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Zhu J, Xia Y, Wang G, Huang G, Zhang M, Li Z, Zhang C. TIPS versus endoscopic cyanoacrylate injection for the treatment of gastric fundal variceal rebleeding: a propensity score-matched retrospective cohort study. Surg Endosc 2025; 39:3662-3670. [PMID: 40301155 DOI: 10.1007/s00464-025-11761-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2025] [Accepted: 04/20/2025] [Indexed: 05/01/2025]
Abstract
BACKGROUND The optimal strategy for preventing rebleeding with gastroesophageal varices type 2 (GOV2) and isolated gastric varices type 1 (IGV1) is unclear. In this retrospective study, we aimed to compare the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic cyanoacrylate injection (ECI) on GOV2 and IGV1 varices. METHODS In this retrospective cohort study, we collected data from patients with cirrhosis with GOV2 and IGV1 varices who received TIPS or ECI treatment between June 2018 and June 2023. The primary endpoint was rebleeding, and the secondary endpoints were death and overt hepatic encephalopathy (OHE). Propensity score matching (PSM) and adjusted survival curves were used to assess the robustness of the results. RESULTS A total of 111 eligible patients were included, of whom, 35 patients received TIPS and 76 patients received ECI. The median follow-up time for the TIPS and ECI groups were 746 and 683 days, respectively. TIPS reduced the all-cause rebleeding rate (14.3% versus 33.8%, p = 0.033; after PSM, 16.7% versus 40.0%, p = 0.045) compared with ECI, with lower risk of ectopic embolism (all were in the ECI group). The Incidence of OHE in the TIPS group was higher than that in the ECI group (28.6% versus 1.4%, p < 0.001; after PSM, 33.3% versus 3.3%, p < 0.001). However, no significant difference was found in mortality (17.1% versus 12.2%, p = 0.684; after PSM, 16.7% versus 16.7%, p = 1.000). The results were not affected by the adjusted survival curve. CONCLUSION TIPS was more effective than ECI in preventing rebleeding in patients with GOV2 and IGV1 varices with similar survival rates and lower risk of ectopic embolism, although TIPS was associated with a higher incidence of OHE.
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Affiliation(s)
- Junyuan Zhu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yifu Xia
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
| | - Guangchuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Guangjun Huang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Mingyan Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhen Li
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China.
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Ye Y, Liu L, Xu L. Preliminary exploration of the application of cyanoacrylate glue in Forrest IIa and IIb peptic ulcer hemorrhage. Surg Endosc 2025; 39:3155-3166. [PMID: 40199748 DOI: 10.1007/s00464-025-11702-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2025] [Accepted: 03/31/2025] [Indexed: 04/10/2025]
Abstract
OBJECTIVE This study aims to preliminarily investigate the therapeutic effect of cyanoacrylate glue (CG) on Forrest IIa and IIb peptic ulcer hemorrhage (PCH). METHODS From January 2020 to May 2024, we retrospectively collected data on patients with Forrest IIa and IIb PCH treated with CG using emergency endoscopic hemostasis at a single center and subsequently evaluated and compared the efficacy of CG with respect to ulcer location, Forrest staging, and ulcer size. RESULTS A total of 93 patients were enrolled, achieving 100% technical success without 24-h rebleeding. The rebleeding rate at 72 h was 1.1% (95% confidence interval [CI]: 0.2-5.9%), and the rebleeding rate at 7 days was 2.2% (95% CI: 0.6-7.6%). The median age of the patients was 43.0 years. There were 42 patients (45.2%) with Forrest IIa ulcers and 51 patients (54.8%) with Forrest IIb ulcers. Sixty patients (64.5%) had ulcers ranging in size from 1.0 to 2.0 cm, while 33 patients (35.5%) had ulcers larger than 2.0 cm. The ulcers were located in the antrum (19 cases), angulus (38 cases), gastric body (11 cases), and duodenal bulb (25 cases). Median procedure time was 12.0 min, with duodenal PCH requiring significantly less time than stomach PCH (P < 0.05). CG treatment efficacy was comparable between Forrest IIa/IIb ulcers as well as across ulcer sizes (P > 0.05). CONCLUSIONS CG is particularly effective and safe for PCH located in the duodenal bulb, as well as for both Forrest IIa and IIb PCH.
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Affiliation(s)
- Ye Ye
- Department of Gastroenterology, Changshu Hospital Affiliated to Soochow University, Suzhou, China
| | - Luojie Liu
- Department of Gastroenterology, Changshu Hospital Affiliated to Soochow University, Suzhou, China.
| | - Liansheng Xu
- Department of Gastroenterology, Changshu Hospital Affiliated to Soochow University, Suzhou, China.
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Trikudanathan G, Rahimi EF, Bhatt A, Bucobo JC, Chandrasekhara V, Copland AP, Han S, Kahn A, Krishnan K, Kumta NA, Lichtenstein DR, Obando JV, Pannala R, Parsi MA, Saumoy M, Trindade AJ, Yang J, Law RJ. Endoscopic devices and techniques for the management of gastric varices (with videos). Gastrointest Endosc 2025; 101:496-510. [PMID: 39480369 DOI: 10.1016/j.gie.2024.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 06/30/2024] [Indexed: 01/05/2025]
Abstract
BACKGROUND AND AIMS Gastric variceal bleeding occurs less commonly than bleeding from esophageal varices (EVs), although it is associated with higher morbidity and mortality. Bleeding from gastroesophageal varices type 1 (GOV1) is treated like EVs. In contrast, other forms of gastric variceal bleeding, including gastroesophageal varices type 2 (GOV2) and isolated gastric varices types 1 (IGV1) and 2 (IGV2), are treated with varying endoscopic approaches. Nonendoscopic methods include transjugular intrahepatic portosystemic shunt (TIPS) or balloon-occluded retrograde transvenous obliteration (BRTO). This technology report focuses on endoscopic management of gastric varices (GVs). METHODS The MEDLINE database was searched through August 2022 for relevant articles by using key words such as gastric varices, glue, cyanoacrylate, thrombin, sclerosing agents, band ligation, topical hemostatic spray, coils, EUS, TIPS, and BRTO. The article was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee and approved by the Governing Board of the ASGE. RESULTS Endoscopic injection with cyanoacrylate (CYA) glue has been the primary endoscopic method to treat GVs. EUS-guided angiotherapy with CYA glue and coil embolization has emerged as an alternative method enabling improved detection of GVs with a high technical success for targeting and obliterating GVs. Combining CYA glue with coil therapy allows the coil to act as a scaffold for the glue, reducing the risk of glue embolization and improving outcomes. Alternative injectates or topical treatments have been described but remain poorly studied. CONCLUSIONS The mainstay paradigm for the endoscopic management of gastric variceal bleeding is the injection of CYA glue. The published success of EUS-guided angiotherapy using CYA glue with or without embolization coils has increased our treatment armamentarium.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Erik F Rahimi
- Department of Gastroenterology, Baylor Scott & White Health, Lakeway, Texas, USA
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Juan Carlos Bucobo
- Gastroenterology Services, Northwell Health Gastroenterology Institute, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew P Copland
- Division of Gastroenterology and Hepatology, University of Virginia Health Systems, Charlottesville, Virginia, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Allon Kahn
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jorge V Obando
- Division of Gastroenterology, Duke University Health System, Raleigh, North Carolina, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Division of Gastroenterology and Hepatology, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Monica Saumoy
- Department of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ryan J Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Albillos A, Bañares R, Hernández-Gea V. Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd). REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2025; 117:14-57. [PMID: 39350672 DOI: 10.17235/reed.2024.10805/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2025]
Abstract
Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.
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Affiliation(s)
- Agustín Albillos
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, España
| | - Rafael Bañares
- Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón
| | - Virginia Hernández-Gea
- Servicio de Hepatología, Hospital Clínic. Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)
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Mertens A, Essing T, Kunstein A, Weigel C, Bode J, Roderburg C, Luedde T, Kandler J, Loosen SH. Acute Variceal Hemorrhage in Germany-A Nationwide Study of 65,357 Hospitalized Cases: Variceal Hemorrhage in Germany. Can J Gastroenterol Hepatol 2024; 2024:5453294. [PMID: 39483247 PMCID: PMC11527532 DOI: 10.1155/2024/5453294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 08/07/2024] [Accepted: 10/01/2024] [Indexed: 11/03/2024] Open
Abstract
Background: Acute variceal hemorrhage (AVH) is a frequent cause of upper gastrointestinal bleeding (UGIB) in liver cirrhosis. Most cases require urgent endoscopic intervention due to potentially life-threatening courses. Different endoscopic hemostasis techniques can be used, in particular endoscopic variceal ligation (EVL) and endoscopic sclerotherapy (EST), depending on the bleeding side (esophageal, fundal, and gastric) as well as radiological interventions (e.g., embolization and transjugular intrahepatic portosystemic shunt [TIPS]). This study aimed to investigate trends in incidence, treatment modalities, and outcome parameters, such as in-hospital mortality and adverse events in Germany. Methods: We evaluated the current epidemiological trends, therapeutic strategies, and in-hospital mortality of AVH in Germany based on the standardized hospital discharge data provided by the German Federal Statistical Office from 2010 to 2019. Results: A total of 65,357 AVH cases, predominately males (68.3%), were included in the analysis. The annual incidence rate (hospitalization cases per 100,000 persons) was 8.9. The in-hospital mortality was 18.6%. The most common underlying disease was alcohol-related liver cirrhosis (60.6%). The most common clinical complication was bleeding anemia (60.1%), whereas hypovolemic shock (12.8%) was the less frequent. In esophageal variceal hemorrhage (EVH), EVL was the most frequently performed endoscopic therapy, while in gastric variceal hemorrhage (GVH), EST and fibrin glue injection were the most commonly performed therapies. EVL showed the lowest in-hospital mortality (12.3%) in EVH, while EST showed favorable results (14% in-hospital mortality) in GVH. Combination therapies overall showed a higher in-hospital mortality and were more frequent in GVH. The presence of hypovolemic shock, AKI, sepsis, artificial ventilation, ARDS, bleeding anemia, hepatic encephalopathy, and male sex was associated with a significantly worse outcome. Conclusion: Our study provides detailed insight into the incidence, patient-related risk factors, endoscopic treatment, and in-hospital mortality in a sizeable AVH collective in Germany. These data might help improve risk stratification and treatment strategies for AVH patients in the future.
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Affiliation(s)
- Alexander Mertens
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
| | - Tobias Essing
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
- Department of Internal Medicine II, Marien-Hospital, Wesel 46483, Germany
| | - Anselm Kunstein
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
| | - Christian Weigel
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
| | - Johannes Bode
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
| | - Christoph Roderburg
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
| | - Jennis Kandler
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
| | - Sven H. Loosen
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf 40225, Germany
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Shalaby S, Nicoară-Farcău O, Perez-Campuzano V, Olivas P, Torres S, García-Pagán JC, Hernández-Gea V. Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis. J Clin Med 2024; 13:5681. [PMID: 39407741 PMCID: PMC11476950 DOI: 10.3390/jcm13195681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/26/2024] [Accepted: 09/21/2024] [Indexed: 10/20/2024] Open
Abstract
Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.
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Affiliation(s)
- Sarah Shalaby
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Oana Nicoară-Farcău
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Hepatology Department, Regional Institute of Gastroenterology and Hepatology “Octavian Fodor”, “Iuliu Hatieganu” University of Medicine and Pharmacy, 3rd Medical Clinic, 400394 Cluj-Napoca, Romania
| | - Valeria Perez-Campuzano
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Pol Olivas
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Sonia Torres
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; (O.N.-F.); (V.P.-C.); (P.O.); (S.T.); (J.C.G.-P.)
- Fundació de Recerca Clínic Barcelona (FRCB-IDIABPS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-RareLiver), 08036 Barcelona, Spain
- Departament de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036 Barcelona, Spain
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Hu Y, Zhou M, Liu D, Gong J. Risk Factors for Rebleeding After Endoscopic Injection of Cyanoacrylate Glue for Gastric Varices: A Systematic Review and Meta-Analysis. Dig Dis Sci 2024; 69:2890-2903. [PMID: 38864930 DOI: 10.1007/s10620-024-08482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 05/06/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Rebleeding is a significant complication of endoscopic injection of cyanoacrylate in gastric varices in cirrhotic patients. AIM This systematic review and meta-analysis aimed to evaluate the efficiency of endoscopic cyanoacrylate injection and summarized the risk factors for rebleeding. METHODS Databases were searched for articles published between January 2012 and December 2022. Studies evaluating the efficiency of endoscopic injection of cyanoacrylate glue for gastric varices and the risk factors for rebleeding were included. RESULTS The final analysis included data from 24 studies. The hemostatic rates ranged from 65 to 100%. The pooled rate of gastric varices recurrence was 34% [95% CI 21-46, I2 = 61.4%], early rebleeding rate was 16% [95% CI 11-20, I2 = 37.4%], late rebleeding rate was 39% [95% CI 36-42, I2 = 90.9%], mild and moderate adverse events rate were 28% [95% CI 24-31, I2 = 91.6%], 3% [95% CI - 2 to 8, I2 = 15.3%], rebleeding-related mortality rate was 6% [95% CI 2-10, I2 = 0%], all-cause mortality rate was 17% [95% CI 12-22, I2 = 63.6%]. Independent risk factors for gastric variceal rebleeding included portal venous thrombosis, ascites, cyanoacrylate volume, fever/systemic inflammatory response syndrome, red Wale sign, previous history of variceal bleeding, active bleeding and paragastric veins. The use of proton pump inhibitors could be a protective factor. CONCLUSIONS Endoscopic cyanoacrylate glue injection is an effective and safe treatment for gastric varices. Cirrhotic patients with the above risk factors may benefit from treatment aimed at reducing portal hypertension, antibiotic prophylaxis, and anticoagulation if they meet the indications.
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Affiliation(s)
- Yihuan Hu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan, China
| | - Mei Zhou
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan, China
| | - Deliang Liu
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan, China
| | - Jian Gong
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China.
- Research Center of Digestive Diseases, Central South University, Changsha, 410011, Hunan, China.
- Clinical Research Center of Digestive Diseases of Hunan Province, Changsha, 410011, Hunan, China.
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 116] [Impact Index Per Article: 116.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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Chen D, Fu S, Shen R. Efficacy and safety of EUS-guided coil embolization in combination with cyanoacrylate injection versus conventional endoscopic cyanoacrylate injection in the treatment of gastric varices with spontaneous portosystemic shunts. Gastroenterol Rep (Oxf) 2024; 12:goae026. [PMID: 38586537 PMCID: PMC10997409 DOI: 10.1093/gastro/goae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/27/2024] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
Background Gastric varices (GV) with spontaneous portosystemic shunts (SPSS) pose considerable risks and challenges for administering endoscopic cyanoacrylate (CYA) injection. This study aimed to evaluate the efficacy and safety of EUS-guided coil embolization in combination with CYA injection compared to conventional endoscopic CYA injection for managing GV with SPSS. Methods This retrospective analysis included patients with SPSS treated with either EUS-guided coil embolization in combination with CYA injection or conventional CYA injection for gastric variceal bleeding at Ningbo Medical Center Lihuili Hospital (Zhejiang, China) between January 2018 and March 2023. Patient demographics, procedural details, and follow-up results were reviewed. Results The study evaluated 57 patients: 21 in the combined treatment group undergoing EUS-guided coil embolization in combination with CYA injection and 36 in the conventional group receiving conventional endoscopic CYA injection. Both cohorts achieved a 100% technical success rate. The mean volume of CYA used was significantly lower in the combined group (1.64 ± 0.67 mL) than in the conventional group (2.38 ± 0.72 mL; P < 0.001). Early GV rebleeding rates did not differ significantly between the groups; in contrast, the combined treatment group exhibited a considerably lower incidence of late GV rebleeding than the conventional group (4.8% vs 27.8%, P = 0.041). Conclusions EUS-guided coil embolization in combination with CYA injection demonstrated superiority over conventional endoscopic CYA injection in reducing late GV rebleeding in treating GV with SPSS.
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Affiliation(s)
- Dawei Chen
- Department of Gastroenterology, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, P. R. China
| | - Sunya Fu
- Department of Radiology, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, P. R. China
| | - Ruiwei Shen
- Department of Gastroenterology, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, P. R. China
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10
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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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11
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Wang Z, Zeng Z, Chen L, Shi C, Jin J, Zhang F, Zhang Q, Mei X, Kong D. Endoscopic ultrasonography-guided injection of cyanoacrylate in the treatment of gastroesophageal varices type 1: a single-center randomized study. Surg Endosc 2023; 37:8277-8284. [PMID: 37674054 DOI: 10.1007/s00464-023-10342-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/30/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND AND AIM First, it has been demonstrated that endoscopic ultrasonography (EUS)-guided cyanoacrylate (CYA) injection (EUS-CYA) has greater efficacy than direct endoscopic injection of cyanoacrylate (DEI-CYA) for treating type 1-isolated gastric varices. However, it is necessary to conduct further studies to determine whether EUS has any advantage over the current guidelines for treating gastroesophageal varices type 1 (GOV1). Second, liver function is an important prognostic factor in patients with liver cirrhosis. Therefore, we evaluated the liver function of patients treated with EUS-CYA. METHODS In a single-center study, a prospective cohort from February 2021 to September 2022 involving 89 patients with cirrhosis with GOV1 were assigned to undergo EUS-CYA (n = 45) or DEI-CYA (n = 44). The success rate of CYA injection, the rate of overall rebleeding, the rate of reintervention, the complications during the follow-up period, and the liver function were compared. RESULTS In both groups, 100% of the operations were successful. The follow-up time of the two groups was 290 (153-398) days and 267 (177-416) days, respectively. In the EUS group, the perforating veins had an average diameter of 7.0 ± 2.7 mm, and they had a 100% occlusion rate. A statistically significant difference was found between the two groups regarding the number of sessions needed to eradicate GV (p = 0.005, pairwise comparisons were conducted using the Bonferroni correction method.), the late rebleeding rate after EUS-CYA [n = 3 (6.7%) vs n = 10 (22.7%); p = 0.032], and the incidence of postinjection ulcers [n = 4 (8.9%) vs n = 12 (27.3); p = 0.023)]. Following EUS or DEI-CYA treatment, the patient's liver function did not show any significant deterioration or decline. CONCLUSION EUS-CYA has a higher eradication success rate and fewer complications, recurrences, and rebleeding episodes than DEI-CYA used for GOV1 treatment. In addition, EUS-CYA did not impair liver function.
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Affiliation(s)
- Zhihong Wang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Zhuang Zeng
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Lihong Chen
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Chen Shi
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Jing Jin
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Fumin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Qianqian Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Xuecan Mei
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China
| | - Derun Kong
- Department of Gastroenterology, The First Affiliated Hospital of Anhui Medical University, Key Laboratory of Digestive Diseases of Anhui Province, Jixi Road 218, Hefei, 230022, Anhui, China.
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12
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Todd A, Shekhar C, O'Rourke J, Forde C, Pallan A, Wadhwani SS, Tripathi D, Mahon BS. Technical and clinical outcomes following EUS-guided thrombin injection and coil implantation for parastomal varices. BMJ Open Gastroenterol 2023; 10:e000819. [PMID: 37562855 PMCID: PMC10423785 DOI: 10.1136/bmjgast-2021-000819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/28/2022] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND AND AIMS Bleeding from parastomal varices causes significant morbidity and mortality. Treatment options are limited, particularly in high-risk patients with significant underlying liver disease and other comorbidities. The use of EUS-guided embolisation coils combined with thrombin injection in gastric varices has been shown to be safe and effective. Our institution has applied the same technique to the treatment of parastomal varices. METHODS A retrospective review was performed of 37 procedures on 24 patients to assess efficacy and safety of EUS-guided injection of thrombin, with or without embolisation coils for treatment of bleeding parastomal varices. All patients had been discussed in a multidisciplinary team meeting, and correction of portal hypertension was deemed to be contraindicated. Rebleeding was defined as stomal bleeding that required hospital admission or transfusion. RESULTS All patients had significant parastomal bleeding at the time of referral. 100% technical success rate was achieved. 70.8% of patients had no further significant bleeding in the follow-up period (median 26.2 months) following one procedure. 1-year rebleed-free survival was 80.8% following first procedure. 7 patients (29.1%) had repeat procedures. There was no significant difference in rebleed-free survival following repeat procedures. Higher age was associated with higher risk of rebleeding. No major procedure-related complications were identified. CONCLUSIONS EUS-guided thrombin injection, with or without embolisation coils, is a safe and effective technique for the treatment of bleeding parastomal varices, particularly for patients for whom correction of portal venous hypertension is contraindicated.
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Affiliation(s)
- Andrew Todd
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Chander Shekhar
- Department of Gastroenterology, Walsall Healthcare NHS Trust, Walsall, UK
| | - Joanne O'Rourke
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colm Forde
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Arvind Pallan
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunulogy and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Brinder Singh Mahon
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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13
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Ivashkin VT, Chulanov VP, Mamonova NA, Maevskaya MV, Zharkova MS, Tikhonov IN, Bogomolov PO, Volchkova EV, Dmitriev AS, Znojko OO, Klimova EA, Kozlov KV, Kravchenko IE, Malinnikova EY, Maslennikov RV, Mikhailov MI, Novak KE, Nikitin IG, Syutkin VE, Esaulenko EV, Sheptulin AA, Shirokova EN, Yushchuk ND. Clinical Practice Guidelines of the Russian Society for the Study of the Liver, the Russian Gastroenterological Association, the National Scientific Society of Infectious Disease Specialists for the Diagnosis and Treatment of Chronic Hepatitis C. RUSSIAN JOURNAL OF GASTROENTEROLOGY, HEPATOLOGY, COLOPROCTOLOGY 2023; 33:84-124. [DOI: 10.22416/1382-4376-2023-33-1-84-124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2024]
Abstract
Аim:diagnosis and treatment algorithms in the clinical recommendations intended for general practitioners, gastroenterologists, infectious disease specialists, hepatologists on the of chronic hepatitis C are presented.Summary.Chronic viral hepatitis C is a socially significant infection, the incidence of which in the Russian Federation remains significantly high. Over the past 10 years, great progress has been made in the treatment of hepatitis C — direct acting antiviral drugs have appeared. The spectrum of their effectiveness allows to achieve a sustained virological response in more than 90 % of cases, even in groups that were not previously considered even as candidates for therapy or were difficult to treat — patients receiving renal replacement therapy, after liver transplantation (or other organs), at the stage of decompensated liver cirrhosis, HIV co-infected, etc. Interferons are excluded from the recommendations due to their low effectiveness and a wide range of adverse events. The indications for the treatment have been expanded, namely, the fact of confirmation of viral replication. The terms of dispensary observation of patients without cirrhosis of the liver have been reduced (up to 12 weeks after the end of therapy). Also, these recommendations present approaches to active screening of hepatitis in risk groups, preventive and rehabilitation measures after the end of treatment.Conclusion.Great success has been achieved in the treatment of chronic hepatitis C. In most cases, eradication of viral HCV infection is a real task even in patients at the stage of cirrhosis of the liver, with impaired renal function, HIV co-infection, after solid organs transplantation.
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Affiliation(s)
- V. T. Ivashkin
- Sechenov First Moscow State Medical University (Sechenov University)
| | - V. P. Chulanov
- Center for Epidemiologically Significant Infectious Diseases, National Medical Research Center for Phthisiopulmonology and Infectious Diseases
| | - N. A. Mamonova
- Center for Epidemiologically Significant Infectious Diseases, National Medical Research Center for Phthisiopulmonology and Infectious Diseases
| | - M. V. Maevskaya
- Sechenov First Moscow State Medical University (Sechenov University)
| | - M. S. Zharkova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - I. N. Tikhonov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - P. O. Bogomolov
- M.F. Vladimirsky Moscow Regional Research Clinical Institute
| | - E. V. Volchkova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - A. S. Dmitriev
- Sechenov First Moscow State Medical University (Sechenov University)
| | - O. O. Znojko
- Moscow State University of Medicine and Dentistry
| | | | | | | | - E. Yu. Malinnikova
- Department of Virology, Russian Medical Academy of Continuing Professional Education
| | - R. V. Maslennikov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - M. I. Mikhailov
- North-Western State Medical University named after I.I. Mechnikov
| | | | | | - V. E. Syutkin
- Sklifosovsky Clinical and Research Institute for Emergency Medicine; Russian State Research Center — Burnazyan Federal Medical Biophysical Center
| | | | - A. A. Sheptulin
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E. N. Shirokova
- Sechenov First Moscow State Medical University (Sechenov University)
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Dhar J, Samanta J. Endoscopic ultrasound-guided vascular interventions: An expanding paradigm. World J Gastrointest Endosc 2023; 15:216-239. [PMID: 37138933 PMCID: PMC10150286 DOI: 10.4253/wjge.v15.i4.216] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/09/2023] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.
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Affiliation(s)
- Jahnvi Dhar
- Gastroenterology, Sohana Multispeciality Hospital, Mohali 140308, India
| | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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15
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Zeng HT, Zhang ZL, Lin XM, Peng MS, Wang LS, Xu ZL. Aluminum phosphate gel reduces early rebleeding in cirrhotic patients with gastric variceal bleeding treated with histoacryl injection therapy. World J Gastrointest Endosc 2023; 15:153-162. [PMID: 37034972 PMCID: PMC10080557 DOI: 10.4253/wjge.v15.i3.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/26/2022] [Accepted: 03/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Esophageal-gastro varices bleeding (EGVB) is the most widely known cause of mortality in individuals with cirrhosis, with an occurrence rate of 5% to 15%. Among them, gastric varices bleeding (GVB) is less frequent than esophageal varices bleeding (EVB), but the former is a more critical illness and has a higher mortality rate. At present, endoscopic variceal histoacryl injection therapy (EVHT) is safe and effective, and it has been recommended by relevant guidelines as the primary method for the treatment of GVB. However, gastric varices after endoscopic treatment still have a high rate of early rebleeding, which is mainly related to complications of its treatment, such as bleeding from drained ulcers, rebleeding of varices etc. Therefore, preventing early postoperative rebleeding is very important to improve the quality of patient survival and outcomes. AIM To assess the efficacy of aluminium phosphate gel (APG) combined with proton pump inhibitor (PPI) in preventing early rebleeding after EVHT in individuals with GVB. METHODS Medical history of 196 individuals with GVB was obtained who were diagnosed using endoscopy and treated with EVHT in Shenzhen People's Hospital from January 2016 to December 2021. Based on the selection criteria, 101 patients were sorted into the PPI alone treatment group, and 95 patients were sorted into the PPI combined with the APG treatment group. The incidences of early rebleeding and corresponding complications within 6 wk after treatment were compared between both groups. Statistical methods were performed by two-sample t-test, Wilcoxon rank sum test and χ 2 test. RESULTS No major variations were noted between the individuals of the two groups in terms of age, gender, Model for End-Stage Liver Disease score, coagulation function, serum albumin, hemoglobin, type of gastric varices, the dose of tissue glue injection and EV that needed to be treated simultaneously. The early rebleeding rate in PPI + APG group was 3.16% (3/95), which was much lower than that in the PPI group (12.87%, 13/101) (P = 0.013). Causes of early rebleeding: the incidence of gastric ulcer bleeding in the PPI + APG group was 2.11% (2/95), which was reduced in comparison to that in the PPI group (11.88%, 12/101) (P = 0.008); the incidence of venous bleeding in PPI + APG group and PPI group was 1. 05% (1/95) and 0.99% (1/101), respectively, and there was no significant difference between them (0.999). The early mortality rate was 0 in both groups within 6 wk after the operation, and the low mortality rate was related to the timely hospitalization and active treatment of all patients with rebleeding. The overall incidence of complications in the PPI + APG group was 12.63% (12/95), which was not significantly different from 13.86% (14/101) in the PPI group (P = 0.800). of abdominal pain in the PPI + APG group was 3.16% (3/95), which was lower than that in the PPI group (11.88%, 12/101) (P = 0.022). However, due to aluminum phosphate gel usage, the incidence of constipation in the PPI + APG group was 9.47% (9/95), which was higher than that in the PPI group (1.98%, 2/101) (P = 0.023), but the health of the patients could be improved by increasing drinking water or oral lactulose. No patients in either group developed spontaneous peritonitis after taking PPI, and none developed hepatic encephalopathy and ectopic embolism within 6 wk of EVHT treatment. CONCLUSION PPI combined with APG can significantly reduce the incidence of early rebleeding and postoperative abdominal pain in cirrhotic patients with GVB after taking EVHT.
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Affiliation(s)
- Hao-Tian Zeng
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Zhu-Liang Zhang
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Xi-Min Lin
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Min-Si Peng
- Department of Gastroenterology, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Li-Sheng Wang
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Shenzhen People’s Hospital, The Second Clinical Medical College, Jinan University, Shenzhen 518000, Guangdong Province, China
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16
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Interventional Management of Portal Hypertension in Cancer Patients. Curr Oncol Rep 2022; 24:1461-1475. [PMID: 35953600 DOI: 10.1007/s11912-022-01319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches. RECENT FINDINGS In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.
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17
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Coelho-Prabhu N, Forbes N, Thosani NC, Storm AC, Pawa S, Kohli DR, Fujii-Lau LL, Elhanafi S, Calderwood AH, Buxbaum JL, Kwon RS, Amateau SK, Al-Haddad MA, Qumseya BJ. Adverse events associated with EGD and EGD-related techniques. Gastrointest Endosc 2022; 96:389-401.e1. [PMID: 35843754 DOI: 10.1016/j.gie.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nirav C Thosani
- Center for Interventional Gastroenterology at UTHealth, McGovern Medical School, Houston, Texas, USA
| | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Divyanshoo R Kohli
- Division of Gastroenterology, Kansas City VA Medical Center, Kansas City, Missouri, USA
| | - Larissa L Fujii-Lau
- Department of Gastroenterology, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Sherif Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Richard S Kwon
- Division of Gastroenterology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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18
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Korobka VL, Pasetchnikov VD, Korobka RV, Pak ES, Shapovalov AM. Use of endoscopic band ligation alone and in combination with nonselective beta blockers for prevention of variceal bleeding in ascites patients on the liver transplant waiting list. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2022; 24:42-50. [DOI: 10.15825/1995-1191-2022-3-42-50] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
Objective: to conduct a comparative analysis of the effectiveness of two methods – endoscopic band ligation (EBL) alone and in combination with nonselective beta blockers (NSBB) – used for prevention of variceal bleeding (VB); to evaluate their impact on patient survival in severe ascites during long-term stay on the liver transplant waiting list (LTWL). Materials and methods. A retrospective comparative study of two groups of patients with decompensated liver disease, ascites and varices included in the LTWL, who received EBL (n = 41, group 1) and EBL + NSBB (n = 45, group 2). Results. The groups being compared did not differ in demographics, clinical parameters, MELD and Child–Turcotte–Pugh scores. There were no significant differences in the incidence of severe ascites, particularly diuretic-resistant ascites. The study groups did not differ in the incidence of mediumand large-sized varices. Incidence of bleeding did not differ in both groups. Overall mortality was significantly higher in the EBL + NSBB group than in the EBL group. Patient survival was lower, while mortality was higher in the EBL + NSBB group. The combined therapy group had a significantly higher number of acute kidney injury (AKI) than the EBL group. Conclusion. The compared methods are equivalently effective in preventing VB in patients with decompensated cirrhosis with a prolonged stay on the waiting list. Survival rate is significantly lower, while mortality is significantly higher in the EBL + NSBB group than in the EBL group.
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Affiliation(s)
- V. L. Korobka
- Rostov Regional Clinical Hospital; Rostov State Medical University
| | | | - R. V. Korobka
- Rostov Regional Clinical Hospital; Rostov State Medical University
| | - E. S. Pak
- Rostov Regional Clinical Hospital; Rostov State Medical University
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19
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Image Features of Dynamic Enhanced Computed Tomography Scanning Combined with Digestive Endoscopy in the Treatment of Gastroesophageal Varices and Nursing of Esophagogastric Gastric Varices Bleeding. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:7926114. [PMID: 35770117 PMCID: PMC9236783 DOI: 10.1155/2022/7926114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 12/27/2022]
Abstract
The objective of this study was to investigate the application of dynamic contrast-enhanced CT images in the nursing of patients with gastroesophageal varices (GOV) treated by digestive endoscopy and its role in relieving bleeding symptoms. A total of 60 patients with liver cirrhosis and GOV were selected as the research objects. According to whether CT was used to evaluate the position of tissue adhesion embolism, the patients were divided into the control group (24 cases) and the observation group (36 cases). The treatment effect and bleeding situation of patients in the two groups were analyzed and compared. The results showed that the main portal vein pressure (17.24 ± 1.02 cmH2O), liver function recovery effect (2.84 ± 0.45 points), and total effective rate (100%) in observation group were better than those in control group (9.70 ± 1.22 cmH2O, 0.95 ± 0.72 points, and 79.17%, respectively) (P < 0.05). In addition, the bleeding rate in observation group (0%) was significantly lower than that in control group (16.67%) (P < 0.05). In conclusion, dynamically enhanced CT scan images combined with digestive endoscopy can help improve the therapeutic effect of GOV and reduce postoperative bleeding, which was worthy of clinical application and promotion.
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20
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Xia RQ, Huang XQ, Chen J, Luo TC, Wang J, Jiang SY, Ni LY, Zeng XQ, Chen SY. Practice patterns in endoscopic treatment for gastric varices: A Chinese survey. J Dig Dis 2022; 23:270-279. [PMID: 35770900 DOI: 10.1111/1751-2980.13108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Gastric varices (GV), a common complication of liver cirrhosis, often cause serious consequences. However, the management of GV remains debated. In this study we aimed to explore the practice patterns of Chinese practitioners in GV treatment and discuss whether these patterns conform to the guidelines in China and around the world. METHODS Between October 2020 and January 2021, an online questionnaire was sent to doctors from different regions in China via WeChat. Data on the practice patterns for endoscopic treatment with and without a multidisciplinary discussion team (MDT) clinic for GV were analyzed. RESULTS Questionnaires were collected from 241 practitioners from 29 provinces in China. Before endoscopic treatment, 100 (41.5%) of the practitioners arranged computed tomography angiography (CTA) examination. In endoscopic tissue adhesive (ETA) treatment, 183 (75.9%) of the practitioners chose ETA combined with lauromacrogol. Approximately one-fourth of all practitioners did not prescribe drugs to reduce portal pressure. Only 75 (31.1%) of physicians preferred using early transjugular intrahepatic portosystemic shunt (TIPS) for patients at a high risk of treatment failure for GV. Compared to those without MDT clinics, practitioners with MDT clinics more often chose early TIPS for high-risk patients (39.0% vs 18.9%, P = 0.001). CONCLUSIONS Treatment for GV differ across China. Practitioners with MDT clinics can better use assistant strategies such as CTA to evaluate the risk and efficacy. Further clinical studies are needed, and more guidelines and consensuses are warranted to standardize clinical practice for GV.
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Affiliation(s)
- Rui Qi Xia
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao Quan Huang
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie Chen
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tian Cheng Luo
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jian Wang
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Si Yu Jiang
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Yuan Ni
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiao Qing Zeng
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shi Yao Chen
- Department of Gastroenterology, Zhongshan Hospital, Fudan University, Shanghai, China.,Evidence-based Medicine Center, Fudan University, Shanghai, China
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21
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Long-term outcomes of hemostatic therapy for variceal bleeding and the challenge pending in the post-direct-acting antivirals era. Acta Gastroenterol Belg 2022; 85:7-14. [PMID: 35304988 DOI: 10.51821/85.1.9276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background and study aims This study evaluated the longterm outcomes of mainly endoscopic hemostatic therapy for gastrointestinal variceal bleeding and of the transition of hemostatic therapy. Patients and methods Among 1,163 patients treated for gastrointestinal varices between April 2006 and June 2020, a total of 125 patients who underwent emergency hemostatic therapy were enrolled. Survival rates and secondary evaluation points were analyzed. Additionally, patients were classified into two groups: the previous and latter term. Patients' background, therapeutic method, and treatment results were compared between the groups. Results 94.4% had cirrhosis. The average Child-Pugh score was 8.90. Successful primary hemostasis rate was 98.4%, and 5.6% died within 2 weeks, all with a Child-Pugh score ≥9. The respective 1- and 5-year survival rates for Child-Pugh grade A/B were 81.3% and 55.4%, while those for Child-Pugh grade C were 58.1% and 17.8%. Child-Pugh grade C or hepatocellular carcinoma was significantly associated with poor prognosis. In total, 21.6% experienced variceal re-bleeding; 62.9% of these cases were triggered by continued alcohol consumption. There was no significant difference in survival between patients with and without variceal re-bleeding and in post-treatment survival between the previous and latter terms. In the latter term, the number of cases caused by continued alcohol consumption significantly increased. Conclusions Multidisciplinary treatment and continuation of proper management after hemostatic therapy for variceal bleeding are crucial. Continued alcohol consumption leads to variceal bleeding and re-bleeding; its proper management, including alcohol abstinence, is one of the major challenges left in the post-directacting antivirals era.
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22
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Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 PMCID: PMC8567466 DOI: 10.3748/wjg.v27.i40.6874] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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23
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Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 DOI: 10.3748/wjg.v27.i40.6874'"] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 01/29/2024] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States.
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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24
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Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 DOI: 10.3748/wjg.v27.i40.6874'||'] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 01/29/2024] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States.
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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25
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Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 DOI: 10.3748/wjg.v27.i40.6874����%2527%2522\'\"] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 01/29/2024] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States.
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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26
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Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 DOI: 10.3748/wjg.v27.i40.6874' and 2*3*8=6*8 and 'hmkj'='hmkj] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 01/29/2024] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States.
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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27
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Mann R, Goyal H, Perisetti A, Chandan S, Inamdar S, Tharian B. Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques. World J Gastroenterol 2021; 27:6874-6887. [PMID: 34790012 DOI: 10.3748/wjg.v27.i40.6874efoudmzk] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 09/14/2021] [Indexed: 01/29/2024] Open
Abstract
Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA 93730, United States
| | - Hemant Goyal
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA 18503, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States.
| | - Saurabh Chandan
- Department of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68107, United States
| | - Sumant Inamdar
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Internal Medicine, Gastroenterology and Hepatology Division, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
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28
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Rudnick SR, Conway JD, Russo MW. Current state of endohepatology: Diagnosis and treatment of portal hypertension and its complications with endoscopic ultrasound. World J Hepatol 2021; 13:887-895. [PMID: 34552695 PMCID: PMC8422923 DOI: 10.4254/wjh.v13.i8.887] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/18/2021] [Accepted: 08/04/2021] [Indexed: 02/06/2023] Open
Abstract
The diagnosis and management of cirrhosis and portal hypertension (PH) with its complications including variceal hemorrhage, ascites, and hepatic encephalopathy continues to evolve. Although there are established “standards of care” in liver biopsy and measurement of PH, gastric varices remain an area without a universally accepted therapeutic approach. The concept of “Endo Hepatology” has been used to describe of the applications of endoscopic ultrasound (EUS) to these challenges. EUS-liver biopsy (EUS-LB) offers an alternative to percutaneous and transjuglar liver biopsy without compromising safety or efficacy, and with added advantages including the potential to reduce sampling error by allowing biopsies in both hepatic lobes. Furthermore, EUS-LB can be performed during the same procedure as EUS-guided portal pressure gradient (PPG) measurements, allowing for the collection of valuable diagnostic and prognostic data. EUS-guided PPG measurements provide an appealing alternative to the transjugular approach, with proposed advantages including the ability to directly measure portal vein pressure. In addition, EUS-guided treatment of gastric varices (GV) offers several possible advantages to current therapies. EUS-guided treatment of GV allows detailed assessment of the vascular anatomy, similar efficacy and safety to current therapies, and allows the evaluation of treatment effect through doppler ultrasound visualization. The appropriate selection of patients for these procedures is paramount to ensuring generation of useful clinical data and patient safety.
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Affiliation(s)
- Sean R Rudnick
- Section on Gastroenterology & Hepatology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Jason D Conway
- Section on Gastroenterology & Hepatology, Wake Forest School of Medicine, Winston-Salem, NC 27157, United States
| | - Mark W Russo
- Department of Hepatology, Atrium Health, Carolinas Medical Center, Charlotte, NC 28204, United States
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Chevallier O, Guillen K, Comby PO, Mouillot T, Falvo N, Bardou M, Midulla M, Aho-Glélé LS, Loffroy R. Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10112298. [PMID: 34070534 PMCID: PMC8198169 DOI: 10.3390/jcm10112298] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/17/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
We performed a systematic review and meta-analysis of published studies to assess the efficacy, safety, and outcomes of N-butyl cyanoacrylate (NBCA) injection for the treatment of variceal gastrointestinal bleeding (GIB). The MEDLINE/PubMed, EMBASE, and SCOPUS databases were searched for English-language studies published from January 1980 to December 2019 and including patients who had injection of NBCA for variceal GIB. Two independent reviewers extracted and evaluated the data from eligible studies. Exclusion criteria were sample size < 5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. NBCA was injected during endoscopy in 42 studies and through a direct percutaneous approach for stomal varices in 1 study. The study’s endpoints were: Technical success, 30-day rebleeding, and 30-day overall and major complications. The estimated overall rates were computed with 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. In total, 43 studies with 3484 patients were included. The technical success rate was 94.1% (95% CI: 91.6–96.1%), the 30-day rebleeding rate was 24.2% (18.9–29.9%), and 30-day overall and major complications occurred in 15.9% (11.2–21.3%) and 5.3% (3.3–7.8%) of patients, respectively. For treating variceal GIB, NBCA injection is a safe and effective method that demonstrates high technical success rate and very low major complication rate.
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Affiliation(s)
- Olivier Chevallier
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Kévin Guillen
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Pierre-Olivier Comby
- Department of Neuroradiology and Emergency Radiology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France;
| | - Thomas Mouillot
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (T.M.); (M.B.)
| | - Nicolas Falvo
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Marc Bardou
- Department of Gastroenterology and Hepatology, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (T.M.); (M.B.)
| | - Marco Midulla
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
| | - Ludwig-Serge Aho-Glélé
- Department of Biostatistics and Epidemiology, François-Mitterrand University Hospital, 14 Rue Paul, Gaffarel, BP 77908, 21079 Dijon, France;
| | - Romaric Loffroy
- Department of Vascular and Interventional Radiology, Image-Guided Therapy Center, ImViA Laboratory-EA 7535, François-Mitterrand University Hospital, 14 Rue Paul Gaffarel, BP 77908, 21079 Dijon, France; (O.C.); (K.G.); (N.F.); (M.M.)
- Correspondence: ; Tel.: +33-380-293-358
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Roberts D, Best LM, Freeman SC, Sutton AJ, Cooper NJ, Arunan S, Begum T, Williams NR, Walshaw D, Milne EJ, Tapp M, Csenar M, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013155. [PMID: 33837526 PMCID: PMC8094233 DOI: 10.1002/14651858.cd013155.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed within about one to three years after diagnosis. Several different treatments are available, including, among others, endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade. However, there is uncertainty surrounding the individual and relative benefits and harms of these treatments. OBJECTIVES To compare the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis, through a network meta-analysis; and to generate rankings of the different treatments for acute bleeding oesophageal varices, according to their benefits and harms. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until 17 December 2019, to identify randomised clinical trials (RCTs) in people with cirrhosis and acute bleeding from oesophageal varices. SELECTION CRITERIA We included only RCTs (irrespective of language, blinding, or status) in adults with cirrhosis and acutely bleeding oesophageal varices. We excluded RCTs in which participants had bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those in whom initial haemostasis was achieved before inclusion into the trial, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS software, using Bayesian methods, and calculated the differences in treatments using odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. We performed also the direct comparisons from RCTs using the same codes and the same technical details. MAIN RESULTS We included a total of 52 RCTs (4580 participants) in the review. Forty-eight trials (4042 participants) were included in one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those with and without a previous history of bleeding. We included outcomes assessed up to six weeks. All trials were at high risk of bias. A total of 19 interventions were compared in the trials (sclerotherapy, somatostatin analogues, vasopressin analogues, sclerotherapy plus somatostatin analogues, variceal band ligation, balloon tamponade, somatostatin analogues plus variceal band ligation, nitrates plus vasopressin analogues, no active intervention, sclerotherapy plus variceal band ligation, balloon tamponade plus sclerotherapy, balloon tamponade plus somatostatin analogues, balloon tamponade plus vasopressin analogues, variceal band ligation plus vasopressin analogues, balloon tamponade plus nitrates plus vasopressin analogues, balloon tamponade plus variceal band ligation, portocaval shunt, sclerotherapy plus transjugular intrahepatic portosystemic shunt (TIPS), and sclerotherapy plus vasopressin analogues). We have reported the effect estimates for the primary and secondary outcomes when there was evidence of differences between the interventions against the reference treatment of sclerotherapy, but reported the other results of the primary and secondary outcomes versus the reference treatment of sclerotherapy without the effect estimates when there was no evidence of differences in order to provide a concise summary of the results. Overall, 15.8% of the trial participants who received the reference treatment of sclerotherapy (chosen because this was the commonest treatment compared in the trials) died during the follow-up periods, which ranged from three days to six weeks. Based on moderate-certainty evidence, somatostatin analogues alone had higher mortality than sclerotherapy (OR 1.57, 95% CrI 1.04 to 2.41; network estimate; direct comparison: 4 trials; 353 participants) and vasopressin analogues alone had higher mortality than sclerotherapy (OR 1.70, 95% CrI 1.13 to 2.62; network estimate; direct comparison: 2 trials; 438 participants). None of the trials reported health-related quality of life. Based on low-certainty evidence, a higher proportion of people receiving balloon tamponade plus sclerotherapy had more serious adverse events than those receiving only sclerotherapy (OR 4.23, 95% CrI 1.22 to 17.80; direct estimate; 1 RCT; 60 participants). Based on moderate-certainty evidence, people receiving vasopressin analogues alone and those receiving variceal band ligation had fewer adverse events than those receiving only sclerotherapy (rate ratio 0.59, 95% CrI 0.35 to 0.96; network estimate; direct comparison: 1 RCT; 219 participants; and rate ratio 0.40, 95% CrI 0.21 to 0.74; network estimate; direct comparison: 1 RCT; 77 participants; respectively). Based on low-certainty evidence, the proportion of people who developed symptomatic rebleed was smaller in people who received sclerotherapy plus somatostatin analogues than those receiving only sclerotherapy (OR 0.21, 95% CrI 0.03 to 0.94; direct estimate; 1 RCT; 105 participants). The evidence suggests considerable uncertainty about the effect of the interventions in the remaining comparisons where sclerotherapy was the control intervention. AUTHORS' CONCLUSIONS Based on moderate-certainty evidence, somatostatin analogues alone and vasopressin analogues alone (with supportive therapy) probably result in increased mortality, compared to endoscopic sclerotherapy. Based on moderate-certainty evidence, vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy. Based on low-certainty evidence, balloon tamponade plus sclerotherapy may result in large increases in serious adverse events compared to sclerotherapy. Based on low-certainty evidence, sclerotherapy plus somatostatin analogues may result in large decreases in symptomatic rebleed compared to sclerotherapy. In the remaining comparisons, the evidence indicates considerable uncertainty about the effects of the interventions, compared to sclerotherapy.
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Affiliation(s)
- Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Dana Walshaw
- Acute Medicine, Barts and The London NHS Trust, London, UK
| | | | | | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Roccarina D, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Benmassaoud A, Plaz Torres MC, Iogna Prat L, Csenar M, Arunan S, Begum T, Milne EJ, Tapp M, Pavlov CS, Davidson BR, Tsochatzis E, Williams NR, Gurusamy KS. Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013121. [PMID: 33822357 PMCID: PMC8092414 DOI: 10.1002/14651858.cd013121.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years. There are several different treatments to prevent bleeding, including: beta-blockers, endoscopic sclerotherapy, and variceal band ligation. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different treatments for prevention of first variceal bleeding from oesophageal varices in adults with liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for prevention of first variceal bleeding from oesophageal varices according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers to December 2019 to identify randomised clinical trials in people with cirrhosis and oesophageal varices with no history of bleeding. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and oesophageal varices with no history of bleeding. We excluded randomised clinical trials in which participants had previous bleeding from oesophageal varices and those who had previously undergone liver transplantation or previously received prophylactic treatment for oesophageal varices. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR), and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute for Health and Care Excellence Decision Support Unit guidance. We performed the direct comparisons from randomised clinical trials using the same codes and the same technical details. MAIN RESULTS We included 66 randomised clinical trials (6653 participants) in the review. Sixty trials (6212 participants) provided data for one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those at high risk of bleeding from oesophageal varices. The follow-up in the trials that reported outcomes ranged from 6 months to 60 months. All but one of the trials were at high risk of bias. The interventions compared included beta-blockers, no active intervention, variceal band ligation, sclerotherapy, beta-blockers plus variceal band ligation, beta-blockers plus nitrates, nitrates, beta-blockers plus sclerotherapy, and portocaval shunt. Overall, 21.2% of participants who received non-selective beta-blockers ('beta-blockers') - the reference treatment (chosen because this was the most common treatment compared in the trials) - died during 8-month to 60-month follow-up. Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates all had lower mortality versus no active intervention (beta-blockers: HR 0.49, 95% CrI 0.36 to 0.67; direct comparison HR: 0.59, 95% CrI 0.42 to 0.83; 10 trials, 1200 participants; variceal band ligation: HR 0.51, 95% CrI 0.35 to 0.74; direct comparison HR 0.49, 95% CrI 0.12 to 2.14; 3 trials, 355 participants; sclerotherapy: HR 0.66, 95% CrI 0.51 to 0.85; direct comparison HR 0.61, 95% CrI 0.41 to 0.90; 18 trials, 1666 participants; beta-blockers plus nitrates: HR 0.41, 95% CrI 0.20 to 0.85; no direct comparison). No trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation had a higher number of serious adverse events (number of events) than beta-blockers (rate ratio 10.49, 95% CrI 2.83 to 60.64; 1 trial, 168 participants). Based on low-certainty evidence, beta-blockers plus nitrates had a higher number of 'any adverse events (number of participants)' than beta-blockers alone (OR 3.41, 95% CrI 1.11 to 11.28; 1 trial, 57 participants). Based on low-certainty evidence, adverse events (number of events) were higher in sclerotherapy than in beta-blockers (rate ratio 2.49, 95% CrI 1.53 to 4.22; direct comparison rate ratio 2.47, 95% CrI 1.27 to 5.06; 2 trials, 90 participants), and in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison rate ratio 1.72, 95% CrI 1.08 to 2.76; 1 trial, 140 participants). Based on low-certainty evidence, any variceal bleed was lower in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison HR 0.21, 95% CrI 0.04 to 0.71; 1 trial, 173 participants). Based on low-certainty evidence, any variceal bleed was higher in nitrates than beta-blockers (direct comparison HR 6.40, 95% CrI 1.58 to 47.42; 1 trial, 52 participants). The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. AUTHORS' CONCLUSIONS Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates may decrease mortality compared to no intervention in people with high-risk oesophageal varices in people with cirrhosis and no previous history of bleeding. Based on low-certainty evidence, variceal band ligation may result in a higher number of serious adverse events than beta-blockers. The evidence indicates considerable uncertainty about the effect of beta-blockers versus variceal band ligation on variceal bleeding. The evidence also indicates considerable uncertainty about the effect of the interventions in most of the remaining comparisons.
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Affiliation(s)
- Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Amine Benmassaoud
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | | | - Laura Iogna Prat
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | | | | | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Plaz Torres MC, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Roccarina D, Benmassaoud A, Iogna Prat L, Williams NR, Csenar M, Fritche D, Begum T, Arunan S, Tapp M, Milne EJ, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 3:CD013122. [PMID: 33784794 PMCID: PMC8094621 DOI: 10.1002/14651858.cd013122.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years of diagnosis. Several different treatments are available, which include endoscopic sclerotherapy, variceal band ligation, beta-blockers, transjugular intrahepatic portosystemic shunt (TIPS), and surgical portocaval shunts, among others. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different initial treatments for secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for secondary prevention according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until December 2019 to identify randomised clinical trials in people with cirrhosis and a previous history of bleeding from oesophageal varices. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and previous history of bleeding from oesophageal varices. We excluded randomised clinical trials in which participants had no previous history of bleeding from oesophageal varices, previous history of bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those who had acute bleeding at the time of treatment, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included a total of 48 randomised clinical trials (3526 participants) in the review. Forty-six trials (3442 participants) were included in one or more comparisons. The trials that provided the information included people with cirrhosis due to varied aetiologies. The follow-up ranged from two months to 61 months. All the trials were at high risk of bias. A total of 12 interventions were compared in these trials (sclerotherapy, beta-blockers, variceal band ligation, beta-blockers plus sclerotherapy, no active intervention, TIPS (transjugular intrahepatic portosystemic shunt), beta-blockers plus nitrates, portocaval shunt, sclerotherapy plus variceal band ligation, beta-blockers plus nitrates plus variceal band ligation, beta-blockers plus variceal band ligation, sclerotherapy plus nitrates). Overall, 22.5% of the trial participants who received the reference treatment (chosen because this was the commonest treatment compared in the trials) of sclerotherapy died during the follow-up period ranging from two months to 61 months. There was considerable uncertainty in the effects of interventions on mortality. Accordingly, none of the interventions showed superiority over another. None of the trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation may result in fewer serious adverse events (number of people) than sclerotherapy (OR 0.19; 95% CrI 0.06 to 0.54; 1 trial; 100 participants). Based on low or very low-certainty evidence, the adverse events (number of participants) and adverse events (number of events) may be different across many comparisons; however, these differences are due to very small trials at high risk of bias showing large differences in some comparisons leading to many differences despite absence of direct evidence. Based on low-certainty evidence, TIPS may result in large decrease in symptomatic rebleed than variceal band ligation (HR 0.12; 95% CrI 0.03 to 0.41; 1 trial; 58 participants). Based on moderate-certainty evidence, any variceal rebleed was probably lower in sclerotherapy than in no active intervention (HR 0.62; 95% CrI 0.35 to 0.99, direct comparison HR 0.66; 95% CrI 0.11 to 3.13; 3 trials; 296 participants), beta-blockers plus sclerotherapy than sclerotherapy alone (HR 0.60; 95% CrI 0.37 to 0.95; direct comparison HR 0.50; 95% CrI 0.07 to 2.96; 4 trials; 231 participants); TIPS than sclerotherapy (HR 0.18; 95% CrI 0.08 to 0.38; direct comparison HR 0.22; 95% CrI 0.01 to 7.51; 2 trials; 109 participants), and in portocaval shunt than sclerotherapy (HR 0.21; 95% CrI 0.05 to 0.77; no direct comparison) groups. Based on low-certainty evidence, beta-blockers alone and TIPS might result in more, other compensation, events than sclerotherapy (rate ratio 2.37; 95% CrI 1.35 to 4.67; 1 trial; 65 participants and rate ratio 2.30; 95% CrI 1.20 to 4.65; 2 trials; 109 participants; low-certainty evidence). The evidence indicates considerable uncertainty about the effect of the interventions including those related to beta-blockers plus variceal band ligation in the remaining comparisons. AUTHORS' CONCLUSIONS The evidence indicates considerable uncertainty about the effect of the interventions on mortality. Variceal band ligation might result in fewer serious adverse events than sclerotherapy. TIPS might result in a large decrease in symptomatic rebleed than variceal band ligation. Sclerotherapy probably results in fewer 'any' variceal rebleeding than no active intervention. Beta-blockers plus sclerotherapy and TIPS probably result in fewer 'any' variceal rebleeding than sclerotherapy. Beta-blockers alone and TIPS might result in more other compensation events than sclerotherapy. The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. Accordingly, high-quality randomised comparative clinical trials are needed.
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Affiliation(s)
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Amine Benmassaoud
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Laura Iogna Prat
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | | | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | | | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Robles-Medranda C, Nebel JA, Puga-Tejada M, Oleas R, Baquerizo-Burgos J, Ospina-Arboleda J, Valero M, Pitanga-Lukashok H. Cost-effectiveness of endoscopic ultrasound-guided coils plus cyanoacrylate injection compared to endoscopic cyanoacrylate injection in the management of gastric varices. World J Gastrointest Endosc 2021; 13:13-23. [PMID: 33520103 PMCID: PMC7809595 DOI: 10.4253/wjge.v13.i1.13] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/09/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cyanoacrylate (CYA) injection can be performed using a standard upper endoscopy technique or under endoscopic ultrasound (EUS) guidance alone or in combination with coils. There is little information available on the economic impact of these treatment methods.
AIM To compare the cost-effectiveness of treating gastric varices by CYA injection via upper endoscopy vs coils plus CYA guided by EUS.
METHODS This was an observational, descriptive, and retrospective study. Patients were allocated into two groups: A CYA group and coils plus CYA group. The baseline characteristics were compared, and a cost analysis was performed.
RESULTS Overall, 36 patients were included (19 in the CYA group and 17 in the coils + CYA group). All patients in the CYA group had acute bleeding. They underwent a higher mean number of procedures (1.47 vs 1, P = 0.025), and the mean volume of glue used was 2.15 vs 1.65 mL, P = 0.133. The coils + CYA group showed a higher technical success rate (100% vs 84.2%), with a complication rate similar to the CYA group. The majority of CYA patients required hospitalization, and although the mean total per procedure cost was lower (United States $ 1350.29 vs United States $ 2978), the mean total treatment cost was significantly different (United States $ 11060.89 for CYA vs United States $ 3007.13 for coils + CYA, P = 0.03).
CONCLUSION The use of EUS-guided coils plus cyanoacrylate is more cost-effective than cyanoacrylate injection when the total costs are evaluated. Larger, randomized trials are needed to validate the cost-effectiveness of the EUS-guided approach to treat gastric varices.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Guayas, Ecuador
| | - Joao Autran Nebel
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Guayas, Ecuador
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Guayas, Ecuador
| | - Roberto Oleas
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Guayas, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Guayas, Ecuador
| | - Jesenia Ospina-Arboleda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Guayas, Ecuador
| | - Manuel Valero
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Guayas, Ecuador
| | - Hannah Pitanga-Lukashok
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Guayas, Ecuador
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Thiruvengadam SS, Sedarat A. The Role of Endoscopic Ultrasound (EUS) in the Management of Gastric Varices. Curr Gastroenterol Rep 2021; 23:1. [PMID: 33389241 PMCID: PMC7778619 DOI: 10.1007/s11894-020-00801-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Gastric varices (GV) are an important complication of portal hypertension, and the current recommendation for management is beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt (TIPS) for active bleeding or secondary prophylaxis. Direct endoscopic injection of cyanoacrylate (CYA) glue has been investigated but has drawbacks including limited endoscopic characterization of GV and possible distal glue embolism. To this end, endoscopic ultrasound (EUS) has been pursued to help in characterization of GV, visualization of treatment in real time, and confirmation of obliteration with Doppler. RECENT FINDINGS In this paper, we review treatments for GV involving EUS, including EUS-guided injection of CYA and coils, either alone or in combination. We also discuss less common methods, including EUS-guided injection of thrombin and absorbable gelatin sponge. We then review literature comparing EUS-guided methods with direct endoscopic therapy and comparing individual EUS-guided methods with one another. We conclude by highlighting drawbacks of EUS in this field, including the unproven benefit over conventional therapy, lack of a standardized approach, and limited availability of expertise and necessary materials. Novel EUS-based methods offer a unique opportunity to directly visualize and access gastric varices for treatment and obliteration. This may provide key advantages over current endoscopic or angiographic treatments. Comparative studies investigating the benefit of EUS over conventional therapy are needed.
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Affiliation(s)
| | - Alireza Sedarat
- Division of Digestive Diseases, UCLA Vatche and Tamar Manoukian, Los Angeles, CA USA
- Santa Monica, USA
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35
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Kovalic AJ, Satapathy SK. Secondary Prophylaxis of Variceal Bleeding in Liver Cirrhosis. VARICEAL BLEEDING IN LIVER CIRRHOSIS 2021:77-121. [DOI: 10.1007/978-981-15-7249-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Beyond the scope and the glue: update on evaluation and management of gastric varices. BMC Gastroenterol 2020; 20:361. [PMID: 33126847 PMCID: PMC7602314 DOI: 10.1186/s12876-020-01513-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/23/2020] [Indexed: 02/08/2023] Open
Abstract
Gastric varices are encountered less frequently than esophageal varices. Nonetheless, gastric variceal bleeding is more severe and associated with worse outcomes. Conventionally, gastric varices have been described based on the location and extent and endoscopic treatments offered based on these descriptions. With improved understanding of portal hypertension and the dynamic physiology of collateral circulation, gastric variceal classification has been refined to include inflow and outflow based hemodynamic pathways. These have led to an improvement in the management of gastric variceal disease through newer modalities of treatment such as endoscopic ultrasound-guided glue-coiling combination therapy and the emergence of highly effective endovascular treatments such as shunt and variceal complex embolization with or without transjugular intrahepatic portosystemic shunt (TIPS) placement in patients who are deemed 'difficult' to manage the traditional way. Furthermore, the decisions regarding TIPS and additional endovascular procedures in patients with gastric variceal bleeding have changed after the emergence of 'portal hypertension theories' of proximity, throughput, and recruitment. The hemodynamic classification, grounded on novel theories and its cognizance, can help in identifying patients at baseline, in whom conventional treatment could fail. In this exhaustive review, we discuss the conventional and hemodynamic diagnosis of gastric varices concerning new classifications; explore and illustrate new 'portal hypertension theories' of gastric variceal disease and corresponding management and shed light on current evidence-based treatments through a 'new' algorithmic approach, established on hemodynamic physiology of gastric varices.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Laboratory, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India.
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, 682028, India
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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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Pandhi MB, Kuei AJ, Lipnik AJ, Gaba RC. Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding. Semin Intervent Radiol 2020; 37:3-13. [PMID: 32139965 DOI: 10.1055/s-0039-3402015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.
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Affiliation(s)
- Mithil B Pandhi
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Kuei
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Illinois
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39
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Binmoeller KF. Endoscopic 'hybrid' treatments for gastric varices: Do we need belt and suspenders? Endosc Int Open 2020; 8:E228-E230. [PMID: 32011610 PMCID: PMC6986943 DOI: 10.1055/a-1024-3852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kenneth F Binmoeller
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, United States
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40
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von Bornstädt D, Wang H, Paulsen MJ, Goldstone AB, Eskandari A, Thakore A, Stapleton L, Steele AN, Truong VN, Jaatinen K, Hironaka C, Woo YJ. Rapid Self-Assembly of Bioengineered Cardiovascular Bypass Grafts From Scaffold-Stabilized, Tubular Bilevel Cell Sheets. Circulation 2019; 138:2130-2144. [PMID: 30474423 DOI: 10.1161/circulationaha.118.035231] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cardiovascular bypass grafting is an essential treatment for complex cases of atherosclerotic disease. Because the availability of autologous arterial and venous conduits is patient-limited, self-assembled cell-only grafts have been developed to serve as functional conduits with off-the-shelf availability. The unacceptably long production time required to generate these conduits, however, currently limits their clinical utility. Here, we introduce a novel technique to significantly accelerate the production process of self-assembled engineered vascular conduits. METHODS Human aortic smooth muscle cells and skin fibroblasts were used to construct bilevel cell sheets. Cell sheets were wrapped around a 22.5-gauge Angiocath needle to form tubular vessel constructs. A thin, flexible membrane of clinically approved biodegradable tissue glue (Dermabond Advanced) served as a temporary, external scaffold, allowing immediate perfusion and endothelialization of the vessel construct in a bioreactor. Subsequently, the matured vascular conduits were used as femoral artery interposition grafts in rats (n=20). Burst pressure, vasoreactivity, flow dynamics, perfusion, graft patency, and histological structure were assessed. RESULTS Compared with engineered vascular conduits formed without external stabilization, glue membrane-stabilized conduits reached maturity in the bioreactor in one-fifth the time. After only 2 weeks of perfusion, the matured conduits exhibited flow dynamics similar to that of control arteries, as well as physiological responses to vasoconstricting and vasodilating drugs. The matured conduits had burst pressures exceeding 500 mm Hg and had sufficient mechanical stability for surgical anastomoses. The patency rate of implanted conduits at 8 weeks was 100%, with flow rate and hind-limb perfusion similar to those of sham controls. Grafts explanted after 8 weeks showed a histological structure resembling that of typical arteries, including intima, media, adventitia, and internal and external elastic membrane layers. CONCLUSIONS Our technique reduces the production time of self-assembled, cell sheet-derived engineered vascular conduits to 2 weeks, thereby permitting their use as bypass grafts within the clinical time window for elective cardiovascular surgery. Furthermore, our method uses only clinically approved materials and can be adapted to various cell sources, simplifying the path toward future clinical translation.
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Affiliation(s)
- Daniel von Bornstädt
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA
| | - Hanjay Wang
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA
| | - Michael J Paulsen
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA
| | - Andrew B Goldstone
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA
| | - Anahita Eskandari
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA
| | - Akshara Thakore
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA
| | - Lyndsay Stapleton
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA.,Bioengineering (L.S., A.N.S., Y.J.W.), Stanford University, CA
| | - Amanda N Steele
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA.,Bioengineering (L.S., A.N.S., Y.J.W.), Stanford University, CA
| | - Vi N Truong
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA
| | - Kevin Jaatinen
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA
| | - Camille Hironaka
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA
| | - Y Joseph Woo
- Departments of Cardiothoracic Surgery (D.v.B., H.W., M.J.P., A.B.G., A.E., A.T., L.S., A.N.S., V.N.T., K.J., C.H., Y.J.W.), Stanford University, CA.,Bioengineering (L.S., A.N.S., Y.J.W.), Stanford University, CA
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New Era of Endoscopic Ultrasound-Guided Tissue Acquisition: Next-Generation Sequencing by Endoscopic Ultrasound-Guided Sampling for Pancreatic Cancer. J Clin Med 2019; 8:jcm8081173. [PMID: 31387310 PMCID: PMC6723875 DOI: 10.3390/jcm8081173] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/20/2019] [Accepted: 08/02/2019] [Indexed: 12/14/2022] Open
Abstract
Pancreatic cancer is a lethal cancer with an increasing incidence. Despite improvements in chemotherapy, patients with pancreatic cancer continue to face poor prognoses. Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is the primary method for obtaining tissue samples of pancreatic cancer. Due to advancements in next-generation sequencing (NGS) technologies, multiple parallel sequencing can be applied to EUS-TA samples. Genomic biomarkers for therapeutic stratification in pancreatic cancer are still lacking, however, NGS can unveil potential predictive genomic biomarkers of treatment response. Thus, the importance of NGS using EUS-TA samples is becoming recognized. In this review, we discuss the recent advances in EUS-TA application for NGS of pancreatic cancer.
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Goral V, Yılmaz N. Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:335. [PMID: 31277322 PMCID: PMC6681371 DOI: 10.3390/medicina55070335] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/28/2019] [Accepted: 06/28/2019] [Indexed: 12/21/2022]
Abstract
Gastric varices are less common than esophageal varices, and their treatment is quite challenging. Gastric varix bleedings (GVB) occur less frequently than esophageal varix (EV) bleedings and represent 10% to 30% of all variceal bleedings. They are; however, more severe and are associated with high mortality. Re-bleeding may occur in 35% to 90% of cases after spontaneous hemostasis. GV bleedings represent a serious clinical problem compared with esophageal varices due to their location. Sclerotherapy and band ligation, in particular, are less effective. Based on the anatomic site and location, treatment differs from EV and is categorized into two groups (i.e., endoscopic or radiologic treatment). Surgical management is used less frequently. Balloon-occluded retrograde transvenous obliteration (BRTO) and cyanoacrylate are safe but there is a high risk of re-bleeding. Portal pressure elevates following BRTO and leads to worsening of esophageal varix pressure. Other significant complications may include hemoglobinuria, abdominal pain, fever, and pleural effusion. Shock and atrial fibrillation are major complications. New and efficient treatment modalities will be possible in the future.
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Affiliation(s)
- Vedat Goral
- Istanbul Medipol University, School of Medicine Department of Gastroenterology, 34214 Istanbul, Turkey.
| | - Nevin Yılmaz
- Department of Gastroenterology, School of Medicine, Near East University, 99138 Nicosia, Cyprus
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Abstract
Hepatorenal syndrome is a severe complication of end-stage cirrhosis characterized by increased splanchnic blood flow, hyperdynamic state, a state of decreased central volume, activation of vasoconstrictor systems, and extreme kidney vasoconstriction leading to decreased GFR. The contribution of systemic inflammation, a key feature of cirrhosis, in the development of hepatorenal syndrome has been highlighted in recent years. The mechanisms by which systemic inflammation precipitates kidney circulatory changes during hepatorenal syndrome need to be clarified. Early diagnosis is central in the management and recent changes in the definition of hepatorenal syndrome help identify patients at an earlier stage. Vasoconstrictive agents (terlipressin in particular) and albumin are the first-line treatment option. Several controlled studies proved that terlipressin is effective at reversing hepatorenal syndrome and may improve short-term survival. Not all patients are responders, and even in responders, early mortality rates are very high in the absence of liver transplantation. Liver transplantation is the only curative treatment of hepatorenal syndrome. In the long term, patients transplanted with hepatorenal syndrome tend to have lower GFR compared with patients without hepatorenal syndrome. Differentiating hepatorenal syndrome from acute tubular necrosis (ATN) is often a challenging yet important step because vasoconstrictors are not justified for the treatment of ATN. Hepatorenal syndrome and ATN may be considered as a continuum rather than distinct entities. Emerging biomarkers may help differentiate these two conditions and provide prognostic information on kidney recovery after liver transplantation, and potentially affect the decision for simultaneous liver-kidney transplantation.
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Affiliation(s)
- Claire Francoz
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France
- INSERM U1149, University Paris Diderot, Paris, France; and
| | - François Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France
- INSERM U1149, University Paris Diderot, Paris, France; and
| | - Jeffrey A Kahn
- Division of Gastrointestinal and Liver Disease, Department of Medicine
| | - Yuri S Genyk
- Division of Hepatobiliary, Pancreas, and Abdominal Organ Transplant, Department of Surgery, and
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
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Huang BY, Zhou JJ, Song XY, Wu JH, Zheng D, Li XM, Li L. Clinical analysis of percutaneous computed tomography-guided injection of cyanoacrylate for localization of 115 small pulmonary lesions in 113 asymptomatic patients. J Int Med Res 2019; 47:2145-2156. [PMID: 30966824 PMCID: PMC6567758 DOI: 10.1177/0300060518822229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective This study was performed to assess the clinical feasibility, safety, and effectiveness of a computed tomography (CT)–guided cyanoacrylate injection system and investigate the relationship between clinical features and pathologic characteristics of diminutive pulmonary lesions. Methods In total, 115 pulmonary nodules from 113 patients (63 female, 50 male) with a diameter of <20 mm were percutaneously localized with a CT-guided cyanoacrylate injection system and then resected. Results Of the pure ground-glass opacities (GGOs), 16.0% were atypical adenomatous hyperplasia (AAH), 18.7% were adenocarcinoma in situ (AIS), 49.3% were lung adenocarcinoma (ADC), and 16.0% were benign inflammatory fibrosis/fibrotic scars. Of the mixed GGOs, 18.2% were AAH, 22.7% were AIS, 22.7% were ADC, and 36.4% were benign lesions. Lesions of >10 mm and those located in relation to vessels were significantly more likely to be malignant. The success rate of both the cyanoacrylate injection system and video-assisted thoracoscopic surgery was 100% with no severe complications. Conclusions Preoperative localization of small pulmonary nodules using a cyanoacrylate injection system is a safe, simple, and useful technique.
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Affiliation(s)
- Bing-Yang Huang
- 1 Department of Cardiothoracic Surgery, The 306th Hospital of PLA, Chao-yang District, Beijing, People's Republic of China
| | - Jun-Jun Zhou
- 1 Department of Cardiothoracic Surgery, The 306th Hospital of PLA, Chao-yang District, Beijing, People's Republic of China
| | - Xiao-Yong Song
- 1 Department of Cardiothoracic Surgery, The 306th Hospital of PLA, Chao-yang District, Beijing, People's Republic of China
| | - Ji-Hua Wu
- 2 Department of Pathology, The 306th Hospital of PLA, Chao-yang District, Beijing, People's Republic of China
| | - Dong Zheng
- 3 Department of Radiology, The 306th Hospital of PLA, Chao-yang District, Beijing, People's Republic of China
| | - Xin-Ming Li
- 1 Department of Cardiothoracic Surgery, The 306th Hospital of PLA, Chao-yang District, Beijing, People's Republic of China
| | - Lu Li
- 1 Department of Cardiothoracic Surgery, The 306th Hospital of PLA, Chao-yang District, Beijing, People's Republic of China
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Roberts D, Tsochatzis E, Gurusamy KS. Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Hippokratia 2018. [DOI: 10.1002/14651858.cd013155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Danielle Roberts
- Royal Free Campus, UCL Medical School; Department of Surgery; Royal Free Hospital Rowland Hill Street London UK NW3 2PF
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive Health; Sheila Sherlock Liver Centre; Pond Street London UK NW3 2QG
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical School; Department of Surgery; Royal Free Hospital Rowland Hill Street London UK NW3 2PF
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46
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Bick BL, Al-Haddad M, Liangpunsakul S, Ghabril MS, DeWitt JM. EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding. Surg Endosc 2018; 33:1837-1845. [PMID: 30259158 DOI: 10.1007/s00464-018-6462-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic injection of cyanoacrylate into gastric varices may be performed by EUS-guided fine needle injection (EUS-FNI) or direct endoscopic injection (DEI). The aim of this study is to compare the rate of recurrent GV bleeding and adverse events between DEI and EUS-FNI for treatment of GV. METHODS In a single-center study, a retrospective cohort of patients with actively/recently bleeding or high-risk GV treated with DEI were compared with a prospective cohort of similar patients treated with EUS-FNI. Repeat endoscopy after index treatment was performed 3 months later or earlier if rebleeding occurred. The main outcomes assessed were rates of GV or overall rebleeding and adverse events. RESULTS Forty patients (mean age 57.2 ± 9.1 years, 73% male) and 64 patients (mean age 58.0 ± 12.5 years, 52% male) underwent DEI and EUS-FNI, respectively. Compared to the DEI group, the frequency of isolated gastric varices type 1 (IGV1) were higher (p < 0.001) but MELD scores were lower (p = 0.004) in the EUS-FNI group. At index endoscopy, EUS-FNI utilized a lower mean volume of cyanoacrylate (2.0 ± 0.8 mL vs. 3.3 ± 1.3 mL; p < 0.001) and injected a greater number of varices (1.6 ± 0.7 vs. 1.1 ± 0.4; p < 0.001) compared to DEI. Overall, GV rebleeding [5/57 (8.8%) vs. 9/38 (23.7%); p = 0.045] and non-GV-related gastrointestinal bleeding [7/64 (10.9%) vs. 11/40 (27.5%); p = 0.030] were less frequent in the EUS-FNI group compared to the DEI group, respectively. Adverse event rates were similar (20.3% vs. 17.5%, p = 0.723). CONCLUSIONS EUS-guided CYA injection of active or recently bleeding GV in patients with portal hypertension appears to decrease the rate of GV rebleeding despite injection of more varices and less CYA volume during the initial endoscopic procedure. Adverse events are similar between the two groups. EUS-FNI appears to be the preferred strategy for treatment of these patients.
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Affiliation(s)
- Benjamin L Bick
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | - Suthat Liangpunsakul
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | - Marwan S Ghabril
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | - John M DeWitt
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA.
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47
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Gurusamy KS, Tsochatzis E. Primary prevention of bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis. Hippokratia 2018. [DOI: 10.1002/14651858.cd013121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical School; Department of Surgery; Royal Free Hospital Rowland Hill Street London UK NW3 2PF
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive Health; Sheila Sherlock Liver Centre; Pond Street London UK NW3 2QG
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48
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Gurusamy KS, Tsochatzis E. Secondary prevention of bleeding in people with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta‐analysis. Cochrane Database Syst Rev 2018; 2018:CD013122. [PMCID: PMC6513430 DOI: 10.1002/14651858.cd013122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To compare the benefits and harms of different treatments for the prevention of rebleeding in people with a history of oesophageal varices due to decompensated liver cirrhosis.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Emmanuel Tsochatzis
- Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetLondonUKNW3 2QG
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49
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Kibrit J, Khan R, Jung BH, Koppe S. Clinical Assessment and Management of Portal Hypertension. Semin Intervent Radiol 2018; 35:153-159. [PMID: 30087517 DOI: 10.1055/s-0038-1660793] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The development of portal hypertension in a patient with cirrhosis portends a poor prognosis. Untreated or progressive portal hypertension has serious clinical outcomes, which are often fatal. It is important to recognize portal hypertension early to delay progression and to treat complications of portal hypertension as they arise. This review will focus on the clinical assessment and management of portal hypertension.
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Affiliation(s)
- Jacob Kibrit
- Division of Gastroenterology and Hepatology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Ruben Khan
- Division of Gastroenterology and Hepatology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Barbara H Jung
- Division of Gastroenterology and Hepatology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Sean Koppe
- Division of Gastroenterology and Hepatology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois
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50
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The Role of Therapeutic Endoscopy in Patients With Cirrhosis-Related Causes of Gastrointestinal Bleeding. Curr Gastroenterol Rep 2018; 20:31. [PMID: 29886513 DOI: 10.1007/s11894-018-0637-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW This article aims to review current therapeutic endoscopic treatments available for the management of gastrointestinal bleeding related to cirrhosis. RECENT FINDINGS Endoscopic band ligation is an effective treatment for primary prophylaxis, acute bleeding, and secondary prophylaxis of esophageal varices as well as for acute bleeding and secondary prophylaxis of select gastric varices. Sclerotherapy is a treatment option for acute bleeding and secondary prophylaxis of esophageal varices when band ligation is technically difficult. Cyanoacrylate glue injection is an effective treatment for acute bleeding of gastric and ectopic varices. Argon plasma coagulation is first-line and radiofrequency ablation is second-line treatment for chronic bleeding secondary to gastric antral vascular ectasia. There are a variety of endoscopic treatment modalities for cirrhosis-related gastrointestinal bleeding, and the appropriate therapy depends on the location of the bleed, history or presence of acute bleeding, and risk factors for intervention-related adverse events.
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