Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: A meta-analysis

Radiological and Surgical Treatments of Portal Hypertension

Interventions for portal hypertension are continuously evolving and expanding beyond the realm of medical management. When complications such as varices and ascites persist despite conservative interventions, procedures including transjugular intrahepatic portosystemic shunt creation, transvenous obliteration, portal vein recanalization, splenic artery embolization, surgical shunt creation, and devascularization are all potential interventions detailed in this article. Selection of the optimal procedure to address the underlying cause, treat symptoms, and, in some cases, bridge to liver transplantation depends on the specific etiology of portal hypertension and the patient's comorbidities.

Comparison of the management of gastric variceal bleeding techniques

Background and Aim

Managing gastric variceal (GV) hemorrhage is more complicated than managing esophageal variceal (EV) bleeding, resulting in significantly higher morbidity and mortality. We aim to compare the outcomes of endoscopic variceal ligation (EVL), transhepatic intrahepatic portosystemic shunt (TIPS), and balloon-occluded retrograde transvenous obliteration (BRTO) in the management of GV bleeding.

Methods

We utilized the National Inpatient Sample (NIS) database from January 2016 to December 2019 to include adult patients with GV hemorrhage.

Results

Our study identified 7160 hospitalizations with a primary diagnosis of GV hemorrhage who underwent the interventions of interest. EVL was performed in 69.83%, TIPS in 8.72%, and BRTO in 4.88%. Patients with liver cirrhosis had a higher frequency of undergoing BRTO (68.6%), followed by TIPS (64.0%) and esophagogastroduodenoscopy (EGD) + TIPS (63.7%) (P < 0.001). Patients with cirrhosis secondary to alcoholism had a higher prevalence of TIPS (62.4%), followed by EGD + TIPS (69.4%) and BRTO (52.9%) (P < 0.001). Overall, the inpatient mortality was 6.5%. Overall inpatient mortality was highest in the TIPS cohort (8.8%), followed by BRTO (7.1%), EGD + TIPS (6.5%), EVL (6.2%), and EGD + BRTO (2.8%) (P < 0.001); However, the Kaplan-Meier graph showed endoscopy with BRTO had the most favorable 30-day survival, trailed by TIPS alone and BRTO alone.

Conclusion

EVL remains a prominent therapeutic strategy. Remarkably, the combination of endoscopy with BRTO shows promising 30-day survival outcomes. Considering these observations, although EVL holds its primacy, it is essential to further explore the potential benefits of combined therapies in larger studies to ascertain the best treatment strategies.

TIPS: indications, Contraindications, and Evaluation

PURPOSE OF REVIEW

This review summarizes the current and emerging indications, contraindications, and evaluation for TIPS. In the last three decades of use, there have been substantial changes and progress in this field, including the use of controlled-expansion, covered stents, which has broadened the clinical uses of TIPS.

RECENT FINDINGS

Recent findings have rapidly expanded the indications for TIPS, including emerging uses in hepatorenal syndrome, hepatopulmonary syndrome and before abdominal surgery. The widespread use of controlled-expansion, covered stents has decreased rates of post-TIPS hepatic encephalopathy, opening TIPS to a larger patient population. Overall, with newer stent technology and more research in this area, the clinical utility and potential of TIPS has rapidly expanded. Going forward, a renewed focus on randomized-control trials and long-term outcomes will be a crucial element to selecting appropriate TIPS recipients and recommending emerging indications for this procedure.

Long-Term Prognosis and Related Factors in Patients with Cirrhosis Treated with Balloon-Occluded Retrograde Transvenous Obliteration

INTRODUCTION

Balloon-occluded retrograde transvenous obliteration (BRTO) was developed as an effective treatment for gastric varices in patients with cirrhosis. Because liver fibrosis in these patients is assumed to be advanced, their prognosis is expected to be poor. In this study, we investigated the prognosis and characteristics of the patients.

METHODS

We enrolled 55 consecutive patients with liver cirrhosis treated with BRTO between 2009 and 2021 at our department. To evaluate factors related to variceal recurrence and long-term prognosis, survival analysis was performed on 45 patients, excluding those who died within 1 month, had an unknown prognosis, or whose treatments were converted to other treatments.

RESULTS

During a mean follow-up period of 2.3 years, esophageal varices recurred in 10 patients and could be treated endoscopically. Non-alcoholic steatohepatitis (NASH) was related to the variceal recurrence (hazard ratio [HR] = 4.27, 95% CI: 1.17-15.5, p = 0.028). The survival rate after the procedure at 1, 3, and 5 years was 94.2%, 74.0%, and 63.5%, respectively, and 10 patients died of hepatocellular carcinoma (n = 6), liver failure (n = 1), sepsis (n = 1), and unknown reasons (n = 2). The estimated glomerular filtration rate (eGFR) level was proved to be a significant poor prognostic factor (HR = 0.96, 95% CI: 0.93-0.99, p = 0.023). The comorbid hypertension (HTN) was the main cause of low eGFR, and HTN was also significantly related to survival (HR = 6.18, 95% CI: 1.57-24.3, p = 0.009). Most of the patients with HTN were treated with calcium channel blocker and/or angiotensin receptor blocker.

CONCLUSION

The clinical course of patients with cirrhosis treated with BRTO was dependent on the metabolic factors including renal function, comorbid HTN, and NASH.

Use of Balloon Occluded Retrograde Transvenous Obliteration (BRTO) for Treatment of Gastric Varices: A Narrative Review

Gastric Varices occur as a result of portal hypertension. Balloon Retrograde Transvenous Obliteration (BRTO) is a modality for managing gastric varices. The ultimate goal of this review is to promote the broader adoption of BRTO in managing gastric varices and to promote further research to improve patient outcomes. Before this study, an electronic literature search was undertaken based on identified concepts, keywords, and other pertinent descriptions. Search databases were developed and included "Gastric varices" AND "BRTO" OR "intervention" OR "treatment" OR "procedure" OR "glue" OR "adhesive".  The databases selected and thoroughly searched were PubMed, Cochrane Library and ScienceDirect. Following the first search, 274 articles were found in total. By applying inclusion criteria of full-text articles and a period of fewer than five years, the database was reduced to 37 articles, which was then further filtered to include only articles on adults over 19 years old, leaving a total count of 17 articles. BRTO is a relatively simple procedure to perform once the essential skill is attained and helpful in both emergency and elective management of gastric varices. Its use still needs to be improved by the unavailability and lack of skills. However, there are side effects associated with BRTO as it causes elevation of portal hypertension, recurrent bleeding, hemoglobinuria and pain post procedure. This review emphasizes the need for further research in this field, focusing on refining patient selection criteria, improving the technical aspect of the procedure and enhancing long-term outcomes.

North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric cardiofundal variceal bleeding in liver cirrhosis

BACKGROUND/AIMS

We retrospectively compared the effect of endoscopic variceal obturation (EVO) and retrograde transvenous obliteration (RTO) in acute cardiofundal variceal bleeding.

METHODS

Patients with acute cardiofundal variceal bleeding treated with EVO or RTO at two hospitals were included.

RESULTS

Ninety patients treated with EVO and 86 treated with RTO were analyzed. The mean model for end-stage liver disease score was significantly higher in EVO group than in RTO group (13.5 vs. 11.7, P = 0.016). The bleeding control rates were high (97.8% vs. 96.5%), and the treatment-related complication rates were low in both EVO and RTO groups (2.2% vs. 3.5%). During the median follow-up of 18.0 months, gastric variceal (GV) and esophageal variceal rebleeding occurred in 34 (19.3%) and 7 (4.0%) patients, respectively. The all-variceal rebleeding rates were comparable between EVO and RTO groups (32.4% vs. 20.8% at 2-year, P = 0.150), while the GV rebleeding rate was significantly higher in EVO group than in RTO group (32.4% vs. 12.8% at 2-year, P = 0.003). On propensity score-matched analysis (71 patients in EVO vs. 71 patients in RTO group), both all-variceal and GV rebleeding rates were significantly higher in EVO group than in RTO group (all P < 0.05). In Cox regression analysis, EVO (vs. RTO) was the only significant predictor of higher GV rebleeding risk (hazard ratio 3.132, P = 0.005). The mortality rates were similar between two groups (P = 0.597).

CONCLUSIONS

Both EVO and RTO effectively controlled acute cardiofundal variceal bleeding. RTO was superior to EVO in preventing all-variceal and GV rebleeding after treatment, with similar survival outcomes.

Long-term outcomes of patients with cirrhosis presenting with bleeding gastric varices

Aim

To establish a therapeutic strategy for cirrhosis patients with gastric variceal bleeding.

Methods

The outcomes of 137 patients with bleeding gastric varices were evaluated.

Results

The bleeding source was gastroesophageal varices (GOV) in 86 patients, and gastric fundal varices (FV) in 51 patients. The Child-Turcotte-Pugh classes were A, B, and C in 26, 79, and 32 patients, respectively; 34 patients (24.8%) had hepatocellular carcinoma (HCC), of which 11 also had complicating portal venous tumor thrombosis (PVTT). Patients with GOV were treated by endoscopic variceal ligation or endoscopic injection sclerotherapy (EIS) with ethanolamine oleate, while those with FV were treated by EIS with cyanoacrylate; 29 patients with FV also underwent additional balloon-occluded retrograde transvenous obliteration (BRTO). Hemostasis was successfully achieved in 136 patients (99.3%), and the cumulative 1-year, 3-year, and 5-year rebleeding rates were 18.1%, 30.8%, and 30.8%, respectively, in the patients with GOV, and 2.2%, 12.5% and 12.5%, respectively, in the patients with FV. The overall 1-year, 3-year, and 5-year survival rates were 79.7%, 71.5% and 64.4%, respectively, in the patients with GOV, and 91.0%, 76.9% and 59.5%, respectively, in the patients with FV. Multivariable analysis identified PVTT and alcoholic cirrhosis as a significant risk factor associated with rebleeding, model for end-stage liver disease (MELD) score and PVTT as significant factors associated with survival.

Conclusions

Endoscopic therapies with or without BRTO appeared to be useful therapeutic strategies to prevent rebleeding in patients with gastric variceal bleeding, and favorable outcomes were obtained, except in patients with underlying HCC associated with PVTT and/or severe liver damage.

Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding

Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.

The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: advantages and pitfalls

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.

AGA Clinical Practice Update on Management of Bleeding Gastric Varices: Expert Review

Management of bleeding gastric varices (GV) presents a unique challenge for patients with portal hypertension. Despite over thirty years of diagnostic and treatment advances standardized practices for bleeding GV are lacking and unsupported by adequate evidence. There are no definitive natural history studies to help with risk assessment or prospective clinical trials to guide clinical decision making. Available literature on the natural history and management of gastric varices consists of case series, restricted cohort studies, and a few small randomized trials, all of which have significant selection biases. This review summarizes the available data and recommendations based on expert opinion on how best to diagnose and manage bleeding from gastric varices. Table 1 summarizes our recommendations.

Treatment of Acute Variceal Bleeding in 2021-When to Use Transjugular Intrahepatic Portosystemic Shunts?

Variceal bleeding in patients with cirrhosis is associated with high mortality if not adequately managed. Treatment of acute variceal bleeding with adequate resuscitation maneuvers, restrictive transfusion policy, antibiotic prophylaxis, pharmacologic therapy, and endoscopic therapy is highly effective at controlling bleeding and preventing death. There is a subgroup of high-risk cirrhotic patients in whom this strategy fails, however, and who have a high-mortality rate. Placing a preemptive transjugular intrahepatic portosystemic shunt in these high-risk patients, as soon as possible after admission, to achieve early control of bleeding has proved not only to control bleeding but also to improve survival.

Transjugular Intrahepatic Portosystemic Shunt Creation for Treatment of Gastric Varices: Systematic Literature Review and Meta-Analysis of Clinical Outcomes

PURPOSE

To quantify the pooled clinical outcomes of stent-graft transjugular intrahepatic portosystemic shunt (TIPS) creation for the management of gastric varices (GVs) through systematic review of the literature and meta-analysis.

MATERIALS AND METHODS

A PubMed and Embase search was performed from 2003 to 2020. Search terms included: (transjugular intrahepatic portosystemic shunt OR TIPS) AND (gastric varices OR fundal varices OR gastroesophageal varices OR gastroesophageal varices) AND (hemorrhage OR rebleeding OR rebleeding OR survival). Inclusion criteria spanned: English language studies, publication in peer reviewed journals, sample size ≥ 10, reported clinical outcome data, exclusive treatment of GVs (no esophageal varices), exclusive use of stent-grafts for TIPS, no chemical obliteration of GVs. Outcomes included GV rebleeding rate, overall rebleeding rate, GV occlusion rate, hepatic encephalopathy (HE) incidence, and adverse event (AE) rate.

RESULTS

Literature search yielded 936 articles. Of these, 5 (0.5%) retrospective observational cohort studies met inclusion criteria, spanning 209 patients (quinquagenarian men with viral or alcoholic liver disease) with GVs treated using TIPS with adjunctive coil embolization (47%). Clinical follow-up time ranged from 4.3 to 30.6 months. Outcomes included a pooled GV rebleeding rate of 15% (95% CI: 11%, 20%), total rebleeding rate of 21% (95% CI: 15%, 27%), GV occlusion rate of 33% (95% CI: 22%, 45%), HE incidence of 30% (95% CI: 24%, 36%), and AE incidence of 3% (95% CI: 1%, 8%).

CONCLUSION

The incidence of GV rebleeding after stent-graft TIPS is high. The results suggest the need for additional measures to reduce recurrent hemorrhage incidence from GVs.

Successful retrograde transvenous obliteration for splenorenal shunts after liver ransplantation: Midterm results

BACKGROUND/AIMS

The objective of this study was to evaluate the use of Amplatzer-assisted retrograde transvenous obliteration (RTO) in patients with splenorenal shunts (SRSs) after orthotopic liver transplantation (OLT).

MATERIALS AND METHODS

From August 2015 to March 2017, 5 patients received RTO at our center because of SRSs after OLT. The clinical features of the patients with SRSs included demographics, donor type, new-onset symptoms, liver function tests, imaging examinations, interventional examinations and treatments, and outcomes. The patients who received RTO were regularly monitored, and data were gathered before and after the procedures and compared using the paired-sample t test.

RESULTS

Percutaneous interventional management was successfully undertaken in all patients, and 5 Amplatzers and 2 stents were also implanted successfully in patients owing to portal vein (PV) stenosis. There were no procedure-related complications in these patients. In all 5 patients with SRSs, 2 weeks after the interventional therapy, the computed tomography findings showed that the splenic renal shunt vein was completely blocked. The mean blood pressure in the donor lateral PV and the mean blood flow velocity of the donor lateral PV after RTO were all improved significantly (p<0.05). It also suggested that all 5 patients with SRSs survived, with the primary graft functioning normally at the final follow-up.

CONCLUSION

Amplatzer-assisted RTO is a safe and effective treatment for SRSs after OLT. Considering the complexity of the diagnosis and treatment of SRSs in liver transplantation, this complication should be taken seriously.

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

PURPOSE

To compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs).

MATERIALS AND METHODS

A single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy.

RESULTS

The mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups.

CONCLUSIONS

The GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.

Balloon-occluded Retrograde Transvenous Obliteration Versus Transjugular Intrahepatic Portosystemic Shunt for Gastric Varices: A Meta-Analysis

INTRODUCTION

Balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) are well-validated techniques in the management of portal hypertensive gastric variceal bleeding when medical management alone is not sufficient. However, despite their effectiveness, the adverse effects from both procedures make each technique more suitable to different cohorts of patient's depending on presence or lack of certain comorbidities. This study aims to compare clinical outcomes of patients who have undergone both procedures for portal hypertensive gastric variceal bleeding.

MATERIALS AND METHODS

We conducted a search of electronic databases from their establishment to April 2019. The goal was to compare the efficacy of BRTO and TIPS in preventing variceal rebleeding and the risk of adverse events such as ascites and hepatic encephalopathy. Predictors of overall survival and rebleeding were also analyzed. Meta-analysis was performed with STATA 15.1.

RESULTS

Five randomized controlled trials and retrospective cohort studies were included in our meta-analysis. The number of patients who underwent BRTO and TIPS were 308 and 127, respectively. BRTO and TIPS have similar technical success rates (91.4% vs. 89.7%, P=0.995) and immediate bleeding control rates (97.7% vs. 95.9%, P=0.836). However, compared with TIPS, BRTO has lower likelihood of future cumulative rebleeding (10.6% vs. 18.7%, P=0.027) and hepatic encephalopathy (0.00% vs. 23.1%, P<0.001) but is more likely to aggravate ascites (22.4% vs. 4.3%, P=0.009). Serum albumin level and presence of hepatocellular carcinoma are both independent predictors of increased likelihood of rebleeding and overall survival (P<0.001).

CONCLUSIONS

Both BRTO and TIPS are safe and effective interventions in the management algorithm of portal hypertensive gastric variceal bleeding. Although BRTO may be more effective at the prevention of future variceal rebleeding, the choice of BRTO versus TIPS should be tailored according to patient's comorbidities.

Beyond the scope and the glue: update on evaluation and management of gastric varices

Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed ‘difficult’ to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of ‘portal hypertension theories’ of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new ‘portal hypertension theories’ of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a ‘new’ algorithmic approach, established on hemodynamic physiology of gastric varices.

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Versus Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Gastric Varices Because of Portal Hypertension: A Systematic Review and Meta-Analysis

BACKGROUND

Although gastric variceal (GV) bleeding is less common than esophageal variceal bleeding, the severity of GV bleeding is often greater with higher morbidity and mortality rates. Minimally invasive endovascular treatments such as balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) have been used for the management of GVs with varying results, and individual and institutional differences exist in the use of BRTO and TIPS. We performed a systematic review and meta-analysis to compare the feasibility, efficacy, and safety of BRTO and TIPS for the treatment of GVs because of portal hypertension.

METHODS

Searches of PubMed, EMBASE, Google Scholar, and Cochrane Library databases were performed from inception through March 2019. Summary odds ratio (OR) with 95% confidence intervals (CI) was estimated for technical success, hemostasis rate, postprocedural complications, rebleeding rate, incidence of hepatic encephalopathy, and mortality rate at 1 year utilizing a random-effects model.

RESULTS

Seven studies with a total of 676 patients (BRTO: 462 and TIPS: 214) were included. There was no difference in pooled technical success rate (OR, 0.87; 95% CI, 0.28-2.73; P=0.81), hemostasis rate (OR, 2.74; 95% CI, 0.61-12.26; P=0.19), and postoperative procedure-related complications (OR, 1.95; 95% CI, 0.44-8.72; P=0.38). However, treatment with BRTO was associated with lower rates of postoperative rebleeding (OR, 0.30; 95% CI, 0.18-0.48; P<0.00001), postoperative encephalopathy (OR, 0.06; 95% CI, 0.02-0.15; P < 0.00001), and mortality at 1 year (OR, 0.43; 95% CI, 0.21-0.87; P=0.02).

CONCLUSIONS

BRTO was associated with lower rates of rebleeding, postprocedure hepatic encephalopathy, and mortality at 1 year. BRTO should be considered first-line modality for the treatment of GVs because of portal hypertension.

Where does TIPS fit in the management of patients with cirrhosis?

In this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery ('preoperative TIPS') in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10-13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.

Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices using foam sclerosant and a reduced balloon inflation time: Feasibility and efficacy

INTRODUCTION

Balloon-occluded retrograde transvenous obliteration (BRTO) is recommended for secondary prevention of gastric variceal bleeding in the American Association for the Study of Liver Disease (AASLD) guidelines, as an alternative to Transjugular intrahepatic portosystemic shunt (TIPS). However, there is significant heterogeneity in how BRTO is performed, including how and how long to occlude the outflow venous shunt amongst other variables such as variceal size, flow rate, agent used, and preparation technique. We propose a method using foam sclerotherapy and reducing balloon occlusion to as little as 30 min, with assessment of the efficacy of this shorter balloon inflation time.

METHODS

Retrospective single-centre analysis of BRTO procedures between July 2015 and February 2019 for isolated gastric varices in a non-acute setting, where inflation time was 2 h or less.

RESULTS

Six patients underwent BRTO with a short inflation time, with a mean age of 66 years. The median balloon inflation and thus 3% athoxysclerol foam contact time was 30 min (range 30-60 min). Four of the 6 patients showed complete resolution of varices, while 2 of the 6 showed a partial response. Mean follow-up was 27 months. There were no patients who did not show a response to treatment and no episodes of clinically significant upper gastrointestinal bleeding.

CONCLUSIONS

This technique using a shortened balloon occlusion time resulted in complete or partial clinical and technical success in all patients and suggests that the threshold for initiation of gastric variceal thrombosis may be below 30 min. This timepoint may provide a balance between adequate balloon inflation, angiography room efficiency and hospital resource allocation with resultant procedural cost implications.

Comparison of the Effects of TIPS versus BRTO on Bleeding Gastric Varices: A Meta-Analysis

Background and Aim. Upper gastrointestinal bleeding is a threat to patients with gastric varices (GVs). Previous studies have concluded that both transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded retrograde transvenous obliteration (BRTO) are effective treatments for patients with GV. We aimed to compare the efficiency and outcomes of these two procedures in GV patients through meta-analysis.

METHODS

The PubMed, Cochrane Library, EMBASE, and Web of Science databases were searched using the keywords: GV, bleeding, TIPS, and BRTO to identify relevant randomized controlled trials and cohort studies. The overall survival (OS) rate, imminent haemostasis rate, rebleeding rate, technical success rate, procedure complication rate (hepatic encephalopathy and aggravated ascites), and Child-Pugh score were evaluated. Randomized clinical trials and cohort studies comparing TIPS and BRTO for GV due to portal hypertension were included in our meta-analysis. Two independent reviewers performed data extraction and assessed the study quality. A meta-analysis was performed to calculate risk ratios (RRs), mean differences (MDs), and 95% CIs using random effects models.

RESULTS

A total of nine studies fulfilled the inclusion criteria. There was a significant difference between TIPS and BRTO in the OS rate (RR, 0.81 (95% CI, 0.66 to 0.98); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90).

CONCLUSIONS

In this meta-analysis, BRTO brought more benefits to patients, with a higher OS rate and lower rebleeding rate. BRTO is a feasible method for GVB.

Successful Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices Using Foam Sclerosant Followed by Glue Embolization of Gastrorenal Shunt via the Brachial Vein Approach in a Severely Obese Patient

Balloon-occluded retrograde transvenous obliteration is an effective treatment for gastric varices. In this report, we illustrate a consecutive treatment strategy via brachial vein approach and n-butyl cyanoacrylate (NBCA) packing of the gastrorenal shunt (GRS) after injecting sclerosing agent in a severely obese patient. The brachial vein approach reduced the burden on the patient, and the closure of the GRS using NBCA shortened the procedure time. These techniques may improve patient comfort as well as reduce medical costs and the risks of several complications.

Role of Transjugular Intrahepatic Portosystemic Shunt in the Management of Portal Hypertension: Review and Update of the Literature

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure used in the management of complications of portal hypertension. Although the most robust evidence supports the use of TIPS as salvage therapy in variceal hemorrhage, secondary prophylaxis of variceal bleeding, and treatment of refractory ascites, there is also data to suggest its efficacy in other indications such as hepatic hydrothorax, hepatorenal syndrome, and Budd-Chiari syndrome. Recent literature also suggests that TIPS may improve survival for certain subpopulations if placed early after variceal bleeding. This article provides an updated evidence-based review of the indications for TIPS. Outcomes, complications, and adequate patient selection are also discussed.

Endoscopic Therapy and Radiologic Intervention of Acute Gastroesophageal Variceal Bleeding

Acute gastroesophageal variceal hemorrhage is a dreaded complication in patients with liver cirrhosis. Endoscopic therapy and radiologic intervention for gastroesophageal bleeding have rapidly developed in the recent decades. Endoscopic treatment is initially performed to stop variceal hemorrhage. For the treatment of esophageal variceal bleeding, endoscopic variceal ligation (EVL) is considered the endoscopic treatment of choice. In cases of gastric variceal hemorrhage, the type of gastric varices (GVs) is important in deciding the strategy of endoscopic treatment. Endoscopic variceal obturation (EVO) is recommended for fundal variceal bleeding. For the management of gastroesophageal varix type 1 bleeding, both EVO and EVL are available treatment options; however, EVO is preferred over EVL. If endoscopic management fails to control variceal hemorrhage, radiologic interventional modalities could be considered. Transjugular intrahepatic portosystemic shunt is a good option for rescue treatment in refractory variceal bleeding. In cases of refractory hemorrhage of GVs in patients with a gastrorenal shunt, balloon-occluded retrograde transvenous obliteration could be considered as a salvage treatment.

RECOMMENDATIONS FOR INVASIVE PROCEDURES IN PATIENTS WITH DISEASES OF THE LIVER AND BILIARY TRACT: REPORT OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SOBED) AND BRAZILIAN SOCIETY OF INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR SURGERY (SOBRICE)

Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.

Balloon-Occluded Retrograde Transvenous Obliteration versus Transjugular Intrahepatic Portosystemic Shunt for the Management of Gastric Variceal Bleeding

Background/Aims

Gastric varices (GVs) are a major cause of upper gastrointestinal bleeding in patients with liver cirrhosis. The current treatments of choice are balloon-occluded retrograde transvenous obliteration (BRTO) and the placement of a transjugular intrahepatic portosystemic shunt (TIPS). We aimed to compare the efficacy and outcomes of these two methods for the management of GV bleeding.

Methods

This retrospective study included consecutive patients who received BRTO (n=157) or TIPS (n=19) to control GV bleeding from January 2005 to December 2014 at a single tertiary hospital in Korea. The overall survival (OS), immediate bleeding control rate, rebleeding rate and complication rate were compared between patients in the BRTO and TIPS groups.

Results

Patients in the BRTO group showed higher immediate bleeding control rates (p=0.059, odds ratio [OR]=4.72) and lower cumulative rebleeding rates (log-rank p=0.060) than those in the TIPS group, although the difference failed to reach statistical significance. There were no significant differences in the rates of complications, including pleural effusion, aggravation of esophageal varices, portal hypertensive gastropathy, and portosystemic encephalopathy, although the rate of the progression of ascites was significantly higher in the BRTO group (p=0.02, OR=7.93). After adjusting for several confounding factors using a multivariate Cox analysis, the BRTO group had a significantly longer OS (adjusted hazard ratio [aHR]=0.44, p=0.01) and a longer rebleeding-free survival (aHR=0.34, p=0.001) than the TIPS group.

Conclusions

BRTO provides better bleeding control, rebleeding-free survival, and OS than TIPS for patients with GV bleeding.

Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.

Balloon-occluded retrograde transvenous obliteration of varices: focusing on the portal hemodynamics and the recent techniques

PURPOSE

To evaluate the recent topics of Ballloon-occluded retrograde trasnvenous obliteration(B-RTO).

METHOD

We overviewed the recent scientific papers regarding B-RTO.

RESULT

B-RTO is a treatment method for occluding varices retrogradely using a sclerosing agent under balloon occlusion of a major draining vein. It has been recognized as an effective treatment method for gastric varices. Hepatic function reserve is improved and liver volume is increased after B-RTO. In recent years, various technical options, such as plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, or foam B-RTO, have also been reported. In performing B-RTO, portal hemodynamics must be thoroughly examined radiologically. Judging the classification of the grade of collateral venous hemodynamics is important to select the appropriate embolization technique of B-RTO and to successfully occlude varices. Finally, the word "portosystemic shunt syndrome" has been proposed and the condition should be considered while selecting a treatment for gastric varices.

CONCLUSION

B-RTO is effective for gastrointestinal varices and portosystemic shunts.

胃肾及脾肾分流道对胃底曲张静脉内镜治疗的影响

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.

Acute variceal bleeding: risk stratification and management (including TIPS)

Acute variceal bleeding should be suspected in all patients with cirrhosis presenting with upper gastrointestinal bleeding. Vasoactive drugs and prophylactic antibiotics must be started as soon as possible, even before performing the diagnostic endoscopy. Once the patient is hemodynamically stable, upper gastrointestinal endoscopy should be performed in order to confirm the diagnosis and provide endoscopic therapy (preferably banding ligation). After this initial approach, the most appropriate therapy to prevent both early and late rebleeding must be instituted following a risk stratification strategy. The present chapter will focus on the initial management of patients with acute variceal bleeding, including general management and hemostatic therapies, as well as the available treatments in case of failure to control bleeding or development of rebleeding.

Balloon-occluded retrograde transvenous obliteration for treatment of bleeding gastric varices: case report and review of literature

Gastric variceal bleeding is a major complication of portal hypertension and is associated with high morbidity and mortality. While esophageal varices are more common, gastric varices are often more challenging to treat. Balloon-Occluded Retrograde Transvenous Obliteration is an interventional procedure whereby the portosystemic gastrorenal shunt is accessed via the left renal vein and the gastric varix outflow tract obliterated using direct sclerotherapy. Herein, we present a case of a 68-year-old female patient with cirrhosis who presented with bleeding gastric varices and successfully treated. This case highlights the procedural steps and the importance of detailed knowledge of the patient's portosystemic anatomy for determining suitability for balloon-occluded retrograde transvenous obliteration of gastric varices.

Prediction for Improvement of Liver Function after Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices to Manage Portosystemic Shunt Syndrome

PURPOSE

To investigate predictive factors and cutoff value of transient elastography (TE) measurements for assessing improvement in liver function after balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices (GV).

MATERIALS AND METHODS

Retrospective analysis was performed of 50 consecutive patients followed for > 3 months after BRTO, who had undergone TE before BRTO between January 2011 and February 2015. The correlation between change in liver function (total bilirubin, albumin, and prothrombin time) and baseline liver function values and liver stiffness measurement (LSM) by TE was evaluated by Pearson correlation test. Receiver operating characteristic curves were used to determine cutoff values for discriminating between patients who had improved liver function and patients who did not. The time interval from BRTO to aggravation of esophageal varices (EV) (worsening morphology, development of new varices, or variceal rupture) grouped by cutoff values was also analyzed.

RESULTS

Serum albumin was significantly improved at 3 months after BRTO (3.57 g/dL vs 3.74 g/dL, P < .001). There was a significant negative correlation between change in albumin and baseline LSM (r = -0.50, P < .001). The best cutoff point for LSM was ≤ 22.9 kPa, with sensitivity and specificity of 78.4% and 69.2%, respectively, for predicting which patients would have improved albumin after BRTO. Among 33 patients, 29 (88%) patients had improved albumin. The 1-year progression rate of EV after BRTO was 13.6% in patients with LSM ≤ 22.9 kPa.

CONCLUSIONS

The predictive factor for improvement in albumin after BRTO was lower LSM (≤ 22.9 kPa) using TE.

Management of gastric varices associated with portal hypertension

The rate of gastric variceal bleeding is significantly lower than that of esophageal variceal bleeding. Although gastric variceal bleeding occurs in only 10% of cirrhotic patients with hemorrhage, the bleeding is usually more severe, and is associated with higher mortality. To date, the majority of studies have focused on the treatment of esophageal variceal bleeding, but there were few studies on the treatment of gastric varices. As a result, there is still no standardized treatment for gastric varices. Endoscopic injection of cyanoacrylate is currently the optimum approach to control active bleeding from gastric varices. Transjugular intrahepatic portosystemic shunt (TIPS) can be used in acute gastric variceal bleeding and secondary prophylaxis. Balloon-occluded retrograde transvenous obliteration (BRTO) may be used in patients with gastric varices associated with a gastrorenal shunt. In recent years, endoscopic therapy and radiologic therapy have been developed for the treatment of patients with gastric variceal bleeding associated with portal hypertension. Here we describe the optimum treatment strategies for gastric variceal bleeding associated with portal hypertension as well as their therapeutic effects and complications.