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Nicoară-Farcău O, Han G, Rudler M, Angrisani D, Monescillo A, Torres F, Casanovas G, Bosch J, Lv Y, Thabut D, Fan D, Hernández-Gea V, García-Pagán JC, Abraldes JG, Nevens F, Caca K, Laleman W, Appenrodt B, Luca A, Vinel JP, Mössner J, Di Pascoli M, Zipprich A, Sauerbruch T, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E, Marrero JM, Buceta E, Sanchez J, Castellot A, Penate M, Cruz A, Pena E, Procopeț B, Giráldez Á, Amitrano L, Villanueva C, Ibañez-Samaniego L, Silva-Junior G, Martinez J, Genescà J, Trebicka J, Llop E, Palazon JM, Castellote J, Rodrigues S, Gluud LL, Ferreira CN, Barcelo R, Cañete N, Rodríguez M, Ferlitsch A, Mundi JL, Gronbaek H, Hernández-Guerra M, Sassatelli R, Dell’Era A, Senzolo M, Romero-Gómez M, Casas M, Masnou H, Primignani M, Krag A, Calleja JL, Jansen C, Robic MA, Conejo I, Catalina MV, Albillos A, Alvarado E, Guardascione MA, Tanțău M, Zuo L, Zhu X, Zhao J, Xue H, Jiang Z, Zhuge Y, Zhang C, Sun J, Ding P, Ren W, Li Y, Zhang K, Zhang W, He C, Zhong J, Peng Q, Ma F, Luo J, Zhang M, Wang G, Sun M, Dong J, Bai W, Guo W, Wang Q, Yuan X, Wang Z, Yu T, Luo B, Li X, Yuan J, Han N, Zhu Y, Niu J, Li K, Yin Z, Nie Y, Fischer P, Horia Ștefănescu, Pop A, Laursen SB, Turon F, Baiges A, Ferrusquía-Acosta J, Magaz M, Cerda E, Tellez L, Allegretti G, Macedo G, Haldrup D, Santos P, Moura M, Reis D, Meireles L, Sousa P, Alexandrino P, Navascues C, Augustin S, La Mura V, Bañares R, Diaz R, Gómez ML, Ripoll C. Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: a Meta-analysis of Individual Patient Data. Gastroenterology 2021; 160:193-205.e10. [PMID: 32980344 DOI: 10.1053/j.gastro.2020.09.026] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 08/25/2020] [Accepted: 09/17/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Compared with drugs plus endoscopy, placement of transjugular portosystemic shunt within 72 hours of admission to the hospital (early or preventive transjugular intrahepatic portosystemic shunt [TIPS], also called preemptive TIPS) increases the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survive for 1 year. However, the benefit of preemptive TIPS is less clear for patients with a Child-Pugh score of B and active bleeding (CP-B+AB). We performed an individual data meta-analysis to assess the efficacy of preemptive TIPS in these patients and identify factors associated with reduced survival of patients receiving preemptive TIPS. METHODS We searched publication databases for randomized controlled trials and observational studies comparing the effects of preemptive TIPS versus endoscopy plus nonselective beta-blockers in the specific population of high-risk patients with cirrhosis and acute variceal bleeding (CP-B+AB or Child-Pugh C, below 14 points), through December 31, 2019. We performed a meta-analysis of data from 7 studies (3 randomized controlled trials and 4 observational studies), comprising 1327 patients (310 received preemptive TIPS and 1017 received drugs plus endoscopy). We built adjusted models to evaluate risk using propensity score for baseline covariates. Multivariate Cox regression models were used to assess the factors associated with survival time. The primary endpoint was effects of preemptive TIPS versus drugs plus endoscopy on 1-year survival in the overall population as well as CP-B+AB and Child-Pugh C patients. RESULTS Overall, preemptive TIPS significantly increased the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survived for 1 year, compared with drugs plus endoscopy (hazard ratio [HR] 0.443; 95% CI 0.323-0.607; P < .001). This effect was observed in CP-B+AB patients (HR 0.524; 95% CI 0.307-0.896; P = .018) and in patients with Child-Pugh C scores below 14 points (HR 0.374; 95% CI 0.253-0.553; P < .001). Preemptive TIPS significantly improved control of bleeding and ascites without increasing risk of hepatic encephalopathy in Child-Pugh C and CP-B+AB patients, compared with drugs plus endoscopy. Cox analysis of patients who received preemptive TIPS showed that patients could be classified into 3 categories for risk of death, based on age, serum level of creatinine, and Child-Pugh score. In each of these risk categories, preemptive TIPS increased the proportion of patients who survived for 1 year, compared with drugs plus endoscopy. CONCLUSIONS In a meta-analysis of data from 1327 patients with cirrhosis, acute variceal bleeding, and Child-Pugh score between 10 and 13 points or CP-B+AB, preemptive TIPS increased the proportion who survived for 1 year, in both subgroups separately, compared with drugs plus endoscopy.
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Affiliation(s)
- Oana Nicoară-Farcău
- Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", Hepatology Department and "Iuliu Hatieganu" University of Medicine and Pharmacy, 3rd Medical Clinic, Cluj-Napoca, Romania; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Marika Rudler
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Sorbonne University, Paris, France
| | - Debora Angrisani
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Alberto Monescillo
- Digestive Disease Department, Hospital Universitario Insular de Gran Canaria, Canary Islands
| | - Ferran Torres
- Medical Statistics Core Facility, Institut D'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Hospital Clinic Barcelona, Barcelona, Spain; Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Georgina Casanovas
- Medical Statistics Core Facility, Institut D'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Hospital Clinic Barcelona, Barcelona, Spain
| | - Jaime Bosch
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain; Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, Bern University, Bern, Switzerland
| | - Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Dominique Thabut
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, Sorbonne University, Paris, France
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain; Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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Martin-Cardona A, Fernandez-Esparrach G, Subtil JC, Iglesias-Garcia J, Garcia-Guix M, Barturen Barroso A, Gimeno-Garcia AZ, Esteban JM, Pardo Balteiro A, Velasco-Guardado A, Vazquez-Sequeiros E, Loras C, Martinez-Moreno B, Castellot A, Huertas C, Martinez-Lapiedra M, Sanchez-Yague A, Teran A, Morales-Alvarado VJ, Betes M, de la Iglesia D, Sánchez-Montes C, Lozano MD, Lariño-Noia J, Gines A, Tebe C, Gornals JB. EUS-guided tissue acquisition in the study of the adrenal glands: Results of a nationwide multicenter study. PLoS One 2019; 14:e0216658. [PMID: 31170163 PMCID: PMC6553722 DOI: 10.1371/journal.pone.0216658] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/25/2019] [Indexed: 02/07/2023] Open
Abstract
Background There are limited data about the role of endoscopic ultrasound-guided tissue acquisition (EUS-TA), by fine needle aspiration (EUS-FNA) or biopsy (EUS-FNB), in the evaluation of the adrenal glands (AG). The primary aim was to assess the diagnostic yield and safety. The secondary aims were the malignancy predictors, and to create a predictive model of malignancy. Methods This was a retrospective nationwide study involving all Spanish hospitals experienced in EUS-TA of AGs. Inclusion period was from April-2003 to April-2016. Inclusion criteria: all consecutive cases that underwent EUS-TA of AGs. EUS and cytopathology findings were evaluated. Statistical analyses: diagnostic accuracy of echoendoscopist’s suspicion using cytology by EUS-TA, as gold standard; multivariate logistic regression model to predict tumor malignancy. Results A total of 204 EUS-TA of AGs were evaluated. Primary tumor locations were lung70%, others19%, and unknown11%. AG samples were adequate for cytological diagnosis in 91%, and confirmed malignancy in 60%. Diagnostic accuracy of the endosonographer's suspicion was 68%. The most common technique was: a 22-G (65%) and cytological needle (75%) with suction-syringe (66%). No serious adverse events were described. The variables most associated with malignancy were size>30mm (OR2.27; 95%CI, 1.16–4.05), heterogeneous echo-pattern (OR2.11; 95%CI, 1.1–3.9), variegated AG shape (OR2.46; 95%CI, 1–6.24), and endosonographer suspicion (OR17.46; 95%CI, 6.2–58.5). The best variables for a predictive multivariate logistic model of malignancy were age, sex, echo-pattern, and AG-shape. Conclusions EUS-TA of the AGs is a safe, minimally invasive procedure, allowing an excellent diagnostic yield. These results suggest the possibility of developing a pre-EUS procedure predictive malignancy model.
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Affiliation(s)
- A Martin-Cardona
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Department of Digestive Diseases, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, CIBERehd, Terrassa, Spain
| | - G Fernandez-Esparrach
- Endoscopy Unit, ICMDiM, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - J C Subtil
- Endoscopy Unit, University of Navarra Clinic, Pamplona, Spain
| | - J Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago, Spain
| | - M Garcia-Guix
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - A Barturen Barroso
- Department of Digestive Diseases, Hospital Universitario Cruces, Bilbao, Spain
| | - A Z Gimeno-Garcia
- Department of Gastroenterology and Hepatology, Hospital Universitario de Canarias, Tenerife, Spain
| | - J M Esteban
- Endoscopy Unit, Department of Digestive Diseases, Hospital Clínico San Carlos, Madrid, Spain
| | - A Pardo Balteiro
- Department of Digestive Diseases, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - A Velasco-Guardado
- Department of Digestive Diseases, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - E Vazquez-Sequeiros
- Endoscopy unit, Gastroenterology and Hepatology Service, Hospital Ramon y Cajal, IRYCIS, Madrid, Spain
| | - C Loras
- Department of Digestive Diseases, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, CIBERehd, Terrassa, Spain.,Health Sciences, Universitat Oberta de Catalunya, Barcelona, Spain
| | - B Martinez-Moreno
- Department of Digestive Diseases, Hospital General Universitario de Alicante, Alicante, Spain
| | - A Castellot
- Department of Digestive Diseases, Hospital Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - C Huertas
- Department of Digestive Diseases, Hospital Dr. Josep Trueta Girona, Girona, Spain
| | | | | | - A Teran
- Department of Digestive Diseases, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - V J Morales-Alvarado
- Endoscopy Unit, ICMDiM, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - M Betes
- Endoscopy Unit, University of Navarra Clinic, Pamplona, Spain
| | - D de la Iglesia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago, Spain
| | - C Sánchez-Montes
- Endoscopy Unit, ICMDiM, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - M D Lozano
- Endoscopy Unit, University of Navarra Clinic, Pamplona, Spain
| | - J Lariño-Noia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago, Spain
| | - A Gines
- Endoscopy Unit, ICMDiM, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - C Tebe
- Biostatistics Unit, Institute of Biomedical Research of Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J B Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Health Sciences, Universitat Oberta de Catalunya, Barcelona, Spain
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Caballero Y, López-Tomassetti E, Castellot A, Hernández JR. Endoscopic management of a gastric leak after laparoscopic sleeve gastrectomy using the over-the-scope-clip (Ovesco®) system. Rev Esp Enferm Dig 2017; 108:746-750. [PMID: 26864585 DOI: 10.17235/reed.2016.3901/2015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Laparoscopic sleeve gastrectomy is currently used for the management of morbid obesity. Gastric fistula is the primary life-threatening complication, and its resolution continues to be a strong challenge for surgeons. Multiple treatment options are available, ranging from conservative therapy to endoscopic use of clips or stents, and even surgical reoperation involving total gastrectomy or conversion to a different bariatric technique. The applicability of each individual option will depend on the type of fistula and the patient clinical status. A clinical case is reported of a 29-year-old male patient with a body mass index at 49% who following laparoscopic sleeve gastrectomy had a delayed gastric fistula that failed to respond to conservative management but was successfully treated using the over-the-scope clip (Ovesco®) system.
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Affiliation(s)
- Yurena Caballero
- Servicio de Cirugía General y del Aparat Digestivo, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas. Las Palmas de Gran Canar, España
| | - Eudaldo López-Tomassetti
- Cirugía General y Digestiva, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas. Las Palmas de Gran Canar
| | - Ana Castellot
- Medicina del Aparato Digestivo, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas. Las Palmas de Gran Canar
| | - Juan Ramón Hernández
- Cirugía General y Digestiva, Complejo Hospitalario Universitario Insular-Materno Infantil de Las Palmas. Las Palmas de Gran Canar
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Vazquez-Sequeiros E, Baron TH, Pérez-Miranda M, Sánchez-Yagüe A, Gornals J, Gonzalez-Huix F, de la Serna C, Gonzalez Martin JA, Gimeno-Garcia AZ, Marra-Lopez C, Castellot A, Alberca F, Fernandez-Urien I, Aparicio JR, Legaz ML, Sendino O, Loras C, Subtil JC, Nerin J, Perez-Carreras M, Diaz-Tasende J, Perez G, Repiso A, Vilella A, Dolz C, Alvarez A, Rodriguez S, Esteban JM, Juzgado D, Albillos A. Evaluation of the short- and long-term effectiveness and safety of fully covered self-expandable metal stents for drainage of pancreatic fluid collections: results of a Spanish nationwide registry. Gastrointest Endosc 2016; 84:450-457.e2. [PMID: 26970012 DOI: 10.1016/j.gie.2016.02.044] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 02/17/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Initial reports suggest that fully covered self-expandable metal stents (FCSEMSs) may be better suited for drainage of dense pancreatic fluid collections (PFCs), such as walled-off pancreatic necrosis. The primary aim was to analyze the effectiveness and safety of FCSEMSs for drainage of different types of PFCs in a large cohort. The secondary aim was to investigate which type of FCSEMS is superior. METHODS This was a retrospective, noncomparative review of a nationwide database involving all hospitals in Spain performing EUS-guided PFC drainage. From April 2008 to August 2013, all patients undergoing PFC drainage with an FCSEMS were included in a database. The main outcome measurements were technical success, short-term (2 weeks) and long-term (6 months) effectiveness, adverse events, and need for surgery. RESULTS The study included 211 patients (pseudocyst/walled-off pancreatic necrosis, 53%/47%). The FCSEMSs used were straight biliary (66%) or lumen-apposing (34%). Technical success was achieved in 97% of patients (95% confidence interval [CI], 93%-99%). Short-term- and long-term clinical success was obtained in 94% (95% CI, 89%-97%) and 85% (95% CI, 79%-89%) of patients, respectively. Adverse events occurred in 21% of patients (95% CI, 16%-27%): infection (11%), bleeding (7%), and stent migration and/or perforation (3%). By multivariate analysis, patient age (>58 years) and previous failed drainage were the most important factors associated with negative outcome. CONCLUSIONS An FCSEMS is effective and safe for PFC drainage. Older patients with a history of unsuccessful drainage are more likely to fail EUS-guided drainage. The type of FCSEMS does not seem to influence patient outcome.
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Affiliation(s)
- Enrique Vazquez-Sequeiros
- Endoscopy Unit, Gastroenterology Division, University Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain; Gastroenterology Division, University Hospital Quirón, Madrid, Spain
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Manuel Pérez-Miranda
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Andres Sánchez-Yagüe
- Gastroenterology Department, Hospital Costa del Sol, Marbella, Spain; Gastroenterology Department, Vithas Xanit Internacional Hospital, Benalmadena, Spain
| | - Joan Gornals
- Endoscopy Unit, Digestive Disease Department, Hospital Universitari de Bellvitge-Institut d'Investigació Biomèdica de Bellvitge, Barcelona, Spain
| | | | - Carlos de la Serna
- Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Juan Angel Gonzalez Martin
- Endoscopy Unit, Gastroenterology Division, University Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Antonio Z Gimeno-Garcia
- Gastroenterology Department, Hospital Universitario de Canarias, San Cristóbal de La Laguna, Spain
| | - Carlos Marra-Lopez
- Gastroenterology Department, Araba University Hospital, Vitoria-Gasteiz, Spain
| | - Ana Castellot
- Complejo Hospitalario Universitario Insular Materno Infantil, Gran Canaria, Spain
| | - Fernando Alberca
- Gastroenterology Department, Unidad de Gestión Clínica Digestivo, Hospital Clinico Universitario de la Arrixava, Murcia, Spain
| | | | | | - Maria Luisa Legaz
- Gastroenterology Department, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | - Oriol Sendino
- Endoscopy Unit, Gastroenterology Department, Institute of Digestive and Metabolic Diseases, Hospital Clínic, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, University of Barcelona, Barcelona, Spain
| | - Carmen Loras
- Gastroenterology Department, Servei Aparell Digestiu-Unitat d'Endoscòpia, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - Jose Carlos Subtil
- Gastroenterology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan Nerin
- Gastroenterology Department, Hospital Clínico Universitario "Lozano Blesa," Zaragoza, Spain
| | - Mercedes Perez-Carreras
- Endoscopy Unit, Gastroenterology Department, Servicio de Medicina de Aparato Digestivo, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jose Diaz-Tasende
- Endoscopy Unit, Gastroenterology Department, Servicio de Medicina de Aparato Digestivo, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Gustavo Perez
- Endoscopy Unit, Gastroenterology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Alejandro Repiso
- Endoscopy Unit, Gastroenterology Department, Hospital Virgen de la Salud, Toledo, Spain
| | - Angels Vilella
- Endoscopy Unit, Gastroenterology Department. Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Carlos Dolz
- Endoscopy Unit, Gastroenterology Department. Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Alberto Alvarez
- Gastroenterology Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Santiago Rodriguez
- Gastroenterology Department, Complejo Asistencial Universitario de Zamora, Zamora, Spain
| | | | - Diego Juzgado
- Gastroenterology Division, University Hospital Quirón, Madrid, Spain
| | - Agustin Albillos
- Endoscopy Unit, Gastroenterology Division, University Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
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Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jiménez E, Marrero JM, Buceta E, Sánchez J, Castellot A, Peñate M, Cruz A, Peña E. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40:793-801. [PMID: 15382120 DOI: 10.1002/hep.20386] [Citation(s) in RCA: 305] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Increased portal pressure during variceal bleeding may have an influence on the treatment failure rate, as well as on short- and long-term survival. However, the usefulness of hepatic hemodynamic measurement during the acute episode has not been prospectively validated, and no information exists about the outcome of hemodynamically defined high-risk patients treated with early portal decompression. Hepatic venous pressure gradient (HVPG) measurement was made within the first 24 hours after admission of 116 consecutive patients with cirrhosis with acute variceal bleeding treated with a single session of sclerotherapy injection during urgent endoscopy. Sixty-four patients had an HVPG less than 20 mm Hg (low-risk [LR] group), and 52 patients had an HVPG greater than or equal to 20 mm Hg (high-risk [HR] group). HR patients were randomly allocated into those receiving transjugular intrahepatic portosystemic shunt (TIPS; HR-TIPS group, n = 26) within the first 24 hours after admission and those not receiving TIPS (HR-non-TIPS group). The HR-non-TIPS group had more treatment failures (50% vs. 12%, P =.0001), transfusional requirements (3.7 +/- 2.7 vs. 2.2 +/- 2.3, P =.002), need for intensive care (16% vs. 3%, P <.05), and worse actuarial probability of survival than the LR group. Early TIPS placement reduced treatment failure (12%, P =.003), in-hospital and 1-year mortality (11% and 31%, respectively; P <.05). In conclusion, increased portal pressure estimated by early HVPG measurement is a main determinant of treatment failure and survival in variceal bleeding, and early TIPS placement reduces treatment failure and mortality in high risk patients defined by hemodynamic criteria.
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Affiliation(s)
- Alberto Monescillo
- Digestive Disease Department, Hospital Universitario Insular de Gran Canaria, Canary Islands, Spain.
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Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jiménez E, Marrero JM, Buceta E, Sánchez J, Castellot A, Peñate M, Cruz A, Peña E. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004. [PMID: 15382120 DOI: 10.1002/hep.1840400408] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Increased portal pressure during variceal bleeding may have an influence on the treatment failure rate, as well as on short- and long-term survival. However, the usefulness of hepatic hemodynamic measurement during the acute episode has not been prospectively validated, and no information exists about the outcome of hemodynamically defined high-risk patients treated with early portal decompression. Hepatic venous pressure gradient (HVPG) measurement was made within the first 24 hours after admission of 116 consecutive patients with cirrhosis with acute variceal bleeding treated with a single session of sclerotherapy injection during urgent endoscopy. Sixty-four patients had an HVPG less than 20 mm Hg (low-risk [LR] group), and 52 patients had an HVPG greater than or equal to 20 mm Hg (high-risk [HR] group). HR patients were randomly allocated into those receiving transjugular intrahepatic portosystemic shunt (TIPS; HR-TIPS group, n = 26) within the first 24 hours after admission and those not receiving TIPS (HR-non-TIPS group). The HR-non-TIPS group had more treatment failures (50% vs. 12%, P =.0001), transfusional requirements (3.7 +/- 2.7 vs. 2.2 +/- 2.3, P =.002), need for intensive care (16% vs. 3%, P <.05), and worse actuarial probability of survival than the LR group. Early TIPS placement reduced treatment failure (12%, P =.003), in-hospital and 1-year mortality (11% and 31%, respectively; P <.05). In conclusion, increased portal pressure estimated by early HVPG measurement is a main determinant of treatment failure and survival in variceal bleeding, and early TIPS placement reduces treatment failure and mortality in high risk patients defined by hemodynamic criteria.
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Affiliation(s)
- Alberto Monescillo
- Digestive Disease Department, Hospital Universitario Insular de Gran Canaria, Canary Islands, Spain.
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Llach J, Elizalde JI, Guevara MC, Pellisé M, Castellot A, Ginès A, Soria MT, Bordas JM, Piqué JM. Endoscopic injection therapy in bleeding Mallory-Weiss syndrome: a randomized controlled trial. Gastrointest Endosc 2001; 54:679-81. [PMID: 11726841 DOI: 10.1067/mge.2001.119874] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic injection is widely used in the therapy of bleeding gastroduodenal ulcers, but its role in the management of bleeding Mallory-Weiss tears has not been properly assessed. METHODS Sixty-three patients undergoing emergency endoscopy in whom there was a high index of suspicion that a Mallory-Weiss tear was the source of bleeding were randomly assigned to undergo endoscopic injection therapy (epinephrine and polidocanol) or no endoscopic therapy in 2 university-affiliated hospitals. Rates of recurrent bleeding, transfusion requirements, complications, mortality, and length of hospital stay were determined for both groups of patients. RESULTS Bleeding recurred in 8 patients in the control group versus only 2 in the endoscopic treatment group (25.8% vs. 6.2%, p < 0.05). Hospital stay was longer for the control group (5.5 +/- 0.2, median 6.0, range 2.0-8.0 days vs. 3.4 +/- 0.2, median 3.0, range 2.0-6.0 days; p < 0.001). There was a trend toward a higher transfusion requirement after endoscopy in the control group versus the patients treated by injection (0.9 +/- 0.2, median 0.0, range 0.0-4.0 units vs. 0.2 +/- 0.1, median 0.0, range 0.0-2.0 units; p = 0.09). No complications or adverse events caused by endoscopic injection were noted. Two patients in the control group died of causes unrelated to bleeding. CONCLUSIONS Endoscopic injection therapy is a useful option in the management of patients with Mallory-Weiss syndrome at high risk for recurrent bleeding.
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Affiliation(s)
- J Llach
- Endoscopy Unit, Gastroenterology Department, Institut de Malalties Digestives, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, University of Barcelona, and Hospital Insular de Gran Canaria, Barcelona, Catalonia, Spain
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