- Department of Gastroenterology, Toyama University Hospital, Toyama, Japan
| | - Hironori Ochi
- Center of Liver-Biliary-Pancreatic Disease, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Hidenori Toyoda
- Department of Gastroenterology and Hepatology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Chikara Ogawa
- Department of Gastroenterology, Japanese Red Cross Takamatsu Hospital, Takamatsu, Japan
| | - Takashi Nishimura
- Department of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Hatanaka
- Department of Gastroenterology, Gunma Saiseikai Maebashi Hospital, Maebashi, Gunma, Japan
| | - Satoru Kakizaki
- Department of Clinical Research, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
| | - Noritomo Shimada
- Division of Gastroenterology and Hepatology, Otakanomori Hospital, Kashiwa, Japan
| | - Kazuhito Kawata
- Hepatology Division, Department of Internal Medicine II, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Atsushi Naganuma
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, Takasaki, Japan
| | - Hisashi Kosaka
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - Tomomitsu Matono
- Department of Hepatology, Himeji St. Mary's Hospital, Himeji, Japan
| | - Hidekatsu Kuroda
- Division of Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
| | - Yutaka Yata
- Department of Gastroenterology, Hanwa Memorial Hospital, Osaka, Japan
| | - Hideko Ohama
- Gastroenterology Center, Ehime Prefectural Central Hospital, 83 Kasuga-cho, Matsuyama, Ehime, 790-0024, Japan
| | - Kazuhiro Nouso
- Department of Hepatology, Okayama City Hospital, Okayama, Japan
| | - Asahiro Morishita
- Department of Gastroenterology and Hepatology, Kagawa University, Takamatsu, Kagawa, Japan
| | - Akemi Tsutsui
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Takuya Nagano
- Department of Hepatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Norio Itokawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Tomomi Okubo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Taeang Arai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
| | - Keisuke Yokohama
- Department of Gastroenterology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Hiroki Nishikawa
- Department of Gastroenterology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Michitaka Imai
- Department of Gastroenterology, Saiseikai Niigata Hospital, Niigata, Japan
| | - Yohei Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Shinichiro Nakamura
- Department of Internal Medicine, Japanese Red Cross Himeji Hospital, Himeji, Japan
| | - Hiroko Iijima
- Department of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masaki Kaibori
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - Yoichi Hiasa
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takashi Kumada
- Department of Nursing, Gifu Kyoritsu University, Ogaki, Japan
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Wang J, Zhang X, Zhao S. Transparent cap-assisted endoscopic injection sclerotherapy for the treatment of patients with esophageal varices. Medicine (Baltimore) 2020; 99:e20721. [PMID: 32541523 PMCID: PMC7302636 DOI: 10.1097/md.0000000000020721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The aim of this study was to compare the efficacy and safety of cap-assisted endoscopic injection sclerotherapy (EIS) versus direct EIS in the management of esophageal variceal bleeding in patients with cirrhosis.This retrospective study included patients with cirrhosis and esophageal variceal bleeding who underwent EIS with or without the use of a transparent cap at Shandong Provincial Hospital between December 2014 and April 2017. Patients were divided into two groups: Group A (EIS with transparent cap, n = 50) and Group B (direct EIS, n = 45). Data collected included patients' demographics, procedure details, and rates of variceal eradication, variceal rebleeding, variceal recurrence, and survival during the follow-up period. All data were expressed as mean ± SD. Quantitative variables were compared with Student t test; qualitative variables were compared with the Fisher exact test or chi-square test. P values less than .05 were considered significant.The mean follow-up duration was similar in both groups (16.3 ± 10.2 mo in Group A and 15.5 ± 9.5 mo in Group B). The volume of sclerosant (64.86 ± 10.62 vs 104.73 ± 21.25 ml, P = .044), mean number of sessions (2.37 ± 1.15 vs 5.70 ± 1.57, P = .042), time required to perform endoscopic treatment (6.57 ± 1.50 vs 11.22 ± 2.29 minutes, P = .049), and time to initial esophageal varices eradication (5.43 ± 1.38 vs 8.93 ± 1.5 wk, P = .041) were significantly smaller in the cap-assisted EIS group than in the direct EIS group. The probability of variceal recurrence and rebleeding was significantly higher in the direct EIS group than in the cap-assisted EIS group (14% versus 35.6% and 20% versus 40%). Only 22 patients (44%) developed complications in the cap-assisted group versus 30 patients (66.7%) in the EIS group (P = .039). The probability of survival was similar in both groups (86% versus 75.6%, P = .133).Modified EIS with the use of a transparent cap resulted in lower rates of esophageal variceal recurrence, rebleeding, and complications, compared with direct EIS.
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Affiliation(s)
| | - Xiaohua Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shulei Zhao
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Elsebaey MA, Tawfik MA, Ezzat S, Selim A, Elashry H, Abd-Elsalam S. Endoscopic injection sclerotherapy versus N-Butyl-2 Cyanoacrylate injection in the management of actively bleeding esophageal varices: a randomized controlled trial. BMC Gastroenterol 2019; 19:23. [PMID: 30717684 PMCID: PMC6362581 DOI: 10.1186/s12876-019-0940-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/25/2019] [Indexed: 12/20/2022] Open
Abstract
Background The management of acute esophageal variceal bleeding remains a clinical challenge. Band ligation is the main therapeutic option, but it may be technically difficult to perform in active bleeders. This may necessitate an alternative therapy for this group of patients. This study was conducted to assess the safety and efficacy of sclerotherapy versus cyanoacrylate injection for management of actively bleeding esophageal varices in cirrhotic patients. Methods This prospective study included 113 cirrhotic patients with actively bleeding esophageal varices. They were randomly treated by endoscopic sclerotherapy or cyanoacrylate injection as banding was not suitable for those patients due to profuse bleeding making unclear endoscopic visual field. Primary outcome was incidence of active bleeding control and secondary outcomes were incidence of six weeks rebleeding, complications, and mortality among the studied patients. Results Initial bleeding control was significantly higher in cyanoacrylate versus sclerotherapy groups (98.25, 83.93% respectively, P = 0.007). No significant differences between sclerotherapy and cyanoacrylate groups regarding rebleeding (26.79, 19.30% respectively, P = 0.344), complications, hospital stay or mortality rate were observed. Conclusions Based on this single-center prospective study, both of these therapies appear to have relatively favorable outcomes, although cyanoacrylate injection may be superior to sclerotherapy for initial control of active bleeding. Trial registration [ClinicalTrials.gov Identifier:NCT03388125]–Date of registration: January 2, 2018 “Retrospectively registered”.
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Affiliation(s)
- Mohamed A Elsebaey
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed A Tawfik
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt.
| | - Sherif Ezzat
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amal Selim
- Internal Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Heba Elashry
- Tropical Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sherief Abd-Elsalam
- Tropical Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Endoscopic variceal ligation combined with argon plasma coagulation versus ligation alone for the secondary prophylaxis of variceal bleeding: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2017; 29:621-628. [PMID: 28195875 DOI: 10.1097/meg.0000000000000861] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic variceal ligation (EVL) is often recommended as an effective method for the treatment of esophageal varices, despite the important tendency of variceal recurrence. Recent studies indicate that combining EVL with argon plasma coagulation (APC) may be a more effective therapy than ligation alone. To investigate these findings, we carried out a systematic review and meta-analysis to compare the safety and efficacy of EVL combined with APC versus ligation alone for the secondary prophylaxis of esophageal variceal hemorrhage. All studies were searched through PubMed, the Cochrane Library, and Science Direct. The outcome measures were relative risk (RR) or risk difference with 95% confidence intervals (CIs) for dichotomous data and standardized mean difference for continuous data. Heterogeneity was calculated using the χ and the I-tests. Two investigators independently identified four randomized-controlled trials included in the research. The variceal recurrence rate was significantly lower in the combined therapy group (RR=0.19, 95% CI: 0.09-0.41, P=0.000). The bleeding recurrence and mortalities in the two groups showed no significant differences (RR=0.29, 95% CI: 0.08-1.04, P=0.058; risk difference=-0.02, 95% CI: -0.08-0.04, P=0.576, respectively). Although the pyrexia incidence rate was significantly higher in the combined group (RR=3.42, 95% CI: 1.56-7.48, P=0.002), there was intertrial heterogeneity (I=52.5%, P=0.097). EVL combined with APC is superior to ligation alone for endoscopic variceal recurrence without severe adverse events in secondary prophylaxis against esophageal variceal bleeding. More high-quality studies are needed to strengthen this conclusion.
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Is computerised tomography better than fibreoptic gastroscopy for early detection of gastric varices? GASTROENTEROLOGY REVIEW 2017; 12:34-37. [PMID: 28337234 PMCID: PMC5360658 DOI: 10.5114/pg.2016.63284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 09/21/2015] [Indexed: 11/17/2022]
Abstract
Introduction Video endoscopic diagnosis of gastric varices is particularly limited, owing to the deep submucosal or subserosal location of the varices and the normal appearance of the overlying mucosa. Aim We present and emphasise the value of computerised tomography (CT) examination in the early detection of gastric varices (GVs). Material and methods In this retrospective study, a total of 216 consecutive patients with cirrhosis were evaluated at the Turkiye Yuksek Ihtisas Training and Research Hospital between September 2008 and March 2011. Results One hundred and thirty patients with cirrhosis were enrolled in the study. The mean age of the male (88 cases) patients was 59.45 ±2.42 years, and the mean age of the female (42 cases) patients was 56.29 ±1.14 years. Computerised tomography identified oesophageal varices (EVs) in 103/130 patients, and endoscopy identified EVs in 103/130 patients. Computerised tomography identified GVs in 86/130 patients, and endoscopy identified GVs in 26/130 patients. After endoscopic elastic band ligation (EBL), CT identified GVs in 22/26 patients, and endoscopy identified GVs in 7/26 patients. Conclusions Gastric varices lie in the submucosa, deeper than EVs, and distinguishing GVs from gastric rugae may be difficult with video endoscopy. This study demonstrated that CT is a sensitive method for early detection of GVs and has been used previously in the evaluation of GVs.
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Ali SM, Wu S, Xu H, Liu H, Hao J, Qin C. A Prospective Study of Endoscopic Injection Sclerotherapy and Endoscopic Variceal Ligation in the Treatment of Esophageal Varices. J Laparoendosc Adv Surg Tech A 2016; 27:333-341. [PMID: 28221819 DOI: 10.1089/lap.2016.0436] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The aim of this study was to compare the effectiveness and safety of endoscopic injection sclerotherapy (EIS) with endoscopic variceal ligation (EVL) in the management of esophageal variceal bleeding (EVB). PATIENTS AND METHODS In this prospective study, we compared the EIS and EVL in 124 patients who had endoscopically proved bleeding from esophageal varices. According to different treatment methods, they were randomly divided into the EIS and the EVL groups. Sixty-four patients were treated with sclerotherapy and 60 with ligation. The patients were followed for a mean of 2 years, during which we determined the incidence of complications and recurrences of bleeding and the number of treatment sessions needed to eradicate varices, mortality, and survival. RESULTS Active bleeding at the first treatment was controlled by EIS in 19 of 19 patients and by EVL in 16 of 16 patients. The likelihood of early rebleeding was slightly smaller in the patients treated with EIS (7.8% versus 11.7%, P = .47). However, late rebleeding rate was slightly more in EIS patients (28.1% versus 23.3%, P = .54) without statistical significance. The rate of eradication of varices in the EIS group was slightly lower than in the EVL group (79.7% versus 86.7%, P = .30). There were also no statistically significant differences in mortality (1.6% versus 3.3%, P = .61) or survival rate (71.9% versus 78.3%, P = .41) (all P > .05) after EIS and EVL. However, fever in the EIS group was significantly higher compared to that of in the EVL group (n = 17, 26.6% versus n = 6, 10.0%, P = .02). CONCLUSIONS Both EIS and EVL produce excellent results, are safe, effective, feasible, and acceptable for EVB with minimum complications and obviate need for subsequent procedures in the short term. To make better choice, we should consider the hospital conditions, operator experience, and the characteristics of esophageal varices.
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Affiliation(s)
- Syed Mohsin Ali
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Shanbin Wu
- 2 Qianfoshan Hospital Affiliated to Shandong University , Jinan, China
| | - Hongwei Xu
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Hui Liu
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Jinghua Hao
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Chengyong Qin
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
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Laurain A, de Leusse A, Gincul R, Vanbiervliet G, Bramli S, Heyries L, Martane G, Amrani N, Serraj I, Saurin JC, Borentain P, Filoche B, Duburque C, Gaudric M, Sogni P, Dumortier J. Oesophageal capsule endoscopy versus oesophago-gastroduodenoscopy for the diagnosis of recurrent varices: a prospective multicentre study. Dig Liver Dis 2014; 46:535-40. [PMID: 24631032 DOI: 10.1016/j.dld.2014.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/22/2014] [Accepted: 02/04/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Oesophago-gastroduodenoscopy is the standard method for the diagnosis of recurrent oesophago-gastric varices after endoscopic treatment and eradication. The aim of this study was to evaluate the PillCam Eso capsule endoscopy in this setting. METHODS Prospective, multicentre study in which patients with history of oesophageal varices treated by band ligation underwent PillCam Eso capsule and oesophago-gastroduodenoscopy. Capsule recordings were blindly read by two endoscopists. Indication for a new prophylactic treatment and patient satisfaction were determined for both procedures. RESULTS 80 patients (80% males, mean age: 57±12 years) were included, after a median delay of 16 months from last endoscopic treatment. Recurrent oesophageal varices requiring a new prophylactic treatment were detected in 26 patients (32.5%). The mean oesophageal transit time of the capsule was 153 s (range 2-930 s). Capsule sensitivity, specificity, negative and positive predictive values for indication of new prophylactic treatments were 65%, 83%, 83%, and 65%, respectively. Capsule adequately classified 77.5% of the patients for prophylaxis indication. Inter-observer concordance for capsule readings was 88% for the prophylaxis indication. CONCLUSION This study demonstrates that accuracy of PillCam Eso capsule for the diagnosis of recurrent oesophageal varices after endoscopic eradication is suboptimal. PillCam Eso capsule might therefore be proposed in patients unable or unwilling to undergo oesophago-gastroduodenoscopy.
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Affiliation(s)
- Anne Laurain
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France
| | - Antoine de Leusse
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France; Jean Mermoz Hospital, Lyon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Rodica Gincul
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Geoffroy Vanbiervliet
- Archet II Hospital, Department of Digestive Diseases, Nice, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Slim Bramli
- Avignon Hospital, Department of Digestive Diseases, Avignon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Laurent Heyries
- Conception Hospital - AP-HM, Department of Digestive Diseases, Marseille, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Gabriel Martane
- Avignon Hospital, Department of Digestive Diseases, Avignon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Naima Amrani
- Ibn Sina Hospital, Department of Digestive Diseases, Rabat, Morocco; Société Française d'Endoscopie Digestive, Paris, France
| | - Ilham Serraj
- Ibn Sina Hospital, Department of Digestive Diseases, Rabat, Morocco
| | - Jean-Christophe Saurin
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France; Lyon Sud Hospital, Department of Digestive Diseases, Pierre Benite, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Patrick Borentain
- Conception Hospital - AP-HM, Department of Digestive Diseases, Marseille, France
| | - Bernard Filoche
- Saint Philibert Hospital, Department of Digestive Diseases, Lomme, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Clotilde Duburque
- Saint Philibert Hospital, Department of Digestive Diseases, Lomme, France
| | - Marianne Gaudric
- Cochin Hospital - AP-HP, Department of Digestive Endoscopy, Paris, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Philippe Sogni
- Cochin Hospital - AP-HP, Department of Digestive Endoscopy, Paris, France
| | - Jérôme Dumortier
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France.
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. Disability index in a randomized controlled trial of emergency sclerotherapy versus portacaval shunt for bleeding varices in cirrhosis. Am J Surg 2012; 204:157-66. [PMID: 22575398 DOI: 10.1016/j.amjsurg.2011.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 09/04/2011] [Accepted: 09/04/2011] [Indexed: 01/23/2023]
Abstract
BACKGROUND Disability has not been studied after emergency treatment of bleeding esophageal varices (BEV). We created a disability index (DI) in a randomized controlled trial comparing emergency endoscopic therapy (EST) versus emergency portacaval shunt (EPCS). METHODS There were 211 unselected, consecutive patients with cirrhosis and acute BEV who were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic work-up and treatment were performed within 8 hours. Ninety-six percent underwent more than 10 years follow-up evaluation. Disability was measured by assessing 9 factors to create a DI. RESULTS Ten-year survival was 8% after EST versus 51% after EPCS (P < .001). EPCS had a significantly better DI. The EST and EPCS values were as follows: liver function improvement: not applicable and ++; worsening liver function, ++ and not applicable; portal-systemic encephalopathy (PSE) incidence, 36 and 15; PSE episodes, 179 and 94; packed red blood cell units, 1,005 and 320; hospital readmissions, 387 and 292; and number of readmission days, 9.6 and 4.7. All of the P values were less than .001. CONCLUSIONS EPCS resulted in a markedly better DI than EST, a significantly higher survival rate, better control of bleeding, and a lower incidence of PSE. EPCS is an effective first-line emergency treatment of BEV.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California San Diego Medical Center, 200 West Arbor Dr., San Diego, CA 92103-8999, USA.
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Child-Turcotte score versus MELD for prognosis in a randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis. J Surg Res 2012; 178:139-46. [PMID: 22480831 DOI: 10.1016/j.jss.2012.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 12/14/2011] [Accepted: 01/03/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Bleeding esophageal varices is responsible for much of the high mortality rate in cirrhosis. An important objective of management of bleeding varices is to develop reliable tools for predicting survival, controlling bleeding and encephalopathy, and improve quality of life. This study compared two widely used prognostic tools, the model for end-stage liver disease (MELD) and the Child-Turcotte (C-T) score, in a randomized controlled trial of emergency treatment of bleeding varices. METHODS We randomized 211 unselected consecutive patients with cirrhosis and bleeding varices to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnosis and treatment were accomplished within 20 hours. Follow-up was 100% for 10 y. We compared the prognostic powers of MELD and C-T upon entry, and then monthly for the first year and every 3 months thereafter. Statistical analysis included computation of receiver operating curves, the area under the curve, and the proportion of variability. RESULTS In baseline determinations of MELD versus C-T, there were no significant differences in predicting survival, recurrent encephalopathy, and rebleeding. The Child-Turcotte score was a stronger predictor than MELD of hospital readmissions and readmission days. In serial determinations over years, the prognostic power of both MELD and C-T was substantial, but C-T was significantly more effective in predicting survival and time to recurrent encephalopathy. CONCLUSIONS In this first long-term comparison of MELD versus C-T in cirrhosis with bleeding varices, C-T was consistently as effective as MELD in predicting survival, encephalopathy, rebleeding, hospital readmissions, and readmission days. In some measures, C-T was a more effective prognostic tool than MELD.
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma. Am J Surg 2011; 203:182-90. [PMID: 21679921 DOI: 10.1016/j.amjsurg.2011.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 02/10/2011] [Accepted: 02/10/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied. METHODS Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had >10 years of follow-up. HCC screening involved serum α-fetoprotein (AFP) every 3 months, ultrasonography every 6 months, and selective computed tomography (CT). RESULTS HCC occurred in 15 patients, all incurable, a mean of 2.94 years after entry. They died a mean 1.33 years after discovery. Serial AFP and ultrasound examinations were unrevealing over a mean of 2.3 years. The mean model of end-stage liver disease score was 12.7 at entry and 17.4 at HCC diagnosis. CONCLUSIONS Long-term screening by AFP and ultrasound plus selective CT failed to detect HCC at a curable stage. The detection of HCC in cirrhotic patients with BEV remains a serious, unsolved problem. The use of CT for routine screening warrants consideration despite increased costs.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego, Medical Center, USA.
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11
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Direct costs of care in a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt for bleeding esophageal varices in cirrhosis--Part 4. J Gastrointest Surg 2011; 15:38-47. [PMID: 20824373 PMCID: PMC3023018 DOI: 10.1007/s11605-010-1332-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Accepted: 08/12/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency treatment of bleeding esophageal varices (BEV) in cirrhotic patients is of prime importance because of the high mortality rate surrounding the episode of acute bleeding. Nevertheless, there is a paucity of randomized controlled trials of emergency surgical therapy and no reports of the costs of any of the widely used forms of emergency treatment. The important issue of direct costs of care was examined in a randomized controlled trial that compared endoscopic sclerotherapy (EST) to emergency portacaval shunt (EPCS). METHODS Two hundred eleven unselected consecutive patients with ultimately biopsy-proven cirrhosis and endoscopically proven acute BEV were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic workup was completed, and EST or EPCS was initiated within 8 h. Criteria for failure of EST or EPCS were clearly defined, and crossover rescue treatment was applied, when primary therapy failed. Ninety-six percent of patients underwent more than 10 years follow-up, or until death. Complete charges for all aspects of care were obtained continuously for more than 10 years. RESULTS Direct charges for all aspects of care were significantly lower in patients treated by EPCS than in patients treated by emergency EST followed by long-term repetitive sclerotherapy. Charges per patient, per year of treatment, and per year in each child's risk class were significantly lower in patients randomized to EPCS. Charges in patients who failed endoscopic sclerotherapy and underwent a rescue portacaval shunt were significantly higher than the charges in both the unshunted sclerotherapy patients and the patients randomized to EPCS. This result was particularly noteworthy given the widespread practice of using surgical portacaval shunt as rescue treatment only when all other forms of therapy have failed. CONCLUSIONS In this randomized controlled trial of emergency treatment of acute BEV, EPCS was significantly superior to EST with regard to direct costs of care as reflected in charges for care as well as in survival rate, control of bleeding, and incidence of portal-systemic encephalopathy. These results provide support for the use of EPCS as a first line of emergency treatment of BEV in cirrhosis.
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. Alcoholic versus nonalcoholic cirrhosis in a randomized controlled trial of emergency therapy of bleeding varices. J Surg Res 2010; 174:98-105. [PMID: 21195430 DOI: 10.1016/j.jss.2010.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 10/28/2010] [Accepted: 11/03/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND It has been proposed that portal-systemic shunts be avoided in alcoholic cirrhotics because survival rate is allegedly lower in alcoholics than in nonalcoholics. We examined this issue in a randomized controlled trial. METHODS Two hundred eleven unselected, consecutive patients with cirrhosis and bleeding esophageal varices were randomized to endoscopic sclerotherapy (EST) (n = 106) or emergency portacaval shunt (EPCS) (105). Treatment was initiated within 8 h. EST failure was treated by rescue portacaval shunt (PCS). Ten-year follow-up was 96%. RESULTS Results strongly favored EPCS over EST (P < 0.001). Among EPCS patients, 83% were alcoholic and 17% nonalcoholic. Outcomes were (1) permanent control of bleeding 100% versus 100%; (2) 5-y survival 71% versus 78%; (3) encephalopathy 14% versus 19%; (4) yearly charges $38,300 versus $43,000. CONCLUSIONS EPCS results were similar in alcoholic and nonalcoholic cirrhotics. EPCS is an effective first line emergency treatment in all forms of cirrhosis, including alcoholic.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego Medical Center, 200West Arbor Drive, San Diego, CA 92103-8999, USA.
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13
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. Liver transplantation in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis. Transplant Proc 2010; 42:4101-8. [PMID: 21168637 PMCID: PMC3032417 DOI: 10.1016/j.transproceed.2010.09.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 09/03/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bleeding esophageal varices (BEV) in cirrhosis has been considered an indication for liver transplantation (LT). This issue was examined in a randomized controlled trial (RCT) of unselected, consecutive patients with advanced cirrhosis and BEV that compared endoscopic sclerotherapy (EST; n = 106) to emergency direct portacaval shunt (EPCS; n = 105). METHODS Diagnostic work-up and treatment were initiated within 8 hours. Patients were evaluated for LT on admission and repeatedly thereafter; 96% underwent over 10 years of regular follow-up. The analysis was supplemented by 1300 unrandomized cirrhotic patients who previously underwent portacaval shunt (PCS) with 100% follow-up. RESULTS In the RCT long-term bleeding control was 100% following EPCS, only 20% following EST. Also, 3-, 5-, 10-, and 15-year survival rates were 75%, 73%, 46%, and 46%, respectively, following EPCS compared with 44%, 21%, 9%, and 9% following EST, respectively (P < .001). Only 13 RCT patients (6%) were ultimately referred for LT mainly because of progressive liver failure; only 7 (3%) were approved for LT and only 4 (2%) underwent LT. The 1- and 5-year LT survival rates were 0.68% and 0, respectively, compared with 81% and 73%, respectively, after EPCS. In the 1300 unrandomized PCS patients, 50 (3.8%) were referred and 19 (1.5%) underwent LT. The 5-year survival rate was 53% compared with 72% for all 1300 patients. CONCLUSIONS If bleeding is permanently controlled, as occurred invariably following EPCS, cirrhotic patients with BEV seldom require LT. PCS is effective first-line and long-term treatment. Should LT be required in patients with PCS, although technically more demanding, numerous studies have shown that PCS does not increase mortality or complications. EST is not effective emergency or long-term therapy.
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Affiliation(s)
- M J Orloff
- Department of Surgery, University of California, San Diego Medical Center, San Diego, California 92103-8999, USA.
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Abstract
Purpose: The purpose of this article is to educate nurse practitioners about the pathophysiology surrounding the development of portal hypertension and the effective use of nonselective ß-blockers to prevent primary bleeding and decrease the mortality risk. Data sources: The articles included were retrieved via ISI Web of Science using the years 2004–2009 and key words cirrhosis, portal hypertension, esophageal varices, and beta-blockers. This information included scholarly books, journal reviews, retrospective chart reviews, and prospective randomized studies. Conclusions: Cirrhosis is the leading cause of portal hypertension in Europe and North America. Esophageal varices are a result of the portosystemic collaterals the body develops to decompress the portal system. Hemorrhage from esophageal varices is a major cause of morbidity and mortality. Prevention of a primary bleed is the goal of therapy and is accomplished with nonselective ß-blockers. Implications for practice: Very few patients with portal hypertension and esophageal varices are on ß-blockers. Use of nonselective ß-blockers has been found to lower portal pressure and decreases the risk of bleeding from esophageal varices and therefore decreases mortality. Patients unable to use ß-blockers can undergo endoscopic variceal ligation as an alternate method to reduce risk of bleeding.
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Affiliation(s)
- Tammy Tursi
- Endoscopy Department, Hospital of the University of Pennsylvania, Philadelphia, USA.
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15
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ. Emergency portacaval shunt versus rescue portacaval shunt in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis--part 3. J Gastrointest Surg 2010; 14:1782-95. [PMID: 20658205 PMCID: PMC2956038 DOI: 10.1007/s11605-010-1279-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 06/28/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Emergency treatment of bleeding esophageal varices in cirrhosis is of singular importance because of the high mortality rate. Emergency portacaval shunt is rarely used today because of the belief, unsubstantiated by long-term randomized trials, that it causes frequent portal-systemic encephalopathy and liver failure. Consequently, portacaval shunt has been relegated solely to salvage therapy when endoscopic and pharmacologic therapies have failed. QUESTION Is the regimen of endoscopic sclerotherapy with rescue portacaval shunt for failure to control bleeding varices superior to emergency portacaval shunt? A unique opportunity to answer this question was provided by a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt conducted from 1988 to 2005. METHODS Unselected consecutive cirrhotic patients with acute bleeding esophageal varices were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup was completed and treatment was initiated within 8 h. Failure of endoscopic sclerotherapy was defined by strict criteria and treated by rescue portacaval shunt (n = 50) whenever possible. Ninety-six percent of patients had more than 10 years of follow-up or until death. RESULTS Comparison of emergency portacaval shunt and endoscopic sclerotherapy followed by rescue portacaval shunt showed the following differences in measurements of outcomes: (1) survival after 5 years (72% versus 22%), 10 years (46% versus 16%), and 15 years (46% versus 0%); (2) median post-shunt survival (6.18 versus 1.99 years); (3) mean requirements of packed red blood cell units (17.85 versus 27.80); (4) incidence of recurrent portal-systemic encephalopathy (15% versus 43%); (5) 5-year change in Child's class showing improvement (59% versus 19%) or worsening (8% versus 44%); (6) mean quality of life points in which lower is better (13.89 versus 27.89); and (7) mean cost of care per year ($39,200 versus $216,700). These differences were highly significant in favor of emergency portacaval shunt (all p < 0.001). CONCLUSIONS Emergency portacaval shunt was strikingly superior to endoscopic sclerotherapy as well as to the combination of endoscopic sclerotherapy and rescue portacaval shunt in regard to all outcome measures, specifically bleeding control, survival, incidence of portal-systemic encephalopathy, improvement in liver function, quality of life, and cost of care. These results strongly support the use of emergency portacaval shunt as the first line of emergency treatment of bleeding esophageal varices in cirrhosis.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, UCSD Medical Center, 200 West Arbor Drive, San Diego, CA 92103-8999, USA.
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Harras F, Sheta ES, Shehata M, El Saadany S, Selim M, Mansour L. Endoscopic band ligation plus argon plasma coagulation versus scleroligation for eradication of esophageal varices. J Gastroenterol Hepatol 2010; 25:1058-65. [PMID: 20594219 DOI: 10.1111/j.1440-1746.2010.06265.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to evaluate endoscopic band ligation plus argon plasma coagulation versus scleroligation. METHODS Patients were randomized to: Group I, 50 patients subjected to endoscopic injection sclerotherapy; Group II, 50 patients subjected to variceal band ligation; Group III, 50 patients subjected to combined endoscopic sclerotherapy and band ligation; and Group IV, 50 patients subjected to endoscopic band ligation plus argon plasma coagulation. RESULTS A comparison of the number of therapeutic sessions showed that group III underwent significantly fewer sessions. As regards post-treatment complications, Group I showed a high incidence of transient pyrexia, transient dysphagia and/or retrosternal pain and ulceration, while in group II a higher incidence of rebleeding was demonstrated, as well as a higher incidence of esophageal varix recurrence after eradication during the follow-up period. A higher mortality incidence was detected in groups I and II. The follow-up incidence did not significantly differ between the different study groups. CONCLUSION Scleroligation allows very rapid eradication of varices, has a low recurrence rate, avoids the disadvantage of high recurrence of band ligation alone, and does not require special skills over sclerotherapy or band ligation. Also, band ligation plus argon plasma coagulation allows for very rapid eradication of varices, and a low recurrence rate, with no obvious recorded complications, but it has the disadvantage of being the most expensive technique and requires special equipment that is only available in a few endoscopic centers.
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Affiliation(s)
- Fouad Harras
- Department of Internal Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
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17
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Abstract
The rate of rebleeding from esophageal varices remains appreciably high after cessation of acute esophageal variceal hemorrhage. Many measures have been developed to prevent the occurrence of rebleeding. Endoscopic therapy plays a central role in the prevention of variceal bleeding. In the 1980s sclerotherapy played a pivotal role in the prevention of variceal rebleeding, but now yields to endoscopic variceal ligation. Compared with sclerotherapy, a lower incidence of complications and rebleeding is associated with banding ligation. On the other hand, beta-blockers are also noted to be able to reduce portal pressure, leading to the reduction of variceal rebleeding. The reduction of variceal rebleeding with beta-blockers plus nitrates is as effective as banding ligation. The combination of beta-blockers and endoscopic variceal ligation has proven to be more efficacious than banding ligation alone in the reduction of variceal rebleeding and is the treatment of choice for patients with failure in either medical or endoscopic therapy. Patients with repeated rebleeding despite endoscopic therapies may require transjugular intrahepatic portosystemic stent shunt or shunt operation as a rescue therapy.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Education, Digestive Center, E-DA Hospital, Kaohsiung County, Taiwan, Republic of China.
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Lukashok HP, Robles-Medranda C, Santana MDA, Costa MHM, Borges ADA, Zaltmani C. Intramural esophageal hematoma after elective injection sclerotherapy. ARQUIVOS DE GASTROENTEROLOGIA 2010; 46:279-83. [PMID: 20232006 DOI: 10.1590/s0004-28032009000400006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Accepted: 03/23/2009] [Indexed: 11/22/2022]
Abstract
CONTEXT Although endoscopic esophageal variceal sclerotherapy has been largely supplanted by variceal band ligation, it is still performed routinely in many institutions, especially in developing countries. Intramural esophageal hematoma has been described as a rare complication of sclerotherapy. Risk factors have not been completely established. OBJECTIVE To demonstrate the incidence of post-sclerotherapy intramural esophageal hematoma in our hospital and discuss the possible factors involved. METHODS This is a retrospective observational study made at the 'Hospital Universitário Clementino Fraga Filho', Rio de Janeiro, RJ, Brazil, reviewing the medical records of all esophageal variceal sclerotherapy procedures performed from April 2000 to November 2005. The evaluation of the clinical, laboratorial and endoscopic features in our patients and those reported in the literature was also done. Review of literature was performed through MEDLINE search. RESULTS A total of 1,433 esophageal variceal sclerotherapy procedures were performed in 397 patients, with an intramural esophageal hematoma incidence of 4 cases (0.28%). Three of our patients developed additional complications, and one death was a direct consequence of a rupture of the hematoma. Nineteen well described cases were reported in the literature. Intramural esophageal hematoma occurred mostly after the forth esophageal variceal sclerotherapy session. Coagulation disturbances were present in the majority of cases. CONCLUSION Intramural esophageal hematoma is a rare complication of esophageal variceal sclerotherapy and its incidence in our institution was similar to those observed in the literature. Our study suggests that this complication occurs as a result of a fragile esophageal mucosa after previous esophageal variceal sclerotherapy sessions. Impaired coagulation, although not essential, could contribute to hematoma formation and extension through esophageal submucosa.
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Affiliation(s)
- Hannah Pitanga Lukashok
- Gastroenterology Division, University Hospital Clementino Fraga Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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Krige JEJ, Kotze UK, Distiller G, Shaw JM, Bornman PC. Predictive factors for rebleeding and death in alcoholic cirrhotic patients with acute variceal bleeding: a multivariate analysis. World J Surg 2009; 33:2127-35. [PMID: 19672651 DOI: 10.1007/s00268-009-0172-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bleeding from esophageal varices is a leading cause of death in alcoholic cirrhotic patients. The aim of the present single-center study was to identify risk factors predictive of variceal rebleeding and death within 6 weeks of initial treatment. METHODS Univariate and multivariate analyses were performed on 310 prospectively documented alcoholic cirrhotic patients with acute variceal hemorrhage (AVH) who underwent 786 endoscopic variceal injection treatments between January 1984 and December 2006. All injections were administered during the first 6 weeks after the patients were treated for their first variceal bleed. RESULTS Seventy-five (24.2%) patients experienced a rebleed, 38 within 5 days of the initial treatment and 37 within 6 weeks of their initial treatment. Of the 15 variables studied and included in a multivariate analysis using a logistic regression model, a bilirubin level >51 mmol/l and transfusion of >6 units of blood during the initial hospital admission were predictors of variceal rebleeding within the first 6 weeks. Seventy-seven (24.8%) patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days after the initial treatment. Stepwise multivariate logistic regression analysis showed that six variables were predictors of death within the first 6 weeks: encephalopathy, ascites, bilirubin level >51 mmol/l, international normalized ratio (INR) >2.3, albumin <25 g/l, and the need for balloon tube tamponade. CONCLUSIONS Survival was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients. Patients with AVH and encephalopathy, ascites, bilirubin levels >51 mmol/l, INR >2.3, albumin <25 g/l and who require balloon tube tamponade are at increased risk of dying within the first 6 weeks. Bilirubin levels >51 mmol/l and transfusion of >6 units of blood were predictors of variceal rebleeding.
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Affiliation(s)
- Jake E J Krige
- Department of Surgery J45OMB, Groote Schuur Hospital, Anzio Road, Observatory 7925, Cape Town, South Africa.
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Doppler Ultrasound Could Predict Varices Progression and Rebleeding After Portal Hypertension Surgery: Lessons from 146 EGDS and 10 Years of Follow-Up. World J Surg 2009; 33:2136-43. [DOI: 10.1007/s00268-009-0196-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ. Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. J Am Coll Surg 2009; 209:25-40. [PMID: 19651060 PMCID: PMC6420230 DOI: 10.1016/j.jamcollsurg.2009.02.059] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 02/13/2009] [Accepted: 02/16/2009] [Indexed: 01/15/2023]
Abstract
BACKGROUND The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage. STUDY DESIGN A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death. RESULTS The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01). CONCLUSIONS EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027).
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA 92103-8999, USA
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Fang HP, Deng MH, Lin N, Pan WD, Liu B, Lin YB, Tang ZF, Xu RY. A novel canine model of esophageal varices with a balloon dilatation constrictor. Dig Dis Sci 2009; 54:1449-55. [PMID: 18958619 DOI: 10.1007/s10620-008-0515-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 08/22/2008] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVE The canine model of esophageal varices with an agar constrictor has been used for studies of the endoscopic treatment of esophageal variceal bleeding, but it has limitations in both stability and successful rate. This study was designed to enhance the model's efficiency and success rate by using a novel approach with a balloon dilatation constrictor. METHODS We used 22 adult mongrel dogs to establish the model by progressively compressing and constricting the portal vein through a rechargeable balloon dilatation constrictor in combination with side-to-side portocaval shunt and inferior vena cava (IVC) ligation to increase portal vein pressure (PVP). The rechargeable balloon dilatation constrictor was composed of a hyaline polypropylene (PP) ring, a silica gel tube with a balloon, and an injection pedestal (silica gel) in an implantable vascular access port. The effects were evaluated with pre- and post-shunt PVP measurement, weekly gastroscopy, and portocaval venography. RESULTS The mean PVP increased significantly from a preoperative (before side-to-side portocaval shunt and IVC ligation) 12.86 +/- 0.18 cmH(2)O to 26.75 +/- 0.39 cmH(2)O after the model had been established (P < 0.05). After the model was established, gastroscopy performed to assess esophageal varix size demonstrated four varicose veins of grade I, six of grade II, eight of grade III and four of grade IV. The portocaval angiography showed that the IVC and portal vein were completely blocked, that the anastomosis stoma was unobstructed and that the blood flow through esophageal varices via splenetic and gastric veins was blocked. CONCLUSION The novel canine model developed with a rechargeable balloon dilatation constrictor is feasible and reliable for modeling esophageal varices.
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Affiliation(s)
- He-Ping Fang
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital, SUN Yat-Sen University, Guangzhou, 510630, China
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Study of oesophageal motility in Egyptian cirrhotic patients before and after prophylactic endoscopic variceal ligation. Arab J Gastroenterol 2009. [DOI: 10.1016/j.ajg.2009.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Yuki M, Kazumori H, Yamamoto S, Shizuku T, Kinoshita Y. Prognosis following endoscopic injection sclerotherapy for esophageal varices in adults: 20-year follow-up study. Scand J Gastroenterol 2009; 43:1269-74. [PMID: 18609148 DOI: 10.1080/00365520802130217] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Endoscopic injection sclerotherapy (EIS) is beneficial in the management of active hemorrhaging and prevention of recurrent bleeding from esophageal varices. However, its long-term efficacy and safety are poorly defined. The aim of this study was to determine long-term cumulative survival and clarify negative predictive factors for survival following EIS in patients with esophageal varices. MATERIAL AND METHODS Between 1981 and 1987, 72 patients were prospectively enrolled in a post-EIS follow-up program. Variceal rebleeding, recurrence, and survival were recorded in follow-up examinations conducted for up to 20 years. RESULTS The mean follow-up period was 86.9 months. The cumulative survival rates were 65.2%, 53.6%, 26.1%, and 11.6% at 36, 60, 120, and 240 months, respectively, with liver failure the most common cause of death. Esophageal varices were eradicated in 93.1% of the patients following EIS and no recurrence of varices was seen beyond 7 years. Significant negative predictive factors for survival rate shown by Cox's proportional multivariate hazard model analysis were older age, advanced liver damage, presence of hepatocellular carcinoma, and occurrence of rebleeding. CONCLUSIONS Long-term survival, rebleeding, and recurrence rates following EIS were clarified. Furthermore, our results clearly demonstrate negative predictive factors for survival after EIS.
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Affiliation(s)
- Mika Yuki
- Department of Internal Medicine, Izumo City General Medical Center, Shimane, Japan
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Abstract
For years splenectomy in hepatic disorders has been indicated only for the treatment of gastro-esophageal varices. However, with recent advances in medical and surgical treatments for chronic hepatic disorders, the use of splenectomy has been greatly expanded, such that splenectomy is used for reversing hypersplenism, for applying interferon treatment for hepatitis C, for treating hyperdynamic portal circulation associated with intractable ascites, and for controlling portal pressure during small grafts in living donor liver transplantation. Such experiences have shown the importance of portal hemodynamics, even in cirrhotic livers. Recent advances in surgical techniques have enabled surgeons to perform splenectomy more safely and less invasively, but the procedure still has considerable clinical outcomes. Splenectomy in hepatic disorders may become a more common procedure with expanded indications. However, it should also be noted that the long-term effects of splenectomy, in terms of improved hematological or hepatic function, is still not guaranteed. Moreover, the impact of splenectomy on immunologic status remains unclear and needs to be elucidated in both experimental and clinical settings.
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Affiliation(s)
- Toru Ikegami
- The Department of Surgery, the University of Tokushima, Tokushima, Japan
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Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for variceal bleeding disorders of the GI tract. Gastrointest Endosc 2008; 67:313-23. [PMID: 18226695 DOI: 10.1016/j.gie.2007.09.052] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 09/27/2007] [Indexed: 02/07/2023]
Affiliation(s)
- Walter G Park
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California 94305, USA.
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Sogaard KK, Astrup LB, Vilstrup H, Gronbaek H. Portal vein thrombosis; risk factors, clinical presentation and treatment. BMC Gastroenterol 2007; 7:34. [PMID: 17697371 PMCID: PMC1976099 DOI: 10.1186/1471-230x-7-34] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Accepted: 08/15/2007] [Indexed: 12/15/2022] Open
Abstract
Background Portal vein thrombosis (PVT) is increasingly frequently being diagnosed, but systematic descriptions of the natural history and clinical handling of the condition are sparse. The aim of this retrospective study was to describe risk factors, clinical presentation, complications and treatment of portal vein thrombosis in a single-centre. Methods Sixty-seven patients were identified in the electronic records from 1992 to 2005. All data were obtained from the patient records. Results One or more risk factors (e.g. prothrombotic disorder or abdominal inflammation) were present in 87%. Symptoms were abdominalia, splenomegaly, fever, ascites, haematemesis, and weight loss. Abdominalia and fever occurred more frequently in patients with acute PVT. Frequent complications were splenomegaly, oesophageal- and gastric varices with or without bleeding, portal hypertensive gastropathy and ascites. Varices and bleeding were more frequent in patients with chronic PVT. Patients who received anticoagulant therapy more frequently achieved partial/complete recanalization. Patients with varices who were treated endoscopically in combination with β-blockade had regression of the varices. The overall mortality was 13% in one year, and was dependent on underlying causes. Conclusion Most patients had a combination of local and systemic risk factors for PVT. We observed that partial/complete recanalization was more frequent in patients treated with anticoagulation therapy, and that regression of varices was more pronounced in patients who where treated with active endoscopy combined with pharmacological treatment.
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Affiliation(s)
- Kirstine K Sogaard
- Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, 8000 Aarhus C, Denmark
| | - Lone B Astrup
- Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, 8000 Aarhus C, Denmark
| | - Hendrik Vilstrup
- Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, 8000 Aarhus C, Denmark
| | - Henning Gronbaek
- Department of Medicine V (Hepatology and Gastroenterology), Aarhus University Hospital, 8000 Aarhus C, Denmark
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Krige JEJ, Kotze UK, Bornman PC, Shaw JM, Klipin M. Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices. Ann Surg 2006; 244:764-70. [PMID: 17060770 PMCID: PMC1856595 DOI: 10.1097/01.sla.0000231704.45005.4e] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis. SUMMARY BACKGROUND DATA Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy. METHODS Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24-87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565 upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded. RESULTS Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1-174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3-198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death. CONCLUSION Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients.
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Affiliation(s)
- Jake E J Krige
- Department of Surgery, University of Cape Town Health Sciences Faculty, Anzio Road, Observatory 7925, Cape Town, South Africa.
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Stiegmann GV. Evolution of endoscopic therapy for esophageal varices. Surg Endosc 2006; 20 Suppl 2:S467-70. [PMID: 16544066 DOI: 10.1007/s00464-006-0003-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2006] [Accepted: 01/30/2006] [Indexed: 01/06/2023]
Abstract
Endoscopic treatment for bleeding esophageal varices was first described 65 years ago, but the technique was not widely adopted until the 1970s. Rapid progress since then has resulted in new, more effective forms of endoscopic treatment. Currently, endoscopic therapy is the primary treatment for patients with bleeding esophageal varices at most centers. This review traces the evolution of endoscopic treatment, summarizes current outcomes data, and speculates on future development.
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Affiliation(s)
- G V Stiegmann
- University of Colorado Denver and Health Sciences Center, Denver, CO 80262, USA.
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