Massive gastrointestinal bleeding complicating portal vein cross-clamping during liver transplantation

Incidence of Gastrointestinal Bleeding after Transesophageal Echocardiography in Patients with Gastroesophageal Varices: A Systematic Review and Meta-Analysis

BACKGROUND

Transesophageal echocardiography (TEE) is useful for cardiac assessment and intraoperative monitoring. However, the safety of TEE in patients with cirrhosis and gastroesophageal varices has remained uncertain. The aim of this meta-analysis was to determine the incidence of gastrointestinal bleeding after TEE in patients with varices. The secondary objectives were to compare bleeding risks between patients with and without varices and to determine the incidence of TEE-related esophageal perforation and mortality.

METHODS

A systematic literature search was conducted on MEDLINE, Embase, and the Cochrane Library using the terms "transesophageal echocardiography," "varices," "bleeding," and related terms. Articles describing the incidence of post-TEE bleeding in patients with varices were included. Non-English-language articles were excluded. Risk of bias and level of evidence were assessed using validated scales. The pooled weighted incidence of gastrointestinal bleeding and the risk difference in bleeding were calculated using a random-effects model.

RESULTS

Five hundred and sixty-nine articles were identified initially, and 10 articles (comprising of 908 patients) were included. The incidence of post-TEE bleeding in patients with varices was 0.84% (95% CI, 0.34% to 1.56%). When stratified by indication for TEE, the pooled incidence of bleeding was 0.68% (95% CI, 0.11% to 1.63%) for intraoperative TEE and 1.03% (95% CI, 0.23% to 2.29%) for diagnostic TEE. No cases of esophageal perforation or mortality were reported. Six studies included comparator groups of patients without varices, and the bleeding risk was comparable between patients with and those without varices (risk difference, 0.26%; 95% CI, -0.80% to 1.32%; I² = 0%; P = .88). Eight studies had moderate or high risk for bias, and the overall level of evidence was low.

CONCLUSIONS

TEE appears to be associated with low gastrointestinal bleeding incidence in patients with gastroesophageal varices. Nonetheless, results should be treated with caution because of bias and low level of evidence. Large-scale high-quality studies will be required to confirm the safety of TEE in patients with gastroesophageal varices.

Inferolateral ST-segment elevation with use of Sengstaken-Blakemore tube for variceal bleeding during orthotopic liver transplantation

Oesophageal balloon tamponade tubes are a rare cause of ST-segment elevation (STE), thought to result from extrinsic compression of coronary arteries. This case describes STE following the use of a Sengstaken-Blakemore tube (SBT) under traction for management of bleeding oesophageal varices during orthotopic liver transplantation. This case is the first to report a significant troponin rise with STE indicative of myocardial injury following the use of SBT. Interestingly, we found that releasing traction from the SBT resulted in resolution of STE within minutes, suggesting that SBT traction may reversibly impede coronary perfusion. We recommend vigilant monitoring of patients following SBT insertion and for clinicians to consider that SBT traction may impair coronary perfusion and result in myocardial injury in patients without pre-existing coronary artery disease.

Two cases of variceal haemorrhage during living-donor liver transplantation

Some patients with cirrhosis experience rupture of venous varices before operation, and liver transplantation is a therapy of last resort for these patients. However, we have experienced two cases of intraoperative rupture in whom no abnormalities of the venous varices were seen on endoscopy before operation. One patient with ruptured gastrointestinal varices was treated by direct surgical ligation and the other with ruptured oesophageal gastric varices, spontaneously recovered with a Sengstaken-Blakemore tube. These cases suggest that acute variceal haemorrhage should always be considered as a possibility during living-donor liver transplantation in patients with a history of upper gastrointestinal bleeding. Careful observation of the nasogastic tube is important during clamping of the hepatic portal vein.

Management of impending or ruptured esophageal varices during anesthesia for liver transplantation: A report of 3 cases

Portal hypertension may develop as a result of hepatic cirrhosis. One of the serious complications of portal hypertension is variceal hemorrhage. In recipients with esophageal varices, despite refinements in surgical techniques, variceal bleeding can occur during liver transplantation. The vascular isolation during cross-clamped inferior vena cava, hepatic and portal veins is associated with increases of inferior vena caval and portal venous pressures. We experienced three cases of bleeding from esophageal varices before and during living related liver transplantation and considered their management. One is bleeding during cross-clamped inferior vena cava, hepatic and portal veins. The others were carried out intraoperative endoscopy and endoscopic variceal ligation because of high risk of the esophageal variceal rupture. They were all managed successfully and recovered uneventfully. The anesthesiologists must keep in mind of the possibility of esophageal variceal bleeding during liver transplantation, and if that happens, prompt diagnosis and management must be taken.