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Wilen J, Trieu JA, Baron TH. Endoscopic ultrasound-guided embolization of a gastric varix by injection of RADA16 self-assembling peptide and coils. Endoscopy 2024; 56:E266. [PMID: 38485162 PMCID: PMC10940064 DOI: 10.1055/a-2261-7485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
Affiliation(s)
- Jonathan Wilen
- Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, United States
| | - Judy A Trieu
- Gastroenterology, Washington University in St Louis, St Louis, United States
| | - Todd H. Baron
- Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, United States
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2
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Rai P, Kumar P, Hoda US, Balankhe K. Endoscopic ultrasound-guided vascular interventions: A review (with videos). Indian J Gastroenterol 2024; 43:927-942. [PMID: 39352686 DOI: 10.1007/s12664-024-01681-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 08/19/2024] [Indexed: 10/10/2024]
Abstract
Endoscopic ultrasound (EUS) has evolved from a diagnostic to an interventional modality, allowing precise vascular access and therapy. EUS-guided vascular access of the portal vein has received increasing attention in recent years as a diagnostic and therapeutic tool. EUS-guided portal pressure gradient directly measures the hepatic vein portal pressure gradient and is crucial for understanding of liver function and prognostication of liver disease. EUS facilitates the sampling of portal venous blood to obtain circulating tumor cells (CTCs) in pancreatobiliary malignancies. This technique aids in the diagnosis and staging of cancers. EUS-guided interventions have a substantial potential for diagnosing portal vein tumor thrombus (PVTT) in patients with hepatocellular carcinoma. EUS-guided coil and glue embolization have higher efficacy for the treatment of gastric varices than direct endoscopic glue. Pseudoaneurysm (PsA), a rare vascular complication of acute and chronic pancreatitis, is typically managed with interventional radiology (IR)-guided embolization and surgery. EUS is increasingly used in specialized centers for non-variceal gastrointestinal bleeding, particularly for pseudoaneurysm-related bleeding. There is limited data on EUS-guided intervention for bleeding ectopic varices, rectal varices and Dieulafoy lesions, but it is becoming more widely accepted. In this extensive review, we evaluated both current and potential future applications of EUS-guided vascular interventions, including EUS-guided gastric variceal bleed therapy, rectal and ectopic varices, pseudoaneurysmal bleeding, splenic artery embolization, portal pressure gradient measurement, portal vein sampling for CTCs, fine needle aspiration of PVTT, intrahepatic portosystemic shunt placement, liver tumor ablation and EUS-guided cardiac intervention.
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Affiliation(s)
- Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India.
| | - Pankaj Kumar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Umair Shamsul Hoda
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Kartik Balankhe
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
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Irisawa A, Nagashima K, Yamamiya A, Abe Y, Maki T, Kashima K, Kunogi Y, Fukushi K, Sakuma F, Inaba Y, Tominaga K. Endoscopic ultrasound-guided vascular interventions. Dig Endosc 2024. [PMID: 39319363 DOI: 10.1111/den.14925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 08/25/2024] [Indexed: 09/26/2024]
Abstract
With the recent development of interventional endoscopic ultrasound (EUS), EUS-guided vascular interventions have seen increased clinical and research focus. This modality can be used to diagnose portal hypertension and treat portal hypertension-related gastrointestinal varices and refractory gastrointestinal hemorrhage, including pseudoaneurysm. The vascular embolic materials used for treatment include tissue adhesives (cyanoacrylates), sclerosants, thrombin, and vascular embolic coils, all of which are associated with favorable results. The feasibility of EUS-guided procedures, including portal vein stenting and portosystemic shunt formation conventionally performed percutaneously and transvenously, has also been demonstrated, albeit in animal studies. As EUS-guided vascular intervention is a technique that may receive significant attention in the future, we provide a thorough review of the current evidence for its use.
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Affiliation(s)
- Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Kazunori Nagashima
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Akira Yamamiya
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Yoko Abe
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Takumi Maki
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Ken Kashima
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Yasuhito Kunogi
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Koh Fukushi
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Fumi Sakuma
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Yasunori Inaba
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Keiichi Tominaga
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
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Zhang HY, He CC, Zhong DF. Endoscopic ultrasound-guided treatment of isolated gastric varices entwined with arteries: A case report. World J Gastrointest Endosc 2024; 16:489-493. [PMID: 39156000 PMCID: PMC11325873 DOI: 10.4253/wjge.v16.i8.489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/30/2024] [Accepted: 07/05/2024] [Indexed: 08/01/2024] Open
Abstract
BACKGROUND Interventional endoscopic ultrasound is clinically used for the treatment of isolated gastric varices (IGVs) owing to its precise visualization. CASE SUMMARY A 39-year-old man was diagnosed with a large IGV during a routine physical examination. Endoscopic ultrasonography showed gastric varices entwined with an artery, which greatly increased the difficulty of treatment. We successfully treated the patient with endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection. CONCLUSION Endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection was safe and effective for the treatment of an IGV entwined with an artery.
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Affiliation(s)
- Hong-Ying Zhang
- Department of Gastroenterology, Jinhua People's Hospital, Jinhua 321000, Zhejiang Province, China
| | - Chen-Cong He
- Department of General Medicine, Jinhua Guangfu Hospital, Jinhua 321001, Zhejiang Province, China
| | - Ding-Fu Zhong
- Department of Gastroenterology, Jinhua People's Hospital, Jinhua 321000, Zhejiang Province, China
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Cao L, Shen G, Wu R, Shen X, Xu J, Sun H, Xiang X. Spring coil displacement after interventional embolization of severe pelvic fracture: a case report. J Int Med Res 2024; 52:3000605241266219. [PMID: 39075863 PMCID: PMC11289803 DOI: 10.1177/03000605241266219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 06/10/2024] [Indexed: 07/31/2024] Open
Abstract
Haemorrhagic shock, which arises as a complication of pelvic fracture subsequent to severe trauma, represents a perilous state. The utilization of interventional endovascular haemostasis assumes a pivotal role in the management of patients with vascular injury following pelvic fracture. This article reports the treatment of a patient with pelvic fracture caused by a serious work-related vehicle accident. Despite the implementation of timely blood and fluid transfusion to combat shock, the application of aortic balloon obstruction, and interventional iliac artery embolization for haemostasis, the patient's condition failed to display any discernible improvement. Repeat angiography further revealed a displacement of the interventional embolization material, and the patient subsequently died of multiple organ failure. The occurrence of spring coil displacement is infrequent, but the consequences thereof are considered grave, necessitating meticulous discernment in the selection of haemostatic materials for this type of patient. The diagnostic and therapeutic processes encompassing the particular case described here were analysed and are discussed with the objective of augmenting the efficacy and success rate of treatment modalities for patients in similar circumstances.
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Affiliation(s)
- Lijun Cao
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Guoping Shen
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Renyan Wu
- Department of Ultrasound, Wangdian People’s Hospital, Jiaxing, Zhejiang, China
| | - Xuning Shen
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Jun Xu
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Hui Sun
- Emergency Department, The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Xianhua Xiang
- Outpatient Department, Sunto Women and Children’s Hospital, Jiaxing, Zhejiang, China
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6
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Li T, Kang C, Ren G, Lv Y, Luo H, Kang X, Liang S, Wang X, Pan Y. Top 100 cited articles related to EUS: A bibliometric analysis. Endosc Ultrasound 2024; 13:259-268. [PMID: 39318756 PMCID: PMC11419419 DOI: 10.1097/eus.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/27/2024] [Indexed: 09/26/2024] Open
Abstract
Background and Objectives Citation analysis is a fundamental method in bibliometrics for quantifying the impact and contribution of articles on a specific biomedical field. The purpose of our study was to identify and analyze the top 100 cited articles in the field of EUS. Methods All published articles in the field of EUS were searched by using "endoscopic ultrasound" and its synonyms as the search terms without time limit. The Institute for Scientific Information Web of Science Core database was searched to determine the citations. The top 100 cited articles were identified and further evaluated for characteristics including publication year, authors, journals, impact factor, countries, institutions, article type, topic term, and evidence grade, among others. Results A total of 430 articles were cited more than 100 times. The 100 most-cited articles were published between 1988 and 2018, and the medium citation was 240.5 (104.25). The top 100 cited articles mainly focused on diagnostic performance (80%) and interventional therapy (20%). The numbers of articles studying the diagnostic accuracy of FNA (n = 29) and tumor diagnosis (n = 29) were the highest among research articles on FNA and EUS of diagnostic categories, and EUS transluminal drainage (n = 14) was the most frequently used EUS technique for therapy. The focus of the majority of the articles was on diseases of pancreas (n = 55), and among the 55 articles related to pancreatic diseases, pancreatic cancer (n = 17) and solid pancreatic masses (n = 13) were the most researched topics. In addition, we found that the proportions of diagnostic and treatment-related articles at different time periods have statistical significance (P < 0.05). Conclusions Our analysis provides an insight into the top 100 articles in the field of EUS, revealing EUS-guided FNA, tumor staging, and transluminal drainage as the major advances in the past 35 years. Pancreatic diseases were the most researched, especially pancreatic cancer or solid pancreatic masses. Our research has found that the number of articles on the application of EUS treatment has significantly increased.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yanglin Pan
- State Key Laboratory of Holistic Integrative Management of Gastrointestinal Cancers and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an 710032, Shaanxi Province, China
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Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
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Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
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8
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Chen D, Fu S, Shen R. Efficacy and safety of EUS-guided coil embolization in combination with cyanoacrylate injection versus conventional endoscopic cyanoacrylate injection in the treatment of gastric varices with spontaneous portosystemic shunts. Gastroenterol Rep (Oxf) 2024; 12:goae026. [PMID: 38586537 PMCID: PMC10997409 DOI: 10.1093/gastro/goae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/27/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
Background Gastric varices (GV) with spontaneous portosystemic shunts (SPSS) pose considerable risks and challenges for administering endoscopic cyanoacrylate (CYA) injection. This study aimed to evaluate the efficacy and safety of EUS-guided coil embolization in combination with CYA injection compared to conventional endoscopic CYA injection for managing GV with SPSS. Methods This retrospective analysis included patients with SPSS treated with either EUS-guided coil embolization in combination with CYA injection or conventional CYA injection for gastric variceal bleeding at Ningbo Medical Center Lihuili Hospital (Zhejiang, China) between January 2018 and March 2023. Patient demographics, procedural details, and follow-up results were reviewed. Results The study evaluated 57 patients: 21 in the combined treatment group undergoing EUS-guided coil embolization in combination with CYA injection and 36 in the conventional group receiving conventional endoscopic CYA injection. Both cohorts achieved a 100% technical success rate. The mean volume of CYA used was significantly lower in the combined group (1.64 ± 0.67 mL) than in the conventional group (2.38 ± 0.72 mL; P < 0.001). Early GV rebleeding rates did not differ significantly between the groups; in contrast, the combined treatment group exhibited a considerably lower incidence of late GV rebleeding than the conventional group (4.8% vs 27.8%, P = 0.041). Conclusions EUS-guided coil embolization in combination with CYA injection demonstrated superiority over conventional endoscopic CYA injection in reducing late GV rebleeding in treating GV with SPSS.
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Affiliation(s)
- Dawei Chen
- Department of Gastroenterology, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, P. R. China
| | - Sunya Fu
- Department of Radiology, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, P. R. China
| | - Ruiwei Shen
- Department of Gastroenterology, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, P. R. China
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9
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Chavan R, Baraldo S, Patel N, Gandhi C, Rajput S. Technical tips for EUS-guided embolization of varices and pseudoaneurysms. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2024; 9:211-219. [PMID: 38618622 PMCID: PMC11009482 DOI: 10.1016/j.vgie.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Backgrounds and Aims EUS-guided vascular intervention has expanded the horizons of diagnostic as well as therapeutic interventions for vascular pathology. EUS-guided embolization is a commonly performed technique for the treatment of gastric varices. However, there is a lack of data on the standardization of the technique. Here, we review the techniques and difficulties encountered during EUS-guided embolization of varices and pseudoaneurysms. Methods This article and accompanying video describe the EUS-guided embolization techniques for various vascular lesions. EUS-guided embolization was achieved by combination therapy using coils and cyanoacrylate. Complete obliteration of the lesions was documented on follow-up. The existing literature of EUS-guided embolization therapy is also reviewed. Results Patients with various vascular lesions, including gastric varices, ectopic duodenal varices, and splenic artery pseudoaneurysms, were successfully treated with EUS-guided coil plus cyanoacrylate injection. Patients with gastric varices underwent treatment with 2 EUS-guided techniques: (1) direct puncture of the varix and embolization and (2) feeder vessel embolization. Following embolization, the absence of Doppler flow within the varix and pseudoaneurysm was documented. Conclusions Techniques of EUS-guided embolization of varices and pseudoaneurysms are demonstrated. Understanding the techniques and the challenges encountered during therapy is crucial to optimize outcomes and reduce adverse events.
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Affiliation(s)
| | | | - Nishant Patel
- Arnold Palmer Hospital for Children, Orlando Health, Orlando, Florida, USA
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10
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Wang P, Leong QY, Lau NY, Ng WY, Kwek SP, Tan L, Song SW, You K, Chong LM, Zhuang I, Ong YH, Foo N, Tadeo X, Kumar KS, Vijayakumar S, Sapanel Y, Raczkowska MN, Remus A, Blasiak A, Ho D. N-of-1 medicine. Singapore Med J 2024; 65:167-175. [PMID: 38527301 PMCID: PMC11060644 DOI: 10.4103/singaporemedj.smj-2023-243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/19/2024] [Indexed: 03/27/2024]
Abstract
ABSTRACT The fields of precision and personalised medicine have led to promising advances in tailoring treatment to individual patients. Examples include genome/molecular alteration-guided drug selection, single-patient gene therapy design and synergy-based drug combination development, and these approaches can yield substantially diverse recommendations. Therefore, it is important to define each domain and delineate their commonalities and differences in an effort to develop novel clinical trial designs, streamline workflow development, rethink regulatory considerations, create value in healthcare and economics assessments, and other factors. These and other segments are essential to recognise the diversity within these domains to accelerate their respective workflows towards practice-changing healthcare. To emphasise these points, this article elaborates on the concept of digital health and digital medicine-enabled N-of-1 medicine, which individualises combination regimen and dosing using a patient's own data. We will conclude with recommendations for consideration when developing novel workflows based on emerging digital-based platforms.
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Affiliation(s)
- Peter Wang
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
| | - Qiao Ying Leong
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Ni Yin Lau
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Wei Ying Ng
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Siong Peng Kwek
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Lester Tan
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
| | - Shang-Wei Song
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
| | - Kui You
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
| | - Li Ming Chong
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
| | - Isaiah Zhuang
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Yoong Hun Ong
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Nigel Foo
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
| | - Xavier Tadeo
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Kirthika Senthil Kumar
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Smrithi Vijayakumar
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Yoann Sapanel
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Singapore’s Health District @ Queenstown, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Marlena Natalia Raczkowska
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
| | - Alexandria Remus
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
- Heat Resilience Performance Centre (HRPC), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Agata Blasiak
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Dean Ho
- Institute for Digital Medicine (WisDM), Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The N.1 Institute for Health (N.1), National University of Singapore, Singapore
- Department of Biomedical Engineering, College of Design and Engineering, National University of Singapore, Singapore
- Singapore’s Health District @ Queenstown, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- The Bia-Echo Asia Centre for Reproductive Longevity and Equality, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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11
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Tehami N, Kaushal K, Maher B. The contribution of EUS to the management of endoscopic and surgical complications. Best Pract Res Clin Gastroenterol 2024; 69:101914. [PMID: 38749584 DOI: 10.1016/j.bpg.2024.101914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 04/10/2024] [Accepted: 04/15/2024] [Indexed: 05/26/2024]
Abstract
Endoscopic Ultrasound (EUS) stands as a remarkable innovation in the realm of gastroenterology and its allied disciplines. EUS has evolved to such an extent that it now assumes a pivotal role in both diagnosis and therapeutics. In addition, it has developed as a tool which is also capable of addressing complications arising from endoscopic and surgical procedures. This minimally invasive technique combines endoscopy with high-frequency ultrasound, facilitating, high-resolution images of the gastrointestinal tract and adjacent structures. Complications within the gastrointestinal tract, whether stemming from endoscopic or surgical procedures, frequently arise due to disruption in the integrity of the gastrointestinal tract wall. While these complications are usually promptly detected, there are instances where their onset is delayed. EUS plays a dual role in the management of these complications. Firstly, in its ability to assess and increasingly to definitively manage complications through drainage procedures. It is increasingly employed to manage post-surgical collections, abscesses biliary strictures and bleeding. Its high-resolution imaging capability allows precise real-time visualisation of these complications.
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Affiliation(s)
- N Tehami
- Department of Hepatology & HPB Medicine, University Hospital Southampton, UK.
| | - K Kaushal
- Department of Hepatology & HPB Medicine, University Hospital Southampton, UK
| | - B Maher
- Department of Hepatology & HPB Medicine, University Hospital Southampton, UK
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12
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Gralnek IM, Garcia-Pagan JC, Hernández-Gea V. Challenges in the Management of Esophagogastric Varices and Variceal Hemorrhage in Cirrhosis - A Narrative Review. Am J Med 2024; 137:210-217. [PMID: 38128860 DOI: 10.1016/j.amjmed.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
Over the past decade, significant advancements in pharmacological, endoscopic, and radiographic treatments have emerged in the management of patients with cirrhosis and esophagogastric varices or variceal hemorrhage. These advances have been in several areas, including the role of screening and primary prophylaxis (preventing an initial variceal bleed), evaluation and management of acute esophagogastric variceal hemorrhage, and in preventing variceal rebleeding. Therefore, we believe there is a need for an updated, evidence-based "narrative review" on this important clinical topic that will be relevant for internists, hospitalists, intensive care unit physicians, and those in training. We believe the guidance presented in this narrative review will enhance daily medical practice of health care professionals and has the potential to improve quality of care for these complex patients.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel; Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel.
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
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Wang Z, Zhang F, Zeng Z, Bai Y, Chen L, Shi C, Jin J, Zhang Q, Mei X, Kong D. Application of Indian ink markers for locating gastric varices under endoscopic ultrasonography. Surg Endosc 2024; 38:633-639. [PMID: 38012437 DOI: 10.1007/s00464-023-10532-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/12/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE The present study aimed to investigate the accuracy of endoscopic ultrasonography (EUS) combined with Indian ink in locating target vessels of gastric varices (GVs) compared with conventional endoscopic techniques. Additionally, the characteristics of GVs under conventional endoscopy were also explored. METHODS All 50 cirrhotic patients with GVs between August 2021 and December 2022 were included in the study. Firstly, conventional endoscopy was employed to identify GVs and to record the expected injection sites. Subsequently, EUS was used to locate the perforated vessel and the injection site was them marked with India ink followed by injection with cyanoacrylate (CYA). Finally, conventional endoscopy was used to examine GVs, to identify the marker points of Indian ink and to compare whether the injection points under conventional endoscopy were consistent with those marked with Indian ink. Furthermore, patients with consistent and inconsistent distribution of endoscopic markers and injection sites were divided into two groups. RESULTS EUS could detect the perforating vessels in real time and intuitively. The distribution of markers using EUS was significantly different compared with the injection points obtained by conventional endoscopy (P < 0.001). Therefore, 20 cases were allocated to the consistent group and 30 cases to the non-consistent group. 16 patients who showed red wale signs were obtained in the consistent group and 11 patients in the non-consistent group (P = 0.048). The diameter of the largest GVs was 13.5 (10-15) mm in the consistent group compared with 10 (7.5-10) mm in the non-consistent group (P = 0.006). CONCLUSION EUS could provide the exact location of GVs, thus more accurately describing the endoscopic characteristics of the GVs. Furthermore, the red wale signs and diameter of the largest GVs obtained using conventional endoscopy were helpful in determining the location of target GVs.
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Affiliation(s)
- Zhihong Wang
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Fumin Zhang
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Zhuang Zeng
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Yuchuan Bai
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Lihong Chen
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Chen Shi
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Jing Jin
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Qianqian Zhang
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Xuecan Mei
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China.
| | - Derun Kong
- Key Laboratory of Digestive Diseases of Anhui Province, Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Hefei, 230022, Anhui, China.
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14
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Mayer P, Venkatasamy A, Baumert TF, Habersetzer F, Pessaux P, Saviano A, Felli E. Left-sided portal hypertension: Update and proposition of management algorithm. J Visc Surg 2024; 161:21-32. [PMID: 38142180 DOI: 10.1016/j.jviscsurg.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
Left-sided or segmental portal hypertension (SPHT) is a rare entity, most often associated with pancreatic disease or antecedent pancreatic surgery. The starting point is splenic vein obstruction secondary to local inflammation or, less often, extrinsic compression. SPHT leads to splenomegaly and development of collateral porto-systemic venous circulation. SPHT should be suspected in patients with pancreatic history who present with episodic upper gastrointestinal bleeding and splenomegaly with normal liver function tests. The most common clinical presentation is major upper gastrointestinal bleeding secondary to rupture of esophageal and/or gastric varices. At the present time, there are no management recommendations for SPHT, particularly when the patient is asymptomatic. In patients with upper gastro-intestinal bleeding, hemostasis can be obtained either by medical or interventional means according to patient status and available resources. For symptomatic patients, splenectomy is the reference treatment. Recently, less invasive, radiologic procedures, such as splenic artery embolization, have been developed as an alternative to surgery. Additionally, sonography-guided endoscopic hemostasis can also be envisioned, leading to the diagnosis and treatment of the lesion by elastic band ligation or by glue injection into the varices during the same procedure. The goal of this article is to describe the pathophysiological mechanisms behind SPHT and its clinical manifestations and treatment, based on a review of the literature. Because of the absence of recommendations for the management of SPHT, we propose a decisional algorithm for the management of SPHT based on the literature.
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Affiliation(s)
- Pierre Mayer
- Hepato-gastroenterology Department, Hepato-digestive Unit, New Civil Hospital, University Hospitals of Strasbourg (HUS), Strasbourg, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France.
| | - Aïna Venkatasamy
- IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Streinth Lab (Stress Response and Innovative Therapies), Inserm UMR_S 1113 IRFAC, Interface Recherche Fondamentale et Appliquée à la Cancérologie, 3 avenue Molière, Strasbourg, France
| | - Thomas F Baumert
- Hepato-gastroenterology Department, Hepato-digestive Unit, New Civil Hospital, University Hospitals of Strasbourg (HUS), Strasbourg, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France
| | - François Habersetzer
- Hepato-gastroenterology Department, Hepato-digestive Unit, New Civil Hospital, University Hospitals of Strasbourg (HUS), Strasbourg, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France
| | - Patrick Pessaux
- IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France; Hepato-biliary surgery unit, Department of Digestive and Endocrine Surgery, New Civil Hospital, Strasbourg University Hospital, Strasbourg, France
| | - Antonio Saviano
- Hepato-gastroenterology Department, Hepato-digestive Unit, New Civil Hospital, University Hospitals of Strasbourg (HUS), Strasbourg, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France
| | - Emanuele Felli
- Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France; Department of Digestive Surgery and Liver Transplantation, Trousseau Hospital, Tours, France
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15
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Alwassief A, Al-Busafi S, Abbas QL, Al Shamusi K, Paquin SC, Sahai AV. Endohepatology: The endoscopic armamentarium in the hand of the hepatologist. Saudi J Gastroenterol 2024; 30:4-13. [PMID: 37988109 PMCID: PMC10852142 DOI: 10.4103/sjg.sjg_214_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 10/10/2023] [Accepted: 10/15/2023] [Indexed: 11/22/2023] Open
Abstract
ABSTRACT Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease.
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Affiliation(s)
- Ahmed Alwassief
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Said Al-Busafi
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Qasim L. Abbas
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Khalid Al Shamusi
- Department of Internal Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Sarto C. Paquin
- Division of Gastroenterology, Hopital Saint Luc, Centre Hospitaliér de l’Universite de Montréal, Montreal, Quebec, Canada
| | - Anand V. Sahai
- Division of Gastroenterology, Hopital Saint Luc, Centre Hospitaliér de l’Universite de Montréal, Montreal, Quebec, Canada
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Lesmana CRA. Role of endoscopic ultrasound in non-variceal upper gastrointestinal bleeding management. Artif Intell Gastrointest Endosc 2023; 4:12-17. [DOI: 10.37126/aige.v4.i2.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/14/2023] [Accepted: 12/04/2023] [Indexed: 12/07/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (NVUGIB) is one of the challenging situations in clinical practice. Despite that gastric ulcer and duodenal ulcer are still the main causes of acute NVUGIB, there are other causes of bleeding which might not always be detected through the standard endoscopic evaluation. Standard endoscopic management of UGIB consists of injection, thermal coagulation, hemoclips, and combination therapy. However, these methods are not always successful for rebleeding prevention. Endoscopic ultrasound (EUS) has been used recently for portal hypertension management, especially in managing acute variceal bleeding. EUS has been considered a better tool to visualize the bleeding vessel in gastroesophageal variceal bleeding. There have been studies looking at the role of EUS for managing NVUGIB; however, most of them are case reports. Therefore, it is important to review back to see the evolution and innovation of endoscopic treatment for NVUGIB and the role of EUS for possibility to replace the standard endoscopic haemostasis management in daily practice.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta 10430, DKI, Indonesia
- Digestive Disease & GI Oncology Center, Medistra Hospital, Jakarta 12950, Indonesia
- Gastrointestinal Cancer Center, MRCCC Siloam Semanggi Hospital, Jakarta 12930, Indonesia
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17
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Wang Z, Zeng Z, Chen L, Shi C, Jin J, Zhang F, Zhang Q, Mei X, Kong D. Endoscopic ultrasonography-guided injection of cyanoacrylate in the treatment of gastroesophageal varices type 1: a single-center randomized study. Surg Endosc 2023; 37:8277-8284. [PMID: 37674054 DOI: 10.1007/s00464-023-10342-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/30/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND AND AIM First, it has been demonstrated that endoscopic ultrasonography (EUS)-guided cyanoacrylate (CYA) injection (EUS-CYA) has greater efficacy than direct endoscopic injection of cyanoacrylate (DEI-CYA) for treating type 1-isolated gastric varices. However, it is necessary to conduct further studies to determine whether EUS has any advantage over the current guidelines for treating gastroesophageal varices type 1 (GOV1). Second, liver function is an important prognostic factor in patients with liver cirrhosis. Therefore, we evaluated the liver function of patients treated with EUS-CYA. METHODS In a single-center study, a prospective cohort from February 2021 to September 2022 involving 89 patients with cirrhosis with GOV1 were assigned to undergo EUS-CYA (n = 45) or DEI-CYA (n = 44). The success rate of CYA injection, the rate of overall rebleeding, the rate of reintervention, the complications during the follow-up period, and the liver function were compared. RESULTS In both groups, 100% of the operations were successful. The follow-up time of the two groups was 290 (153-398) days and 267 (177-416) days, respectively. In the EUS group, the perforating veins had an average diameter of 7.0 ± 2.7 mm, and they had a 100% occlusion rate. A statistically significant difference was found between the two groups regarding the number of sessions needed to eradicate GV (p = 0.005, pairwise comparisons were conducted using the Bonferroni correction method.), the late rebleeding rate after EUS-CYA [n = 3 (6.7%) vs n = 10 (22.7%); p = 0.032], and the incidence of postinjection ulcers [n = 4 (8.9%) vs n = 12 (27.3); p = 0.023)]. Following EUS or DEI-CYA treatment, the patient's liver function did not show any significant deterioration or decline. CONCLUSION EUS-CYA has a higher eradication success rate and fewer complications, recurrences, and rebleeding episodes than DEI-CYA used for GOV1 treatment. In addition, EUS-CYA did not impair liver function.
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Affiliation(s)
- Zhihong Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Zhuang Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Lihong Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Chen Shi
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Jing Jin
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Fumin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Qianqian Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Xuecan Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Derun Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China.
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18
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Ashat M, El-Abiad R, Shrigiriwar A, Khashab MA. Interventional Endoscopic Ultrasound: Current Status and Future Frontiers. Am J Gastroenterol 2023; 118:1768-1778. [PMID: 37646335 DOI: 10.14309/ajg.0000000000002487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
Interventional endoscopic ultrasound has fueled remarkable advancements in the field of therapeutic procedures, revolutionizing minimally invasive interventions for a diverse range of conditions. This review highlights the latest breakthroughs and advancements in therapeutic endoscopic ultrasound, showcasing its potential to transform patient care.
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Affiliation(s)
- Munish Ashat
- Department of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Rami El-Abiad
- Department of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Apurva Shrigiriwar
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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19
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Canakis A, Baron TH. Therapeutic Endoscopic Ultrasound: Current Indications and Future Perspectives. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:4-18. [PMID: 37818395 PMCID: PMC10561320 DOI: 10.1159/000529089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/26/2022] [Indexed: 10/12/2023]
Abstract
The transcendence of endoscopic ultrasound (EUS) from diagnostic to therapeutic tool has revolutionized management options in the field of gastroenterology. Through EUS-guided methods, pancreaticobiliary obstruction can now be utilized as an alternative to surgical and percutaneous approaches. This modality also allows for gallbladder drainage in patients who are not ideal operative candidates. By utilizing its unique imaging capabilities, EUS also allows for drainage access points in cases of gastric outlet obstruction as well as windows to ablate pancreatic cystic lesions. As technical progress continues to evolve, interventional gastroenterology continues to push the envelope of minimally invasive therapeutic procedures in a multidisciplinary setting. In this comprehensive review, we set out to describe current indications and innovations through EUS.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Todd H. Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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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: 11] [Impact Index Per Article: 11.0] [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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Chandan S, Nguyen AK, Mohan BP, Deliwala S, Ramai D, Kassab LL, Muthusamy A, Facciorusso A, Kamal F, Bilal M, Samanta J, Adler DG. EUS-guided therapies for primary and secondary prophylaxis in gastric varices-An updated systematic review and meta-analysis. Endosc Ultrasound 2023; 12:351-361. [PMID: 37795350 PMCID: PMC10547242 DOI: 10.1097/eus.0000000000000017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 04/12/2023] [Indexed: 10/06/2023] Open
Abstract
Background and Objectives Gastric varices (GVs) are associated with a higher risk of uncontrolled bleeding and death when compared with esophageal varices. While endoscopic glue injection therapy has been traditionally used for secondary prophylaxis in GV, data regarding primary prophylaxis continue to emerge. Recently, EUS-guided therapies have been used in GV bleeding. Methods We conducted a comprehensive search of several major databases from inception to June 2022. Our primary goals were to estimate the pooled rates of treatment efficacy, GV obliteration, GV recurrence, and rebleeding with EUS-guided therapy in primary and secondary prophylaxis. Overall adverse events and technical failures were assessed. Random-effects model was used for our meta-analysis, and heterogeneity was assessed using the I2 % statistics. Results Eighteen studies with 604 patients were included. In primary prophylaxis, pooled rate of GV obliteration was 90.2% (confidence interval [CI], 81.1-95.2; I2 = 0). With combination EUS-glue and coil therapy, the rate was 95.4% (CI, 86.7%-98.5%; I2 = 0). Pooled rate of posttherapy GV bleeding was 4.9% (CI, 1.8%-12.4%; I2 = 0). In secondary prophylaxis, pooled rate of treatment efficacy was 91.9% (CI, 86.8%-95.2%; I2 = 12). With EUS-glue, EUS-coil, and combination EUS-glue and coil, the rates were 94.3% (CI, 88.9%-97.1%; I2 = 0), 95.5% (CI, 80.3%-99.1%; I2 = 0), and 88.7% (CI, 76%-95.1%; I2 = 14), respectively. Pooled rate of GV obliteration was 83.6% (CI, 71.5%-91.2%; I2 = 74). With EUS-glue, EUS-coil, and combination EUS-glue and coil, the rates were 84.6% (CI, 75.9%-90.6%; I2 = 31), 92.3% (CI, 81.1%-97.1%; I2 = 0), and 84.5% (CI, 50.8%-96.7%; I2 = 75), respectively. Pooled rates of GV rebleeding and recurrence were 18.1% (CI, 13.1%-24.3%; I2 = 16) and 20.6% (CI, 9.3%-39.5%; I2 = 66), respectively. Conclusion Our analysis shows that EUS-guided therapy for GVs is technically feasible and clinically successful in both primary and secondary prophylaxis of GV.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE, USA
| | - Andrew Khoi Nguyen
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Smit Deliwala
- Division of Gastroenterology, Emory University, Atlanta, GA, USA
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | | | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Faisal Kamal
- Department of Gastroenterology, University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Mohammad Bilal
- Division of Gastroenterology, University of Minnesota and Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Douglas G. Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Adventist Hospital, Denver, CO, USA
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Ryou M, DeWitt JM, Das KK, Shami VM. AGA Clinical Practice Update on Interventional EUS for Vascular Investigation and Therapy: Commentary. Clin Gastroenterol Hepatol 2023; 21:1699-1705.e2. [PMID: 37162434 DOI: 10.1016/j.cgh.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 05/11/2023]
Abstract
DESCRIPTION The purpose of this AGA Institute Clinical Practice Update is to review the available evidence supporting and examine opportunities for future research in endoscopic ultrasound-guided vascular investigation and therapies. METHODS This Clinical Practice Update was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in endoscopic ultrasound-guided vascular investigation and therapy.
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Affiliation(s)
- Marvin Ryou
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts.
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health, Indianapolis, Indiana
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia Medical Center, Charlottesville, Virginia
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Vanderschueren E, Trebicka J, Laleman W. Endoscopic Advances in Hepatology. Semin Liver Dis 2023; 43:176-188. [PMID: 37192654 DOI: 10.1055/s-0043-1769009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Endoscopy is and remains an indispensable tool in diagnosing and managing liver disease and its complications. Due to the progress in advanced endoscopy, endoscopy has become an alternative route for many surgical, percutaneous, and angiographic interventions, not only as a backup tool when conventional interventions fail but increasingly as a first-line choice. The term endo-hepatology refers to the integration of advanced endoscopy in the practice of hepatology. Endoscopy is key in the diagnosis and management of esophageal and gastric varices, portal hypertensive gastropathy, and gastric antral vascular ectasia. Endoscopic ultrasound (EUS) can be used for the evaluation of the liver parenchyma, liver lesions, and surrounding tissues and vessels, including targeted biopsy and complemented with new software functions. Moreover, EUS can guide portal pressure gradient measurement, and assess and help manage complications of portal hypertension. It is crucial that each present-day hepatologist is aware of the (rapidly increasing) full spectrum of diagnostic and therapeutic tools that exist within this field. In this comprehensive review, we would like to discuss the current endo-hepatology spectrum, as well as future directions for endoscopy in hepatology.
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Affiliation(s)
- Emma Vanderschueren
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Jonel Trebicka
- Department of Gastroenterology and Hepatology, Universitätsklinikum Münster, Münster, Germany
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, Universitätsklinikum Münster, Münster, Germany
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24
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Dhar J, Samanta J. Endoscopic ultrasound-guided vascular interventions: An expanding paradigm. World J Gastrointest Endosc 2023; 15:216-239. [PMID: 37138933 PMCID: PMC10150286 DOI: 10.4253/wjge.v15.i4.216] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/09/2023] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.
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Affiliation(s)
- Jahnvi Dhar
- Gastroenterology, Sohana Multispeciality Hospital, Mohali 140308, India
| | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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25
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Sabry F, Seif S, Eldesoky A, Hakim H, Altonbary AY. EUS-guided cyanoacrylate injection into the perforating vein versus direct endoscopic injection in the treatment of gastric varices. Endosc Int Open 2023; 11:E202-E210. [PMID: 36845270 PMCID: PMC9949986 DOI: 10.1055/a-1984-7070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Background and study aims Endoscopic injection of gastric varices (GVs) using cyanoacrylate (CYA) is associated with significant adverse events (AEs). We aimed to compare the efficacy and safety of endoscopic ultrasound (EUS)-guided CYA injection into the perforating vein versus direct endoscopic injection (DEI) of CYA in treatment of high-risk GVs. Patients and methods This was a randomized controlled trial that included 52 patients with high-risk GVs. Group A underwent EUS-guided injection into the perforator vein and Group B underwent DEI of 1 mL CYA. Endoscopic examination and Doppler EUS were repeated after 3 months to confirm eradication. Obliteration by Doppler EUS was considered by absence of Doppler flow within the varix. Repeated injection was performed in the absence of obliteration. Doppler EUS examination was repeated at 3 and 6 months after each injection. Results Forty-three patients including 27 males and 16 females with mean age 57 years completed the study. Variceal obliteration was achieved during the index session after 3 months in eight of 21 (38.1 %) in group B compared to 17 of 22 (77.2 %) in group A ( P = 0.014). There was a significant difference in the amount of CYA needed to achieve obliteration in group B compared to group A (2 vs.1 mL, P = 0.027). There was no statistically significant difference in the overall AE rate between group A and group B (4.5 % vs. 14.3 %, P = 0.345). Conclusions EUS-guided CYA injection into the perforating veins achieved less amount of CYA, fewer number of sessions to obliteration, and similar overall AE rates in the treatment of high-risk GVs compared to DEI.
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Affiliation(s)
- Fady Sabry
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Seham Seif
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Ayman Eldesoky
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Hazem Hakim
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
| | - Ahmed Youssef Altonbary
- Mansoura University Faculty of Medicine, Department of Gastroenterology and Hepatology, Mansoura, Egypt
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26
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Altonbary AY. Endoscopic ultrasound-guided vascular interventions: An overview of current and emerging techniques. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2023. [DOI: 10.18528/ijgii220030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ahmed Youssef Altonbary
- Department of Gastroenterology and Hepatology, Mansoura Specialized Medical Hospital, Mansoura University, Mansoura, Egypt
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27
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Han JH. Role of endoscopic ultrasound in the secondary prevention of gastric varices. Clin Endosc 2023; 56:50-52. [PMID: 36646421 PMCID: PMC9902684 DOI: 10.5946/ce.2022.301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea,Correspondence: Joung-Ho Han Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, 776 1Sunhwan-ro, Seowon-gu, Cheongju 28644, Korea E-mail:
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28
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Jamwal KD, Padhan RK, Sharma A, Sharma MK. Endoscopic ultrasound-guided coiling and glue is safe and superior to endoscopic glue injection in gastric varices with severe liver disease: a retrospective case control study. Clin Endosc 2023; 56:65-74. [PMID: 36594180 PMCID: PMC9902678 DOI: 10.5946/ce.2021.119] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/04/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND/AIMS Gastric varices (GV) are present in 25% of cirrhotic patients with high rates of rebleeding and mortality. Data on endoscopic ultrasound (EUS)-guided treatment in severe liver disease (model for end stage liver disease sodium [MELD-Na] >18 and Child-Turcotte-Pugh [CTP] C with GV) are scarce. Thus, we performed a retrospective comparison of endoscopic glue injection with EUS-guided therapy in cirrhotic patients with large GV. METHODS A retrospective study was performed in the tertiary hospitals of India. A total of 80 patients were recruited. The inclusion criteria were gastroesophageal varices type 2, isolated gastric varices type 1, bleeding within 6 weeks, size of GV >10 mm, and a MELD-Na >18. Treatment outcomes and complications of endoscopic glue injection and EUS-guided GV therapy were compared. RESULTS In this study, the patients' age, sex, liver disease severity (CTP, MELD-Na) and clinical parameters were comparable. The median number of procedures, injected glue volume, complications, and GV obturation were better in the EUS group, respectively. On subgroup analysis of the EUS method (e.g., direct gastric fundus vs. paragastric collateral [PGC] coil placement), PGC coil placement showed decreased coil requirement, less injected glue volume, decreased luminal coil extrusion, and increased successful GV obturation. CONCLUSION EUS-guided treatment is more efficient and safer, and requires a smaller number of treatment sessions, as compared to endoscopic treatment in severe liver disease patients with large GV. Furthermore, PGC coil placement increases the complete obliteration of GV.
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Affiliation(s)
- Kapil D. Jamwal
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India,Institute of Liver and Biliary Sciences, New Delhi, India,Correspondence: Kapil D. Jamwal Department of Gastroenterology, Artemis Hospitals, Sector 51, Gurugram, Haryana 122001, India E-mail:
| | - Rajesh K. Padhan
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India
| | - Atul Sharma
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India
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29
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Chooklin S, Chuklin S. Comprehensive treatment of patients with gastric variceal bleeding. EMERGENCY MEDICINE 2022; 18:14-21. [DOI: 10.22141/2224-0586.18.8.2022.1539] [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
Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Bleeding from gastric varices is usually severe and is associated with higher mortality and a higher risk of rebleeding than from esophageal varices. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiological interventions. In terms of treatment, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires prompt intervention to stop it and achieve long-term hemostasis. This review describes the features of pharmacological, endoscopic and interventional radiological prophylactic and treatment options in gastric variceal bleeding. We searched the literature in the MedLine database on the PubMed platform.
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30
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Yang J, Zeng Y, Zhang JW. Endoscopic ultrasound-guided diagnosis and treatment of gastric varices. World J Gastrointest Endosc 2022; 14:748-758. [PMID: 36567822 PMCID: PMC9782569 DOI: 10.4253/wjge.v14.i12.748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
Gastric varices (GV) represent a common and severe complication in patients with portal hypertension, commonly seen in patients with cirrhosis and severe pancreatic disease. Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa, portal vein and its tributaries, and collateral circulations during direct endoscopic observation. Recently, various studies have been published about endoscopic ultrasound (EUS)-guided management of GV, mainly including diagnosis, treatment, and prognostic analysis. This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.
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Affiliation(s)
- Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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31
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Singh AD, Bazarbashi AN, Lindenmeyer CC. Endo-hepatology: The changing paradigm of endoscopic ultrasound in cirrhosis. Clin Liver Dis (Hoboken) 2022; 20:209-215. [PMID: 36523865 PMCID: PMC9745261 DOI: 10.1002/cld.1263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022] Open
Abstract
Content available: Author Interview and Audio Recording.
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Affiliation(s)
| | - Ahmad Najdat Bazarbashi
- Division of GastroenterologyWashington University in St. Louis/Barnes Jewish HospitalSt. LouisMissouriUSA
| | - Christina C. Lindenmeyer
- Department of Gastroenterology, Hepatology and NutritionDigestive Disease and Surgery institute, Cleveland ClinicClevelandOhioUSA
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32
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Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, Jovanovic I, Awadie H, Hernandez-Gea V, Tantau M, Ebigbo A, Ibrahim M, Vlachogiannakos J, Burgmans MC, Rosasco R, Triantafyllou K. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:1094-1120. [PMID: 36174643 DOI: 10.1055/a-1939-4887] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Marine Camus Duboc
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA) & Assistance Publique-Hôpitaux de Paris (AP-HP), Endoscopic Center, Saint Antoine Hospital, Paris, France
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCSS-S. Orsola-Malpighi, Hospital, Bologna, Italy
| | - John Gásdal Karstensen
- Gastroenterology Unit, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tomas Hucl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Jovanovic
- Euromedik Health Care System, Visegradska General Hospital, Belgrade, Serbia
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Marcel Tantau
- University of Medicine and Pharmacy 'Iuliu Hatieganu' Cluj-Napoca, Romania
| | - Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Jiannis Vlachogiannakos
- Academic Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Marc C Burgmans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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Chooklin S, Chuklin S, Posivnych M, Krystopchuk S. Ендоваскулярне лікування варикозно розширених вен шлунка під контролем ендосонографії. EMERGENCY MEDICINE 2022; 18:39-47. [DOI: 10.22141/2224-0586.18.6.2022.1519] [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
Шлункова варикозна кровотеча супроводжується високою летальністю. Ендоскопічна ін’єкція ціаноакрилату є стандартною терапією, однак рецидивна кровотеча та побічні ефекти, такі як виразки в місці ін’єкції та дистальна емболія, є підводним каменем цієї терапії. Ендоскопічне лікування варикозного розширення вен шлунка під ендосонографічним контролем має кілька можливих переваг перед сучасними методами лікування. Воно дозволяє детально оцінити анатомію судин, подібну ефективність і безпеку поточних методів лікування, а також дає змогу оцінити ефект лікування за допомогою ультразвукової допплерівської візуалізації. Ми розглядаємо методи лікування варикозного розширення вен шлунка, включаючи ендоскопічну ін’єкцію ціаноакрилату та спіралей під контролем ендосонографії, окремо або в комбінації, ін’єкцію тромбіну та желатинової губки, що розсмоктується. Відповідний відбір пацієнтів для цих процедур має першорядне значення для забезпечення отримання корисних клінічних даних і безпеки пацієнтів. Ми шукали літературу в базі даних MedLine на платформі PubMed.
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Jearth V, Sundaram S, Rana SS. Diagnostic and interventional EUS in hepatology: An updated review. Endosc Ultrasound 2022; 11:355-370. [PMID: 36255023 PMCID: PMC9688142 DOI: 10.4103/eus-d-22-00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
EUS has become an increasingly used diagnostic and therapeutic modality in the armamentarium of endoscopists. With ever-expanding indications, EUS is being used in patients with liver disease, for both diagnosis and therapy. EUS is playing an important role in providing additional important information to that provided by cross-sectional imaging modalities such as computerized tomography and magnetic resonance imaging. Domains of therapy that were largely restricted to interventional radiologists have become accessible to endosonologists. From liver biopsy and sampling of liver lesions to ablative therapy for liver lesions and vascular interventions for varices, there is increased use of EUS in patients with liver disease. In this review, we discuss the various diagnostic and therapeutic applications of EUS in patients with various liver diseases.
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Affiliation(s)
- Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence Prof. Surinder Singh Rana, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail:
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Calmet F, Mohan P, Jalaeian H, Martin P. Management of Patients With Gastric Varices. Gastroenterol Hepatol (N Y) 2022; 18:574-585. [PMID: 36397927 PMCID: PMC9666800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Management of patients with gastric varices represents a unique challenge for clinicians. The broad range of endoscopic and endovascular techniques currently available is in stark contrast with the limited evidence available to inform the optimal management of these patients. This article describes the classification, pathophysiology, and natural history of gastric varices; summarizes the available evidence regarding medical, endoscopic, and endovascular management of gastric varices; and provides recommendations on how to integrate these options. Management of these patients ultimately requires a multidisciplinary approach involving hepatologists, therapeutic endoscopists, and interventional radiologists, with consideration given to patient characteristics and local expertise.
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Affiliation(s)
- Fernando Calmet
- Department of Medicine, Division of Gastroenterology, Newton-Wellesley Hospital, Newton, Massachusetts
- Department of Medicine, Division of Gastroenterology, Tufts University School of Medicine, Boston, Massachusetts
| | - Prasoon Mohan
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Hamed Jalaeian
- Department of Interventional Radiology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Paul Martin
- Department of Medicine, Division of Hepatology, Miller School of Medicine, University of Miami, Miami, Florida
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Monino L, Barthet M. Futures perspectives and therapeutic applications. Best Pract Res Clin Gastroenterol 2022; 60-61:101816. [PMID: 36577535 DOI: 10.1016/j.bpg.2022.101816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Laurent Monino
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France; Department of Hepatogastroenterology, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Marc Barthet
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France.
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Fugazza A, Khalaf K, Colombo M, Carrara S, Spadaccini M, Koleth G, Troncone E, Maselli R, Repici A, Anderloni A. Role of endoscopic ultrasound in vascular interventions: Where are we now? World J Gastrointest Endosc 2022; 14:354-366. [PMID: 35978714 PMCID: PMC9265255 DOI: 10.4253/wjge.v14.i6.354] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/08/2022] [Accepted: 05/17/2022] [Indexed: 02/06/2023] Open
Abstract
From a mere diagnostic tool to an imperative treatment modality, endoscopic ultrasound (EUS) has evolved and revolutionized safer efficient options for vascular interventions. Currently it is an alternative treatment option in the management of gastrointestinal bleeding, primarily variceal type bleeding. Conventional treatment option prior to EUS incorporation had limited efficiency and high adverse events. The characterization and detail provided by EUS gives a cutting edge towards a holistically successful management choice. Data indicates that EUS-guided combination therapy of coil embolization and glue injection has the higher efficacy for the treatment of varices. Conversely, similar treatment options that exist for esophageal and other ectopic variceal bleeding was also outlined. In conclusion, many studies refer that a combination therapy of coil and glue injection under EUS guidance provides higher technical success with fewer recurrence and adverse events, making its adaptation in the guideline extremely favorable. Endo-hepatology is a novel disciple with a promising future outlook, we reviewed topics regarding portal vein access, pressure gradient measurement, and thrombus biopsy that are crucial interventions as alternative of radiological procedures. The purpose of this review is to provide an update on the latest available evidence in the literature regarding the role of EUS in vascular interventions. We reviewed the role of EUS in variceal bleeding in recent studies, especially gastric varices and novel approaches aimed at the portal vein.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Italy
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Glenn Koleth
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Edoardo Troncone
- Department of Systems Medicine, University of Rome "Tor Vergata", Roma 00133, Italy
| | - Roberta Maselli
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Italy
| | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
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Osman KT, Nayfeh T, Abdelfattah AM, Alabdallah K, Hasan B, Firwana M, Alabaji H, Elkhabiry L, Mousa J, Prokop LJ, Murad MH, Gordon F. Secondary Prophylaxis of Gastric Variceal Bleeding: A Systematic Review and Network Meta-Analysis. Liver Transpl 2022; 28:945-958. [PMID: 34860458 DOI: 10.1002/lt.26383] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/21/2021] [Accepted: 11/26/2021] [Indexed: 12/12/2022]
Abstract
There is no clear consensus regarding the optimal approach for secondary prophylaxis of gastric variceal bleeding (GVB) in patients with cirrhosis. We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of available treatments. A comprehensive search of several databases from each database's inception to March 23, 2021, was conducted to identify relevant randomized controlled trials (RCTs). Outcomes of interest were rebleeding and mortality. Results were expressed as relative risk (RR) and 95% confidence interval (CI). We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to rate the certainty of evidence. We included 9 RCTs with 647 patients who had histories of GVB and follow-ups >6 weeks. A total of 9 interventions were included in the NMA. Balloon-occluded retrograde transvenous obliteration (BRTO) was associated with a lower risk of rebleeding when compared with β-blockers (RR, 0.04; 95% CI, 0.01-0.26; low certainty), and endoscopic injection sclerotherapy (EIS)-cyanoacrylate (CYA) (RR, 0.18; 95% CI, 0.04-0.77; low certainty). β-blockers were associated with a higher risk of rebleeding compared with most interventions and with increased mortality compared with EIS-CYA (RR, 4.12, 95% CI, 1.50-11.36; low certainty), and EIS-CYA + nonselective β-blockers (RR, 5.61; 95% CI, 1.91-16.43; low certainty). Analysis based on indirect comparisons suggests that BRTO may be the best intervention in preventing rebleeding, whereas β-blocker monotherapy is likely the worst in preventing rebleeding and mortality. Head-to-head RCTs are needed to validate these results.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Ahmed M Abdelfattah
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA
| | | | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | | | - Homam Alabaji
- Department of Internal Medicine, Wertachklinik Schwabmünchen, Bavaria, Germany
| | - Lina Elkhabiry
- Department of Internal Medicine, University of Alexandria, Alexandria, Egypt
| | - Jehan Mousa
- Department of Internal Medicine, Damascus University, Damascus, Syria
| | - Larry J Prokop
- Department of Library Services, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Fredric Gordon
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA
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Seven G, Musayeva G, Seven OO, Herdan E, Ince AT, Senturk H. Comparison of endoscopic ultrasound-guided coil deployment with and without cyanoacrylate injection for gastric varices. Arab J Gastroenterol 2022; 23:115-119. [PMID: 35525707 DOI: 10.1016/j.ajg.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/01/2022] [Accepted: 04/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND STUDY AIMS Gastric variceal bleeding is more severe than esophageal variceal bleeding, and is associated with higher rebleeding and mortality rates. The benefits of endoscopic ultrasound-guided coil deployment alone for treating gastric varices, compared with concomitant cyanoacrylate injection, remain unclear. Therefore, this study aimed to compare the outcomes of both modalities. PATIENTS AND METHODS Data of patients who underwent endoscopic ultrasound-guided coil deployment with/without concomitant cyanoacrylate injection for gastric varices between 2010 and 2021 were reviewed. The rates of rebleeding, reintervention, and survival were assessed. RESULTS Twenty-eight patients (mean age, 55.9 ± 12.9 years; 17 men) underwent endoscopic ultrasound-guided coil deployment, either alone (EUS-coil) (n = 19) or with cyanoacrylate injection (EUS-coil/CYA) (n = 9), to treat cardiofundal varices. Among the 20 patients treated for secondary prophylaxis, including 3 actively bleeding patients (11 via EUS-coil, 9 with EUS-coil/CYA), no significant differences were observed in the rates of rebleeding (1 vs. 2), reintervention (1 vs. 0) or adverse events (1 vs. 1) (all P > 0.05). The 6-month, 1-year, and 3-year overall survival rates did not differ between the treatment groups (crude survival ratio: 76.9% vs. 77.8%; survival rates: 0.923, 0.682, and 0.615 vs. 0.778 for each year; log-rank = 0.227; P = 0.633). In patients treated for primary prophylaxis (n = 8; all via EUS-coil alone), no bleeding episodes were observed after 433 days of follow-up; however, one patient required reintervention for the reappearance of varices without bleeding. CONCLUSION EUS-coil alone was not inferior to EUS-coil/CYA combination concerning rebleeding, reintervention, or survival.
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Affiliation(s)
- Gulseren Seven
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
| | - Gunel Musayeva
- Division of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Ozden Ozluk Seven
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
| | - Emre Herdan
- Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Ali Tuzun Ince
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey
| | - Hakan Senturk
- Division of Gastroenterology, Bezmialem Vakif University, Istanbul, Turkey.
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Abstract
PURPOSE OF REVIEW This article discusses the most recent studies regarding the emerging field of endohepatology - the use of diagnostic and therapeutic endoscopic tools for the management of patients with liver disease and portal hypertension. RECENT FINDINGS New research has shown that liver biopsy specimens obtained by each Endoscopic ultrasound (EUS)-guidance, the percutaneous approach, and the transjugular approach contained sufficient portal triads to adequately analyzed by experienced pathologists - suggesting that any of these routes of liver biopsy is clinically acceptable; further, all had similar rates of adverse events. An initial prospective study showed that EUS guided portal pressure measurement was safe, effective, and accurate. A recent metanalysis showed that EUS-guided cyanoacrylate injection and coil embolization was statistically more efficacious and with less complications than EUS guided cyanoacrylate injection and EUS guided coil injection alone, suggesting that combination therapy appears to be the preferred approach for gastric varices (GV) bleeding. A prospective study evaluating focal liver lesions showed that the use of artificial intelligence had up to 100% sensitivity and 81% specificity for identifying malignant focal liver lesions. SUMMARY EUS guided liver biopsy is safe and enables accurate diagnosis of underlying liver disease. EUS guided portal pressure measurement is also safe and is accurate. Combination therapy of EUS guided cyanoacrylate injection and coil embolization is more efficacious and has less complications than injection or coil therapy alone when used for GV bleeding. Artificial intelligence is highly sensitive and specific when used in conjunction with EUS in the diagnosis of malignant focal liver lesions. Endohepatology is a rapidly expanding field with great potential.
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Affiliation(s)
- Jerome C Edelson
- Department of Gastroenterology and Hepatology
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Natalie E Mitchell
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
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Abstract
Despite advances in the management of complications of portal hypertension, variceal bleeding continues to be associated with significant morbidity and mortality. While endoscopic variceal band ligation remains first line therapy for treating bleeding and high-risk non-bleeding esophageal varices, alternate therapies have been explored, particularly in cases of refractory bleeding. The therapies being explored include stent placement, hemostatic powder use, over-the-scope clips and others. For gastric variceal bleeding, endoscopic ultrasound-guided therapies have recently emerged as promising interventions for hemostasis. The aim of this article is to highlight these alternative therapies and their potential role in the management of gastric and esophageal variceal bleeding.
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Affiliation(s)
- Amit Maydeo
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospitals, Mumbai, Maharashtra, India.
| | - Gaurav Patil
- Baldota Institute of Digestive Sciences, Gleneagles Global Hospitals, Mumbai, Maharashtra, India
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Safety and efficacy of endoscopic ultrasound-guided combination therapy for treatment of gastric varices: a systematic review and meta-analysis. Clin J Gastroenterol 2022; 15:310-319. [PMID: 35133625 DOI: 10.1007/s12328-022-01600-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND EUS-guided combination therapy (coil and hemostatic glue) for bleeding and non-bleeding gastric varices has recently attracted considerable attention after promising results were published in multiple small studies. We performed a meta-analysis to investigate the safety and efficacy of EUS-guided combination therapy in the treatment of GVs. METHODS Publications investigating the safety and efficacy of EUS-guided combination therapy in patients with gastric varices were searched in Medline, Ovid Journals, Medline non-indexed citations and Cochrane Central Register of Controlled Trials. Pooling was conducted by both fixed and random effects model. RESULTS In pooled analysis of 10 studies (N = 323), the technical success of EUS-guided combination therapy was 98.66% (95% CI 97.14-99.62). The pooled variceal obliteration rate after first session of treatment was 78.31% (95% CI 73.05-83.14). In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.79% (95% CI 94.28-98.60). The pooled rate of hemorrhage from treated gastric varices was 4.92% (95% CI 2.85-7.52). After EUS-guided combination therapy, the pooled percentage of patients developing abdominal pain was 9.79% (95% CI 6.82-13.24), pulmonary embolism was 2.20% (95% CI 0.89-4.06), febrile episodes was 1.17% (95% CI 0.30-2.61), and procedure-related bleeding was noted in 2.62% (95% CI 1.18-4.63) of the patients. Subgroup analysis of studies using coil embolization and cyanoacrylate injection showed pooled variceal obliteration rate of 77.92% (95% CI 72.35-83.01) after first session of treatment. In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.76% (95% CI 94.11-98.65). The pooled rate of re-bleeding from treated gastric varices was 5.09% (95% CI 2.90-7.83). CONCLUSIONS This meta-analysis suggests that EUS-guided combination therapy is safe and effective for patients with gastric varices and should be considered in the clinical management of these patients.
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Forbes N, Coelho-Prabhu N, Al-Haddad MA, Kwon RS, Amateau SK, Buxbaum JL, Calderwood AH, Elhanafi SE, Fujii-Lau LL, Kohli DR, Pawa S, Storm AC, Thosani NC, Qumseya BJ. Adverse events associated with EUS and EUS-guided procedures. Gastrointest Endosc 2022; 95:16-26.e2. [PMID: 34711402 DOI: 10.1016/j.gie.2021.09.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Department of Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Sherif E Elhanafi
- Department of Internal Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, TX, USA
| | | | - Divyanshoo R Kohli
- Division of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO, USA
| | - Swati Pawa
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andrew C Storm
- Department of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Nirav C Thosani
- Center for Interventional Gastroenterology (iGUT), McGovern Medical School, UTHealth, Houston, TX, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, FL, USA
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Kolb JM, Samarasena JB. EUS-guided splenic artery embolization for variceal hemorrhage: balancing creativity and innovation in Endo-hepatology with caution. Gastrointest Endosc 2022; 95:184-186. [PMID: 34802719 DOI: 10.1016/j.gie.2021.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/12/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Jennifer M Kolb
- Department of Medicine, H.H. Chao Digestive Disease Institute, Division of Gastroenterology/Hepatology, University of California, Irvine, Orange, California, U.S.A
| | - Jason B Samarasena
- Department of Medicine, H.H. Chao Digestive Disease Institute, Division of Gastroenterology/Hepatology, University of California, Irvine, Orange, California, U.S.A
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Abstract
Acute variceal bleeding is the major cause of mortality in patients with cirrhosis. The standard medical and endoscopic treatment has reduced the mortality of variceal bleeding from 50% to 10-20%. The refractory variceal bleed is either because of failure to control the bleed or failure of secondary prophylaxis. The patients refractory to standard medical therapy need further interventions. The rescue therapies include balloon tamponade, self-expanding metal stents (SEMS) placement, shunt procedures, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), and endoscopic ultrasound (EUS) guided coiling. In cases where endoscopic variceal ligation (EVL) has failed and the variceal bleeding continues, temporary measures like balloon tamponade can be used to achieve hemostasis and as a bridge to definitive measures. SEMS being in use for refractory bleed is preferred over balloon tamponade due to the reduced complication rate. The shunting procedures are highly effective in reducing portal pressure and represent the gold standard for uncontrolled variceal bleeding. The surgical shunts, as well as nonshunt surgeries such as devascularization have become less popular with the increasing use of minimally invasive techniques like TIPS. TIPS have high success rates in controlling refractory variceal bleeding. The mortality rate is greater in high-risk patients undergoing salvage TIPS, and hence, pre-emptive TIPS should be considered in these patients. BRTO is an interventional radiologic procedure used in the management of bleeding gastric and ectopic varices. The availability of gastrorenal or splenorenal shunts is required for the BRTO procedure, which helps to reach and obliterate the cardiofundal varices through the femoral or jugular vein approach. The EUS guided coiling and glue injection have shown promising results, and further randomized controlled trials are required to establish their efficacy for refractory variceal bleeding.
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Key Words
- BAATO, balloon-assisted antegrade transvenous obliteration
- BRTO
- BRTO, balloonoccluded retrograde transvenous obliteration
- DIPS, direct intrahepatic portacaval shunt
- EUS guided coiling
- EUS, endoscopic ultrasound
- EVL, endsocopic variceal ligation
- HVPG, hepatic venous pressure gradient
- PARTO, plug-assisted retrograde transvenous obliteration
- PTFE, polytetrafluoroethylene
- PVT, portal vein thrombosis
- TIPS, transjugular intrahepatic portosystemic shunt
- TIPSS
- portal hypertension
- refractory variceal bleed
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A state-of-the-art comprehensive review summarizing the emerging data on endoscopic ultrasound-guided liver diseases management. Eur J Gastroenterol Hepatol 2021; 33:e13-e20. [PMID: 32804852 DOI: 10.1097/meg.0000000000001893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Liver diseases are among the most common diseases worldwide accounting for substantial morbidity and mortality. Most liver diseases necessitate radiological evaluation or accurate diagnosis and recently for management as well. In the last decade, the application of therapeutic endoscopic ultrasound (EUS) procedure has been increasingly utilized for the management of various liver diseases. In this comprehensive narrative review article, we provide systematic overview on EUS-guided therapeutic interventions in various liver diseases summarizing most updated data regarding technical success, outcomes and safety profiles. Overall, 35 articles have reported on the use of EUS in the treatment of liver diseases with excellent technical success, favorable radiological response and high safety profiles for EUS-guided treatment of solid and cystic liver lesion and for EUS-guided angiotherapy for gastric varices, except for EUS-guided cyanoacrylate glue injection which was associated with life-threatening fatal systemic embolization adverse events. This suggests that EUS-guided intervention is a new promising therapeutic intervention for the treatment of various liver diseases with durable effect and a limited potential for adverse events.
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Dhar J, Samanta J. Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends. World J Hepatol 2021; 13:1459-1483. [PMID: 34904024 PMCID: PMC8637671 DOI: 10.4254/wjh.v13.i11.1459] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/19/2021] [Accepted: 09/03/2021] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic ultrasound (EUS) as a diagnostic and therapeutic modality for the management of various gastrointestinal diseases has been expanding. The imaging or intervention for various liver diseases has primarily been the domain of radiologists. With the advances in EUS, the domain of endosonologists is rapidly expanding in the field of hepatology. The ability to combine endoscopy and sonography in one hybrid device is a unique property of EUS, together with the ability to bring its probe/transducer near the liver, the area of interest. Its excellent spatial resolution and ability to provide real-time images coupled with several enhancement techniques, such as contrast-enhanced (CE) EUS, have facilitated the growth of EUS. The concept of “Endo-hepatology” encompasses the wide range of diagnostic and therapeutic procedures that are now gradually becoming feasible for managing various liver diseases. Diagnostic advancements can enable a wide array of techniques from elastography and liver biopsy for liver parenchymal diseases, to CE-EUS for focal liver lesions to portal pressure measurements for managing various liver conditions. Similarly, therapeutic advancements range from EUS-guided eradication of varices, drainage of bilomas and abscesses to various EUS-guided modalities of liver tumor management. We provide a comprehensive review of all the different diagnostic and therapeutic EUS modalities available for the management of various liver diseases. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.
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Affiliation(s)
- Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Lesmana CRA, Paramitha MS, Gani RA, Lesmana LA. The role of endoscopic ultrasound for portal hypertension in liver cirrhosis. J Med Ultrason (2001) 2021; 49:359-370. [PMID: 34797476 DOI: 10.1007/s10396-021-01165-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/14/2021] [Indexed: 10/19/2022]
Abstract
Chronic liver disease is still a major problem because disease progression will ultimately lead to liver cirrhosis. Portal hypertension is the hallmark in advanced liver disease management. By establishing portal vein access, endoscopic ultrasound (EUS) has been utilized in various clinical applications. In comparison to standard upper gastrointestinal endoscopy, EUS-Doppler has been shown to be a better modality for detecting esophageal and gastric varices along with peri-esophageal collateral veins, para-esophageal collateral veins, and perforating veins, and may be used to objectively predict the recurrence of bleeding. EUS-guided portal vein catheterization has also been proposed to overcome the limitations of trans-jugular approaches. The combination of EUS-elastography and azygos vein evaluation can also enhance the diagnostic accuracy of each modality. Another well-known implementation of EUS-guided procedures is in the management of ascites; particularly in paracentesis and ascitic fluid analysis. In addition, the most common clinical application of EUS in the treatment of portal hypertension is through vascular therapy or creation of intrahepatic portosystemic shunts. Major drawbacks of EUS mainly revolve around technical difficulties, the high cost of the procedure, as well as the requirement of more studies in humans to evaluate EUS-guided advanced therapeutic modalities in portal hypertension.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia. .,Digestive Disease and GI Oncology Center, Medistra Hospital, Jakarta, Indonesia.
| | - Maria Satya Paramitha
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
| | - Rino A Gani
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
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Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 PMCID: PMC8567466 DOI: 10.3748/wjg.v27.i40.6874] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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