Endoscopic variceal ligation in patients who have failed endoscopic sclerotherapy

Incidence and risk factors of dysphagia after variceal band ligation

Background/Aims

There is a lack of data on long-term morbidity, particularly dysphagia, following endoscopic variceal band ligation (EVL). The aim of this study are to assess the incidence of dysphagia and variables associated with this complication after EVL.

Methods

We identified individuals who completed at least one session of EVL as their sole treatment for varices from August 2012 to December 2017. Included patients achieved “complete eradication” of varices not requiring further therapy. Patients ≥90 days from their last EVL session completed a modified version of the Mayo Clinic Dysphagia Questionnaire. Individuals with dysphagia were invited to undergo a barium esophagram. Patients with pre-EVL dysphagia were excluded.

Results

Of the patients, 68 possessed inclusion criteria, nine (13.2%) died and 20 (29.4%) were lost to follow up. For the remaining 39 (57.4%) patients, 23 were males, mean age of 61.7±8.6 years. The most common etiology of liver disease was hepatitis C virus (n=18; 46.2%). The median number of banding sessions was 2.0 (interquartile range [IQR], 1.0–4.0) with a median of 9.0 bands placed (IQR, 3.0–14.0). Twelve patients (30.8%) developed new-onset dysphagia post-EVL. In univariate analysis, pre-EVL MELD score and non-emergent initial banding were associated with long-term dysphagia. In a regression model adjusted for age, sex, number of bands, and use of acid suppression after EVL, no factor was independently associated with dysphagia (all p>0.05). No strictures were identified on subsequent esophageal evaluation.

Conclusions

Approximately 30% of patients developed new-onset, chronic dysphagia post-EVL. Incident dysphagia was associated with a non-emergent initial banding session. The mechanism for dysphagia remains unknown.

Risk Factors and On-site Rescue Treatments for Endoscopic Variceal Ligation Failure

Background/Aims

The success rate of endoscopic variceal ligation (EVL) is about 85-94%. There is only a few studies attempting to determine the cause of EVL failure, and to date, on-site rescue treatments remains unestablished. This study aimed to elucidate the risk factors for EVL failure and the effectiveness of on-site rescue treatment.

Methods

Data of 454 patients who underwent emergency EVL at Chonnam National University Hospital were retrospectively analyzed. Enrolled patients were divided into two groups: the EVL success and EVL failure groups. EVL failures were defined as inability to ligate the varices due to poor endoscopic visual field, or failure of hemostasis after band ligation for the culprit lesion.

Results

Forty-seven patients experienced EVL failure. In the multivariate analysis, male patients, initial hypovolemic shock, active bleeding on endoscopy, and history of previous EVL were independent risk factors for EVL failure. During endoscopic procedure, we came across the common causes of EVL failure, including unsuctioned varix due to previous EVL-induced scars followed by insufficient ligation of the stigmata and inability to ligate the varix due to poor endoscopic visual field. Endoscopic variceal obturation using N-butyl-2-cyanoacrylate (48.9%) was the most commonly used on-site rescue treatment method, followed by insertion of Sangstaken Blakemore tube (14.9%), and EVL retrial (12.8%). The rescue treatments successfully achieved hemostasis in 91.7% of those in the EVL failure group.

Conclusions

The risk factors of EVL failure should be considered before performing EVL, and in case of such scenario, on-site rescue treatment is needed.

Acute gastrointestinal bleeding - a new approach to clinical and endoscopic management

Overt or occult gastrointestinal bleeding is a frequently observed condition in routine gastroenterological practice. Occult gastrointestinal bleeding is usually a purely incidental finding, based on the discovery of iron deficiency anemia in the laboratory or blood in stool (a positive Hemoccult test). However, overt bleeding accompanied by the clinical features of tarry stool, hematemesis, or hematochezia may be a life-threatening condition, calling for immediate emergency management. In contrast to traumatology, algorithms of emergency and intensive medicine are not sufficiently validated yet for acute life-threatening bleeding. The purpose of this review was to present all established and new endoscopic hemostasis techniques and to evaluate their efficacy, as well as to provide the treating endoscopist with practical advice on how he/she could incorporate these procedures into acute medical management. The recommendations are based on inspection of the study results in the recent published literature, as well as emergency medicine algorithms in traumatology.

Endoscopic management of portal hypertension

Cirrhosis is the leading cause of portal hypertension worldwide, with the development of bleeding gastroesophageal varices being one of the most life-threatening consequences. Endoscopy plays an indispensible role in the diagnosis, staging, and prophylactic or active management of varices. With the expected future refinements in endoscopic technology, capsule endoscopy may one day replace traditional gastroscopy as a diagnostic modality, whereas endoscopic ultrasound may more precisely guide interventional therapy for gastric varices.

Efficacy of absolute alcohol injection compared with band ligation in the eradication of esophageal varices

BACKGROUND

Endoscopic sclerotherapy is an absolute indication for treating esophageal varices. Re-bleeding is common during the treatment period, before all varices become eradicated.

AIM

To compare two techniques of endoscopic esophageal varices eradication: sclerotherapy with absolute alcohol and banding ligation.

PATIENTS AND METHOD

Forty-six patients with liver cirrhosis and esophageal varices were prospectively randomized into two treatment groups: endoscopic sclerotherapy with absolute alcohol and banding ligation. Patients were included if they had large varices with signs of high bleeding risk. Informed writing consent was obtained from every patient and the Ethics Committee of Federal University of São Paulo, SP, Brazil, approved the study. After eradication, all patients were followed up to 1 year to look for re-bleeding episodes and variceal recurrence.

RESULTS

Both groups were similar except that male gender was more common in the sclerotherapy group. There was no statistical difference regarding variceal eradication (78.3% in sclerotherapy group vs 73.9% in the ligation group), recurrence (26.7% vs 42.9%, respectively) and death related to any cause (21.7% vs 13.9%). In the sclerotherapy group more sessions were need to obtain complete variceal eradication. In this group we did observe a high re-bleeding rate (34.8%) and more ulcers associated with retrosternal pain right after the procedure. There was no difference regarding overall morbidity and mortality.

CONCLUSIONS

Banding ligation requires fewer sessions than sclerotherapy with absolute alcohol to eradicate esophageal varices. Both methods are equally efficient regarding variceal eradication and recurrence during a short follow-up period.

Management of portal hypertension after variceal hemorrhage

Each variceal bleed is associated with 20% to 30% risk of dying. Management of portal hypertension after a bleed consists of (1) control of bleeding and (2) prevention of rebleeding. Effective control of bleeding can be achieved either pharmacologically by administering somatostatin or octreotide or endoscopically via sclerotherapy or variceal band ligation. In practice, both pharmacologic and endoscopic therapy are used concomitantly. Rebleeding can be prevented by endoscopic obliteration of varices. In this setting, variceal ligation is the preferred endoscopic modality. B-blockade is as effective as endoscopic therapy and, in combination, the two modalities may be additive.

Management of upper gastrointestinal bleeding in the patient with chronic liver disease

This article reviews the management of severe upper gastrointestinal bleeding in the patient with chronic liver diseases. The initial assessment, diagnostic work-up, and treatment options for variceal and nonvariceal bleeding are discussed. The role of diagnostic and therapeutic endoscopy for esophagogastric varices is reviewed with special emphasis on new endoscopic techniques including variceal band ligation and cyanoacrylate injection. Various pharmacologic, surgical, and radiologic treatment options for variceal bleeding also are discussed. In addition, nonvariceal causes of severe upper gastrointestinal bleeding are reviewed including peptic ulcer diseases, Mallory-Weiss tear, portal hypertensive gastropathy, and gastric antral vascular ectasia.

New approaches to endoscopic therapy for a haemostasis upper GI bleed

Haematemesis and/or melaena are the most common presentations of upper gastrointestinal bleeding. Endoscopic haemostasis after diagnosis still remains a challenge to the gastroenterologist. Most variceal and peptic ulcer bleeding episodes stop spontaneously, and then prevention of rebleeding might be indicated by endoscopic techniques. In the present article, four less well-known endoscopic haemostasis techniques are discussed and, if available, comparative studies are reviewed.

A new method of endoscopic variceal ligation-injection sclerotherapy (EVLIS) for gastric varices

OBJECTIVES

For esophageal varices, endoscopic variceal sclerotherapy and band ligation have been effectively and frequently used, but these methods were not effective for gastric varices. In gastric varices, because of rich networks of feeding vessels and shunts that may exist in many cases, an effective therapeutic level of sclerosant is difficult to be maintained. Accordingly, we propose a new method called "Endoscopic Variceal Ligation-Injection Sclerotherapy (abbreviated EVLIS)" for gastiric varices, with focus on maintenance of the effective therapeutic level of a sclerosant by partially blocking the blood flow of gastric varices using the band ligation method. The study was undertaken prospectively to evaluate the efficacy and safety of EVLIS for the treatment of gastric varices.

METHODS

EVLIS was performed in a group of 32 patients with gastric varices. Active bleeding varices were 11 and non-bleeding 21. Five cases were grade A, 12 grade B, and 14 grade C of Child's classification. Nine cases were type 1, 22 type 2, and 1 was type 3 of Hosking-Johnson's classification.

RESULTS

The results of EVLIS were excellent, active bleeding of gastric varices in the 11 cases were successfully controlled and all the gastric varices of 32 cases including those bleeding varices were completely eradicated. The bleeding status, the Child's grade and the Hosking-Johnson's class do not appear to correlate in any way with the efficacy of this technique. No perforation or re-bleeding was observed in any of the patients until the mean 10.6 months of the follow-up period.

CONCLUSIONS

EVLIS should be considered as an effective and safe treatment for gastric varices.

New approaches to endoscopic therapy for hemostasis of upper GI bleed

Hematemesis and/or melena are the most common presentations of upper gastrointestinal bleeding. Endoscopic hemostasis after diagnosis still remains a challenge to the gastroenterologist. Most variceal and peptic ulcer bleeding episodes stop spontaneously, and then prevention of rebleeding might be indicated by endoscopic techniques. Four not so well known endoscopic hemostasis techniques are discussed and comparative studies are reviewed.

Long-term management of variceal bleeding: the place of varix injection and ligation

Injection sclerotherapy remains the most widely used long-term management for patients after an esophageal variceal bleed. Sclerotherapy treatments should be repeated weekly until the varices are eradicated. Follow-up endoscopy every 6 to 12 months is required for life. Whenever varices recur, further weekly injection treatments are administered until re-eradication is achieved. Failure of sclerotherapy must be diagnosed early and an alternative salvage procedure performed. We currently recommend the distal splenorenal shunt. Although the complications of sclerotherapy are not great, they are cumulative with time. Unlike most surgical procedures for portal hypertension, the technique of performing sclerotherapy is not standardized, making the comparison of controlled trials difficult. The current status of controlled trials comparing sclerotherapy with other treatments is evaluated. We conclude that repeated injection sclerotherapy is at present the initial treatment of choice for patients after an esophageal variceal bleed. The technique of the new procedure of esophageal variceal ligation is described. As with sclerotherapy, weekly treatment sessions are recommended until the esophageal varices are eradicated, followed by long-term endoscopic surveillance and repeat ligation treatment when varices recur. The four controlled trials that have compared variceal ligation with sclerotherapy favor ligation. Ligation eradicated esophageal varices with fewer treatment sessions and a lower complication rate. One trial demonstrated improved survival. Complications due to the overtube are being increasingly reported but were not a problem in the controlled trials. Although esophageal variceal ligation or ligation plus sclerotherapy may ultimately prove to be superior to sclerotherapy alone, more data are required before a final conclusion can be reached.

Portal hypertension management

Injection sclerotherapy is the mainstay of treatment for acute variceal bleeding and for long-term management after a variceal bleed. In those few patients in whom sclerotherapy fails to control acute bleeding, either a surgical shunt or a simple esophageal transection is recommended. A surgical shunt or a more extensive esophagogastric devascularization and transection operation is advocated for the failures of long-term sclerotherapy management. The role of pharmacological agents in acute variceal bleed management remains in question, and the use of propranolol in long-term management, either as an alternative to sclerotherapy or in combination with sclerotherapy, is controversial. The definitive roles of the newly described variceal banding and transjugular intrahepatic porto-systemic shunts (TIPS) procedures have yet to be established. All patients presenting with end-stage liver disease and esophageal variceal bleeding should be evaluated for a liver transplant, although few will qualify. A possible future transplant should be kept in mind when emergency treatment is planned. Any form of prophylactic therapy for patients with esophageal varices that have not yet bled will remain unjustified until those patients at high risk of a first variceal bleed can be identified. The gastric mucosal lesion, portal hypertensive gastropathy, has been underdiagnosed in the past. Although bleeding does occur, it is seldom a major clinical problem. When necessary, bleeding can be controlled by propranolol or a surgical shunt.

Treatment of acute gastroesophageal variceal hemorrhage

About 30% to 35% of patients with portal hypertension bleed from gastroesophageal varices and mortality remains high reflecting the challenges of effectively dealing with the bleeding event itself and the problems of underlying liver disease. Careful resuscitation and control of risk of complications is the most essential element of medical therapy (Fig. 2). Use of newer, more effective drug combinations with vasopressin or somatostatin permit control of hemorrhage in the majority of patients with fewer drug-induced complications. Endoscopic sclerotherapy and, more recently, banding therapy provide immediate control of hemorrhage and eradication of varices and rebleeding in up to 90% of patients. Persistent, recurrent bleeding in the small number of remaining patients can be effectively managed by "portacaval shunt rescue" or orthotopic liver transplantation in selected cases with acceptable surgical morbidity and mortality. The contribution and role of the TIPS procedure is unknown but very promising; at least as a bridge procedure in patients awaiting transplantation. Until appropriate prospective, comparative trials are performed, the role of TIPS as a long-term alternative to portacaval shunt surgery or other endoscopic or surgical options remains unknown.

Comparison and characterization of ulcerations induced by endoscopic ligation of esophageal varices versus endoscopic sclerotherapy

Esophageal variceal ligation and esophageal variceal sclerotherapy are two modes of therapy commonly used in the treatment of esophageal varices. The purpose of this study was to compare the local complications of these procedures, with special emphasis on production and healing of ulcerations. Twenty-three patients entered the study. Ten patients were randomized to esophageal variceal ligation and 13 to esophageal variceal sclerotherapy. Esophageal variceal ligation produced shallow (0.6 +/- 0.07 mm) circular ulcerations with a large surface area (85.4 +/- 20.3 mm2) that resolved in 14.4 +/- 1.4 days. Esophageal variceal sclerotherapy produced linear, deep ulcerations (1.8 +/- 0.01 mm) with a smaller surface area (13.3 +/- 2.8 mm2) and resolution in 20.9 +/- 1.3 days. These differences were statistically significant by independent t test (p < 0.0001). Esophageal variceal ligation patients required 3.6 +/- 0.4 sessions to achieve obliteration, whereas esophageal variceal sclerotherapy patients required 6.2 +/- 0.5 sessions (independent t test, p < 0.0001). No significant difference was noted between the two groups with regard to death or stricture formation.

Approaches to the endoscopic treatment of esophageal varices

Endoscopic therapy is commonly employed for both initial and subsequent definitive treatment of variceal bleeding. Sclerotherapy performed with a flexible endoscope is currently the most widespread technique. Available data suggests that such treatment does not improve outcome in the acute treatment of variceal bleeding (first 30 days) but appears superior to conventional medical management in the long term. Sclerotherapy does not appear better or worse than pharmacological therapy or surgical therapy when these treatments are compared in the elective setting. Although effective, endoscopic sclerotherapy is recognized to be associated with many major and minor treatment-related complications and a significant incidence of recurrent hemorrhage. In response to these shortcomings newer forms of endoscopic therapy such as polymer injection and endoscopic ligation have been developed. Polymer injection appears well suited for patients with active bleeding and for those with gastric varices but does not have advantages for chronic treatment aimed at variceal eradication. Endoscopic ligation appears at least as effective as conventional sclerotherapy for control of acute bleeding and prevention of rebleeding and is associated with few treatment induced complications. While endoscopic therapy will likely continue as the most commonly employed treatment for patients with hemorrhage from esophageal varices, newer methods with wider margins of safety and efficacy seem destined to supplement or replace conventional endoscopic sclerotherapy.

Issues in gastrointestinal endoscopy: oesophageal varices: inject, band, medicate, or operate

Injection sclerotherapy is the most widely used definitive treatment of acute variceal bleeding and is increasingly performed at the time of the first emergency endoscopy. Direct endoscopic ligation of varices by banding is a new technique under evaluation for both acute bleeding varices and long-term management. Repeated injection sclerotherapy is one of the major options for long-term management after variceal bleeding. More major surgical procedures are usually reserved for the failures of sclerotherapy in the management of acute variceal bleeding, whereas portosystemic shunts, particularly the distal splenorenal shunt, or an extensive devascularization and transection operation are commonly used alternative forms of therapy in long-term management. All patients with variceal bleeding should be assessed for liver transplantation, although only a few will ultimately receive a liver transplant. Medication with propranolol is widely recommended in long-term management, but its use in this context remains controversial. The most controversial area of management is prophylactic treatment before variceal bleeding. Major surgical procedures and injection sclerotherapy are not justified at present because it is difficult to identify those patients with a high likelihood of a first variceal bleed. Although medical therapy with propranolol has proved the most successful therapy to date, a case is made for treating most patients conservatively until their first variceal bleed occurs or until better predictive indices for patients at high risk of a first bleed are identified.

Technology assessment status evaluation: endoscopic band ligation of varices

On the basis of limited available data, band ligation appears to be effective for control of active esophageal variceal bleeding and for prevention of recurrent bleeding. It has minimal morbidity and no reported mortality. Preliminary results of a randomized-trial comparing this technique to sclerotherapy show comparable efficacy but band ligation may carry a lower complication rate. Long-term results of ligation are pending.