1
|
Okuno N, Hara K, Haba S, Kuwahara T, Urata M, Kondo T, Yamamoto Y. Endoscopic ultrasound-guided vascular intervention for pancreaticojejunal variceal bleeding. Endoscopy 2024; 56:E329-E330. [PMID: 38594005 PMCID: PMC11003815 DOI: 10.1055/a-2291-9619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Nozomi Okuno
- Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shin Haba
- Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | | | - Minako Urata
- Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takashi Kondo
- Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | | |
Collapse
|
2
|
Sorge A, Pessarelli T, Elli L, Nandi N, Tosetti G, Primignani M, Tontini GE. Band-on-band endoscopic variceal ligation: a technique for the treatment of esophageal varices in case of band misplacement. Endoscopy 2024; 56:E211-E212. [PMID: 38428916 PMCID: PMC10907115 DOI: 10.1055/a-2268-5513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Affiliation(s)
- Andrea Sorge
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tommaso Pessarelli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Luca Elli
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Caʼ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicoletta Nandi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giulia Tosetti
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Caʼ Granda Ospedale Maggiore Policlinico,
| | - Massimo Primignani
- Gastroenterology and Hepatology Unit, Fondazione IRCCS Caʼ Granda Ospedale Maggiore Policlinico,
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Caʼ Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
3
|
Dong Y, Xu H, Zhang Z, Zhou Z, Zhao G, Cao H, Xiao S. A Novel Nomogram for Predicting Early Rebleeding After Endoscopic Treatment of Esophagogastric Variceal Hemorrhage. Dig Dis Sci 2024; 69:1852-1862. [PMID: 38514499 DOI: 10.1007/s10620-024-08382-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Early rebleeding is a significant complication of endoscopic treatment for esophagogastric variceal hemorrhage (EGVH). However, a reliable predictive model is currently lacking. AIMS To identify risk factors for rebleeding within 6 weeks and establish a nomogram for predicting early rebleeding after endoscopic treatment of EVGH. METHODS Demographic information, comorbidities, preoperative evaluation, endoscopic features, and laboratory tests were collected from 119 patients who were first endoscopic treatment for EGVH. Independent risk factors for early rebleeding were determined through least absolute shrinkage and selection operator logistic regression. The discrimination, calibration, and clinical utility of the nomogram were assessed and compared with the model for end-stage liver disease (MELD), Child-Pugh, and albumin-bilirubin (ALBI) scores using receiver-operating characteristic (ROC) curves, calibration plots, and decision curve analyses (DCA). RESULTS Early rebleeding occurred in 39 patients (32.8%) within 6 weeks after endoscopic treatment. Independent early rebleeding factors included gastric variceal hemorrhage (GVH), concomitant hepatocellular carcinoma (HCC), international normalized ratio (INR), and creatinine. The nomogram demonstrated exceptional calibration and discrimination capability. The area under the curve for the nomogram was 0.758 (95% CI 0.668-0.848), and it was validated at 0.71 through cross-validation and bootstrapping validation. The DCA and ROC curves demonstrated that the nomogram outperformed the MELD, Child-Pugh, and ALBI scores. CONCLUSIONS Compared with existing prediction scores, the nomogram demonstrated superior discrimination, calibration, and clinical applicability for predicting rebleeding in patients with EGVH after endoscopic treatment. Therefore, it may assist clinicians in the early implementation of aggressive treatment and follow-up.
Collapse
Affiliation(s)
- Yongqi Dong
- Department of Gastroenterology, Wushan County People's Hospital of Chongqing, No.168, Guangdongxi Road, Wushan County, Chongqing, 404700, People's Republic of China
| | - Hongyan Xu
- Department of Infectious Diseases, The Second Affiliated Hospital of Chongqing Medical University, NO.76, Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Zhihuan Zhang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Chongqing Medical University, NO.76, Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Zhihang Zhou
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, NO.76, Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Gang Zhao
- Department of Gastroenterology, Wushan County People's Hospital of Chongqing, No.168, Guangdongxi Road, Wushan County, Chongqing, 404700, People's Republic of China
| | - Haiyan Cao
- Department of Gastroenterology, Chengdu Second People's Hospital, NO.10, Yunnan Road, Chengdu, 610017, People's Republic of China
| | - Shiyong Xiao
- Department of Clinical Nutrition, Wushan County People's Hospital of Chongqing, No.168, Guangdongxi Road, Wushan County, Chongqing, 404700, People's Republic of China.
| |
Collapse
|
4
|
Bragança S, Ramos M, Lopes S, Alexandrino G, Mendes M, Perdigoto R, Coimbra J, Marques HP, Cardoso FS. Referral for liver transplant following acute variceal bleeding: a multicenter cohort study. Eur J Gastroenterol Hepatol 2024; 36:657-664. [PMID: 38477864 DOI: 10.1097/meg.0000000000002749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/14/2024]
Abstract
OBJECTIVES Referral for liver transplant (LT) following acute variceal bleeding (AVB) varies widely. We aimed to characterize and assess its impact on clinical outcomes. METHODS Observational retrospective cohort including cirrhosis patients with AVB from 3 hospitals in Lisbon, Portugal, from 2018 to 2019. Primary exposure was referral for LT and primary endpoint was all-cause mortality within 2 years of index hospital admission. RESULTS Among 143 patients, median (IQR) age was 59 (52-72) years and 90 (62.9%) were males. Median (IQR) MELDNa scores on hospital admission and discharge were 15 (11-21) and 13 (10-16), respectively. Overall, 30 (21.0%) patients were assessed for LT, 13 (9.1%) prior to and 17 (11.9%) within 2 years of hospital admission. Overall, 58 (40.6%) patients had at least one potential contra-indication for transplant. LT was performed in 3 (2.1%) patients (among 5 listed). Overall, 34 (23.8%) and 62 (43.4%) patients died at 6 weeks and 2 years post hospital admission, respectively. Following adjustment for confounders, referral for LT was associated with lower 2-year mortality (aHR (95% CI) = 0.20 (0.05-0.85)). CONCLUSION In a multicenter cohort of cirrhosis patients with AVB, less than a quarter underwent formal LT evaluation. Improved referral for LT following AVB may benefit cirrhosis patients' longer-term mortality.
Collapse
Affiliation(s)
- Sofia Bragança
- Gastroenterology Division, Fernando Fonseca Hospital, Amadora
| | - Marta Ramos
- Gastroenterology Division, Central Lisbon University Hospital Center, Lisbon
| | - Sara Lopes
- Gastroenterology Division, São Bernardo Hospital, Setúbal
| | | | - Milena Mendes
- Gastroenterology Division, Central Lisbon University Hospital Center, Lisbon
| | - Rui Perdigoto
- Transplant Unit, Curry Cabral Hospital, Nova Medical School, Lisbon, Portugal
| | - João Coimbra
- Gastroenterology Division, Central Lisbon University Hospital Center, Lisbon
| | - Hugo P Marques
- Transplant Unit, Curry Cabral Hospital, Nova Medical School, Lisbon, Portugal
| | - Filipe S Cardoso
- Gastroenterology Division, Central Lisbon University Hospital Center, Lisbon
- Transplant Unit, Curry Cabral Hospital, Nova Medical School, Lisbon, Portugal
| |
Collapse
|
5
|
Zeng A, Li Y, Lyu L, Zhang S, Zhang Y, Ding H, Li L. Risk factors and predictive nomograms for bedside emergency endoscopic treatment following endotracheal intubation in cirrhotic patients with esophagogastric variceal bleeding. Sci Rep 2024; 14:9467. [PMID: 38658605 PMCID: PMC11043454 DOI: 10.1038/s41598-024-59802-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/15/2024] [Indexed: 04/26/2024] Open
Abstract
Data on emergency endoscopic treatment following endotracheal intubation in patients with esophagogastric variceal bleeding (EGVB) remain limited. This retrospective study aimed to explore the efficacy and risk factors of bedside emergency endoscopic treatment following endotracheal intubation in severe EGVB patients admitted in Intensive Care Unit. A total of 165 EGVB patients were enrolled and allocated to training and validation sets in a randomly stratified manner. Univariate and multivariate logistic regression analyses were used to identify independent risk factors to construct nomograms for predicting the prognosis related to endoscopic hemostasis failure rate and 6-week mortality. In result, white blood cell counts (p = 0.03), Child-Turcotte-Pugh (CTP) score (p = 0.001) and comorbid shock (p = 0.005) were selected as independent clinical predictors of endoscopic hemostasis failure. High CTP score (p = 0.003) and the presence of gastric varices (p = 0.009) were related to early rebleeding after emergency endoscopic treatment. Furthermore, the 6-week mortality was significantly associated with MELD scores (p = 0.002), the presence of hepatic encephalopathy (p = 0.045) and postoperative rebleeding (p < 0.001). Finally, we developed practical nomograms to discern the risk of the emergency endoscopic hemostasis failure and 6-week mortality for EGVB patients. In conclusion, our study may help identify severe EGVB patients with higher hemostasis failure rate or 6-week mortality for earlier implementation of salvage treatments.
Collapse
Affiliation(s)
- Ajuan Zeng
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Yangjie Li
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Lingna Lyu
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Shibin Zhang
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Yuening Zhang
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China
| | - Huiguo Ding
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China.
| | - Lei Li
- Department of Gastroenterology and Hepatology, Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, 100069, China.
- Department of Gastroenterology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 102208, China.
| |
Collapse
|
6
|
Chen B, Wang J, Sheng W, Ma B, Xu P, Cheng X, Cheng W, Cai C, Wang G, Pan W, Wan C, Zheng C, Cheng P, Zhang J. Prognosis of LSPD versus TIPS for the treatment of esophagogastric variceal bleeding in cirrhosis. Surg Endosc 2024; 38:2106-2115. [PMID: 38438672 PMCID: PMC10978701 DOI: 10.1007/s00464-024-10729-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/28/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND This study aimed to compare postoperative complications in patients with esophagogastric variceal bleeding (EVB) who underwent laparoscopic splenectomy combined with pericardial devascularization (LSPD) versus transjugular intrahepatic portosystemic shunt (TIPS) procedures. METHODS A retrospective collection of medical records was conducted from January 2014 to May 2020 at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. The study included patients from the departments of trauma surgery, interventional radiology, and general surgery who were diagnosed with EVB caused by portal hypertension and treated with LSPD or TIPS. Follow-up data were obtained to assess the occurrence of postoperative complications in both groups. RESULTS A total of 201 patients were included in the study, with 104 cases in the LSPD group and 97 cases in the TIPS group. There was no significant difference in the 1-year and 3-year post-surgery survival rates between the TIPS and LSPD groups (P = 0.669, 0.066). The 3-year survival rate of Child-Pugh B patients in the LSPD group was higher than TIPS group (P = 0.041). The LSPD group also had a significantly higher rate of freedom from rebleeding at 3-year post-surgery compared to the TIPS group (P = 0.038). Stratified analysis showed no statistically significant difference in the rebleeding rate between the two groups. Furthermore, the LSPD group had a higher rate of freedom from overt hepatic encephalopathy at 1-year and 3-year post-surgery compared to the TIPS group (P = 0.007, < 0.001). The LSPD group also had a lower rate of severe complications at 3-year post-surgery compared to the TIPS group (P = 0.020). CONCLUSION Compared to TIPS, LSPD does not increase the risk of mortality and rebleeding, while demonstrating fewer complications. In patients classified as Child-Pugh A and B, the use of LSPD for treating EVB is both safe and effective.
Collapse
Affiliation(s)
- Biao Chen
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Jingxuan Wang
- Wisdom Lake Academy of Pharmacy, Xi'an Jiaotong-Liverpool University, Suzhou, 215123, Jiangsu, China
| | - Weiyong Sheng
- Department of Cardiac Surgery, Wannan Medical College, Yijishan Hospital, Wuhu, 241000, Anhui, China
| | - Bingqing Ma
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Peng Xu
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Xing Cheng
- Health Management Center, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Weiyi Cheng
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Chengjun Cai
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Guoliang Wang
- Department of Hepatobiliary Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Wenming Pan
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Chidan Wan
- Department of Hepatobiliary Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Chuansheng Zheng
- Department of Interventional Radiology, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Ping Cheng
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China
| | - Jinxiang Zhang
- Department of Emergency Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science & Technology, Wuhan, 430022, Hubei, China.
| |
Collapse
|
7
|
Jobe K, Henry Z. Endoscopic Treatment of Acute Esophageal and Gastric Variceal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:249-261. [PMID: 38395482 DOI: 10.1016/j.giec.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Acute variceal bleeding is a serious complication of portal hypertension. This most often manifests as bleeding from esophageal varices. Although less likely to occur, bleeding from gastric varices is usually more severe. The best endoscopic management for acute esophageal variceal bleeding is band ligation and this often proves to be definitive therapy for these patients. For gastric variceal bleeding, the best endoscopic therapy is endoscopic cyanoacrylate injection but this can be cumbersome to perform and is not a readily available resource at most centers in the United States.
Collapse
Affiliation(s)
- Kendra Jobe
- Department of Medicine, University of Virginia School of Medicine, 1215 Lee Street, PO Box 800708, Charlottesville, VA 22908-0708, USA
| | - Zachary Henry
- Division of Gastroenterology & Hepatology, University of Virginia School of Medicine, 1215 Lee Street, PO Box 800708, Charlottesville, VA 22908-0708, USA.
| |
Collapse
|
8
|
Zhu J, Xia Y, Liu X, Zhang C. Preventing variceal rebleeding in cirrhotic patients with portal vein thrombosis: A systematic review and meta-analysis. J Gastroenterol Hepatol 2024; 39:642-648. [PMID: 38233086 DOI: 10.1111/jgh.16489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND AIM Preventing rebleeding is crucial, but the best prevention technique for patients with cirrhosis and portal vein thrombosis (PVT) remains debatable. Therefore, this systematic review and meta-analysis compared a transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic therapy (ET) plus nonselective beta-blockers (NSBBs) for preventing variceal rebleeding in this patient population. METHODS The PubMed, Embase, Cochrane Library, and Web of Science databases were searched from their inception until May 18, 2023. The studies were screened using predetermined criteria, relevant data were extracted, and pooled analyses were performed using the Reviewer Manager 5.4.1 software. RESULTS We retrieved 1032 studies, of which 5 studies comprising a total of 272 patients were included. The postoperative variceal rebleeding rate was significantly lower in the TIPS group than in the ET + NSBBs group (odds ratio [OR] = 0.19, 95% confidence interval [CI] = 0.11-0.35, P < 0.05, I2 = 0%), but the portal vein recanalization rate was higher (OR = 7.92, 95% CI = 3.04-20.67, P < 0.05, I2 = 0%). The rates of hepatic encephalopathy (HE) and mortality did not differ between the groups. CONCLUSIONS Our results suggest that TIPS prevents variceal rebleeding without increasing the hepatic encephalopathy risk more effectively than ET plus NSBBs, but this benefit did not translate into improved survival. Thus, it may be preferable to ET plus NSBBs for preventing variceal rebleeding in patients with cirrhosis and PVT. However, more large-scale and multicenter randomized controlled trials involving other patient populations are required to verify the clinical efficacy of both these treatments and ensure generalizability.
Collapse
Affiliation(s)
- Junyuan Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yifu Xia
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Xiao Liu
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, China
| |
Collapse
|
9
|
Pfisterer N, Schwarz M, Madl C, Mandorfer M, Reiberger T. Editorial: The safety profile of endoscopic variceal ligation in patients with esophageal varices. Authors' reply. Hepatol Int 2024; 18:706-707. [PMID: 38141150 DOI: 10.1007/s12072-023-10617-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023]
Affiliation(s)
- N Pfisterer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
- Klinik Landstrasse, 4. Medizinische Abteilung Für Gastroenterologie Und Hepatologie, Vienna, Austria
| | - M Schwarz
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - C Madl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Klinik Landstrasse, 4. Medizinische Abteilung Für Gastroenterologie Und Hepatologie, Vienna, Austria
| | - M Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - T Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria.
- Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
10
|
Tripathi D, Patch D, Mehrzad H, Yu D, Aspinall RJ, Armstrong MJ, Stanley A, Ireland H, Travis S, Hayes P, Lomax M, Roslund N, Lam E, Slinn G, Jowett S, Moakes C, Maher A, Brettell E, Sehmi S. Study protocol for a Randomised controlled trial of EArly transjugular intrahepatiC porTosystemic stent-shunt in Acute Variceal Bleeding (REACT-AVB trial). BMJ Open Gastroenterol 2024; 11:e001314. [PMID: 38519049 DOI: 10.1136/bmjgast-2023-001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/16/2024] [Indexed: 03/24/2024] Open
Abstract
INTRODUCTION In liver cirrhosis, acute variceal bleeding (AVB) is associated with a 1-year mortality rate of up to 40%. Data on early or pre-emptive transjugular intrahepatic portosystemic stent-shunt (TIPSS) in AVB is inconclusive and may not reflect current management strategies. Randomised controlled trial of EArly transjugular intrahepatiC porTosystemic stent-shunt in AVB (REACT-AVB) aims to investigate the clinical and cost-effectiveness of early TIPSS in patients with cirrhosis and AVB after initial bleeding control. METHODS AND ANALYSIS REACT-AVB is a multicentre, randomised controlled, open-label, superiority, two-arm, parallel-group trial with an internal pilot. The two interventions allocated randomly 1:1 are early TIPSS within 4 days of diagnostic endoscopy or secondary prophylaxis with endoscopic therapy in combination with non-selective beta blockers. Patients aged ≥18 years with cirrhosis and Child-Pugh Score 7-13 presenting with AVB with endoscopic haemostasis are eligible for inclusion. The primary outcome is transplant-free survival at 1 year post randomisation. Secondary endpoints include transplant-free survival at 6 weeks, rebleeding, serious adverse events, other complications of cirrhosis, Child-Pugh and Model For End-Stage Liver Disease (MELD) scores at 6 and 12 months, health-related quality of life, use of healthcare resources, cost-effectiveness and use of cross-over therapies. The sample size is 294 patients over a 4-year recruitment period, across 30 hospitals in the UK. ETHICS AND DISSEMINATION Research ethics committee of National Health Service has approved REACT-AVB (reference number: 23/WM/0085). The results will be submitted for publication in a peer-reviewed journal. A lay summary will also be emailed or posted to participants before publication. TRIAL REGISTRATION NUMBER ISRCTN85274829; protocol version 3.0, 1 July 2023.
Collapse
Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Homoyon Mehrzad
- Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Dominic Yu
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Richard J Aspinall
- Gastroenterology and Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Matthew J Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | | | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Travis
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Peter Hayes
- Hepatology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Emily Lam
- GI and Liver PPI Group, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Sue Jowett
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Catherine Moakes
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Alisha Maher
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Elizabeth Brettell
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| | - Sukhwant Sehmi
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
| |
Collapse
|
11
|
Yang TC, Chen WC, Hou MC, Chen PH, Lee PC, Chang CY, Lu HS, Chen YJ, Hsu SJ, Huang HC, Luo JC, Huang YH, Lee FY. Endoscopic variceal ligation versus propranolol for the primary prevention of oesophageal variceal bleeding in patients with hepatocellular carcinoma: an open-label, two-centre, randomised controlled trial. Gut 2024; 73:682-690. [PMID: 38123994 DOI: 10.1136/gutjnl-2023-330419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE This randomised trial aimed to address whether endoscopic variceal ligation (EVL) or propranolol (PPL) is more effective at preventing initial oesophageal variceal bleeding (EVB) in patients with hepatocellular carcinoma (HCC). DESIGN Patients with HCC and medium-to-large oesophageal varices (EVs) but without previous EVB were randomised to receive EVL (every 3-4 weeks until variceal eradication) or PPL (up to 320 mg daily) at a 1:1 ratio. Long-term follow-up data on EVB, other upper gastrointestinal bleeding (UGIB), non-bleeding liver decompensation, overall survival (OS) and adverse events (AEs) were analysed using competing risk regression. RESULTS Between June 2011 and April 2021, 144 patients were randomised to receive EVL (n=72) or PPL (n=72). In the EVL group, 7 patients experienced EVB, and 30 died; in the PPL group, 19 patients had EVB, and 40 died. The EVL group had a lower cumulative incidence of EVB (Gray's test, p=0.009) than its counterpart, with no mortality difference (Gray's test, p=0.085). For patients with Barcelona Clinic Liver Cancer (BCLC) stage A/B, EVL was better than PPL in reducing EVB (p<0.001) and mortality (p=0.003). For patients beyond BCLC stage B, between-group outcomes were similar. Other UGIB, non-bleeding liver decompensation and AEs did not differ between groups. A competing risk regression model confirmed the prognostic value of EVL. CONCLUSION EVL is superior to PPL in preventing initial EVB in patients with HCC. The benefits of EVL on EVB and OS may be limited to patients with BCLC stage A/B and not to those with BCLC stage C/D. TRIAL REGISTRATION NUMBER NCT01970748.
Collapse
Affiliation(s)
- Tsung-Chieh Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Chi Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Post-Baccalaureate Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ping-Hsien Chen
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, West Garden Hospital, Taipei, Taiwan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Yu Chang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiao-Sheng Lu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shao-Jung Hsu
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hui-Chun Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiing-Chyuan Luo
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fa-Yauh Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Therapeutic and Research Center of Liver Cirrhosis and Portal Hypertension, Taipei Veterans General Hospital, Taipei, Taiwan
| |
Collapse
|
12
|
Toya Y, Hatta W, Shimada T, Matsuhashi T, Shiroki T, Sasaki Y, Tatsuta T, Nakamura J, Hanabata N, Horikawa Y, Nagino K, Koike T, Masamune A, Harada Y, Ohira T, Iijima K, Abe Y, Hikichi T, Igarashi S, Fushimi S, Takeda H, Fukuda S, Matsumoto T. Clinical outcomes of endoscopic submucosal dissection for esophageal squamous cell carcinoma with esophageal varices: Multicenter retrospective study. Dig Endosc 2024; 36:314-322. [PMID: 37343173 DOI: 10.1111/den.14619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/20/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVES Clinical outcomes of endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) with esophageal varices (EVs) are obscure. We aimed to elucidate the clinical outcomes of ESD for ESCC with EVs in a multicenter, retrospective study. METHODS We established a retrospective cohort of 30 patients with ESCC complicating EVs, who underwent ESD at 11 Japanese institutions. Rates of en bloc resection and R0 resection, procedure time, and adverse events were evaluated as indicators of the feasibility and safety of ESD. Additional treatment, recurrence, and metastasis of the lesions were evaluated as indicators of the long-term efficacy of ESD. RESULTS Portal hypertension was caused by cirrhosis, of which alcohol was the most common cause. En bloc resection was achieved in 93.3% and R0 resection in 80.0% of the patients. The median procedure time was 92 min. Adverse events included a case of uncontrolled intraoperative bleeding leading to discontinuation of ESD and a case of esophageal stricture due to extensive resection. During the follow-up period of a median for 42 months, a patient with local recurrence and another patient with liver metastasis were observed. One patient died of liver failure after receiving chemoradiotherapy as an additional treatment after ESD. No patient died of ESCC. CONCLUSION This multicenter, retrospective cohort study demonstrated the safety and efficacy of ESD for ESCC with EVs. Further studies are needed to establish appropriate treatment methods for EVs before ESD and additional treatments for patients with insufficient ESD.
Collapse
Affiliation(s)
- Yosuke Toya
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Tomohiro Shimada
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Takeharu Shiroki
- Department of Gastroenterology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Yu Sasaki
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Tetsuya Tatsuta
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Norihiro Hanabata
- Department of Gastroenterology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Yohei Horikawa
- Department of Gastroenterology, Hiraka General Hospital, Akita, Japan
| | - Ko Nagino
- Department of Gastroenterology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Yoshihiro Harada
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Tetsuya Ohira
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Katsunori Iijima
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yasuhiko Abe
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Shohei Igarashi
- Department of Gastroenterology, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Saki Fushimi
- Department of Gastroenterology, Hiraka General Hospital, Akita, Japan
| | - Hiroaki Takeda
- Department of Gastroenterology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| |
Collapse
|
13
|
Nicoară-Farcău O, Han G, Rudler M, Angrisani D, Monescillo A, Torres F, Casanovas G, Bosch J, Lv Y, Dunne PDJ, Hayes PC, Thabut D, Fan D, Hernández-Gea V, García-Pagán JC. Pre-emptive TIPS in high-risk acute variceal bleeding. An updated and revised individual patient data meta-analysis. Hepatology 2024; 79:624-635. [PMID: 37782566 DOI: 10.1097/hep.0000000000000613] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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] [Received: 05/21/2023] [Accepted: 08/23/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND AND AIMS A previous individual patient data meta-analysis (IPD-MA) showed that compared with drugs+endoscopy, the placement of transjugular portosystemic shunt within 72 hours of admission (pre-emptive transjugular intrahepatic portosystemic shunt: p-TIPS) increases the survival of high-risk patients (Child-Pugh B+ active bleeding and Child-Pugh C<14 points) with cirrhosis and acute variceal bleeding. However, the previous IPD-MA was not a two-stage meta-analysis, did not consider the potential risk of selection bias of observational studies, and did not include the most recent randomized clinical trial. We performed an updated and revised IPD-MA to reassess the efficacy of p-TIPS, addressing all previous issues. APPROACH AND RESULTS We included all studies from the previous IPD-MA and searched for other possible eligible publications until September 2022. We performed a two-stage IPD-MA of data from 8 studies (4 randomized clinical trials and 4 observational). In addition, we performed a sensitivity analysis excluding those patients dying up to the first 72 hours after admission in the Drugs+Endoscopy arms of the 4 observational studies. The primary end point was the effects of p-TIPS versus Drugs+Endoscopy on 1-year survival.We identified 1389 patients (342 p-TIPS and 1047 Drugs+Endoscopy). The two-stage IPD-MA showed that p-TIPS significantly reduced the mortality in the overall population (HR=0·43, 95% CI: 0.32-0.60, p <0.001. This effect was observed in both subgroups of patients with Child-Pugh. The sensitivity analysis confirmed the survival benefit of p-TIPS. CONCLUSIONS The updated two-stage IPD-MA confirms the significant survival advantage of p-TIPS in high-risk patients with cirrhosis and acute variceal bleeding. As a result, we recommend p-TIPS as the preferred first-choice treatment for these patients.
Collapse
Affiliation(s)
- Oana Nicoară-Farcău
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology "Octavian Fodor", "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, Barcelona, Spain
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, Xi'an International Medical Center Hospital, Digestive Diseases Hospital, Northwest University, Xi'an, China
- Department of Liver Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Xijing Hospital, 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, Barcelona, Spain
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
| | - Alberto Monescillo
- Digestive Disease Department, Hospital Universitario Insular de Gran Canaria, Canary Islands, Spain
| | - 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, Barcelona, Spain
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
- 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 Disease and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Philip D J Dunne
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - 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, Barcelona, Spain
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Juan C García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver)
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| |
Collapse
|
14
|
Berengy MS, Abd El-Hamid Hassan EM, Ibrahim AH, Mohamed EF. Safety and efficacy of transjugular intrahepatic portosystemic shunts vs endoscopic band ligation plus propranolol in patients with cirrhosis with portal vein thrombosis: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:316-326. [PMID: 38445926 DOI: 10.1016/j.gassur.2023.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND This systematic review and meta-analysis aimed to assess the efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) against the combined treatment of endoscopic band ligation (EBL) and propranolol in managing patients with cirrhosis diagnosed with portal vein thrombosis (PVT). METHODS A literature search from inception to September 2023 was performed using MEDLINE, the Cochrane Library, Web of Science, and Scopus. Independent screening, data extraction, and quality assessment were performed. The main measured outcomes were the incidence and recurrence of variceal bleeding (VB), hepatic encephalopathy, and overall survival. RESULTS A total of 5 studies were included. For variceal eradication, there was initially no significant difference between the groups; however, after sensitivity analysis, a significant effect emerged (risk ratio [RR], 1.55; P < .0001). TIPS was associated with a significant decrease in the incidence of VB (RR, 0.34; P < .0001) and a higher probability of remaining free of VB in the first 2 years after the procedure (first year: RR, 1.41; P < .0001; second year: RR, 1.58; P < .0001). TIPS significantly reduced the incidence of death due to acute GI bleeding compared with EBL + propranolol (RR, 0.37; P = .05). CONCLUSION TIPS offers a comprehensive therapeutic advantage over the combined EBL and propranolol regimen, especially for patients with cirrhosis with PVT. Its efficacy in variceal eradication, reducing rebleeding, and mitigating death risks due to acute GI bleeding is evident.
Collapse
Affiliation(s)
- Mahmoud Saad Berengy
- Department of Internal Medicine, Damietta Faculty of Medicine, Al-Azhar University, Damietta, Egypt.
| | | | - Amal H Ibrahim
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Eman F Mohamed
- Department of Internal Medicine, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| |
Collapse
|
15
|
Huang JT, Zhong BY, Li WC, Jiang N, Qian D, Hu ZX, Nie H, Zhang S, Shen J, Zhu XL. Emergent TIPS for acute gastroesophageal variceal bleeding in cirrhotic patients with hepatocellular carcinoma. Abdom Radiol (NY) 2024; 49:900-907. [PMID: 38010526 DOI: 10.1007/s00261-023-04088-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES To estimate the safety and effectiveness of emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for acute variceal bleeding (AVB) in cirrhotic patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS Data of thirty-three patients with AVB and HCC undergoing emergent TIPS creation from January 2016 to January 2022 were enrolled and were retrospectively analyzed. The primary outcomes were the safety of emergent TIPS creation, the bleeding control rate, and the rebleeding rate. The secondary outcomes included overall survival (OS), liver function, overt hepatic encephalopathy (HE), and shunt dysfunction. RESULTS Emergent TIPS creation was technically successful in 33 patients (100%) and one (3.0%) patient suffered a major procedure-related adverse event. The control rate of bleeding (within 5 days) was 100%. During a median follow-up period of 26.3 months, rebleeding occurred in 6 (18.2%) patients. The median OS was 20.0 months. The 6-week and 1-year survival rates were 87% and 65%, respectively. Laboratory tests showed no significant impairment of liver function following TIPS creation. The incidences of overt HE and shunt dysfunction were 24.2% and 6.1%, respectively. CONCLUSION Emergent TIPS creation is feasible and effective for treatment of AVB in cirrhotic patients with HCC.
Collapse
Affiliation(s)
- Jin-Tao Huang
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Bin-Yan Zhong
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Wan-Ci Li
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Nan Jiang
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Duo Qian
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Ze-Xin Hu
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Hong Nie
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Shuai Zhang
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Jian Shen
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China
| | - Xiao-Li Zhu
- Department of Interventional Radiology, The First Affiliated Hospital, Soochow University, No. 188 Shizi Road, Suzhou, 215006, China.
| |
Collapse
|
16
|
Zhao L, Tie J, Wang G, Li Z, Xu J, Zhuge Y, Zhang F, Wu H, Wei B, Xue H, Li P, Wu W, Chen C, Wu Q, Xia Y, Sun X, Zhang C. Efficacy of TIPS plus extrahepatic collateral embolisation in real-world data: a validation study. BMJ Open Gastroenterol 2024; 11:e001310. [PMID: 38395452 PMCID: PMC10895241 DOI: 10.1136/bmjgast-2023-001310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVES The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) plus extrahepatic collateral embolisation (TIPS+E) in reducing rebleeding and hepatic encephalopathy (HE) post-TIPS was recently reported in a meta-analysis, but further validation is essential. This study aims to confirm the effectiveness of TIPS+E using real-world data. METHODS The multicentre retrospective cohort included 2077 patients with cirrhosis who underwent TIPS±E (TIPS: 631, TIPS+E: 1446) between January 2010 and December 2022. Regression and propensity score matching (PSM) were used to adjust for baseline characteristic differences. After PSM, clinical outcomes, including rebleeding, HE, survival and further decompensation (FDC), were analysed. Baseline data from all patients contributed to the construction of prognostic models. RESULTS After PSM, 1136 matched patients (TIPS+E: TIPS=568:568) were included. TIPS+E demonstrated a significant reduction in rebleeding (HR 0.77; 95% CI 0.59 to 0.99; p=0.04), HE (HR 0.82; 95% CI 0.68 to 0.99; p=0.04) and FDC (HR 0.85; 95% CI 0.73 to 0.99; p=0.04), comparing to TIPS. Significantly, TIPS+E also reduced rebleeding, HE and FDC in subgroup of using 8 mm diameter stents and embolising of gastric varices+spontaneous portosystemic shunts (GV+SPSS). However, there were no differences in overall or subgroup survival analysis. Additionally, the random forest models showed higher accuracy and AUROC comparing to other models. Controlling post-TIPS portal pressure gradient (pPPG) within 7 mm Hg CONCLUSION Our real-world data validation confirms the high efficacy of TIPS+E in reducing rebleeding and HE, particularly when using 8 mm diameter stents, embolising GV+SPSS and maintaining an optimal pPPG.
Collapse
Affiliation(s)
- Lianhui Zhao
- Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
- Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
| | - Jun Tie
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, Shaanxi, People's Republic of China
| | - Guangchuan Wang
- Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
- Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
- Department of Biostatistics, School of Public Health, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Zhengjie Li
- School of Automation, Qingdao University, Qingdao, Shandong Province, People's Republic of China
| | - Jiao Xu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, Shaanxi, People's Republic of China
| | - Yuzheng Zhuge
- Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsun Province, People's Republic of China
| | - Feng Zhang
- Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsun Province, People's Republic of China
| | - Hao Wu
- Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Bo Wei
- Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Hui Xue
- Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Peijie Li
- Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Wei Wu
- Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Chao Chen
- Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
| | - Qiong Wu
- Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
| | - Yifu Xia
- Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Xiubin Sun
- Department of Biostatistics, School of Public Health, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Chunqing Zhang
- Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
- Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
| |
Collapse
|
17
|
Li Z, LingHu E, Li W, Zhou L. Guiding role of esophageal variceal diameter in treatment of endoscopic ligation: an animal experimental study. Sci Rep 2024; 14:3929. [PMID: 38365842 PMCID: PMC10873287 DOI: 10.1038/s41598-024-53752-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/05/2024] [Indexed: 02/18/2024] Open
Abstract
In this study, according to the Location, Diameter, Risk factor (LDRf) classification principle, the influence and effect of esophageal varices diameter on the degree of complete ligation of multicyclic ligator were investigated. Methods. The esophageal veins of healthy piglets were filled with methylene blue solution, and the in vitro pig esophageal varices model was made, which were divided into three groups according to the diameter of esophageal varices: D1, 0.4-1.0 cm; D2, 1.1-1.5 cm; and D3, 1.6-2.0 cm. Finally, the ligation effect of each group was analyzed statistically. A total of 407 ligations were performed on the simulated esophageal variceal model. There were 103 ligations in the D1 group and 98 were complete (95.15%, 98/103); 151 ligations in the D2 group and 47 were complete (31.13%, 47/151); and 153 ligations in the D3 group but none were complete (0%, 0/153). There was significant difference in the degree of complete ligation between the two groups (χ2 = 38.0014, P ≤ 0.001). In the varicose ligation model, the complete ligation effect was the most complete and robust when the varicose diameter was 0.4-1.0 cm. This study showed that the varicose vein diameter in LDRf classification was reasonable and feasible to guide endoscopic varicose vein ligation.
Collapse
Affiliation(s)
- Zhiqun Li
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing, 100853, China.
- Department of Gastroenterology, Chinese PLA 984 Hospital, Beijing, 100094, China.
| | - Enqiang LingHu
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Weimin Li
- Beijing Friendship Hospital Pinggu Campus, Capital Medical University, Beijing, 101200, China
| | - Licai Zhou
- Beijing Friendship Hospital Pinggu Campus, Capital Medical University, Beijing, 101200, China
| |
Collapse
|
18
|
Deng Y, Jiang Y, Jiang T, Chen L, Mou HJ, Tuo BG, Shi GQ. Evaluation of the efficacy and safety of endoscopic band ligation in the treatment of bleeding from mild to moderate gastric varices type 1. World J Gastroenterol 2024; 30:440-449. [PMID: 38414583 PMCID: PMC10895593 DOI: 10.3748/wjg.v30.i5.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/15/2023] [Accepted: 01/11/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND According to practice guidelines, endoscopic band ligation (EBL) and endoscopic tissue adhesive injection (TAI) are recommended for treating bleeding from esophagogastric varices. However, EBL and TAI are known to cause serious complications, such as hemorrhage from dislodged ligature rings caused by EBL and hemorrhage from operation-related ulcers resulting from TAI. However, the optimal therapy for mild to moderate type 1 gastric variceal hemorrhage (GOV1) has not been determined. Therefore, the aim of this study was to discover an individualized treatment for mild to moderate GOV1. AIM To compare the efficacy, safety and costs of EBL and TAI for the treatment of mild and moderate GOV1. METHODS A clinical analysis of the data retrieved from patients with mild or moderate GOV1 gastric varices who were treated under endoscopy was also conducted. Patients were allocated to an EBL group or an endoscopic TAI group. The differences in the incidence of varicose relief, operative time, operation success rate, mortality rate within 6 wk, rebleeding rate, 6-wk operation-related ulcer healing rate, complication rate and average operation cost were compared between the two groups of patients. RESULTS The total effective rate of the two treatments was similar, but the efficacy of EBL (66.7%) was markedly better than that of TAI (39.2%) (P < 0.05). The operation success rate in both groups was 100%, and the 6-wk mortality rate in both groups was 0%. The average operative time (26 min) in the EBL group was significantly shorter than that in the TAI group (46 min) (P < 0.01). The rate of delayed postoperative rebleeding in the EBL group was significantly lower than that in the TAI group (11.8% vs 45.1%) (P < 0.01). At 6 wk after the operation, the healing rate of operation-related ulcers in the EBL group was 80.4%, which was significantly greater than that in the TAI group (35.3%) (P < 0.01). The incidence of postoperative complications in the two groups was similar. The average cost and other related economic factors were greater for the EBL than for the TAI (P < 0.01). CONCLUSION For mild to moderate GOV1, patients with EBL had a greater one-time varix eradication rate, a greater 6-wk operation-related ulcer healing rate, a lower delayed rebleeding rate and a lower cost than patients with TAI.
Collapse
Affiliation(s)
- Yue Deng
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
- Department of Gastroenterology, Guizhou Hospital of the First Affiliated Hospital, Sun Yat-sen University, Guiyang 550000, Guizhou Province, China
| | - Ya Jiang
- Department of Gastroenterology, Yinjiang Autonomous County People’s Hospital, Tongren 554300, Guizhou Province, China
| | - Tong Jiang
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Ling Chen
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Hai-Jun Mou
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Bi-Guang Tuo
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Guo-Qing Shi
- Department of Gastroenterology, Digestive Disease Hospital, The Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| |
Collapse
|
19
|
Liang J, Feng X, Peng M, Duan JT, Chen YY, Zhu J. Combined transhepatic and transsplenic recanalization of chronic splenic vein occlusion to treat left-sided portal hypertension: A cases report. Medicine (Baltimore) 2024; 103:e37109. [PMID: 38306530 PMCID: PMC10843399 DOI: 10.1097/md.0000000000037109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/09/2024] [Indexed: 02/04/2024] Open
Abstract
RATIONALE This report describes a unique case of a combination transhepatic and transsplenic recanalization of chronic splenic vein occlusion to treat left-sided portal hypertension (LSPH). PATIENT CONCERNS In this case report, we report a 49-year-old male who was admitted due to LSPH causing black stools for 2 days and vomiting blood for 1 hour. DIAGNOSES The patient has a history of multiple episodes of pancreatitis in the past. After admission, abdominal contrast-enhanced CT scan showed the appearance of pancreatitis, with extensive splenic vein occlusion and accompanied by gastric varicose veins, indicating the formation of LSPH. INTERVENTION The patient received treatment with a combination of splenic and hepatic splenic venoplasty. OUTCOMES Follow up for 1 year, CT and gastroscopy showed disappearance of gastric varices. LESSONS Splenic venoplasty is an effective method for treating LSPH. When it is difficult to pass through the occluded segment of the splenic vein through a single approach, percutaneous double approach splenic venoplasty can be attempted for treatment.
Collapse
Affiliation(s)
- Jie Liang
- School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Xu Feng
- Department of Interventional, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
| | - Min Peng
- School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Jin-Tao Duan
- Department of Interventional, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
| | - Yao-Yong Chen
- Department of Interventional, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
| | - Jun Zhu
- Department of Interventional, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
| |
Collapse
|
20
|
Chen WC, Yang TC, Lee PC, Wang YP, Hou MC, Lee FY. A Randomized Controlled Trial of Propranolol Use During Ligation Program for Secondary Prophylaxis of Esophageal Variceal Bleeding. Am J Gastroenterol 2024; 119:278-286. [PMID: 37543755 DOI: 10.14309/ajg.0000000000002457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/14/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Endoscopic variceal ligation (EVL) plus nonselective β-blockers (NSBB) is the standard of care for secondary prophylaxis of esophageal variceal bleeding (EVB). This trial aimed to compare the rebleeding rates between EVL plus NSBB till eradication of esophageal varices (EEV) and EVL plus long-term NSBB. METHODS After control of acute EVB, patients with cirrhosis were randomized into 2 groups, with group A patients receiving EVL plus propranolol till EEV, while group B patients received standard of care with continuation of propranolol. Recurrent varices were ligated at follow-up endoscopy in both groups. RESULTS The median follow-up period was 23.0 months in group A (n = 106) and 23.6 months in group B (n = 106). Twelve patients (11.3%) in group A and 11 (10.4%) in group B had recurrent EVB. The difference in rebleeding rates and the 95% confidence interval (CI) was 0.9% (-7.5% to 9.3%). The upper 95% CI bound of the difference was within the margin of 13.2%, and the noninferiority of group A to group B was established. Thirty-eight patients (35.8%) in group A and 40 (37.7%) in group B had further decompensation, with the difference (95% CI) of -1.9% (-14.9% to 11.1%). Twenty-four patients (22.6%) in group A and 26 (24.5%) in group B expired, with the difference (95% CI) in mortality rates of -1.9% (-13.3% to 9.5%). DISCUSSION EVL plus propranolol till EEV was noninferior to EVL plus continuing propranolol in secondary prophylaxis of EVB, but the impact on further decompensation and transplantation-free survival deserved further investigation.
Collapse
Affiliation(s)
- Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Tsung-Chieh Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Pei-Chang Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Po Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Yauh Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| |
Collapse
|
21
|
Huang Y, Wang X, Li X, Sun S, Xie Y, Yin X. Comparative efficacy of early TIPS, Non-early TIPS, and Standard treatment in patients with cirrhosis and acute variceal bleeding: a network meta-analysis. Int J Surg 2024; 110:1149-1158. [PMID: 37924494 PMCID: PMC10871647 DOI: 10.1097/js9.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/22/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Cirrhosis is a chronic disease characterized by chronic liver inflammation and diffuse fibrosis. A combination of vasoactive drugs, preventive antibiotics, and endoscopy is the recommended standard treatment for patients with acute variceal bleeding; however, this has been challenged. We compared the effects of early transjugular intrahepatic portosystemic shunt (TIPS), non-early TIPS, and standard treatment in patients with cirrhosis and acute variceal bleeding. MATERIALS AND METHODS The present network meta-analysis was conducted in accordance with the criteria outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Assessing the methodological quality of systematic reviews guidelines. The review has been registered with the International Prospective Register of Systematic Reviews. The PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and World Health Organization-approved trial registry databases were searched for randomized controlled trials (RCTs) evaluating early TIPS, non-early TIPS, and standard treatment in patients with cirrhosis and acute variceal bleeding. RESULTS Twenty-four RCTs (1894 patients) were included in the review. Compared with standard treatment, early TIPS [odds ratio (OR), 0.53; 95% credible interval (Cr), 0.30-0.94; surface under the cumulative ranking curve (SUCRA), 98.3] had a lower risk of all-cause mortality (moderate-to-high-quality evidence), and early TIPS (OR, 0.19; 95% CrI, 0.11-0.28; SUCRA, 98.2) and non-early TIPS (OR, 0.30; 95% CrI, 0.23-0.42; SUCRA, 1.8) were associated with a lower risk of rebleeding (moderate-to-high-quality evidence). Early TIPS was not associated with a reduced risk of hepatic encephalopathy, and non-early TIPS (OR, 2.78; 95% CrI, 1.89-4.23, SUCRA, 0) was associated with an increased incidence of hepatic encephalopathy (moderate-to-high-quality evidence). There was no difference in the incidence of new or worsening ascites (moderate-to-high-quality evidence) among the three interventions. CONCLUSION Based on the moderate-to-high quality evidence presented in this study, early TIPS placement was associated with reduced all-cause mortality [with a median follow-up of 1.9 years (25th-75th percentile range 1.9-2.3 years)] and rebleeding compared to standard treatment and non-early TIPS. Although early TIPS and standard treatment had a comparable incidence of hepatic encephalopathy, early TIPS showed superiority over non-early TIPS in this aspect. Recent studies have also shown promising results in controlling TIPS-related hepatic encephalopathy. However, it is important to consider individual patient characteristics and weigh the potential benefits against the risks associated with early TIPS. Therefore, we recommend that clinicians carefully evaluate the patient's condition, considering factors such as severity of variceal bleeding, underlying liver disease, and overall clinical status, before making a treatment decision. Further well-designed RCTs comparing early TIPS with non-early TIPS are needed to validate these findings and provide more definitive guidance.
Collapse
Affiliation(s)
- Ye Huang
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
- Loudi Center for Diseases Prevention and Control, Loudi, Hunan, China
| | - Xiaokai Wang
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangmin Li
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Shichang Sun
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Yongxiang Xie
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xinbo Yin
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan, P.R. China
- Department of Emergency Medicine, Xiangya Hospital, Central South University, Changsha, China
| |
Collapse
|
22
|
Mony S, Hu B, Joseph A, Aihara H, Ferri L, Bhatt A, Mehta A, Ting PS, Chen A, Kalra A, Farha J, Onimaru M, He L, Luo Q, Wang AY, Inoue H, Ngamruengphong S. Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasia in close proximity to esophageal varices: a multicenter international experience. Endoscopy 2024; 56:119-124. [PMID: 37611620 DOI: 10.1055/a-2159-2557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/25/2023]
Abstract
BACKGROUND : There are limited data on the feasibility of endoscopic submucosal dissection (ESD) for superficial esophageal neoplasia (SEN) located at or adjacent to esophageal varices. We aimed to evaluate the outcomes of ESD in these patients. METHODS This multicenter retrospective study included cirrhotic patients with a history of esophageal varices with SEN located at or adjacent to the esophageal varices who underwent ESD. RESULTS 23 patients with SEN (median lesion size 30 mm; 16 squamous cell neoplasia and seven Barrett's esophagus-related neoplasia) were included. The majority were Child-Pugh B (57 %) and had small esophageal varices (87 %). En bloc, R0, and curative resections were achieved in 22 (96 %), 21 (91 %), and 19 (83 %) of patients, respectively. Severe intraprocedural bleeding (n = 1) and delayed bleeding (n = 1) were successfully treated endoscopically. No delayed perforation, hepatic decompensation, or deaths were observed. During a median (interquartile range) follow-up of 36 (22-55) months, one case of local recurrence occurred after noncurative resection. CONCLUSION ESD is feasible and effective for SEN located at or adjacent to esophageal varices in cirrhotic patients. Albeit, the majority of the esophageal varices in our study were small in size, when expertise is available, ESD should be considered as a viable option for such patients.
Collapse
Affiliation(s)
- Shruti Mony
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Division of Gastroenterology and Hepatology , University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Bing Hu
- Department of Gastroenterology, West China Longquan Hospital, Sichuan University, Sichuan Province, China
| | - Abel Joseph
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lorenzo Ferri
- Department of Surgery, Division of Thoracic Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amit Mehta
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Peng-Sheng Ting
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alex Chen
- Department of Surgery, Division of Thoracic Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew Kalra
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Long He
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qi Luo
- Department of Gastroenterology, West China Longquan Hospital, Sichuan University, Sichuan Province, China
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| |
Collapse
|
23
|
Rangray R. Continuing Medical Education Questions: February 2024. Am J Gastroenterol 2024; 119:248. [PMID: 38305245 DOI: 10.14309/ajg.0000000000002648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 12/28/2023] [Indexed: 02/03/2024]
Abstract
Article Title: A Randomized Controlled Trial of Propranolol Use During Ligation Program for Secondary Prophylaxis of Esophageal Variceal Bleeding.
Collapse
|
24
|
Ichita C, Shimizu S, Goto T, Haruki U, Itoh N, Iwagami M, Sasaki A. Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study. World J Gastroenterol 2024; 30:238-251. [PMID: 38314133 PMCID: PMC10835525 DOI: 10.3748/wjg.v30.i3.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/12/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis. The current standard treatment is endoscopic variceal ligation (EVL), and Western guidelines recommend antibiotic prophylaxis following hemostasis. However, given the improvements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria, there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis. AIM To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL. METHODS We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals. Patients were divided into the prophylaxis group (received antibiotics on admission or the next day) and the non-prophylaxis group (did not receive antibiotics within one day of admission). The primary outcome was composed of 6-wk mortality, 4-wk rebleeding, and 4-wk spontaneous bacterial peritonitis (SBP). The secondary outcomes were each individual result and in-hospital mortality. A logistic regression with inverse probability of treatment weighting was used. A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures, while sensitivity analyses for antibiotic type and duration were also performed. RESULTS Among 980 patients, 790 were included (prophylaxis: 232, non-prophylaxis: 558). Most patients were males under the age of 65 years with a median Child-Pugh score of 8. The composite primary outcomes occurred in 11.2% of patients in the prophylaxis group and 9.5% in the non-prophylaxis group. No significant differences in outcomes were observed between the groups (adjusted odds ratio, 1.11; 95% confidence interval, 0.61-1.99; P = 0.74). Individual outcomes such as 6-wk mortality, 4-wk rebleeding, 4-wk onset of SBP, and in-hospital mortality were not significantly different between the groups. The primary outcome did not differ between the Child-Pugh subgroups. Similar results were observed in the sensitivity analyses. CONCLUSION No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study. Global reassessment of routine antibiotic prophylaxis is imperative.
Collapse
Affiliation(s)
- Chikamasa Ichita
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
| | - Tadahiro Goto
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
- TXP Research, TXP Medical Co., Ltd., Chiyoda-ku 101-0042, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku 113-0033, Tokyo, Japan
| | - Uojima Haruki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
- Department of Genome Medical Sciences Project, Research Institute, National Center for Global Health and Medicine, Ichikawa 272-8516, Chiba, Japan
| | - Naoya Itoh
- Division of Infectious Diseases, Aichi Cancer Center, Nagoya 464-8681, Aichi, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba 305-8575, Ibaraki, Japan
| | - Akiko Sasaki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
| |
Collapse
|
25
|
Liu Y, Chang H, Zeng Y, Li J, Li Y, Chen Y, Zhou T, Gao Y. Influence of subcutaneous adipose tissue index on prognosis in cirrhotic patients following endoscopic therapy: a retrospective cohort study. Lipids Health Dis 2024; 23:7. [PMID: 38185678 PMCID: PMC10773050 DOI: 10.1186/s12944-023-01996-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/27/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND The relation of adipose tissue depletion with prognostic outcome of variceal bleeding among cirrhotic patients is still inconclusive. The present work explored whether adipose tissue, which was measured based on computed tomography (CT), was valuable for analyzing rebleeding and mortality among patients with variceal bleeding who had undergone endoscopic therapy. METHODS The study encompassed cirrhotic patients who underwent endoscopic therapy to prevent variceal rebleeding between January 2016 and October 2022. The L3-level CT images were obtained. Besides, impacts of subcutaneous adipose tissue index (SATI), visceral adipose tissue index (VATI), as well as total adipose tissue index (TATI) on rebleeding and mortality among cirrhotic patients following endoscopic therapy were examined. RESULTS In this work, our median follow-up period was 31 months. Among those adipose tissue indexes, only SATI exhibited an independent relation to higher rebleeding (HR 0.981, 95% CI, 0.971-0.991, p < 0.001) and mortality (HR 0.965, 95% CI, 0.944-0.986, p = 0.001) risks. Upon multivariate Cox regression, low SATI (male < 30.15 cm2/m2, female < 39.82 cm2/m2) was independently linked to higher rebleeding risk (HR 2.511, 95% CI, 1.604-3.932, p < 0.001) and increased mortality risk (HR 3.422, 95% CI, 1.489-7.864, p = 0.004) after adjusting for other predictors. Furthermore, subgroups were created based on using nonselective β-blockers (NSBBs), demonstrating that quantitatively assessing SATI exerts a vital role in evaluating rebleeding incidence in patients with or without NSBB therapy. CONCLUSION This study underscores the potential of quantifying SATI as a means for achieving a more accurate risk classification for individual patients and identifying patients that can gain more benefits from nutritional intervention.
Collapse
Affiliation(s)
- Yongshuai Liu
- Department of Gastroenterology, Qilu Hospital of Shandong University, 107 West Wen Hua Road, Jinan, 250012, Shandong, China
| | - Huijun Chang
- Department of Gastroenterology, Qilu Hospital of Shandong University, 107 West Wen Hua Road, Jinan, 250012, Shandong, China
| | - Yunqing Zeng
- Department of Gastroenterology, Qilu Hospital of Shandong University, 107 West Wen Hua Road, Jinan, 250012, Shandong, China
| | - Jinhou Li
- Department of Gastroenterology, Taian City Central Hospital, Taian, Shandong, China
| | - Yueyue Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, 107 West Wen Hua Road, Jinan, 250012, Shandong, China
| | - Yong Chen
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong First Medical University, Jinan, Shandong, China
| | - Tao Zhou
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Yanjing Gao
- Department of Gastroenterology, Qilu Hospital of Shandong University, 107 West Wen Hua Road, Jinan, 250012, Shandong, China.
| |
Collapse
|
26
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
27
|
DeWitt JM. Endoscopic treatment of gastric variceal bleeding: Where have we come from, and where are we going? Gastrointest Endosc 2024; 99:38-40. [PMID: 37978964 DOI: 10.1016/j.gie.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 11/19/2023]
Affiliation(s)
- John M DeWitt
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| |
Collapse
|
28
|
Balcar L, Mandorfer M, Hernández-Gea V, Procopet B, Meyer EL, Giráldez Á, Amitrano L, Villanueva C, Thabut D, Samaniego LI, Silva-Junior G, Martinez J, Genescà J, Bureau C, Trebicka J, Herrera EL, Laleman W, Palazón Azorín JM, Alonso JC, Gluud LL, Ferreira CN, Cañete N, Rodríguez M, Ferlitsch A, Mundi JL, Grønbæk H, Hernandez Guerra MN, Sassatelli R, Dell'Era A, Senzolo M, Abraldes JG, Romero-Gómez M, Zipprich A, Casas M, Masnou H, Primignani M, Krag A, Nevens F, Calleja JL, Jansen C, Catalina MV, Albillos A, Rudler M, Tapias EA, Guardascione MA, Tantau M, Schwarzer R, Reiberger T, Laursen SB, Lopez-Gomez M, Cachero A, Ferrarese A, Ripoll C, La Mura V, Bosch J, García-Pagán JC. Predicting survival in patients with 'non-high-risk' acute variceal bleeding receiving β-blockers+ligation to prevent re-bleeding. J Hepatol 2024; 80:73-81. [PMID: 37852414 DOI: 10.1016/j.jhep.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/03/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND & AIMS Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for high-risk acute variceal bleeding (AVB; i.e., Child-Turcotte-Pugh [CTP] B8-9+active bleeding/C10-13). Nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation for secondary prophylaxis. We investigated prognostic factors for re-bleeding and mortality in 'non-high-risk' AVB to identify subgroups who may benefit from more potent treatments (i.e., TIPS) to prevent further decompensation and mortality. METHODS A total of 2,225 adults with cirrhosis and variceal bleeding were prospectively recruited at 34 centres between 2011-2015; for the purpose of this study, case definitions and information on prognostic indicators at index AVB and on day 5 were further refined in low-risk patients, of whom 581 (without failure to control bleeding or contraindications to TIPS) who were managed by non-selective beta-blockers/endoscopic variceal ligation, were finally included. Patients were followed for 1 year. RESULTS Overall, 90 patients (15%) re-bled and 70 (12%) patients died during follow-up. Using clinical routine data, no meaningful predictors of re-bleeding were identified. However, re-bleeding (included as a time-dependent co-variable) increased mortality, even after accounting for differences in patient characteristics (adjusted cause-specific hazard ratio: 2.57; 95% CI 1.43-4.62; p = 0.002). A nomogram including CTP, creatinine, and sodium measured at baseline accurately (concordance: 0.752) stratified the risk of death. CONCLUSION The majority of 'non-high-risk' patients with AVB have an excellent prognosis, if treated according to current recommendations. However, about one-fifth of patients, i.e. those with CTP ≥8 and/or high creatinine levels or hyponatremia, have a considerable risk of death within 1 year of the index bleed. Future clinical trials should investigate whether elective TIPS placement reduces mortality in these patients. IMPACT AND IMPLICATIONS Pre-emptive transjugular intrahepatic portosystemic shunt placement improves outcomes in high-risk acute variceal bleeding; nevertheless, some 'non-high-risk' patients have poor outcomes despite the combination of non-selective beta-blockers and endoscopic variceal ligation. This is the first large-scale study investigating prognostic factors for re-bleeding and mortality in 'non-high-risk' acute variceal bleeding. While no clinically meaningful predictors were identified for re-bleeding, we developed a nomogram integrating baseline Child-Turcotte-Pugh score, creatinine, and sodium to stratify mortality risk. Our study paves the way for future clinical trials evaluating whether elective transjugular intrahepatic portosystemic shunt placement improves outcomes in presumably 'non-high-risk' patients who are identified as being at increased risk of death.
Collapse
Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria; Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain
| | - Bogdan Procopet
- Hepatology Department and 3rd Medical Clinic, Regional Institute of Gastroenterology and Hepatology 'Octavian Fodor' and 'Iuliu Hatieganu' University of Medicine and Pharmacy, Romania
| | - Elias Laurin Meyer
- Section for Medical Statistics, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria; Berry Consultants, Vienna, Austria
| | - Álvaro Giráldez
- Clinical Management Unit of Digestive Diseases, University Hospital Virgen Del Rocio, Spain
| | | | - Candid Villanueva
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servei De Patologia Digestiva, Hospital De La Santa Creu I Sant Pau, Spain
| | | | - Luis Ibáñez Samaniego
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servicio De Medicina De Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Lisgm, Spain
| | - Gilberto Silva-Junior
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain
| | - Javier Martinez
- Department of Gastroenterology and Instituto Ramón y Cajal De Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal and University of Alcalá, Spain
| | - Joan Genescà
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Spain
| | - Christophe Bureau
- Department of Hepato-Gastroenterology, Purpan Hospital, University of Toulouse, France
| | - Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Germany; Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark; Department of Internal Medicine I, University of Bonn, Germany
| | - Elba Llop Herrera
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain
| | - Wim Laleman
- Department of Liver and Biliopancreatic Disorders, KU Leuven, Belgium
| | | | - Jose Castellote Alonso
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Idibell, Universitat de Barcelona, Spain
| | - Lise Lotte Gluud
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre and Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria - Centro Hospitalar Universitário Lisboa Norte, Portugal
| | - Nuria Cañete
- Liver Section, Gastroenterology Department and Imim (Hospital del Mar Medical Research Institute), Gastroenterology Department, Spain
| | - Manuel Rodríguez
- Department of Gastroenterology, Hospital Universitario Central de Asturias, Spain
| | - Arnulf Ferlitsch
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria; Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Department of Internal Medicine I, Gastroenterology and Nephrology, St. John of God Hospital, Vienna, Austria
| | - Jose Luis Mundi
- Department of Gastroenterology, University Hospital San Cecilio, Spain
| | - Henning Grønbæk
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Denmark
| | | | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRRCS, Italy
| | - Alessandra Dell'Era
- Gastroenterology Unit, Asst Fatebenefratelli Sacco, Department of Clinical and Biomedical Sciences, Università Degli Studi Di Milano, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Juan Gonzalez Abraldes
- Cirrhosis Care Clinic, Division of Gastroenterology (Liver Unit), CEGIIR, University of Alberta, Canada
| | - Manuel Romero-Gómez
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Unidad De Hepatología, Hospital Universitario De Valme, Spain
| | - Alexander Zipprich
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Germany
| | - Meritxell Casas
- Hepatology Unit, Digestive Disease Department, Hospital De Sabadell, Universitat Autónoma de Barcelona, Spain
| | - Helena Masnou
- Hospital Universitari Germans Trias I Pujol, Universitat Autònoma Barcelona, Spain
| | - Massimo Primignani
- CRC 'a.M. and a. Migliavacca' Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Italy
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Denmark
| | - Frederik Nevens
- Department of Liver and Biliopancreatic Disorders, KU Leuven, Belgium
| | - Jose Luis Calleja
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain
| | | | - María Vega Catalina
- Servicio De Medicina De Aparato Digestivo Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Lisgm, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Instituto Ramón y Cajal De Investigación Sanitaria (IRYCIS), Hospital Universitario Ramón y Cajal and University of Alcalá, Spain
| | - Marika Rudler
- Groupement Hospitalier Pitié-Salpêtrière-Charles Foix, France
| | - Edilmar Alvarado Tapias
- Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Servei De Patologia Digestiva, Hospital De La Santa Creu I Sant Pau, Spain
| | | | - Marcel Tantau
- Hepatology Department and 3rd Medical Clinic, Regional Institute of Gastroenterology and Hepatology 'Octavian Fodor' and 'Iuliu Hatieganu' University of Medicine and Pharmacy, Romania
| | - Rémy Schwarzer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Austria
| | | | - Marta Lopez-Gomez
- Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Universidad Autònoma de Madrid, Spain; Liver Unit, Hospital Universitario Puerta De Hierro Majadahonda, Spain
| | - Alba Cachero
- Gastroenterology Department, Hepatology Unit, Hospital Universitari de Bellvitge, Idibell, Universitat de Barcelona, Spain
| | - Alberto Ferrarese
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Italy
| | - Cristina Ripoll
- First Department of Internal Medicine, Martin Luther University Halle-Wittenberg, Germany; Internal Medicine IV, Universitätsklinikum Jena, Friedrich Schiller University, Jena, Germany
| | - Vincenzo La Mura
- Hospital Universitari Germans Trias I Pujol, Universitat Autònoma Barcelona, Spain; Uoc Medicina Generale - Emostasi e Trombosi, Fondazione IRRCS, Cà Granda, Ospedale Maggiore Policlinico, Italy
| | - Jaime Bosch
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Universitat de Barcelona, Spain; Fundació Clinic Recerca Biomèdica-Institut d'Investigacions Biomèdiques August Pi I Sunyer (FCRB-IDIBAPS), Spain; Centro De Investigación Biomédica Red De Enfermedades Hepáticas y Digestivas (CIBERehd)), Spain.
| |
Collapse
|
29
|
Krige JEJ, Jonas EG, Setshedi M, Beningfield SJ, Lotze UK, Bernon MM, Burmeister S, Kloppers JC. Factors influencing in-hospital mortality for salvage percutaneous transjugular intrahepatic portosystemic shunting in cirrhotic patients with recalcitrant variceal bleeding after failed endoscopic intervention. S Afr Med J 2023; 114:39-43. [PMID: 38525611 DOI: 10.7196/samj.2024.v114i1.1839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND Endoscopic therapy is the first-line treatment of choice for control of acute variceal bleeding (AVB). In high-risk patients with persistent AVB despite pharmacological treatment and endoscopic intervention, percutaneous transjugular intrahepatic portosystemic shunting (TIPS) provides a minimally invasive salvage method to reduce portal pressure and control bleeding. OBJECTIVES To evaluate factors influencing in-hospital mortality after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding despite medical treatment and endoscopic intervention. METHODS Clinical and laboratory data were analysed in all patients treated with sTIPS following failed endoscopic therapy for AVB between August 1991 and November 2020. Factors associated with and predictors of death were determined using bivariate analysis and univariate logistic regression analysis. RESULTS Thirty-four patients (29 men, 5 women), mean age 52 years (range 31 - 80), received sTIPS for uncontrolled (n=11) or refractory (n=23) AVB. The causes of portal hypertension were alcohol-related (n=24) and non-alcohol-related cirrhosis. Salvage TIPS controlled bleeding in 32 patients, with recurrence in 1. Ten patients died in hospital (mean 4.8 days, range 1 - 10) of liver failure (n=4), multiorgan failure (n=3), alcoholic cardiomyopathy (n=2) and uncontrolled gastric variceal bleeding (n=1). On bivariate analysis, factors associated with death were Child-Pugh (C-P) score ≥10 (p=0.006), sodium Model for End-stage Liver Disease (MELD-Na) score ≥22 (p<0.001), ≥8 units of blood transfused (p<0.001), Sengstaken-Blakemore balloon tube placement (p<0.001), endotracheal intubation (p<0.001), inotropic support (p<0.001) and endoscopically uncontrolled bleeding (p<0.001). Univariate logistic regression analysis showed that the most significant predictors of mortality were inotrope dependency (odds ratio (OR) 134; p<0.001), endotracheal intubation (OR 99; p<0.001), endoscopically uncontrolled bleeding (OR 28; p=0.001), grade 3 ascites (OR 20.9; p=0.012) and C-P grade C (OR 8.8; p=0.011). CONCLUSION Salvage TIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy with 29% in-hospital mortality. The most significant predictors of mortality were C-P grade C, grade 3 ascites, inotrope requirement, endotracheal intubation and endoscopically uncontrolled bleeding.
Collapse
Affiliation(s)
- J E J Krige
- Department of Surgery, Faculty of Health Sciences, University of Cape Town, and Surgical Gastroenterology, Hepatopancreatico-Biliary Unit, Groote Schuur Hospital, Cape Town, South Africa.
| | - E G Jonas
- Department of Surgery, Faculty of Health Sciences, University of Cape Town, and Surgical Gastroenterology, Hepatopancreatico-Biliary Unit, Groote Schuur Hospital, Cape Town, South Africa.
| | - M Setshedi
- Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | - S J Beningfield
- Department of Radiology, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
| | - U K Lotze
- Department of Surgery, Faculty of Health Sciences, University of Cape Town, and Surgical Gastroenterology, Hepatopancreatico-Biliary Unit, Groote Schuur Hospital, Cape Town, South Africa.
| | - M M Bernon
- Department of Surgery, Faculty of Health Sciences, University of Cape Town, and Surgical Gastroenterology, Hepatopancreatico-Biliary Unit, Groote Schuur Hospital, Cape Town, South Africa.
| | - S Burmeister
- Department of Surgery, Faculty of Health Sciences, University of Cape Town, and Surgical Gastroenterology, Hepatopancreatico-Biliary Unit, Groote Schuur Hospital, Cape Town, South Africa.
| | - J C Kloppers
- Department of Surgery, Faculty of Health Sciences, University of Cape Town, and Surgical Gastroenterology, Hepatopancreatico-Biliary Unit, Groote Schuur Hospital, Cape Town, South Africa.
| |
Collapse
|
30
|
Huang J, Xu D, Li A. Left diaphragmatic hernia complicated by laparoscopic splenectomy and azygoportal disconnection for a cirrhotic patient with hypersplenism and esophagogastric variceal bleeding. Asian J Surg 2023; 46:5957-5958. [PMID: 37690892 DOI: 10.1016/j.asjsur.2023.08.234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023] Open
Affiliation(s)
- Jie Huang
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China.
| | - Dingwei Xu
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| | - Ao Li
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Kunming Medical University, Kunming, 650101, Yunnan, China
| |
Collapse
|
31
|
de Assis A, de Carvalho Melo JA, Kawakami WY, Moreira AM, Carnevale FC, Massami H, Hirschfeld APM, Pugliese RPS, Foronda FK, Paulino RG, de Araújo AA, Fonseca EA, Seda Neto J. Life-threatening variceal bleeding after liver transplantation and extensive portal vein thrombosis: Desperate times call for desperate measures. Pediatr Transplant 2023; 27:e14555. [PMID: 37291909 DOI: 10.1111/petr.14555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND The management of complex, intra- and extrahepatic portal vein thrombosis (PVT) after liver transplantation (LT) is challenging. Although most of the patients remain asymptomatic or oligosymptomatic in the chronic setting, some of them may develop severe portal hypertension and related complications, notably gastrointestinal (GI) bleeding. In the emergency scenario, clinical and endoscopic treatments as well as intensive support constitute the bases of conservative management, while more definitive treatment options such as surgical shunting and retransplantation are related to high morbidity rates. Transjugular intrahepatic portosystemic shunt (TIPS) was largely considered of limited role due to technical difficulties arising from extensive PVT. Recently, however, new minimally invasive image-guided techniques emerged, allowing portal vein recanalization and TIPS creation simultaneously (TIPS-PVR), even in complex PVT pretransplant patients. METHODS Herein, we describe a novel indication for TIPS-PVR in a post-LT adolescent presenting with life-threatening, refractory GI bleeding. RESULTS The patient presented with complete resolution of the hemorrhagic condition after the procedure, with no deterioration of hepatic function or hepatic encephalopathy. Follow-up Doppler ultrasound after TIPS-PVR showed normal hepatopetal venous flow within the stents, and no evidence of complications, including intraperitoneal or peri splenic bleeding. CONCLUSIONS This report describes the feasibility of TIPS-PVR in the post-LT scenario complicated by extensive PVT. In this case, a complete resolution of the life-threatening GI bleeding was achieved, with no major complications. Other patients with complex chronic PVT might benefit from the use of the described technique, but further studies are required to determine the correct timing and indications of the procedure, eventually before the occurrence of life-threatening complications.
Collapse
Affiliation(s)
| | | | | | | | | | - Hayashi Massami
- Pediatric Intensive Care Unit, Hospital Municipal Infantil Menino Jesus, São Paulo, Brazil
| | | | | | | | | | | | | | - João Seda Neto
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, São Paulo, Brazil
| |
Collapse
|
32
|
Navarro Peiró C, Martí Romero L, Peño Muñoz L, Boix Clemente C, Pasek MA, Alemany Pérez G, Pérez Zahonero MD, Martínez Escapa V. Esophageal stent placement for endoscopic treatment failure. Rev Esp Enferm Dig 2023; 115:734-735. [PMID: 36975143 DOI: 10.17235/reed.2023.9517/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
Up until approximately 10 years ago, the treatment for acute refractory esophageal variceal bleeding was balloon tamponading. Esophageal fully covered self-expanding stents are considered as effective as balloons and also much safer. They are kept in situ for longer periods, what eases the access to more definitive treatments with a low complication rate. We present 6 cases of patients with cirrhosis and massive bleeding due to esophageal varices refractory to conventional treatment, successfully treated with an esophageal fully covered self-expanding stent. There were no major complications, achieving an effective bleeding control in all cases.
Collapse
|
33
|
Patel S, Levin M. Esophageal varices seen in cardiac surgery. J Echocardiogr 2023; 21:181-183. [PMID: 36750502 DOI: 10.1007/s12574-023-00596-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/21/2022] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Affiliation(s)
- Sameer Patel
- Department of Anesthesiology, Mount Sinai School of Medicine: Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1010, New York, NY, USA.
| | - Matthew Levin
- Department of Anesthesiology, Mount Sinai School of Medicine: Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1010, New York, NY, USA
| |
Collapse
|
34
|
Alkhasov A, Komina E, Ratnikov S, Saveleva M, Romanova E, Gusev A, Lochmatov M, Yatsyk S, Dyakonova E. Surgical Treatment of Portal Hypertension in Children. J Laparoendosc Adv Surg Tech A 2023; 33:1231-1235. [PMID: 37844079 DOI: 10.1089/lap.2022.0404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
Introduction: Portal hypertension is a syndrome characterized by increased pressure in the portal vein system and can be caused by impaired blood flow in the portal vein, hepatic veins, or inferior vena cava. The main complications of this condition are bleeding from varicose veins of the esophagus (in our study in 100% of patients), splenomegaly with hypersplenism (in our study in 98% of patients), ascites (in our study in 1 patient). The main goal of treating portal hypertension is to prevent bleeding from esophageal varices. However, today the goal of surgical treatment of portal hypertension in children is not only to prevent the development of bleeding but also the possible restoration of intrahepatic blood flow. Materials and Methods: A retrospective analysis of the results of treatment of portal hypertension in 75 children (41 boys, 34 girls) operated in our Center for the period from 2019 to 2022 was carried out. The mean age of the patients was 7 ± 1 years. Sixty-nine patients had an extrahepatic form of portal hypertension, and 6 patients had an intrahepatic form (liver fibrosis). In 14 patients (18.6%), the operation was repeated (a vascular shunt was previously applied in another hospital; 4 children were operated on repeatedly). Results: A good result was obtained in all children, and the risk of bleeding from varicose veins of the esophagus was eliminated. Vascular bypass surgery was performed in all cases: mesoportal bypass in 17 (22.7%) patients, splenorenal bypass in 37 (49.3%) patients, mesocaval bypass in 21 (28%) patients. In 10 (13%) cases, repeated bypass surgery was required due to dysfunction or thrombosis of the previously performed bypass. In 14 (18.6%) patients with mesoportal shunts, blood flow in the liver was completely restored. Conclusions: The main method of surgical treatment of portal hypertension today is portosystemic bypass surgery, which effectively prevents bleeding from varicose veins of the esophagus. Mesoportal shunting is a definitive treatment for extrahepatic portal hypertension that restores portal perfusion of the liver.
Collapse
Affiliation(s)
- Abdumanap Alkhasov
- "National Medical Research Center for Children's Health" Federal State Autonomous Institution of the Russian Federation Ministry of Health, Moscow, Russia
| | - Elena Komina
- "National Medical Research Center for Children's Health" Federal State Autonomous Institution of the Russian Federation Ministry of Health, Moscow, Russia
| | - Sergey Ratnikov
- "National Medical Research Center for Children's Health" Federal State Autonomous Institution of the Russian Federation Ministry of Health, Moscow, Russia
| | - Maria Saveleva
- "National Medical Research Center for Children's Health" Federal State Autonomous Institution of the Russian Federation Ministry of Health, Moscow, Russia
| | - Ekaterina Romanova
- "National Medical Research Center for Children's Health" Federal State Autonomous Institution of the Russian Federation Ministry of Health, Moscow, Russia
| | - Aleksey Gusev
- "National Medical Research Center for Children's Health" Federal State Autonomous Institution of the Russian Federation Ministry of Health, Moscow, Russia
- Peoples Friendship University of Russia (RUDN University), Moscow, Russia
| | - Maksim Lochmatov
- "National Medical Research Center for Children's Health" Federal State Autonomous Institution of the Russian Federation Ministry of Health, Moscow, Russia
| | - Sergey Yatsyk
- "National Medical Research Center for Children's Health" Federal State Autonomous Institution of the Russian Federation Ministry of Health, Moscow, Russia
| | - Elena Dyakonova
- "National Medical Research Center for Children's Health" Federal State Autonomous Institution of the Russian Federation Ministry of Health, Moscow, Russia
| |
Collapse
|
35
|
Ryu H, Kim TU, Yoon KT, Hong YM. Predicting the risk of early bleeding following endoscopic variceal ligation in cirrhotic patients with computed tomography. BMC Gastroenterol 2023; 23:410. [PMID: 38001426 PMCID: PMC10668468 DOI: 10.1186/s12876-023-03038-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Life-threatening bleeding following endoscopic variceal ligation (EVL) in patients with cirrhosis rarely can occur. The present study aimed to evaluate the performance of computed tomography (CT) in predicting the risk of early bleeding following EVL in cirrhotic patients. METHODS We retrospectively investigated 285 cirrhotic patients who had undergone EVL. EVL was performed for prophylaxis or acute variceal bleeding. The patients were classified into 2 groups: early bleeding (< 14 days after EVL) and non-early bleeding. We compared baseline characteristics including CT findings between the patient groups. RESULTS Among the 285 patients who underwent EVL treatment, 19 patients (6.7%) experienced early bleeding. On average, these bleeding occurred 9.3 ± 3.5 days after the EVL, with a range of 3 to 13 days. Patients who experience early bleeding had a higher six-week bleeding-related mortality rate compared to those in the non-early bleeding group (31.6% vs. 10.2%; p = 0.014). There was a correlation between the grade of esophageal varix observed during endoscopy and the diameter of esophageal varix observed on CT (p < 0.001). The diameter of esophageal varix on CT was identified as the only significant predictive factor for early bleeding (p = 0.005). CONCLUSION A larger esophageal varix diameter observed on CT is associated with an increased risk of early bleeding after EVL treatment. Early identification of this high-risk group can provide a change of treatment strategies to improve patient outcomes.
Collapse
Affiliation(s)
- Hwaseong Ryu
- Department of Radiology, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Tae Un Kim
- Department of Radiology, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Young Mi Hong
- Department of Internal Medicine, Pusan National University College of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.
| |
Collapse
|
36
|
Robbins J, Halegoua-DeMarzio D, Basu Mallick A, Vijayvergia N, Ganetzky R, Lavu H, Giri VN, Miller J, Maley W, Shah AP, DiMeglio M, Ambelil M, Yu R, Sato T, Lefler DS. Liver Transplantation in a Woman with Mahvash Disease. N Engl J Med 2023; 389:1972-1978. [PMID: 37991855 DOI: 10.1056/nejmoa2303226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/24/2023]
Abstract
Mahvash disease is an exceedingly rare genetic disorder of glucagon signaling characterized by hyperglucagonemia, hyperaminoacidemia, and pancreatic α-cell hyperplasia. Although there is no known definitive treatment, octreotide has been used to decrease systemic glucagon levels. We describe a woman who presented to our medical center after three episodes of small-volume hematemesis. She was found to have hyperglucagonemia and pancreatic hypertrophy with genetically confirmed Mahvash disease and also had evidence of portal hypertension (recurrent portosystemic encephalopathy and variceal hemorrhage) in the absence of cirrhosis. These findings established a diagnosis of portosinusoidal vascular disease, a presinusoidal type of portal hypertension previously known as noncirrhotic portal hypertension. Liver transplantation was followed by normalization of serum glucagon and ammonia levels, reversal of pancreatic hypertrophy, and resolution of recurrent encephalopathy and bleeding varices.
Collapse
Affiliation(s)
- Justin Robbins
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Dina Halegoua-DeMarzio
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Atrayee Basu Mallick
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Namrata Vijayvergia
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Rebecca Ganetzky
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Harish Lavu
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Veda N Giri
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Jeffrey Miller
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Warren Maley
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Ashesh P Shah
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Matthew DiMeglio
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Manju Ambelil
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Run Yu
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Takami Sato
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| | - Daniel S Lefler
- From the Department of Internal Medicine (J.R., M.D.), the Division of Gastroenterology and Hepatology (D.H.-D., T.S.), the Department of Medical Oncology, Sidney Kimmel Cancer Center (A.B.M., D.S.L.), the Department of Surgery (H.L., W.M., A.P.S.), the Division of Endocrinology, Diabetes, and Metabolic Diseases (J.M.), and the Department of Pathology and Genomics (M.A.), Thomas Jefferson University, the Department of Medical Oncology, Fox Chase Cancer Center (N.V.), and the Division of Human Genetics, Children's Hospital of Philadelphia (R.G.) - all in Philadelphia; the Division of Clinical Cancer Genetics, Section of Medical Oncology, Department of Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT (V.N.G.); and the Division of Endocrinology, Diabetes, and Metabolism, David Geffen School of Medicine at UCLA, Los Angeles (R.Y.)
| |
Collapse
|
37
|
Gao TM, Xiao KQ, Xiang XX, Jin SJ, Qian JJ, Zhang C, Zhou BH, Tang H, Bai DS, Jiang GQ. The decreased risk of hepatocellular carcinoma in hepatitis B virus-related cirrhotic portal hypertension patients after laparoscopic splenectomy and azygoportal disconnection. Surg Endosc 2023; 37:8522-8531. [PMID: 37775601 DOI: 10.1007/s00464-023-10454-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/06/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Posthepatitic cirrhosis is one of the leading risk factors for hepatocellular carcinoma (HCC) worldwide, among which hepatitis B cirrhosis is the dominant one. This study explored whether laparoscopic splenectomy and azygoportal disconnection (LSD) can reduce the risk of HCC among patients with hepatitis B virus (HBV)-related cirrhotic portal hypertension (CPH). METHODS A total of 383 patients with HBV-related CPH diagnosed as gastroesophageal variceal bleeding and secondary hypersplenism were identified in our hepatobiliary pancreatic center between April 2012 and April 2022, and conducted an 11-year retrospective follow-up. We used inverse probability of treatment weighting (IPTW) to correct for potential confounders, weighted Kaplan-Meier curves, and logistic regression to estimate survival and risk differences. RESULTS Patients were divided into two groups based on treatment method: LSD (n = 230) and endoscopic therapy (ET; n = 153) groups. Whether it was processed through IPTW or not, LSD group showed a higher survival benefit than ET group according to Kaplan-Meier analysis (P < 0.001). The incidence density of HCC was higher in the ET group compared to LSD group at the end of follow-up [32.1/1000 vs 8.0/1000 person-years; Rate ratio: 3.998, 95% confidence intervals (CI) 1.928-8.293]. Additionally, in logistic regression analyses weighted by IPTW, LSD was an independent protective predictor of HCC incidence compared to ET (odds ratio 0.516, 95% CI 0.343-0.776; P = 0.002). CONCLUSION Considering the ability of LSD to improve postoperative survival and prevent HCC in HBV-related CPH patients with gastroesophageal variceal bleeding and secondary hypersplenism, it is worth promoting in the context of the shortage of liver donors.
Collapse
Affiliation(s)
- Tian-Ming Gao
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China
| | - Kun-Qing Xiao
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China
| | - Xiao-Xing Xiang
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China
- Department of Digestive Diseases, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China
| | - Sheng-Jie Jin
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China
| | - Jian-Jun Qian
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China
| | - Chi Zhang
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China
| | - Bao-Huan Zhou
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China
| | - Hua Tang
- The Administration Office, Yangzhou Blood Center, Yangzhou, 225001, China
| | - Dou-Sheng Bai
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China.
| | - Guo-Qing Jiang
- Department of Hepatobiliary Surgery, Clinical Medical College, Yangzhou University, 98 West Nantong Rd, Yangzhou, 225001, China.
| |
Collapse
|
38
|
Gao L, Li MB, Li JY, Liu Y, Ren C, Feng DP. Impressive recompensation in transjugular intrahepatic portosystemic shunt-treated individuals with complications of decompensated cirrhosis based on Baveno VII criteria. World J Gastroenterol 2023; 29:5383-5394. [PMID: 37900585 PMCID: PMC10600797 DOI: 10.3748/wjg.v29.i38.5383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/15/2023] [Accepted: 09/20/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is the standard second-line treatment option for individuals with complications of decompensated cirrhosis, such as variceal bleeding and refractory ascites. AIM To investigate whether recompensation existed in TIPS-treated patients with decompensated cirrhosis according to Baveno VII criteria. METHODS This retrospective analysis was performed on 64 patients who received TIPS for variceal bleeding or refractory ascites. The definition of recompensation referred to Baveno VII criteria and previous study. Clinical events, laboratory tests, and radiological examinations were regularly conducted during a preset follow-up period. The recompensation ratio in this cohort was calculated. Beyond that, univariate and multivariate regression models were conducted to identify the predictors of recompensation. RESULTS Of the 64 patients with a 12-mo follow-up, 20 (31%) achieved recompensation. Age [odds ratio (OR): 1.124; 95% confidence interval (CI): 1.034-1.222] and post-TIPS portal pressure gradient < 12 mmHg (OR: 0.119; 95%CI: 0.024-0.584) were identified as independent predictors of recompensation in patients with decompensated cirrhosis after TIPS. CONCLUSION The present study demonstrated that nearly one-third of the TIPS-treated patients achieved recompensation within this cohort. According to our findings, recompensation is more likely to be achieved in younger patients. In addition, postoperative portal pressure gradient reduction below 12 mmHg contributes to the occurrence of recompensation.
Collapse
Affiliation(s)
- Long Gao
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Man-Biao Li
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Jin-Yu Li
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Yang Liu
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Chao Ren
- College of Medical Imaging, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Dui-Ping Feng
- Department of Oncological and Vascular Intervention, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| |
Collapse
|
39
|
Zuo J, Wang W, Li H, Chen C, Hao Y, Zhang S, Li P, Cheng R. Endoscopic Submucosal Dissection for Hypervascularized Esophageal Squamous Cell Carcinoma in Decompensated Cirrhosis With Esophageal Varices and Scars. Am J Gastroenterol 2023; 118:1737-1738. [PMID: 37543743 PMCID: PMC10545053 DOI: 10.14309/ajg.0000000000002459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/02/2023] [Indexed: 08/07/2023]
Affiliation(s)
- Jiaxuan Zuo
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wenjing Wang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hengcun Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chuyan Chen
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yuanzhen Hao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Rui Cheng
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
40
|
Rathi S, Kalantri A, Shastri A, Shree R, Mahesh KV, Taneja S, Chaluvasetty SB, Bhujade H, Verma N, Premkumar M, De A, Kalra N, Singh V, Duseja A. Endoscopic Ultrasound-Guided Transgastric Shunt Obliteration for Recurrent Hepatic Encephalopathy. Am J Gastroenterol 2023; 118:1895-1898. [PMID: 37589493 DOI: 10.14309/ajg.0000000000002477] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 06/05/2023] [Accepted: 08/11/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Occlusion of spontaneous portosystemic shunts (SPSSs) in patients with cirrhosis may be required in recurrent or refractory hepatic encephalopathy. We describe a novel method for occlusion of SPSS using endoscopic ultrasound (EUS). METHODS EUS-guided transgastric shunt obliteration was performed by injecting glue and coils directly into SPSS. RESULTS EUS-guided transgastric shunt obliteration was performed for 7 patients in 9 sessions. Complete cessation of Doppler flow was achieved in 6/7 cases. Adequate clinical response was observed in 6/7 patients. No procedure-related severe adverse events were seen. DISCUSSION This novel technique is a potentially effective and efficient method for shunt obliteration.
Collapse
Affiliation(s)
- Sahaj Rathi
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amrita Kalantri
- Department of Radiology, Government Medical College and Hospital, Chandigarh, India
| | - Arpit Shastri
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritu Shree
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Karthik Vinay Mahesh
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreedhara B Chaluvasetty
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harish Bhujade
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Kalra
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
41
|
Timmerhuis HC, Ngongoni RF, Jensen CW, Baiocchi M, DeLong JC, Dua MM, Norton JA, Poultsides GA, Worth PJ, Visser BC. Comparison of Spleen-Preservation Versus Splenectomy in Minimally Invasive Distal Pancreatectomy. J Gastrointest Surg 2023; 27:2166-2176. [PMID: 37653153 DOI: 10.1007/s11605-023-05809-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/29/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Spleen-preservation during minimally invasive distal pancreatectomy (MIDP) can be technically challenging and remains controversial. Our primary aim was to compare MIDP and splenectomy with spleen-preserving MIDP. Secondarily, we compared two spleen-preserving techniques. METHODS Adults undergoing MIDP (2007-2021) were retrospectively included in this single-center study. Intraoperative and postoperative outcomes between spleen-preservation and splenectomy and between the two spleen-preserving techniques were compared using the Mann-Whitney U test for continuous data, and Fisher's exact test for categorical data. RESULTS Of the 293 patients who underwent MIDP, preservation of the spleen was intended in 208 (71%) patients. Spleen-preservation was achieved in 174 patients (84%) via the Warshaw technique (130; 75%) or vessel-preservation (44; 25%). The spleen-preserving group had shorter length of stay (3 vs 4 days, p < 0.01), fewer conversions to open (1 vs 12, p < 0.01) and less blood loss (p < 0.01) compared to the splenectomy group. Operative (OR) times were comparable (229 vs 214 min, p = 0.67). Except for the operative time, which was longer for the Warshaw technique (245 vs 183 min, p = 0.01), no other differences between the two spleen-preserving techniques were found. At a median follow-up of 43 (IQR 18-79) months after spleen-preservation, only 2 (1.1%) patients had required splenectomy (1 partial splenectomy for infarct/abscess after Warshaw, 1 for variceal bleeding after vessel-preserving). CONCLUSIONS Spleen-preservation is not associated with increased risk of blood loss, longer hospital stay, conversion, nor lengthy OR times. Late splenectomy is very rarely required. Given the immune consequences of splenectomy, spleen-preservation should be strongly considered in MIDP.
Collapse
Affiliation(s)
- Hester C Timmerhuis
- Department of Surgery, Section of Hepatobiliary Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Rejoice F Ngongoni
- Department of Surgery, Section of Hepatobiliary Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | | | - Michael Baiocchi
- Stanford Prevention Research Center and Departments of Statistics and Health Research and Policy, Stanford University, Stanford, CA, USA
| | - Jonathan C DeLong
- Department of Surgery, Section of Hepatobiliary Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Monica M Dua
- Department of Surgery, Section of Hepatobiliary Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Jeffrey A Norton
- Department of Surgery, Section of Hepatobiliary Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - George A Poultsides
- Department of Surgery, Section of Hepatobiliary Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Patrick J Worth
- Department of Surgery, Section of Hepatobiliary Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Brendan C Visser
- Department of Surgery, Section of Hepatobiliary Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| |
Collapse
|
42
|
Katsumi T, Ueno Y. Prospects for treatment of esophageal varices considering the safety of endoscopic band ligation. Hepatol Int 2023; 17:1079-1081. [PMID: 37421587 DOI: 10.1007/s12072-023-10560-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 06/09/2023] [Indexed: 07/10/2023]
Affiliation(s)
- Tomohiro Katsumi
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, Yamagata, Japan.
| | - Yoshiyuki Ueno
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| |
Collapse
|
43
|
Mukhiya G, Han X, Jiao D, Bi Y, Pokhrel G, Liu Z, Li Z, He Y. Outcomes of Transjugular Intrahepatic Portosystemic Shunt and Gastric Coronary Vein Embolization for Variceal Bleeding in Cirrhotic Portal Hypertension. Clin Med Res 2023; 21:144-154. [PMID: 37985166 PMCID: PMC10659130 DOI: 10.3121/cmr.2023.1796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 03/13/2023] [Accepted: 08/01/2023] [Indexed: 11/22/2023]
Abstract
Purpose: To evaluate the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) combined with gastric coronary vein embolization (GCVE) for cirrhotic portal hypertensive variceal bleeding and compare outcomes of first-line with second-line treatment, coil with glue, and single-covered with double stents.Methods: Fifteen patients received TIPS plus GCVE as the first-line treatment for secondary prophylaxis of variceal bleeding, and 45 received it as second-line treatment. Preoperative and postoperative quantitative variables were compared using a paired t test. The incidence of survival rate, re-bleeding, hepatic encephalopathy, and shunt dysfunction were analyzed using the Kaplan-Meier method.Results: The portal venous pressure was significantly decreased from 39.0 ± 5.0 mm Hg to 22.5 ± 4.4 mm Hg (P≤0.001) after TIPS treatment. After 1, 3, 6, 12, 18, and 24 months re-bleeding rates were 1.6%, 3.3%, 6.6%, 13.3%, 0%, and 0%, respectively. Shunt dysfunction rates were 5%, 0%, 10%, 16.6%, 1.6%, and 5%, respectively. Hepatic encephalopathy rates were 3.3%, 1.6%, 3.3%, 6.6%, 0%, and 0%, respectively. And survival rates were 100%, 100%, 100%, 96.6%, 93.3%, and 88.3% respectively. In comparative analysis, statistically significant differences were seen in re-bleeding between the first-line and second-line treatment groups (26.6% vs 24.4%, log-rank P=0.012), and survival rates between single-covered and double stent (3.7% vs 16.1%, log-rang (P=0.043).Conclusion: The results suggest that TIPS combined with GCVE is effective and safer in the treatment of cirrhotic portal hypertensive variceal bleeding. The use of TIP plus GCVE as first-line treatment, may be preferable for high-risk re-bleeding, and more than 25 mm Hg portal venous pressure with repeated variceal bleeding. However, the sample size was small. Therefore, large, randomized, controlled, multidisciplinary center studies are needed for further evaluation.
Collapse
Affiliation(s)
- Gauri Mukhiya
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xinwei Han
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Dechao Jiao
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yonghua Bi
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Gaurab Pokhrel
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zaoqu Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zhaonan Li
- Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yongfu He
- Department of Interventional Radiology, Southern Central Hospital of Yunnan Province (The First People's Hospital of Honghe state) Mungzi, Yunnan, China
| |
Collapse
|
44
|
Deniz S, Schinner R, Monroe EJ, Horslen S, Srinivasa RN, Lv Y, Fan D, Han G, Sarma MS, Srivastava A, Poddar U, Yadav R, Hoang TPT, Lange CM, Öcal O, Ricke J, Seidensticker M, Lurz E, Di Giorgio A, D'Antiga L, Wildgruber M. Outcome of Children with Transjugular Intrahepatic Portosystemic Shunt: A Meta-Analysis of Individual Patient Data. Cardiovasc Intervent Radiol 2023; 46:1203-1213. [PMID: 37532945 PMCID: PMC10471675 DOI: 10.1007/s00270-023-03520-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023]
Abstract
PURPOSE The purpose of the study was to investigate outcome after pediatric transjugular intrahepatic portosystemic shunt (TIPS) with respect to survival MATERIAL AND METHODS: After searching for studies on TIPS in children in Ovid, Medline, Embase, Scopus and Cochrane published between 2000 and 2022, individual patient data were retrieved from five retrospective cohorts. Overall survival (OS) and transplant-free survival (TFS) were calculated using Kaplan-Meier analysis and log-rank test and compared to the indication (ascites vs. variceal bleeding) as well as to the level of obstruction (pre-hepatic vs. hepatic vs. post-hepatic). Additionally, TIPS patency was analyzed. RESULTS n = 135 pediatric patients were included in the final analysis. Indication for pediatric TIPS creation was heterogeneous among the included studies. TIPS patency decreased from 6 to 24 months, subsequent pediatric liver transplantation was performed in 22/135 (16.3%) of cases. The presence of ascites was related with poorer TFS (HR 2.3, p = 0.023), while variceal bleeding was not associated with impaired survival. Analysis of the level of obstruction (pre-hepatic, hepatic and post-hepatic) failed to prove significantly reduced OS for post-hepatic obstruction (HR 3.2, p = 0.092) and TFS (HR 1.3, p = 0.057). There was no difference in OS and TFS according to age at time of TIPS placement. CONCLUSIONS The presence of ascites associates with impaired survival after TIPS in children, with no differences in survival according to the age of the child. Interventional shunt procedures can be considered feasible for all ages. LEVEL OF EVIDENCE Level 2a.
Collapse
Affiliation(s)
- Sinan Deniz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Regina Schinner
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Eric J Monroe
- Department of Radiology, University of Wisconsin, Madison, WA, USA
| | - Simon Horslen
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Ravi N Srinivasa
- Division of Vascular and Interventional Radiology, Department of Radiology, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Yong Lv
- Military Medical Innovation Center, 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
| | - 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
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, Digestive Diseases Hospital, Xi'an International Medical Center Hospital, Northwest University, Xi'an, China
| | - Moinak Sen Sarma
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Anshu Srivastava
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Ujjal Poddar
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Rajanikant Yadav
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Thi Phuong Thao Hoang
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Christian M Lange
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Osman Öcal
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Eberhard Lurz
- Division for Pediatric Gastroenterology, Hepatology and Transplantation, Department for Pediatrics, Dr. Von Haunersches Kinderspital, University Hospital, LMU Munich, Munich, Germany
| | - Angelo Di Giorgio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Bergamo, Italy
| | - Moritz Wildgruber
- Department of Radiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| |
Collapse
|
45
|
Liu X, Wang Y, Zheng L, Zhu J. Risk factors analysis of endoscopy and TIPS in the treatment of secondary esophagogastric varicose bleeding with cirrhosis. Afr Health Sci 2023; 23:655-663. [PMID: 38357146 PMCID: PMC10862562 DOI: 10.4314/ahs.v23i3.76] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Objective To analyse the risk factors of secondary hemorrhage and survival rate in cirrhotic patients with esophagogastric variceal rupture and to compare the efficacy and safety of endoscopic hemostasis and TIPS (transjugular intrahepatic portosystemic shunt). Methods A total of 120 patients with secondary bleeding after endoscopic treatment of esophagogastric varicose bleeding with cirrhosis in our hospital during the past 3 years were retrospectively analysed. There were 65 males and 55 females, ranging in age from 49 to 74 years old, with an average of (59.5 ± 8.4) years old. The etiology, degree of varicose veins, bleeding location, hemostasis method, Infection, ascites, portal vein thrombosis or cancer thrombus, albumin, platelets, prothrombin activity, Child Pugh (Child-Pugh classification is a diagnostic criterion for liver reserve function) grade were compared in each group. The risk factors of treatment failure and analyse the survival time was analysed. Results There were statistically significant differences in varicosis degree, infection, ascites, portal vein thrombosis or cancer thrombus, child Pugh grade, albumin and prothrombin activity between the failed Endoscopy group and the successful hemostasis group (P< 0.05). There were statistically significant differences in child Pugh grade, albumin and prothrombin activity between the failed TIPS treatment group and successful hemostasis group (P< 0.05). There was no significant difference in 1-year survival between the endoscopy group and the TIPS group. Conclusion Severe varicose veins, infection, ascites, portal vein thrombosis or cancer thrombus, child pugh classification, albumin, and prothrombin activity were the major risk factors for failed secondary endoscopic therapy, child Pugh classification, albumin and prothrombin activity were the main risk factors for failure TIPS treatment. There is no significant difference in long-term survival between the two methods.
Collapse
Affiliation(s)
- Xiaoyan Liu
- Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou 350025, China
| | - Yanli Wang
- Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou 350025, China
| | - Lei Zheng
- Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou 350025, China
| | - Jinzhao Zhu
- Mengchao Hepatobiliary Hospital of Fujian Medical University, Fuzhou 350025, China
| |
Collapse
|
46
|
Simonnot M, Deprez PH, Pioche M, Albuisson E, Wallenhorst T, Caillol F, Koch S, Coron E, Archambeaud I, Jacques J, Basile P, Caillo L, Degand T, Lepilliez V, Grandval P, Culetto A, Vanbiervliet G, Camus Duboc M, Gronier O, Leal C, Albouys J, Chevaux JB, Barret M, Schaefer M. Endoscopic resection of early esophageal tumors in patients with cirrhosis or portal hypertension: a multicenter observational study. Endoscopy 2023; 55:785-795. [PMID: 37137331 DOI: 10.1055/a-2085-3964] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/05/2023]
Abstract
BACKGROUND Liver cirrhosis and esophageal cancer share several risk factors, such as alcohol intake and excess weight. Endoscopic resection is the gold standard treatment for superficial tumors. Portal hypertension and coagulopathy may increase the bleeding risk in these patients. This study aimed to assess the safety and efficacy of endoscopic resection for early esophageal neoplasia in patients with cirrhosis or portal hypertension. METHODS This retrospective multicenter international study included consecutive patients with cirrhosis or portal hypertension who underwent endoscopic resection in the esophagus from January 2005 to March 2021. RESULTS 134 lesions in 112 patients were treated, including by endoscopic submucosal dissection in 101 cases (75 %). Most lesions (128/134, 96 %) were in patients with liver cirrhosis, with esophageal varices in 71 procedures. To prevent bleeding, 7 patients received a transjugular intrahepatic portosystemic shunt, 8 underwent endoscopic band ligation (EBL) before resection, 15 received vasoactive drugs, 8 received platelet transfusion, and 9 underwent EBL during the resection procedure. Rates of complete macroscopic resection, en bloc resection, and curative resection were 92 %, 86 %, and 63 %, respectively. Adverse events included 3 perforations, 8 delayed bleedings, 8 sepsis, 6 cirrhosis decompensations within 30 days, and 22 esophageal strictures; none required surgery. In univariate analysis, cap-assisted endoscopic mucosal resection was associated with delayed bleeding (P = 0.01). CONCLUSIONS In patients with liver cirrhosis or portal hypertension, endoscopic resection of early esophageal neoplasia appeared to be effective and should be considered in expert centers with choice of resection technique, following European Society of Gastrointestinal Endoscopy guidelines to avoid undertreatment.
Collapse
Affiliation(s)
- Mathilde Simonnot
- Department of Gastroenterology, Nancy Regional University Hospital Center, Nancy, France
| | - Pierre H Deprez
- Hepatogastroenterology Department, Cliniques universitaires St-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Mathieu Pioche
- Gastroenterology Department, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Eliane Albuisson
- DRCI, Department MPI, Data management and Statistics UMDS, Nancy Regional University Hospital Center , Nancy, France
| | - Timothée Wallenhorst
- Department of Gastroenterology, Pontchaillou University Hospital, Rennes, France
| | - Fabrice Caillol
- Endoscopy Unit, Paoli-Calmettes Institute, Marseille, France
| | - Stéphane Koch
- Department of Gastroenterology, Besançon Regional University Hospital Center, Besançon, France
| | - Emmanuel Coron
- Institut de Maladies de l'Appareil Digestif, Hotêl Dieu University Hospital Center, Nantes, France
| | - Isabelle Archambeaud
- Institut de Maladies de l'Appareil Digestif, Hotêl Dieu University Hospital Center, Nantes, France
| | - Jérémie Jacques
- Hepato-Gastroenterology Department, Dupuytren University Hospital, Limoges, France
| | - Paul Basile
- Digestive Endoscopy Unit, Gastroenterology Department, University Hospital of Rouen, Rouen, France
| | - Ludovic Caillo
- Gastroenterology Department, University Hospital of Nîmes, Nîmes, France
| | - Thibault Degand
- Division of Gastroenterology, Dijon Bourgogne University Hospital, Dijon, France
| | | | - Philippe Grandval
- Hepatogastroenterology Department, AP-HM, Hôpital La Timone, Marseille, France
| | - Adrian Culetto
- Department of Gastroenterology, Toulouse University Hospital, Toulouse, France
| | | | | | - Olivier Gronier
- Department of Gastroenterology and Hepatology, Clinique Sainte Barbe, Strasbourg, France
| | - Carina Leal
- Hepatogastroenterology Department, Cliniques universitaires St-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Jérémie Albouys
- Hepato-Gastroenterology Department, Dupuytren University Hospital, Limoges, France
| | - Jean-Baptiste Chevaux
- Department of Gastroenterology, Nancy Regional University Hospital Center, Nancy, France
| | | | - Marion Schaefer
- Department of Gastroenterology, Nancy Regional University Hospital Center, Nancy, France
| |
Collapse
|
47
|
Chen T, Wen L, Zhong R, Chen X. General anesthesia in patients with hepatic encephalopathy and acute variceal bleeding undergoing endoscopic treatment: A retrospective study. Medicine (Baltimore) 2023; 102:e34395. [PMID: 37653761 PMCID: PMC10470742 DOI: 10.1097/md.0000000000034395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 09/02/2023] Open
Abstract
The management of cirrhotic patient with encephalopathy and acute variceal bleeding (AVB) remains a clinical challenge with a high mortality. Early endoscopic therapies are frequently applied in patients with AVB. However, the application of general anesthesia in endoscopic surgery for patients with hepatic encephalopathy (HE) is pretty challenging. The present study aimed to evaluate the possible effect of general anesthesia with tracheal intubation on patient complicated with encephalopathy and AVB during endoscopic procedure. Thirty-six cirrhotic patients with encephalopathy and AVB were retrospectively studied, 14 patients underwent endoscopic treatment under general anesthesia with tracheal intubation, and 22 patients received pharmacological treatment, or and endoscopic therapy without general anesthesia served as the control group. Routine clinical and laboratory data were collected. The total mortality rate was 13.9% (5/36), 2 (14.3%) in the anesthesia group, 3 (13.6%) in the control group. The child-Pugh class of death cases were all grade C, 3 (60%) of them were in the stage IV of HE. The stage of HE was all improved in the 2 groups, 12 (85.8 %) patients were totally recovered from consciousness disturbance in the anesthesia group and 16 (72.7 %) in the control group respectively, the difference between the 2 groups was not significant (P>0.05). Except the death cases, there were still 3 patients in the control group had impaired consciousness at discharge. Child-Pugh score, Child-Pugh class and the stage of HE in the anesthesia group were significantly improved at discharge compared with those before operation. General anesthesia does not aggravate the severity of encephalopathy, and endoscopic treatment under general anesthesia with tracheal intubation is effective for HE patients complicated with AVB.
Collapse
Affiliation(s)
- Tao Chen
- Department of Digestive Endoscopy Center, Digestive Disease Center, Suining Central Hospital, Suining, China
| | - Lin Wen
- Department of Respiratory and Critical Care Medicine, Jiangyou Second People’s Hospital, Jiangyou, China
| | - Rui Zhong
- Department of Gastroenterology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Xia Chen
- Department of Gastroenterology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| |
Collapse
|
48
|
Mukund A, Vasistha S, Jindal A, Patidar Y, Sarin SK. Emergent rescue transjugular intrahepatic portosystemic shunt within 8 h improves survival in patients with refractory variceal bleed. Hepatol Int 2023; 17:954-966. [PMID: 36787012 DOI: 10.1007/s12072-022-10479-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/27/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Transjugular-intrahepatic portosystemic-shunt (TIPS) and SX-Ella stent Danis (DE stent) are available rescue therapies for refractory variceal bleeding in cirrhosis. Any delay in appropriate therapy is associated with high mortality. Determining the best timing for rescue TIPS is crucial and largely unknown. METHODS Cirrhotic patients with refractory variceal bleed (n = 121) who underwent rescue TIPS within 24-h (n = 66) were included. Their early rebleed (upto 42 days) rate, 6-week and 1-year survival were compared with matched patients who underwent rescue DE stent (n = 55). Outcomes based on timing of TIPS (within 8-h/8-24 h) were also analyzed. RESULTS At baseline, patients who received rescue DE stent were sicker with higher MELD score (27.6 ± 8.3 vs. 22.3 ± 7.9; p = 0.001), active bleeding at endoscopy (54.5% vs. 34.8%; p = 0.03) compared to TIPS-group. After propensity score matching, adjusting for MELD-Na score and non-bleed complications, DE patients (n = 34) had higher mortality at 6-week (17/34; 50%) and 1-year (29/34; 85.3%) compared to TIPS-group (20.6% and 38.2%, respectively; both p < 0.02), with higher rebleeding rate (10/34; 29.4% vs. 1/34; 2.9%, p = 0.003). Rescue TIPS placed within 8-h compared with 8-24 h had lower 6-week (48.6% vs. 12.9%; p = 0.003) and 1-year mortality (62.9% vs. 16.1%, p = 0.001) despite comparable rebleed rates (2/31; 6.5% vs. 2/35;5.7%; p = 0.90). Post-TIPS Portal pressure gradient at 6-weeks and 1-year was comparable between survivors and non-survivors. Active bleeding at endoscopy [HR = 11.8; 95% CI 2.96-47.53], presence of AKI [HR = 5.8; 95% CI 1.92-17.41], MELD-Na > 24 [HR = 1.1; 95% CI 1.0-1.17], mean arterial pressure > 64.5 mmHg [HR = 0.8; 95% CI 0.75-0.92] independently predicted 6-week mortality in rescue TIPS-group. CONCLUSIONS Rescue TIPS placement preferably within 8-h of refractory variceal bleed improves short- and long-term survival. It provides better outcome than DE stent for control of bleeding and prevention of rebleeding, even in patients with high MELD-Na score.
Collapse
Affiliation(s)
- Amar Mukund
- Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sudhir Vasistha
- Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India
| | - Yashwant Patidar
- Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India.
| |
Collapse
|
49
|
Huang JT, Zhong BY, Li WC, Zhang S, Shen J, Zhu XL. Feasibility of computed tomography portal venography in the preoperative evaluation of emergent TIPS creation for cirrhotic patients with acute variceal bleeding. Eur J Radiol 2023; 165:110944. [PMID: 37356217 DOI: 10.1016/j.ejrad.2023.110944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/13/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVES To evaluate the feasibility of computed tomography portal venography (CTPV) in the preoperative evaluation of emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for cirrhotic patients with acute variceal bleeding (AVB). METHODS One hundred and forty-eightcirrhotic patients with AVB undergoing emergent TIPS creation from January 2016 to December 2022 in our institution were enrolled in the retrospective study. The primary outcome was the consistency between CTPV and endoscopy in the classification and grading of gastroesophageal varices (GEVs). The second outcome was extraluminal CTPV findings. The consistency of CTPV and endoscopy in the classification and grading of GEVs was determined by Kappa values. RESULTS Emergent TIPS creation was technically successful in all patients. Forty-five patients underwent preoperative endoscopy. The results of CTPV diagnosis of GEVs classification were that 112, 28, and 8 patients were classified as gastroesophageal varices type 1 (GOV1), GOV2, and isolated gastric varices type 1 (IGV1), respectively. In diagnosing the classification and grading of GEVs, CTPV showed substantial agreement with preoperative endoscopy, with Kappa values of 0.823 and 0.625, respectively. CTPV provided the afferent and afferent vessels of GEVs for emergent TIPS creation. CONCLUSION CTPV is feasible and effective to act as an alternative preoperative evaluation method to endoscopy for cirrhotic patients with AVB undergoing emergent TIPS creation.
Collapse
Affiliation(s)
- Jin-Tao Huang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Bin-Yan Zhong
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wan-Ci Li
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuai Zhang
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jian Shen
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiao-Li Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China.
| |
Collapse
|
50
|
Wang X, Liu G, Wu J, Xiao X, Yan Y, Guo Y, Yang J, Li X, He Y, Yang L, Luo X. Small-Diameter Transjugular Intrahepatic Portosystemic Shunt versus Endoscopic Variceal Ligation Plus Propranolol for Variceal Rebleeding in Advanced Cirrhosis. Radiology 2023; 308:e223201. [PMID: 37606572 DOI: 10.1148/radiol.223201] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Background Some studies have shown that transjugular intrahepatic portosystemic shunt (TIPS) placement within 72 hours of admission improves survival in patients at high risk who present with acute variceal bleeding. However, the role of small-diameter covered TIPS in the secondary prophylaxis of variceal bleeding is still debatable. Purpose To compare the efficacy of 8-mm TIPS and endoscopic variceal ligation (EVL) plus propranolol in the prevention of variceal rebleeding among participants with advanced cirrhosis. Materials and Methods Between June 2015 and December 2018, participants admitted to the hospital for variceal bleeding were considered for enrollment in this randomized controlled trial (ClinicalTrials.gov). Participants with Child-Pugh class B or C cirrhosis were randomly assigned to receive an 8-mm covered TIPS or EVL and propranolol. The primary end point was recurrent variceal bleeding assessed using Kaplan-Meier curve analysis. Secondary end points included survival and overt hepatic encephalopathy (HE) assessed using Kaplan-Meier curve analysis. Results A total of 100 participants were enrolled, with 50 randomly assigned to the EVL plus propranolol group (median age, 54 years; IQR, 45-60 years; 29 male, 21 female) and 50 randomly assigned to the TIPS group (median age, 49 years; IQR, 43-56 years; 32 male, 18 female). The median follow-up period was 43.4 months. In the TIPS group, variceal rebleeding risk was reduced compared with variceal rebleeding risk in the EVL plus propranolol group (hazard ratio [HR], 0.31; 95% CI: 0.14, 0.69; P = .008), but the incidence of overt HE was higher in the TIPS group (30.0% vs 16.0%, P = .03). No differences in survival were observed between the two groups (1-year survival: TIPS, 98.0%; EVL plus propranolol, 92.0%; 3-year survival: TIPS, 94.0%; EVL plus propranolol, 85.7%; HR, 0.52; 95% CI: 0.19, 1.42; P = .22). Conclusion When compared with EVL plus propranolol, 8-mm TIPS led to reduced variceal rebleeding but did not impact overall survival in participants with Child-Pugh class B or C cirrhosis. Clinical trial registration no. NCT02477384 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Barth in this issue.
Collapse
Affiliation(s)
- Xiaoze Wang
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Guofeng Liu
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Junchao Wu
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Xue Xiao
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Yuling Yan
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Yuxin Guo
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Jinlin Yang
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Xiao Li
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Yazhou He
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Li Yang
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| | - Xuefeng Luo
- From the Department of Gastroenterology and Hepatology, Sichuan University-University of Oxford Huaxi Joint Centre for Gastrointestinal Cancer, West China Hospital, Sichuan University, 37 Guoxue Ln, Chengdu 610041, China (X.W., G.L., J.W., X.X., Y.Y., Y.G., J.Y., L.Y., X. Luo); Department of Interventional Therapy, Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China (X. Li); and Department of Epidemiology and Medical Statistics, Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China (Y.H.)
| |
Collapse
|