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Samanta J, Nabi Z, Facciorusso A, Dhar J, Akbar W, Das A, Birda CL, Mangiavillano B, Auriemma F, Crino SF, Kochhar R, Lakhtakia S, Reddy DN. EUS-guided coil and glue injection versus endoscopic glue injection for gastric varices: International multicentre propensity-matched analysis. Liver Int 2023; 43:1783-1792. [PMID: 37269164 DOI: 10.1111/liv.15630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/28/2023] [Accepted: 05/22/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Gastric varices (GVs) are conventionally managed with endoscopic cyanoacrylate (E-CYA) glue injection. Endoscopic ultrasound (EUS)-guided therapy using combination of coils and CYA glue (EUS-CG) is a relatively recent modality. There is limited data comparing the two techniques. METHODOLOGY This international multicentre study included patients with GV undergoing endotherapy from two Indian and two Italian tertiary care centres. Patients undergoing EUS-CG were compared with propensity-matched E-CYA cases from a cohort of 218 patients. Procedural details such as amount of glue, number of coils used, number of sessions required for obliteration, bleeding after index procedure rates and need for re-intervention were noted. RESULTS Of 276 patients, 58 (male 42, 72.4%; mean age-44.3 ± 12.1 years) underwent EUS-CG and were compared with 118 propensity-matched cases of E-CYA. In the EUS-CG arm, complete obliteration at 4 weeks was noted in 54 (93.1%) cases. Compared to the E-CYA cohort, EUS-CG arm showed significantly lower number of session (1.0 vs. 1.5; p < 0.0001) requirement, lower subsequent-bleeding episodes (13.8% vs. 39.1%; p < 0.0001) and lower re-intervention (12.1% vs. 50.4%; p < 0.001) rates. On multivariable regression analysis, size of the varix (aOR-1.17; CI 1.08-1.26) and technique of therapy (aOR-14.71; CI 4.32-50.0) were significant predictors of re-bleeding. A maximum GV size >17.5 mm had a 69% predictive accuracy for need for re-intervention. CONCLUSION Endoscopic ultrasound-guided therapy of GV using coil and CYA glue is a safe technique with better efficacy and lower re-bleeding rates on follow-up compared to the conventional endoscopic CYA therapy.
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Affiliation(s)
- Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Zaheer Nabi
- Asian Institute of Gastroenterology (AIG), Hyderabad, India
| | - Antonio Facciorusso
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Foggia, Foggia, Italy
| | - Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Wahid Akbar
- Asian Institute of Gastroenterology (AIG), Hyderabad, India
| | | | - Chhagan Lal Birda
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Chooklin S, Chuklin S. Transvenous obliteration of gastric varices. EMERGENCY MEDICINE 2023; 19:2-13. [DOI: 10.22141/2224-0586.19.1.2023.1549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Gastric varices on the background of portal hypertension occur less frequently than esophageal varices but they develop at lower portal pressure and are associated with more massive bleedings and higher mortality rate. Balloon-occluded retrograde transvenous obliteration (BRTO) has been well documented as an effective therapy for gastric varices caused by portal hypertension. However, BRTO requires long-term, higher-level post-procedural monitoring and can have complications related to balloon rupture and adverse effects of sclerosing agents. Several modified BRTO techniques have been developed, including vascular plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, and balloon-occluded antegrade transvenous obliteration. This article provides an overview of BRTO various and modified BRTO techniques.
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Chantarojanasiri T, Sirinawasatien A, Bunchorntavakul C, Siripun A, Treepongkaruna SA, Ratanachu-Ek T. Endoscopic Ultrasound-Guided Vascular Therapy for Portoduodenal Fistula. Clin Endosc 2020; 53:750-753. [PMID: 32050308 PMCID: PMC7719415 DOI: 10.5946/ce.2019.167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/02/2019] [Indexed: 01/30/2023] Open
Abstract
Portoenteric fistula is a rare cause of massive upper gastrointestinal bleeding. Most cases can be treated with radiointervention or surgery, but portoenteric fistula is associated with a high mortality. We reported a case of intermittent massive upper gastrointestinal bleeding in a 33-year-old man with cholangiocarcinoma who underwent surgical resection followed by chemoradiation. A portoduodenal fistula due to chronic duodenal ulceration was identified. The bleeding was successfully controlled by endoscopic ultrasound-guided coil placement through the duodenal bulb using the anchoring technique. Follow-up endoscopy and computed tomography scan showed multiple coil placements between a part of the portal vein and the duodenal bulb without any evidence of portal vein thrombosis. There were no complications, and bleeding did not recur during the 8-month follow-up period.
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Affiliation(s)
| | | | | | - Aroon Siripun
- Department of Internal Medicine, Rajavithi Hospital, Bangkok, Thailand.,Department of Internal Medicine, Bangkok Hospital, Bangkok, Thailand
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Goldis A, Goldis R, Chirila TV. Biomaterials in Gastroenterology: A Critical Overview. ACTA ACUST UNITED AC 2019; 55:medicina55110734. [PMID: 31726779 PMCID: PMC6915447 DOI: 10.3390/medicina55110734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/30/2019] [Accepted: 11/08/2019] [Indexed: 02/07/2023]
Abstract
In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.
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Affiliation(s)
- Adrian Goldis
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Correspondence:
| | | | - Traian V. Chirila
- Queensland Eye Institute, South Brisbane, QL 4101, Australia;
- Science & Engineering Faculty, Queensland University of Technology, Brisbane, QL 4000, Australia
- Faculty of Medicine, University of Queensland, Herston, QL 4029, Australia
- Australian Institute for Bioengineering and Nanotechnology, University of Queensland, St Lucia, 4072 QL, Australia
- Faculty of Science, University of Western Australia, Crawley, WA 6009, Australia
- University of Medicine, Pharmacy, Sciences and Technology, 540139 Targu Mures, Romania
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Goral V, Yılmaz N. Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO. ACTA ACUST UNITED AC 2019; 55:medicina55070335. [PMID: 31277322 PMCID: PMC6681371 DOI: 10.3390/medicina55070335] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/28/2019] [Accepted: 06/28/2019] [Indexed: 12/21/2022]
Abstract
Gastric varices are less common than esophageal varices, and their treatment is quite challenging. Gastric varix bleedings (GVB) occur less frequently than esophageal varix (EV) bleedings and represent 10% to 30% of all variceal bleedings. They are; however, more severe and are associated with high mortality. Re-bleeding may occur in 35% to 90% of cases after spontaneous hemostasis. GV bleedings represent a serious clinical problem compared with esophageal varices due to their location. Sclerotherapy and band ligation, in particular, are less effective. Based on the anatomic site and location, treatment differs from EV and is categorized into two groups (i.e., endoscopic or radiologic treatment). Surgical management is used less frequently. Balloon-occluded retrograde transvenous obliteration (BRTO) and cyanoacrylate are safe but there is a high risk of re-bleeding. Portal pressure elevates following BRTO and leads to worsening of esophageal varix pressure. Other significant complications may include hemoglobinuria, abdominal pain, fever, and pleural effusion. Shock and atrial fibrillation are major complications. New and efficient treatment modalities will be possible in the future.
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Affiliation(s)
- Vedat Goral
- Istanbul Medipol University, School of Medicine Department of Gastroenterology, 34214 Istanbul, Turkey.
| | - Nevin Yılmaz
- Department of Gastroenterology, School of Medicine, Near East University, 99138 Nicosia, Cyprus
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Magalhães J, Monteiro S, Xavier S, Leite S, de Castro FD, Cotter J. Endoscopic ultrasonography - emerging applications in hepatology. World J Gastrointest Endosc 2017; 9:378-388. [PMID: 28874958 PMCID: PMC5565503 DOI: 10.4253/wjge.v9.i8.378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/14/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023] Open
Abstract
The inspection of the liver is a valuable part of the upper endoscopic ultrasonography (EUS) studies, regardless of the primary indication for the examination. The detailed images of the liver segments provided by EUS allows the use of this technique in the study of parenchymal liver disease and even in the diagnosis and classification of focal liver lesions. EUS has also emerged as an important tool in understanding the complex collateral circulation in patients with portal hypertension and their clinical and prognostic value. Recently, EUS-guided portal vein catheterization has been performed for direct portal pressure measurement as an alternative method to evaluate portal hemodynamics. In this review, the authors summarize the available evidence regarding the application of EUS to patients with liver diseases and how we can apply it in our current clinical practice.
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Abstract
肝硬化可以导致门静脉高压, 并通过形成侧支循环和自发性分流来降低门静脉压力, 其中以食管、胃静脉曲张及胃肾、脾肾分流最多见. 因为随机对照研究的缺乏, 规范化治疗胃底静脉曲张破裂出血的临床方案仍未能统一, 现最有效且常用的方法是内镜下组织胶黏合剂注射, 但对于合并自发性分流者可导致异位栓塞等严重并发症; 自发性分流道的存在也影响着胃底曲张静脉治疗方案的选择. 本文就近年来对自发性分流道的研究及其对胃底曲张静脉内镜治疗方案的选择及疗效作一简要综述.
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Burke MP, O'Donnell C, Baber Y. Death from pulmonary embolism of cyanoacrylate glue following gastric varix endoscopic injection. Forensic Sci Med Pathol 2017; 13:82-85. [PMID: 28091982 DOI: 10.1007/s12024-016-9835-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 01/27/2023]
Abstract
We present the case of a 25 year old woman with a complex past medical history including Crigler-Najjar syndrome (Type 1) with a liver transplant in 1993 and subsequent development of cirrhosis with portal hypertension in the transplanted liver. The deceased presented to hospital with hematemesis and investigations showed a large gastric varix. The varix was injected with cyanoacrylate glue. Within 30 min of injection the patient became acutely hypoxic. Urgent chest X-ray demonstrated radio opaque glue within the pulmonary arteries. It was evident that future treatment was futile and supportive treatment was withdrawn. The deceased was referred for medico legal post mortem examination. The post mortem CT scan performed prior to autopsy showed widespread radio-opaque material within the pulmonary arteries. At autopsy, rubbery grey/tan "clot" occluded the major proximal and segmental pulmonary arteries. Microscopic examination of the "clot" showed clumps of erythrocytes surrounded by foreign material. We discuss this relatively uncommon but well recognized complication of variceal injection with cyanoacrylate glue.
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Affiliation(s)
- Michael Philip Burke
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria, 3006, Australia. .,Department of Forensic Medicine, Monash University, Melbourne, Australia.
| | - Chris O'Donnell
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria, 3006, Australia.,Department of Forensic Medicine, Monash University, Melbourne, Australia
| | - Yeliena Baber
- Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, Victoria, 3006, Australia.,Department of Forensic Medicine, Monash University, Melbourne, Australia
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Philips CA, Arora A, Shetty R, Kasana V. A Comprehensive Review of Portosystemic Collaterals in Cirrhosis: Historical Aspects, Anatomy, and Classifications. Int J Hepatol 2016; 2016:6170243. [PMID: 28074159 PMCID: PMC5198179 DOI: 10.1155/2016/6170243] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/01/2016] [Accepted: 11/17/2016] [Indexed: 02/07/2023] Open
Abstract
Portosystemic collateral formation in cirrhosis plays an important part in events that define the natural history in affected patients. A detailed understanding of collateral anatomy and hemodynamics in cirrhotics is essential to envisage diagnosis, management, and outcomes of portal hypertension. In this review, we provide detailed insights into the historical, anatomical, and hemodynamic aspects to portal hypertension and collateral pathways in cirrhosis with emphasis on the various classification systems.
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Affiliation(s)
- Cyriac Abby Philips
- Department of Hepatology and Transplant Medicine, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Ankur Arora
- Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Rajesh Shetty
- Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Vivek Kasana
- Department of Radiodiagnosis, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
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