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Osman KT, Nayfeh T, Abdelfattah AM, Alabdallah K, Hasan B, Firwana M, Alabaji H, Elkhabiry L, Mousa J, Prokop LJ, Murad MH, Gordon F. Secondary Prophylaxis of Gastric Variceal Bleeding: A Systematic Review and Network Meta-Analysis. Liver Transpl 2022; 28:945-958. [PMID: 34860458 DOI: 10.1002/lt.26383] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/21/2021] [Accepted: 11/26/2021] [Indexed: 12/12/2022]
Abstract
There is no clear consensus regarding the optimal approach for secondary prophylaxis of gastric variceal bleeding (GVB) in patients with cirrhosis. We conducted a systematic review and network meta-analysis (NMA) to compare the efficacy of available treatments. A comprehensive search of several databases from each database's inception to March 23, 2021, was conducted to identify relevant randomized controlled trials (RCTs). Outcomes of interest were rebleeding and mortality. Results were expressed as relative risk (RR) and 95% confidence interval (CI). We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to rate the certainty of evidence. We included 9 RCTs with 647 patients who had histories of GVB and follow-ups >6 weeks. A total of 9 interventions were included in the NMA. Balloon-occluded retrograde transvenous obliteration (BRTO) was associated with a lower risk of rebleeding when compared with β-blockers (RR, 0.04; 95% CI, 0.01-0.26; low certainty), and endoscopic injection sclerotherapy (EIS)-cyanoacrylate (CYA) (RR, 0.18; 95% CI, 0.04-0.77; low certainty). β-blockers were associated with a higher risk of rebleeding compared with most interventions and with increased mortality compared with EIS-CYA (RR, 4.12, 95% CI, 1.50-11.36; low certainty), and EIS-CYA + nonselective β-blockers (RR, 5.61; 95% CI, 1.91-16.43; low certainty). Analysis based on indirect comparisons suggests that BRTO may be the best intervention in preventing rebleeding, whereas β-blocker monotherapy is likely the worst in preventing rebleeding and mortality. Head-to-head RCTs are needed to validate these results.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA
| | - Tarek Nayfeh
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Ahmed M Abdelfattah
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA
| | | | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | | | - Homam Alabaji
- Department of Internal Medicine, Wertachklinik Schwabmünchen, Bavaria, Germany
| | - Lina Elkhabiry
- Department of Internal Medicine, University of Alexandria, Alexandria, Egypt
| | - Jehan Mousa
- Department of Internal Medicine, Damascus University, Damascus, Syria
| | - Larry J Prokop
- Department of Library Services, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN
| | - Fredric Gordon
- Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA.,Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA
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Shen B. Endoscopic band ligation with hypertonic glucose cushion in the treatment of ileal pouch prolapse. Gastroenterol Rep (Oxf) 2021; 9:480-482. [PMID: 34733536 PMCID: PMC8560034 DOI: 10.1093/gastro/goaa089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/22/2020] [Indexed: 01/17/2023] Open
Affiliation(s)
- Bo Shen
- Center for Inflammatory Bowel Disease, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA
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Hu Z, Zhang D, Swai J, Liu T, Liu S. Risk of rebleeding from gastroesophageal varices after initial treatment with cyanoacrylate; a systematic review and pooled analysis. BMC Gastroenterol 2020; 20:181. [PMID: 32517718 PMCID: PMC7285616 DOI: 10.1186/s12876-020-01333-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/03/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cyanoacrylate alone or in combination with other interventions, can be used to achieve variable rates of success in preventing rebleeding. Our study aims to assess the pooled risk of gastric and esophageal varices rebleeding after an initial treatment with cyanoacrylate alone and/or in combination with other treatments, by a systematic review of the literature and pooled analysis. METHODS PubMed, EMBASE, SCOPUS, and the Cochrane library were searched for studies that reported the risk of rebleeding during the follow-up period after treatment of gastric or esophageal varices with either cyanoacrylate alone or in combination with other treatments. Standard error, upper and lower confidence intervals at 95% confidence interval for the risk were obtained using STATA Version 15 which was also used to generate forest plots for pooled analysis. The random or fixed effect model was applied depending on the heterogeneity (I2). RESULTS A total of 39 studies were found to report treatment of either gastric or esophageal varices with either cyanoacrylate alone or in combination with other treatments. When gastric varices are treated with cyanoacrylate alone, the risk of rebleeding during the follow-up period is 0.15(Confidence Interval: 0.11-0.18). When combined with lipiodol; polidocanol or sclerotherapy the rebleeding risks are 0.13 (CI:0.03-0.22), 0.10(CI:0.02-0.19), and 0.10(CI:0.05-0.18), respectively. When combined with percutaneous transhepatic variceal embolization; percutaneous transhepatic variceal embolization; endoscopic ultrasound guided coils; or with ethanolamine, the rebleeding risk are 0.10(CI:0.03-0.17), 0.10(CI:0.03-0.17), 0.07(CI:0.03-0.11) and 0.08(CI:0.02-0.14), respectively. When esophageal varices are treated with cyanoacrylate alone, the risk of rebleeding is 0.29(CI:0.11-0.47). When combined with percutaneous transhepatic variceal embolization; sclerotherapy; or band ligation, the risks of rebleeding are 0.16(CI:0.10-0.22), 0.12(CI:0.04-0.20) and 0.10(CI:0.04-0.24), respectively. When combined with a transjugular intrahepatic portosystemic shunt; or ethanolamine, the risks of rebleeding are 0.06(CI: - 0.01-0.12) and 0.02 (CI: - 0.02-0.05), respectively. CONCLUSION In treating both gastric and esophageal varices, cyanoacrylate produces better results in terms of lower risk of rebleeding when combined with other treatments than when used alone. The combination of cyanoacrylate with ethanolamine or with endoscopic ultrasound guided coils produces the lowest risk of rebleeding in esophageal and gastric varices, respectively. We call upon randomized trials to test these hypotheses.
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Affiliation(s)
- Zixuan Hu
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha city, Hunan, P.R. China
| | - Decai Zhang
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha city, Hunan, P.R. China
| | - Joel Swai
- Department of Nephrology and Rheumatology, The Third Xiangya Hospital of Central South University, Changsha city, Hunan, P.R. China.
- Department of Internal Medicine, Benjamin Mkapa Hospital, Dodoma city, East-Africa, Tanzania.
| | - Tao Liu
- Department of Cardiothoracic Surgery, The Third Xiangya Hospital of Central South University, Changsha city, Hunan, P.R. China
| | - Shaojun Liu
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha city, Hunan, P.R. China.
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Lan N, Hull TL, Shen B. Endoscopic sinusotomy versus redo surgery for the treatment of chronic pouch anastomotic sinus in ulcerative colitis patients. Gastrointest Endosc 2019; 89:144-156. [PMID: 30107182 DOI: 10.1016/j.gie.2018.08.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 08/04/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Pouch sinus may be a serious adverse event in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to compare endoscopic sinusotomy (ESi) and redo pouch surgery in the management of pouch sinus. METHODS All consecutive ulcerative colitis patients with chronic pouch sinuses treated with ESi versus redo surgery from 2006 to 2016 were identified. The primary outcomes were recurrence-free and surgery-free survivals. The secondary outcome was postprocedural adverse events. RESULTS This historical cohort study included 226 patients (ESi, n = 141; redo surgery, n = 85). Complete healing of the sinus was achieved in 75 patients (53.2%) and partial healing in 23 patients (16.3%) with ESi, and an initial complete healing (ie, no anastomotic leak before ileostomy closure) was obtained in 80 patients (94.1%) receiving redo surgery. Sinus recurrence after complete healing was seen in 17 patients (22.7%) treated with ESi and 28 patients (32.9%) treated with surgery (P = .15). Subsequent surgery was needed in 34 patients (24.1%) with ESi therapy and 18 patients (21.2%) with initial redo surgery (P = .70). Kaplan-Meier recurrence-free and surgery-free survivals after initial procedures showed no statistical difference between the 2 groups (P = .42 and P = .65, respectively). The rate of adverse events in the ESi group was significantly lower than that in the surgery group (2.5% vs 43.5%, P < .0001). CONCLUSIONS Recurrence-free and surgery-free survivals were comparable between patients treated with ESi and redo surgery, whereas pouch redo surgery was found to be associated with a higher immediate complete healing rate yet a higher morbidity.
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Affiliation(s)
- Nan Lan
- Interventional Inflammatory Bowel Disease Unit and Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracy L Hull
- Interventional Inflammatory Bowel Disease Unit and Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bo Shen
- Interventional Inflammatory Bowel Disease Unit and Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Shashi P, Kochhar G, Shen B. Endoscopic therapy of colorectal anastomotic hematoma with hypertonic dextrose. Gastroenterol Rep (Oxf) 2018; 7:455-458. [PMID: 31857908 PMCID: PMC6911995 DOI: 10.1093/gastro/goy026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/20/2018] [Accepted: 04/08/2018] [Indexed: 12/28/2022] Open
Abstract
Anastomotic dehiscence and leak are dreaded complications after a colorectal resection and can often present with rectal bleeding and pelvic abscess or sepsis. Although most cases of bleeding after gastrointestinal anastomoses are minor and self-limited, major bleeding, as defined by hemodynamic instability or the need for blood transfusions, poses a significant challenge for management. Here we report a case in which a patient presenting with profuse rectal bleeding and pelvic hematoma secondary to a colorectal anastomotic leak was treated endoscopically with 50% dextrose spray then enema.
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Affiliation(s)
- Preeti Shashi
- The Interventional IBD Unit, Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Gursimran Kochhar
- The Interventional IBD Unit, Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Shen
- The Interventional IBD Unit, Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Abstract
BACKGROUND AND AIMS Pouch sinus is a serious complication in patients undergoing ileal pouch-anal anastomosis. The aim of this study was to verify the efficacy and safety of endoscopic needle knife sinusotomy (NKSi) in the management of pouch sinus. METHODS All consecutive patients with a pouch sinus treated with NKSi from 2008 to 2016 were identified. The primary outcomes were complete healing of the sinus and pouch survival. RESULTS A total of 109 patients were included. During a median follow-up of 2.1 years (interquartile range: 0.7-4.4), 54 (49.5%) patients achieved complete healing and 20 (18.3%) patients had partial healing, Twenty-two (20.2%) patients developed sinus-related pouch failure. In multivariable analysis for the sinus healing, Crohn's disease of the pouch was a risk factor [odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8), whereas a longer interval between NKSi (OR: 1.1, 95%CI: 1.0-1.1) and high body mass index (OR: 1.2, 95%CI: 1.0-1.3) were protective factors. In the multivariable analysis for surgery-free survival, previously documented acute anastomotic leak (OR:3.5, 95%CI: 1.2-10.4), toxic megacolon (OR: 7.4, 95%CI: 1.9-29.1), an increased length of sinus (OR: 1.4, 95%CI: 1.0-2.0), and increased duration from sinus diagnosis to NKSi (OR: 2.6, 95%CI: 1.1-6.2) were risk factors; and a longer interval between NKSis (OR: 0.9, 95%CI: 0.9-0.99), and concurrent use of dextrose 50% (OR: 0.2, 95%CI: 0.04-0.6) and doxycycline during the NKSi procedure (OR: 0.2, 95%CI: 0.04-0.7) were protective factors. NKSi-associated complications were reported in 6 (1.8% per procedure) cases. CONCLUSIONS NKSi is an effective and safe procedure for treating pouch sinus.
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Affiliation(s)
- Nan Lan
- Interventional Inflammatory Bowel Disease (i-IBD) Unit, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Bo Shen
- Interventional Inflammatory Bowel Disease (i-IBD) Unit, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Kuo MJ, Chen HH, Chen CL, Fann JCY, Chen SLS, Chiu SYH, Lin YM, Liao CS, Chang HC, Lin YS, Yen AMF. Cost-effectiveness analysis of population-based screening of hepatocellular carcinoma: Comparing ultrasonography with two-stage screening. World J Gastroenterol 2016; 22:3460-3470. [PMID: 27022228 PMCID: PMC4806204 DOI: 10.3748/wjg.v22.i12.3460] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/29/2015] [Accepted: 12/21/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess the cost-effectiveness of two population-based hepatocellular carcinoma (HCC) screening programs, two-stage biomarker-ultrasound method and mass screening using abdominal ultrasonography (AUS).
METHODS: In this study, we applied a Markov decision model with a societal perspective and a lifetime horizon for the general population-based cohorts in an area with high HCC incidence, such as Taiwan. The accuracy of biomarkers and ultrasonography was estimated from published meta-analyses. The costs of surveillance, diagnosis, and treatment were based on a combination of published literature, Medicare payments, and medical expenditure at the National Taiwan University Hospital. The main outcome measure was cost per life-year gained with a 3% annual discount rate.
RESULTS: The results show that the mass screening using AUS was associated with an incremental cost-effectiveness ratio of USD39825 per life-year gained, whereas two-stage screening was associated with an incremental cost-effectiveness ratio of USD49733 per life-year gained, as compared with no screening. Screening programs with an initial screening age of 50 years old and biennial screening interval were the most cost-effective. These findings were sensitive to the costs of screening tools and the specificity of biomarker screening.
CONCLUSION: Mass screening using AUS is more cost effective than two-stage biomarker-ultrasound screening. The most optimal strategy is an initial screening age at 50 years old with a 2-year inter-screening interval.
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Liu HT, Cheng SB, Wu CC, Yeh HZ, Chang CS, Wang J. Impact of severe oesophagogastric varices on liver resection for hepatocellular carcinoma in cirrhotic patients. World J Surg 2015; 39:461-8. [PMID: 25338186 DOI: 10.1007/s00268-014-2811-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of the present study was to clarify both short-term and long-term results of patients with concomitant hepatocellular carcinoma (HCC) and high-risk oesophagogastric varices (OGV). METHODS This retrospective study identified 927 cirrhotic patients who underwent curative resection of HCC between 1995 and 2012 in single institution. Patients were separated into 3 groups (A, B, and C) according to general rules for recording endoscopic findings of oesophagogastric varices proposed in Japan in 1991. Groups A, B, and C consisted of patients without OGV (F0), patients with mild to moderate OGV (F1 to F2), and patients with high-risk OGV (F3 and/or red color sign), respectively. All patients in group C underwent prophylactic endoscopic variceal ligation/sclerotherapy. Post-operative complications, mortality, overall survival, and disease-free survival were compared among 3 groups. RESULTS No patient had post-operative variceal bleeding. Complication rates of Clavien-Dindo grade II to V in three groups were 13.6, 14.0, and 6.9 %, respectively (P > 0.05). Operative mortality, 5-year overall survival rate, and disease-free survival rate among the 3 groups were not significantly different (P > 0.05). CONCLUSIONS Prophylactic endoscopic variceal ligation/sclerotherapy effectively prevented from post-operative variceal bleeding in patients with high-risk OGV. Operative mortality, major morbidity, and survival of patients with high-risk OGV were similar to those of patients without OGV or those with mild OGV. Liver resection remains a feasible choice for cirrhotic patients with concomitant HCC and high-risk OGV.
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Affiliation(s)
- Hsiao-Tien Liu
- Department of Surgery, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan, Roc
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Endoscopic Therapy of Bleeding from Radiation Enteritis with Hypertonic Glucose Spray. ACG Case Rep J 2014; 1:181-3. [PMID: 26157869 PMCID: PMC4435317 DOI: 10.14309/crj.2014.45] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/13/2014] [Indexed: 12/23/2022] Open
Abstract
Non-variceal and non-ulcerative bleeding in the gastrointestinal (GI) tract, such as radiation enteritis with active and extensive oozing, is common, and management of these conditions can be challenging. We describe the first case in the literature to use hypertonic glucose spray in radiation enteritis-associated diffuse mucosal bleeding.
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Wu XR, Wong RCK, Shen B. Endoscopic needle-knife therapy for ileal pouch sinus: a novel approach for the surgical adverse event (with video). Gastrointest Endosc 2013; 78:875-885. [PMID: 23810326 DOI: 10.1016/j.gie.2013.05.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 05/14/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pouch sinus is an adverse event in patients undergoing ileal pouch surgery. OBJECTIVE To evaluate the efficacy of needle-knife therapy in managing pouch sinus and to assess factors associated with the healing of pouch sinus. DESIGN An historical cohort study from a prospectively collected database. SETTING A high-volume specialized pouch center. PATIENTS From tertiary-care pouch center. INTERVENTIONS Endoscopic needle-knife therapy. RESULTS This cohort consisted of 65 patients. Men accounted for 76.9% (n = 50). The median interval from colectomy to the diagnosis of pouch sinus was 4.0 years (interquartile range [IQR]: 2.0-7.5). Pouch sinus was located at the anastomosis in 59 patients (90.8%), at the mid pouch suture line in 4 patients (6.2%), and at the tip of "J" in 2 patients (3.1%). The mean depth of the pouch sinus was 4.4 ± 1.8 cm. Twenty patients (30.8%) had complex pouch sinuses. After a median of 2.0 needle-knife therapies (IQR: 1.5-3.5) during a follow-up period of 1.1 years (IQR: 0.4-2.8), 28 patients (43.1%) with pouch sinus experienced a complete response, 27 (41.5%) had a partial response, and 10 (15.4%) had persistent sinus. Fifty-three patients (81.5%) maintained a functional pouch at the last follow-up. Multivariate analysis showed that a longer duration from colectomy to diagnosis of pouch sinus (odds ratio: 0.85; 95% confidence interval: 0.73-0.99; P = .033) and complex sinuses (odds ratio: 0.17; 95% confidence interval: 0.04-0.70; P = .014) were inversely associated with the healing of pouch sinuses, whereas the increased sessions of needle-knife therapy (odds ratio: 1.36; 95% confidence interval: 1.01-1.81; P = .041) improved the healing of the pouch sinuses. LIMITATIONS Single-center study with a relatively small number of patients. CONCLUSION In experienced hands, endoscopic needle-knife therapy is an efficacious and safe procedure for pouch sinuses. A longer duration from colectomy to diagnosis of pouch sinus and complex pouch sinuses appeared to be associated with a higher risk for nonhealing of the sinus, suggesting that early diagnosis and intervention have an impact on outcomes.
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Affiliation(s)
- Xian-Rui Wu
- Department of Colorectal Surgery, the Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Richard C K Wong
- Division of Gastroenterology and Liver Disease, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Bo Shen
- Department of Gastroenterology/Hepatology, the Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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Sofue K, Takeuchi Y, Shibamoto K, Sugimoto K, Sugimura K, Arai Y. Infusion of 50% glucose solution to occlude an intrahepatic portosystemic venous shunt before percutaneous transhepatic portal embolization: report of a case. Surg Today 2013; 44:2366-8. [PMID: 24091863 DOI: 10.1007/s00595-013-0745-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
Abstract
A 68-year-old man with cholangiocarcinoma underwent percutaneous transhepatic portal embolization to expand the indication for hepatic resection. Selective right posterior portography revealed an intrahepatic portosystemic venous shunt (IPSVS) connecting the segment VII branch to the right hepatic venous branch. An infusion of 50 % glucose solution was given to occlude the shunt. This is novel management for IPSVSs when they are numerous, small, or torturous, and makes the subsequent procedures simpler, shorter, and less expensive.
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Affiliation(s)
- Keitaro Sofue
- Department of Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo, Tokyo, 104-0045, Japan,
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Prachayakul V, Aswakul P, Chantarojanasiri T, Leelakusolvong S. Factors influencing clinical outcomes of Histoacryl ® glue injection-treated gastric variceal hemorrhage. World J Gastroenterol 2013; 19:2379-2387. [PMID: 23613633 PMCID: PMC3631991 DOI: 10.3748/wjg.v19.i15.2379] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/03/2013] [Accepted: 01/24/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the factors associated with clinical outcomes and complications of Histoacryl® glue injection for acute gastric variceal hemorrhage.
METHODS: Patients who presented to the Siriraj Gastrointestinal Endoscopy Center with active gastric variceal bleeding and were admitted for treatment between April 2008 and October 2011 were selected retrospectively for study inclusion. All bleeding varices were treated by injection of Histoacryl® tissue glue (B. Braun Melsungen AG, Germany) through a 21G or 23G catheter primed with lipiodol to prevent premature glue solidification. Data recorded for each patient included demographic and clinical characteristics, endoscopic findings, clinical outcomes in terms of early and late re-bleeding, mortality, and procedure-related complications. Data from admission (baseline) and post-treatment were comparatively analyzed using stepwise logistic regression analysis to determine the correlation between factors and clinical outcomes.
RESULTS: A total of 90 patients underwent Histoacryl® injection to treat bleeding gastric varices. The mean age was 55.9 ± 13.9 (range: 15-88) years old, and 74.4% of the patients were male. The most common presentations were hematemesis (71.1%), melena (12.2%), and coffee ground emesis (8.9%). Initial hemostasis was experienced in 97.8% of patients, while re-bleeding within 120 h occurred in 10.0%. The presence of ascites was the only factor associated with early and late re-bleeding [odds ratio (OR) = 10.67, 95%CI: 1.27-89.52, P = 0.03 and OR = 4.15, 95%CI: 1.34-12.86, P = 0.01, respectively]. Early procedure-related complications developed in 14.4% of patients, and were primarily infections and non-fatal systemic embolization. Late re-bleeding was significantly correlated with early procedure-related complications by univariate analysis (OR = 4.01, 95%CI: 1.25-12.87, P = 0.04), but no factors were significantly correlated by multivariate analysis. The overall mortality rate was 21.1%, the majority of which were related to infections. The factors showing strong association with higher mortality risk were elevated total bilirubin (OR = 16.71, 95%CI: 3.28-85.09, P < 0.01), a large amount of transfused fresh frozen plasma (OR = 1.001, 95%CI: 1.000-1.002, P = 0.03), and late re-bleeding (OR = 10.99, 95%CI: 2.15-56.35, P = 0.02).
CONCLUSION: Histoacryl® injection is a safe and effective hemostatic method for treating gastric variceal hemorrhage. Patients with compromised liver, including ascites, have a higher risk of re-bleeding.
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Abstract
Bleeding from gastric varices (GVs) is generally more severe than bleeding from esophageal varices (EVs), but is thought to occur less frequently. Although several recent developments in the agents and the techniques have improved the outcome of GV bleeds no consensus has been reached on the optimum treatment. Because the blood flow in the GVs is relatively large and the bleeding is rapid and often profuse endoscopic means of treating bleeding GVs are the treatments of choice. Endoscopic injection of cyanoacrylate glue is the treatment of choice for the control of active bleeding of gastric avarices and to prevent rebleeding. This article reviews the current endoscopic treatment modalities used in gastric variceal bleeding, and the primary and secondary prophylaxis of gastric variceal bleeding.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G B Pant Hospital, University of Delhi, Institute of Liver and Biliary Sciences, New Delhi, India.
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Seewald S, Ang TL, Imazu H, Naga M, Omar S, Groth S, Seitz U, Zhong Y, Thonke F, Soehendra N. A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos). Gastrointest Endosc 2008; 68:447-54. [PMID: 18760173 DOI: 10.1016/j.gie.2008.02.050] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Accepted: 02/11/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND N-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported. OBJECTIVE Our purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using a standardized injection technique and regimen. DESIGN Retrospective. SETTING Two tertiary referral centers. PATIENTS A total of 131 patients (91 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen. INTERVENTIONS (1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration. MAIN OUTCOME MEASUREMENTS Immediate hemostasis rate, early rebleeding rate, bleeding-related mortality rate, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate. RESULTS Initial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively. CONCLUSION Obliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.
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Affiliation(s)
- Stefan Seewald
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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