Potential application of interventional endoscopic ultrasonography for the treatment of esophageal and gastric varices

Correlation between serum liver fibrosis markers and early gastroesophageal varices among patients with compensated liver cirrhosis: a cross-sectional analysis

BACKGROUND AND AIM

Portal hypertension is a common complication of chronic liver diseases responsible for most liver cirrhosis consequences. In patients with portal hypertension, oesophagogastric variceal bleeding is a leading cause of death. Most research has focused on high-risk gastroesophageal varices and bleeding, with only a few studies on early varices. However, early intervention of gastroesophageal varices was found to better improve the prognosis and reduce mortality, but there is still no relevant research. Ultrasonic endoscopy is a combination of endoscopy and ultrasonic imaging. It can gastroscopically detect varices around the oesophagus and stomach and detect oesophageal collateral veins and perforating veins earlier, which is helpful for the early diagnosis of varices. Therefore, this study aimed to explore the correlation between serum fibrosis markers and early gastroesophageal varices in compensated cirrhosis patients.

METHODS

This study included 791 patients with compensated cirrhosis. The selected patients were categorized into three groups. The early gastroesophageal varices group included patients with gastroesophageal varices found by endoscopic ultrasonography but not by gastroscopy. The no gastroesophageal varices group underwent endoscopic ultrasonography and gastroscopy without varices. In addition, gastroesophageal varices can be detected with both techniques. Multiple logistic regression analysis explored the association of serum fibrosis markers with early gastroesophageal varices.

RESULTS

Among the 791 compensated liver cirrhosis patients, 198 patients were without gastroesophageal varices, 279 patients had early gastroesophageal varices, 314 patients had gastroesophageal varices, and both techniques could detect varices. There was a positive correlation between serum fibrosis markers and early gastroesophageal varices. In univariate logistic regression analysis, the patients with early gastroesophageal varices had lower platelet counts (P = 0.034) and higher aspartate aminotransferase (P = 0.046), total bilirubin (P = 0.041), hyaluronic acid (P < 0.001), laminin (P < 0.001), type III procollagen (P = 0.005), type IV collagen (P = 0.002), liver stiffness measurement (P = 0.001), APRI (P = 0.019) and FIB-4 (P = 0.002). Multivariate analysis showed that laminin (OR 1.011; 95% CI 1.004-1.017, P = 0.001) was an independent risk factor for predicting early gastroesophageal varices in compensated cirrhosis patients.

CONCLUSION

Higher laminin was independently associated with early gastroesophageal varices in compensated cirrhosis patients.

Endoscopic ultrasonography and small-bowel endoscopy: Present and future

Over the last decade, impressive technological advances have occurred in ultrasonography and small-bowel endoscopy. Nowadays, endoscopic ultrasonography is an essential diagnostic tool and a therapeutic weapon for pancreatobiliary disorders. Capsule endoscopy and device-assisted enteroscopy have quickly become the reference standard for the diagnosis of small-bowel luminal diseases, thereby leading to radical changes in diagnostic and therapeutic pathways. We herein provide an up-to-date overview of the latest advances in endoscopic ultrasonography and small-bowel endoscopy, focusing on the emerging paradigms and technological innovations that might improve clinical practice in the near future.

Endoscopic-ultrasound-guided coil and cyanoacrylate embolization for gastric varices and the roles of endoscopic Doppler and endosonographic varicealography in vascular targeting

OBJECTIVE

To report the results of endoscopic ultrasound-guided injection of coils with cyanoacrylate (CYA) using a less-expensive coil with an emphasis on the roles of Doppler and endosonographic varicealography (EV) in identifying the feeder vessel in gastric varix treatment.

METHODS

An observational, descriptive study with prospectively collected data. Patients with gastric varices (GV) were included and were treated by endoscopic ultrasound-guided injection of CYA and a less-expensive coil. Technical success, complete and immediate variceal obliteration, rebleeding, complication and survival rates were evaluated.

RESULTS

Thirty patients with GV with a mean age of 62 years (range: 44-76 years) were treated. Median number of coils used was 2 (range: 1-3), and median volume of CYA was 1.8 mL (1.2-2.4 mL). Technical success rate was 100%. EV technical success was observed in 26/30 patients. Complete variceal obliteration was observed in 96.6% of patients, and immediate disappearance of the varix was observed in 24 (80%) patients. The complication rate was 6.7%.

CONCLUSIONS

Endoscopic-ultrasound guidance for gastric varix treatment with the addition of EV and the use of a less-expensive coil is a safe and effective technique that results in the immediate disappearance of GV after targeting the feeding vessel.

The endoscopic ultrasound probe findings in prediction of esophageal variceal recurrence after endoscopic variceal eradication therapies in cirrhotic patients: a cohort prospective study

Background

The recurrence of esophageal varices remains high in patients with hepatic portal hypertension after the endoscopic esophageal variceal eradication therapies, including endoscopic variceal band ligation (EVL), injection sclerotherapy (EIS) or EVL plus EIS. The aim of this study was to evaluate the endoscopic ultrasound probe examinations (EUP) findings in the prediction of recurrence following esophageal variceal eradication in a prospective cohort.

Methods

A total of 206 cirrhotic portal hypertension patients with esophageal variceal eradication, who underwent endoscopic variceal therapy (EVL or EIS or EVL plus EIS) were initially enrolled. All patients were scheduled for a follow-up every 6 months for up to 3 years. EUP was performed to evaluate peri-esophageal collateral veins (peri-ECVs), perforating veins (PFV) and para-esophageal collateral veins (para-ECVs). In addition, computed tomography (CT) were conducted to detect portal vein diameter, portal vein embolus, and major portosystemic collateral shunts. The relationship between esophageal variceal recurrence and EUP findings were analyzed.

Results

We found that as high as 93.5% of patients developed esophageal variceal recurrence in the 3-year follow-up. The time of esophageal variceal recurrence after variceal eradication was 13.4 months (13.4 ± 9.2 months). Furthermore, the median time of recurrence in patients who were undertaken EVL,EIS and EVL plus EIS was 10, 13 and 12 months, respectively. We identified that the risk factors, including EVL (OR 0.23, 95% CI 0.08–0.71, p < 0.01), Child-Pugh score (OR 3.32,95% CI 1.31–35.35, p < 0.05), large peri-ECVs (OR 4.56, 95% CI 2.17–9.58, p < 0.0001), and existence of PFV (OR 2.14, 95% CI 1.44–3.16, p < 0.001), were significantly associated with the recurrence of esophageal varices. The peri-ECVs and PFV showed better ability to predict esophageal variceal recurrence. When cut-off value of peri-ECVs diameter was 3.5 mm, the specificity of prediction 1-year variceal recurrence was 86% and the sensitivity was 45%.

Conclusions

The EUP appears to be very effective, convenient and economical examinations to predict esophageal varices recurrence after variceal eradication by endoscopic therapies. The high Child-pugh score, large peri-ECVs, and PFV are independent risk factors related to esophageal varices recurrence.

EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding

BACKGROUND

Endoscopic injection of cyanoacrylate into gastric varices may be performed by EUS-guided fine needle injection (EUS-FNI) or direct endoscopic injection (DEI). The aim of this study is to compare the rate of recurrent GV bleeding and adverse events between DEI and EUS-FNI for treatment of GV.

METHODS

In a single-center study, a retrospective cohort of patients with actively/recently bleeding or high-risk GV treated with DEI were compared with a prospective cohort of similar patients treated with EUS-FNI. Repeat endoscopy after index treatment was performed 3 months later or earlier if rebleeding occurred. The main outcomes assessed were rates of GV or overall rebleeding and adverse events.

RESULTS

Forty patients (mean age 57.2 ± 9.1 years, 73% male) and 64 patients (mean age 58.0 ± 12.5 years, 52% male) underwent DEI and EUS-FNI, respectively. Compared to the DEI group, the frequency of isolated gastric varices type 1 (IGV1) were higher (p < 0.001) but MELD scores were lower (p = 0.004) in the EUS-FNI group. At index endoscopy, EUS-FNI utilized a lower mean volume of cyanoacrylate (2.0 ± 0.8 mL vs. 3.3 ± 1.3 mL; p < 0.001) and injected a greater number of varices (1.6 ± 0.7 vs. 1.1 ± 0.4; p < 0.001) compared to DEI. Overall, GV rebleeding [5/57 (8.8%) vs. 9/38 (23.7%); p = 0.045] and non-GV-related gastrointestinal bleeding [7/64 (10.9%) vs. 11/40 (27.5%); p = 0.030] were less frequent in the EUS-FNI group compared to the DEI group, respectively. Adverse event rates were similar (20.3% vs. 17.5%, p = 0.723).

CONCLUSIONS

EUS-guided CYA injection of active or recently bleeding GV in patients with portal hypertension appears to decrease the rate of GV rebleeding despite injection of more varices and less CYA volume during the initial endoscopic procedure. Adverse events are similar between the two groups. EUS-FNI appears to be the preferred strategy for treatment of these patients.

Role of combined propofol and sufentanil anesthesia in endoscopic injection sclerotherapy for esophageal varices

AIM

To investigate the efficacy and safety of a combination of sufentanil and propofol injection in patients undergoing endoscopic injection sclerotherapy (EIS) for esophageal varices (EVs).

METHODS

Patients with severe EVs who underwent EIS with sufentanil and propofol anesthesia between April 2016 and July 2016 at our hospital were reviewed. Although EIS and sequential therapy were performed under endotracheal intubation, we only evaluated the efficacy and safety of anesthesia for the first EIS procedure. Patients were intravenously treated with 0.5-1 μg/kg sufentanil. Anesthesia was induced with 1-2 mg/kg propofol and maintained using 2-5 mg/kg per hour of propofol. Information, regarding age, sex, weight, American Association of Anesthesiologists (ASA) physical status, Child-Turcotte-Pugh (CTP) classification, indications, preanesthetic problems, endoscopic procedure, successful completion of the procedure, anesthesia time, recovery time, and anesthetic agents, was recorded. Adverse events, including hypotension, hypertension, bradycardia, and hypoxia, were also noted.

RESULTS

Propofol and sufentanil anesthesia was provided in 182 procedures involving 140 men and 42 women aged 56.1 ± 11.7 years (range, 25-83 years). The patients weighed 71.4 ± 10.7 kg (range, 45-95 kg) and had ASA physical status classifications of II (79 patients) or III (103 patients). Ninety-five patients had a CTP classification of A and 87 had a CTP classification of B. Intravenous anesthesia was successful in all cases. The mean anesthesia time was 33.1 ± 5.8 min. The mean recovery time was 12.3 ± 3.7 min. Hypotension occurred in two patients (1.1%, 2/182). No patient showed hypertension during the endoscopic therapy procedure. Bradycardia occurred in one patient (0.5%, 1/182), and hypoxia occurred in one patient (0.5%, 1/182). All complications were easily treated with no adverse sequelae. All endoscopic procedures were completed successfully.

CONCLUSION

The combined use of propofol and sufentanil injection in endotracheal intubation-assisted EIS for EVs is effective and safe.