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Jang JY, Jeon UB, Kim JH, Kim TU, Ryu H, Cho M, Hong YM, Yoon KT. Plug-assisted retrograde transvenous obliteration via gastrocaval shunt for the gastric variceal bleeding: A case report. Medicine (Baltimore) 2021; 100:e28107. [PMID: 34889266 PMCID: PMC8663895 DOI: 10.1097/md.0000000000028107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/16/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Most gastric varices at the fundus drain into the left renal vein via the gastrorenal shunt (80-85% of cases) or the inferior vena cava via the gastrocaval shunt (10-15%). Therefore, plug-assisted retrograde transvenous obliteration (PARTO) is usually performed via a gastrorenal shunt. Here, we report a case of gastric varix treated with PARTO via a gastrocaval shunt. PATIENT CONCERNS A 46-year-old woman with hepatitis B virus and liver cirrhosis visited the emergency room in our hospital with the main symptom of hematemesis and hematochezia. DIAGNOSES Endoscopy and computed tomography (CT) revealed a gastric varix and thrombotic-occluded transjugular intrahepatic portosystemic shunt (TIPS) stent. INTERVENTIONS The patient underwent PARTO via a gastrocaval shunt to manage gastric variceal bleeding after failed TIPS revision. OUTCOMES On CT, the gastric varix completely disappeared. The patient did not experience any additional bleeding events. LESSONS PARTO via a gastrocaval shunt is safe and effective.
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Affiliation(s)
- Joo Yeon Jang
- Department of Radiology, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Busan, Korea
| | - Ung Bae Jeon
- Department of Radiology, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Busan, Korea
| | - Jin Hyeok Kim
- Department of Radiology, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Busan, Korea
| | - Tae Un Kim
- Department of Radiology, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Busan, Korea
| | - Hwaseong Ryu
- Department of Radiology, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Busan, Korea
| | - Mong Cho
- Department of Internal Medicine, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Busan, Korea
| | - Young Mi Hong
- Department of Internal Medicine, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Busan, Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, College of Medicine, Pusan National University, Busan, Korea
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Waguri N, Osaki A, Watanabe Y. Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices. World J Hepatol 2021; 13:650-661. [PMID: 34239700 PMCID: PMC8239489 DOI: 10.4254/wjh.v13.i6.650] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/12/2021] [Accepted: 05/22/2021] [Indexed: 02/06/2023] Open
Abstract
Rupture of gastric varices (GVs) can be fatal. Balloon-occluded retrograde transvenous obliteration (BRTO), as known as retrograde sclerotherapy, has been widely adopted for treatment of GVs because of its effectiveness, ability to cure, and utility in emergency and prophylactic treatment. Simplifying the route of blood flow from GVs to the gastrorenal shunt is important for the successful BRTO. This review outlines BRTO indications and contraindications, describes basic BRTO procedures and modifications, compares BRTO with other GVs treatments, and discusses various combination therapies. Combined BRTO and partial splenic embolization may prevent exacerbation of esophageal varices and shows promise as a treatment option.
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Affiliation(s)
- Nobuo Waguri
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata 950-1197, Japan
| | - Akihiko Osaki
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata 950-1197, Japan
| | - Yusuke Watanabe
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata 950-1197, Japan
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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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Xiaoqing Z, Na L, Lili M, Jie C, Tiancheng L, Jian W, Shiyao C. Endoscopic Cyanoacrylate Injection with Lauromacrogol for Gastric Varices: Long-Term Outcomes and Predictors in a Retrospective Cohort Study. J Laparoendosc Adv Surg Tech A 2019; 29:1135-1143. [PMID: 31313965 DOI: 10.1089/lap.2019.0360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction: The first-line treatment for gastric variceal rebleeding in cirrhotic patients is endoscopic cyanoacrylate injection. We focused on the efficacy and prognosis of cyanoacrylate combined with Lauromacrogol® for gastric varices (GV) in a retrospective study of long-term follow-up. Materials and Methods: One hundred thirty patients with cirrhosis and GV from March 2011 to February 2013 were included. Sixty-eight patients underwent endoscopic cyanoacrylate injection with Lauromacrogol and 62 patients without Lauromacrogol. The median follow-up was 40.1 and 38.8 months, respectively. Results: The volumes of cyanoacrylate used for the GV eradication in the Lauromacrogol group were significantly lower than those in the Ethiodol® group (1.6 ± 0.8 versus 2.1 ± 1.2 mL, P = .029). No ectopic embolisms were observed during follow-up. The 1- and 3-year rebleeding-free rate did not differ between groups (83.7% and 59.2% versus 75.8% and 62.5%; P = .797). The same was observed for mortality (86.6% and 83.5% versus 85.5% and 83.7%; P = .955). New portal venous thrombosis (PVT) and progression of previous partial PVT were independently associated with rebleeding (hazard ratio [HR] 5.127, 95% confidence interval [CI], 2.430-10.817, P = .000) and death (HR 10.093, 95% CI, 3.988-25.548, P = .000). Conclusions: Endoscopic cyanoacrylate injection with Lauromacrogol might minimize the required dosage of cyanoacrylate, but it did not improve rebleeding rate or survival. Exacerbation of PVT was associated with rebleeding and death.
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Affiliation(s)
- Zeng Xiaoqing
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Na
- Department of Infectious Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ma Lili
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Jie
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Luo Tiancheng
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wang Jian
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Shiyao
- Department of Gastroenterology and Hepatology, Zhongshan Hospital, Fudan University, Shanghai, China.,Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
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5
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Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW, Olliff SP, Hudson M, Christie JM. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 64:1680-1704. [PMID: 25887380 PMCID: PMC4680175 DOI: 10.1136/gutjnl-2015-309262] [Citation(s) in RCA: 406] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/11/2015] [Accepted: 03/17/2015] [Indexed: 12/12/2022]
Abstract
These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London, London, UK
| | - Charles Millson
- Gastrointestinal and Liver Services, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Homoyon Mehrzad
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Austin
- Department of Gastroenterology, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - James W Ferguson
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon P Olliff
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Hudson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - John M Christie
- Department of Gastroenterology, Royal Devon and Exeter Hospital, Devon, UK
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Arora A, Rajesh S, Meenakshi YS, Sureka B, Bansal K, Sarin SK. Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review. Insights Imaging 2015; 6:559-72. [PMID: 26337049 PMCID: PMC4569600 DOI: 10.1007/s13244-015-0419-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/25/2015] [Accepted: 06/29/2015] [Indexed: 12/14/2022] Open
Abstract
The purpose of this article is to describe the various portosystemic collateral pathways pertinent to portal hypertension on multi-detector row computed tomography (MDCT) and their clinical relevance, with special emphasis on the uncommon ones. The knowledge and understanding of the various patterns of portosystemic collateral channels has important implications both for the clinician and the interventionist. MDCT with its advanced post processing capabilities can exquisitely demonstrate these vascular pathways to help in therapeutic decision making. Teaching points • Portosystemic collaterals are an important cause of bleeding and hepatic encephalopathy. • Radiologists should be familiar with the imaging findings to effectively identify them. • Pre-operative knowledge of portosystemic collaterals is essential to avoid inadvertent vascular injury.
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Affiliation(s)
- Ankur Arora
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - S Rajesh
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Yamini S Meenakshi
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Binit Sureka
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Kalpana Bansal
- Department of Radiology, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, 110070, India.
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences, D-1, Vasant Kunj, New Delhi, 110070, India.
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7
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Orloff MJ, Hye RJ, Wheeler HO, Isenberg JI, Haynes KS, Vaida F, Girard B, Orloff KJ. Randomized trials of endoscopic therapy and transjugular intrahepatic portosystemic shunt versus portacaval shunt for emergency and elective treatment of bleeding gastric varices in cirrhosis. Surgery 2015; 157:1028-45. [PMID: 25957003 PMCID: PMC6370460 DOI: 10.1016/j.surg.2014.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 11/14/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Bleeding esophageal varices has been studied extensively, but bleeding gastric varices (BGV) has received much less investigation. However, BGV has been reported in ≤ 30% of patients with acute variceal bleeding. In our studies of 1,836 bleeding cirrhotics, 12.7% were bleeding from gastric varices. BGV mortality rate of 45-55% has been reported. The BGV literature has mainly involved retrospective case reports, often with short-term follow-up. OBJECTIVE We sought to describe the results of a prospective, randomized, controlled trial (RCT) in unselected, consecutive patients with BGV comparing endoscopic therapy (ET) with portacaval shunt (PCS; n = 518), and later comparing emergency transjugular intrahepatic portosystemic shunt (TIPS) with emergency portacaval shunt (EPCS; n = 70). DESIGN, SETTING, AND PARTICIPANTS Initially, our RCT involved 518 patients with BGV comparing ET with direct PCS regarding control of bleeding, mortality rate, and disability. When entry of patients ended, the RCT was expanded to compare emergency TIPS with EPCS (n = 70). This RCT of BGV was separate from our other RCTs of bleeding esophageal varices. INTERVENTIONS Initially, ET was compared with PCS. In the second part of our RCT, emergency TIPS was compared with emergency PCS (EPCS). MAIN OUTCOME MEASURES Outcomes were survival, control of bleeding, portal-systemic encephalopathy (PSE), quality of life, and direct costs of care. In the RCT of ET versus PCS, 28 and 30%, respectively, were in Child class C. In the expanded RCT of TIPS versus EPCS, 40 and 41%, respectively, were in Child class C. Permanent control of BGV was achieved in 97-100% of patients treated by emergency or elective PCS, compared with 27-29% by ET. TIPS was even less effective, achieving long-term control of BGV in only 6%. Survival rates after PCS were greater at all time intervals and in all Child classes (P < .001). Repeated episodes of PSE occurred in 50% of TIPS patients, 16-17% treated by ET, and 8-11% treated by PCS. Shunt stenosis or occlusion occurred in 67% of TIPS patients, in contrast with 0-2% of PCS patients. CONCLUSION These results support the conclusion that PCS is uniformly effective, whereas ET and TIPS are not very effective.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA.
| | - Robert J Hye
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA
| | - Henry O Wheeler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego Medical Center, San Diego, CA
| | - Jon I Isenberg
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego Medical Center, San Diego, CA
| | - Kevin S Haynes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego Medical Center, San Diego, CA
| | - Florin Vaida
- Department of Family and Preventive Medicine/Biostatistics and Bioinformatics, University of California, San Diego Medical Center, San Diego, CA
| | - Barbara Girard
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA
| | - Karen J Orloff
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA
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Ríos Castellanos E, Seron P, Gisbert JP, Bonfill Cosp X, Cochrane Hepato‐Biliary Group. Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension. Cochrane Database Syst Rev 2015; 2015:CD010180. [PMID: 25966446 PMCID: PMC10776035 DOI: 10.1002/14651858.cd010180.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In people with portal hypertension, gastric varices are less prevalent than oesophageal varices. The risk of bleeding from gastric varices seems to be lower than from oesophageal varices; however, when gastric varices bleed, it is often severe and associated with higher mortality. Endoscopic sclerotherapy of bleeding gastric varices with N-butyl-2-cyanoacrylate glue (cyanoacrylate) is considered the best haemostasis with a lower risk of re-bleeding compared with other endoscopic methods. However, there are some inconsistencies between trials regarding mortality, incidence of re-bleeding, and adverse effects. OBJECTIVES To assess the benefits and harms of sclerotherapy using cyanoacrylate compared with other endoscopic sclerotherapy procedures or with variceal band ligation for treating acute gastric variceal bleeding with or without vasoactive drugs in people with portal hypertension and to assess the best dosage of cyanoacrylate. SEARCH METHODS We searched the Cochrane Hepato-Biliary Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded from inception to September 2014 and reference lists of articles. We included trials irrespective of trial setting, language, publication status, or date of publication. SELECTION CRITERIA Randomised clinical trials comparing sclerotherapy using cyanoacrylate versus other endoscopic methods (sclerotherapy using alcohol-based compounds or endoscopy band ligation) for acute gastric variceal bleeding in people with portal hypertension. DATA COLLECTION AND ANALYSIS We performed the review following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the Cochrane Hepato-Biliary Module.We presented results as risk ratios (RR) with 95% confidence intervals (CI), with I(2) statistic values as a measure of intertrial heterogeneity. We analysed data with both fixed-effect and random-effects models, and reported the results with random-effects models. We performed subgroup, sensitivity, and trial sequential analyses to evaluate the robustness of the overall results, risk of bias, sources of intertrial heterogeneity, and risk of random errors. MAIN RESULTS We included six randomised clinical trials with three different comparisons: one trial compared two different doses of cyanoacrylate in 91 adults, bleeding actively from all types of gastric varices; one trial compared cyanoacrylate versus alcohol-based compounds in 37 adults with active or acute bleeding from isolated gastric varices only; and four trials compared cyanoacrylate versus endoscopic band ligation in 365 adults, with active or acute bleeding from all types of gastric varices. Main outcomes in the included trials were bleeding-related mortality, failure of intervention, re-bleeding, adverse events, and control of bleeding. Follow-up varied from six to 26 months. The participants included in these trials had chronic liver disease of different severities, were predominantly men, and most were from Eastern countries. We judged all trials at high risk of bias. Application of quality criteria for all outcomes yielded very low quality grade of the evidence in the three analyses, except for the low quality evidence rated for the re-bleeding outcome in the cyanoacrylate versus endoscopic band ligation comparison. Two different doses of cyanoacrylate: we found very low quality evidence from one trial for the effect of 0.5 mL compared with 1.0 mL of cyanoacrylate on all-cause mortality (20/44 (45.5%) with 0.5 mL versus 21/47 (45%) with 1.0 mL; RR 1.02; 95% CI 0.65 to 1.60), 30-day mortality (RR 1.07; 95% CI 0.41 to 2.80), failure of intervention (RR 1.07; 95% CI 0.56 to 2.05), prevention of re-bleeding (RR 1.30; 95% CI 0.73 to 2.31), adverse events reported as fever (RR 0.56; 95% CI 0.32 to 0.98), and control of bleeding (RR 1.04; 95% CI 0.78 to 1.38). Cyanoacrylate versus alcohol-based compounds: we found very low quality evidence from one trial for the effect of cyanoacrylate versus alcohol-based compounds on 30-day mortality (2/20 (10%) with cyanoacrylate versus 4/17 (23.5%) with alcohol-based compound; RR 0.43; 95% CI 0.09 to 2.04), failure of intervention (RR 0.36; 95% CI 0.09 to 1.35), prevention of re-bleeding (RR 0.85; 95% CI 0.30 to 2.45), adverse events reported as fever (RR 0.43; 95% CI 0.22 to 0.80), and control of bleeding (RR 1.79; 95% CI 1.13 to 2.84). Cyanoacrylate versus endoscopic band ligation: we found very low quality evidence for the effect of cyanoacrylate versus endoscopic band ligation on bleeding-related mortality (44/185 (23.7%) with cyanoacrylate versus 50/181 (27.6%) with endoscopic band ligation; RR 0.83; 95% CI 0.52 to 1.31), failure of intervention (RR 1.13; 95% CI 0.23 to 5.69), complications (RR 2.81; 95% CI 0.69 to 11.49), and control of bleeding (RR 1.07; 95% CI 0.90 to 1.27). There was low quality evidence for the prevention of re-bleeding (RR 0.60; 95% CI 0.41 to 0.88). Trial sequential analysis showed that the analyses were underpowered (diversity-adjusted required information size was 5290 participants for bleeding-related mortality). AUTHORS' CONCLUSIONS This review suggests that endoscopic sclerotherapy using cyanoacrylate may be more effective than endoscopic band ligation in terms of preventing re-bleeding from gastric varices. However, due to the very low quality of the evidence, we are very uncertain about our estimates on all-cause and bleeding-related mortality, failure of intervention, adverse events, and control of bleeding. The trials were at high risk of bias; the number of the included randomised clinical trials and number of participants included in each trial was small; and there was evidence of internal heterogeneity across trials, indirectness of evidence in terms of population, and possible publication bias.The effectiveness of different doses of cyanoacrylate and the comparison of cyanoacrylate versus alcohol compounds to treat variceal bleeding in people with portal hypertension is uncertain due to the very low quality of the evidence.The shortcomings mentioned call for more evidence from larger trials that need to be conducted according to the SPIRIT statement and reported according to CONSORT guidelines.
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Affiliation(s)
- Eddy Ríos Castellanos
- Facultad de Medicina, Universidad de La FronteraCIGES ‐ Departamento de Medicina InternaPaula Jaraquemada 02740TemucoIXChile4810448
- CIGES, La Frontera UniversityDepartment of Internal MedicineTemucoChile
| | - Pamela Seron
- Facultad de Medicina, Universidad de La FronteraCIGES ‐ Departamento de Medicina InternaPaula Jaraquemada 02740TemucoIXChile4810448
- CIGES, La Frontera UniversityDepartment of Internal MedicineTemucoChile
| | - Javier P Gisbert
- Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)Gastroenterology UnitMadridSpain
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP) ‐ Universitat Autònoma de BarcelonaIberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret, 167Pavilion 18 (D‐13)BarcelonaCataloniaSpain08025
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9
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Ríos Castellanos E, Seron P, Gisbert JP, Bonfill Cosp X. Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [PMID: 25966446 DOI: 10.1002/14651858.cd010180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In people with portal hypertension, gastric varices are less prevalent than oesophageal varices. The risk of bleeding from gastric varices seems to be lower than from oesophageal varices; however, when gastric varices bleed, it is often severe and associated with higher mortality. Endoscopic sclerotherapy of bleeding gastric varices with N-butyl-2-cyanoacrylate glue (cyanoacrylate) is considered the best haemostasis with a lower risk of re-bleeding compared with other endoscopic methods. However, there are some inconsistencies between trials regarding mortality, incidence of re-bleeding, and adverse effects. OBJECTIVES To assess the benefits and harms of sclerotherapy using cyanoacrylate compared with other endoscopic sclerotherapy procedures or with variceal band ligation for treating acute gastric variceal bleeding with or without vasoactive drugs in people with portal hypertension and to assess the best dosage of cyanoacrylate. SEARCH METHODS We searched the Cochrane Hepato-Biliary Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded from inception to September 2014 and reference lists of articles. We included trials irrespective of trial setting, language, publication status, or date of publication. SELECTION CRITERIA Randomised clinical trials comparing sclerotherapy using cyanoacrylate versus other endoscopic methods (sclerotherapy using alcohol-based compounds or endoscopy band ligation) for acute gastric variceal bleeding in people with portal hypertension. DATA COLLECTION AND ANALYSIS We performed the review following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the Cochrane Hepato-Biliary Module.We presented results as risk ratios (RR) with 95% confidence intervals (CI), with I(2) statistic values as a measure of intertrial heterogeneity. We analysed data with both fixed-effect and random-effects models, and reported the results with random-effects models. We performed subgroup, sensitivity, and trial sequential analyses to evaluate the robustness of the overall results, risk of bias, sources of intertrial heterogeneity, and risk of random errors. MAIN RESULTS We included six randomised clinical trials with three different comparisons: one trial compared two different doses of cyanoacrylate in 91 adults, bleeding actively from all types of gastric varices; one trial compared cyanoacrylate versus alcohol-based compounds in 37 adults with active or acute bleeding from isolated gastric varices only; and four trials compared cyanoacrylate versus endoscopic band ligation in 365 adults, with active or acute bleeding from all types of gastric varices. Main outcomes in the included trials were bleeding-related mortality, failure of intervention, re-bleeding, adverse events, and control of bleeding. Follow-up varied from six to 26 months. The participants included in these trials had chronic liver disease of different severities, were predominantly men, and most were from Eastern countries. We judged all trials at high risk of bias. Application of quality criteria for all outcomes yielded very low quality grade of the evidence in the three analyses, except for the low quality evidence rated for the re-bleeding outcome in the cyanoacrylate versus endoscopic band ligation comparison. Two different doses of cyanoacrylate: we found very low quality evidence from one trial for the effect of 0.5 mL compared with 1.0 mL of cyanoacrylate on all-cause mortality (20/44 (45.5%) with 0.5 mL versus 21/47 (45%) with 1.0 mL; RR 1.02; 95% CI 0.65 to 1.60), 30-day mortality (RR 1.07; 95% CI 0.41 to 2.80), failure of intervention (RR 1.07; 95% CI 0.56 to 2.05), prevention of re-bleeding (RR 1.30; 95% CI 0.73 to 2.31), adverse events reported as fever (RR 0.56; 95% CI 0.32 to 0.98), and control of bleeding (RR 1.04; 95% CI 0.78 to 1.38). Cyanoacrylate versus alcohol-based compounds: we found very low quality evidence from one trial for the effect of cyanoacrylate versus alcohol-based compounds on 30-day mortality (2/20 (10%) with cyanoacrylate versus 4/17 (23.5%) with alcohol-based compound; RR 0.43; 95% CI 0.09 to 2.04), failure of intervention (RR 0.36; 95% CI 0.09 to 1.35), prevention of re-bleeding (RR 0.85; 95% CI 0.30 to 2.45), adverse events reported as fever (RR 0.43; 95% CI 0.22 to 0.80), and control of bleeding (RR 1.79; 95% CI 1.13 to 2.84). Cyanoacrylate versus endoscopic band ligation: we found very low quality evidence for the effect of cyanoacrylate versus endoscopic band ligation on bleeding-related mortality (44/185 (23.7%) with cyanoacrylate versus 50/181 (27.6%) with endoscopic band ligation; RR 0.83; 95% CI 0.52 to 1.31), failure of intervention (RR 1.13; 95% CI 0.23 to 5.69), complications (RR 2.81; 95% CI 0.69 to 11.49), and control of bleeding (RR 1.07; 95% CI 0.90 to 1.27). There was low quality evidence for the prevention of re-bleeding (RR 0.60; 95% CI 0.41 to 0.88). Trial sequential analysis showed that the analyses were underpowered (diversity-adjusted required information size was 5290 participants for bleeding-related mortality). AUTHORS' CONCLUSIONS This review suggests that endoscopic sclerotherapy using cyanoacrylate may be more effective than endoscopic band ligation in terms of preventing re-bleeding from gastric varices. However, due to the very low quality of the evidence, we are very uncertain about our estimates on all-cause and bleeding-related mortality, failure of intervention, adverse events, and control of bleeding. The trials were at high risk of bias; the number of the included randomised clinical trials and number of participants included in each trial was small; and there was evidence of internal heterogeneity across trials, indirectness of evidence in terms of population, and possible publication bias.The effectiveness of different doses of cyanoacrylate and the comparison of cyanoacrylate versus alcohol compounds to treat variceal bleeding in people with portal hypertension is uncertain due to the very low quality of the evidence.The shortcomings mentioned call for more evidence from larger trials that need to be conducted according to the SPIRIT statement and reported according to CONSORT guidelines.
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Affiliation(s)
- Eddy Ríos Castellanos
- CIGES - Departamento de Medicina Interna, Facultad de Medicina, Universidad de La Frontera, Paula Jaraquemada 02740, Temuco, IX, Chile, 4810448
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Emori K, Toyonaga A, Oho K, Kumamoto M, Haruta T, Inoue H, Morita Y, Mitsuyama K, Tsuruta O, Sata M. Balloon-occluded retrograde transvenous obliteration versus endoscopic injection sclerotherapy for isolated gastric varices: a comparative study. Kurume Med J 2014; 60:105-13. [PMID: 24858411 DOI: 10.2739/kurumemedj.ms63009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Isolated gastric varices (IGV) have a lower risk of bleeding than esophageal varices, however IGV bleeding is associated with a higher mortality than bleeding of esophageal varices. In recent years, two widely used treatments for IGV have been balloon-occluded retrograde transvenous obliteration (B-RTO) and endoscopic injection sclerotherapy (EIS) using cyanoacrylate or ethanolamine oleate (EO). This study compared these two treatment methods for IGV. The subjects were 112 patients who were treated at our hospital for IGV bleeding between October 1990 and December 2003. Forty-nine (49) patients were treated with B-RTO and 63 patients with EIS. These two patient groups were compared as regards content of treatment, post-treatment incidence of variceal bleeding, incidence of IGV rebleeding, survival rate, cause of death, and complications. Multivariate analysis was performed on post-treatment variceal bleeding and survival. Although EO was used in higher amounts in the B-RTO group than in the EIS group, the B-RTO group had a significantly lower number of treatment sessions and a significantly shorter treatment period (p<0.05). The EIS group had significantly more patients with IGV rebleeding after treatment than the B-RTO group. Treatment method was the only independent prognostic factor of IGV bleeding after treatment (p=0.024). The two groups did not differ significantly in the percentage of patients with aggravated esophageal varices after treatment. Bleeding from ectopic varices was not observed in any patient. There was no significant difference in survival by treatment method. The presence of hepatocellular carcinoma was the only independent prognostic factor for survival (p=0.003). It is concluded that B-RTO was more effective than EIS in the eradication of IGV and prevention of IGV recurrence and rebleeding.
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Affiliation(s)
- Keigo Emori
- Department of Medicine, Kurume University School of Medicine
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Choi MH, Kim YS, Kim SG, Lee YN, Seo YR, Kim MJ, Lee SH, Jeong SW, Jang JY, Kim HS, Kim BS. The secondary prophylactic efficacy of beta-blocker after endoscopic gastric variceal obturation for first acute episode of gastric variceal bleeding. Clin Mol Hepatol 2013; 19:280-7. [PMID: 24133666 PMCID: PMC3796678 DOI: 10.3350/cmh.2013.19.3.280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Revised: 08/09/2013] [Accepted: 08/13/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS The most appropriate treatment for acute gastric variceal bleeding (GVB) is currently endoscopic gastric variceal obturation (GVO) using Histoacryl®. However, the secondary prophylactic efficacy of beta-blocker (BB) after GVO for the first acute episode of GVB has not yet been established. The secondary prophylactic efficacy of BB after GVO for the first acute episode of GVB was evaluated in this study. METHODS Ninety-three patients at Soonchunhyang University Hospital with acute GVB who received GVO using Histoacryl® were enrolled between June 2001 and March 2010. Among these, 42 patients underwent GVO alone (GVO group) and 51 patients underwent GVO with adjuvant BB therapy (GVO+BB group). This study was intended for patients in whom a desired heart rate was reached. The rates of rebleeding-free survival and overall survival were calculated for the two study groups using Kaplan-Meyer analysis and Cox's proportional-hazards model. RESULTS The follow-up period after the initial eradication of gastric varices was 18.14±25.22 months (mean±SD). During the follow-up period, rebleeding occurred in 10 (23.8%) and 21 (41.2%) GVO and GVO+BB patients, respectively, and 39 patients died [23 (54.8%) in the GVO group and 16 (31.4%) in the GVO+BB group]. The mean rebleeding-free survival time did not differ significantly between the GVO and GVO+BB groups (65.40 and 37.40 months, respectively; P=0.774), whereas the mean overall survival time did differ (52.54 and 72.65 months, respectively; P=0.036). CONCLUSIONS Adjuvant BB therapy after GVO using Histoacryl® for the first acute episode of GVB could decrease the mortality rate relative to GVO alone. However, adjuvant BB therapy afforded no benefit for the secondary prevention of rebleeding in GV.
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Affiliation(s)
- Moon Han Choi
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, Korea
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12
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Zhou J, Wu Z, Pankaj P, Peng B. Long-term postoperative outcomes of hypersplenism: laparoscopic versus open splenectomy secondary to liver cirrhosis. Surg Endosc 2012; 26:3391-400. [PMID: 22648114 DOI: 10.1007/s00464-012-2349-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 04/24/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hypersplenism is a common clinical manifestation in patients with liver cirrhosis. For treatment, surgeons can choose between two options: open splenectomy (OS) or laparoscopic splenectomy (LS). Although splenectomy has wide exposure and acceptance as a remedy for the patients with hypersplenism secondary to liver cirrhosis, the data are sparse with regard to its long-term outcomes, including hematologic response and liver function after the surgery. This study aimed to determine the long-term effect of OS versus LS for cirrhotic patients with hypersplenism. METHODS Between September 2003 and June 2011, the study enrolled 63 consecutive patients with hypersplenism secondary to liver cirrhosis who were treated with LS (n = 34) or OS (n = 29). The hematologic parameters and liver function in both groups were evaluated before and after splenectomy, and a comparative study of the long-term follow-up period was conducted. RESULTS Postoperatively, 100% of the patients in both groups had a complete response in terms of platelet and leukocyte counts. No changes in liver function were noted. The LS group benefited from less intraoperative blood loss and a shorter postoperative hospital stay than the OS group experienced. The mean follow-up period was 25 months. To date, no death has been reported in either group. All the patients showed complete or partial hematologic response to splenectomy and exhibited improvement in liver function. None of the parameters differed significantly between the two groups. Portal or splenic vein thromboses were detected in three patients (2 in OS and 1 in LS), whereas esophageal variceal bleeding occurred for one patient in the LS group and one patient in the OS group. CONCLUSION This study investigated patients with hypersplenism secondary to liver cirrhosis. The findings showed that LS can be considered a well-disposed surgical procedure with good surgical outcomes compared with OS.
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Affiliation(s)
- Jin Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
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Abstract
Although the incidence of bleeding from gastric varices is relatively low (10%-36%), the bleeding is massive once it has occurred and it increases the patient's mortality. The management of esophageal variceal bleeding is highly differentiated with several effective treatments available. In contrast, bleeding from gastric varices continues to be a therapeutic challenge. In the last decade, there have been increasing reports regarding the management of gastric varices. In this article we review recent progress in the management of gastric varices and discuss further expected studies.
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Affiliation(s)
- Makoto Hashizume
- Department of Advanced Medical Initiatives, Kyushu University, Fukuoka, Japan.
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Min SK, Kim SG, Kim YS, Bae JY, Lee JC, Lee SH, Kim HS, Jeong SW, Jang JY, Moon JH, Lee MS, Kim BS. Comparison among Endoscopic Variceal Obliteration, Endoscopic Band Ligation, and Balloon-occluded Retrograde Transvenous Obliteration for Treatment of Gastric Variceal Bleeding. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 57:302-8. [DOI: 10.4166/kjg.2011.57.5.302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Seul Ki Min
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Jun Yong Bae
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Jong Chan Lee
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Sae Hwan Lee
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Hong Soo Kim
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Jong Ho Moon
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Moon Sung Lee
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
| | - Boo Sung Kim
- Department of Internal Medicine, Soon Chun Hyang University School of Medicine, Bucheon, Korea
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Becerro de Bengoa Vallejo R, Losa Iglesias ME, Alou Cervera L, Sevillano Fernández D, Prieto Prieto J. Total nail ablation for onychodystrophy with optimized gauze-phenol application. J Eur Acad Dermatol Venereol 2010; 24:936-42. [PMID: 20180894 DOI: 10.1111/j.1468-3083.2010.03569.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nail disorders are frequent among the geriatric population and unfortunately, repeat avulsion procedures often result in complications. OBJECTIVE To utilize a phenol-based total matricectomy technique for permanent nail ablation and evaluate its effectiveness. METHODS We performed total nail ablation on 34 toenails of the hallux (30 patients) with a gauze-phenol application technique and evaluated the degree of pain reported by the patient 12 months postoperatively compared with the preoperative stage. Furthermore, we evaluated the patients' satisfaction with the final cosmetic appearance as well as their satisfaction with the overall procedure. RESULTS All patients reported 'too much' or 'severe' pain prior to surgery and 94.11% reported 'no pain' 12 months post-surgery. A vast majority of the patients (82.35%) felt pleased with the cosmetic results and all patients reported that they were 'very satisfied' or 'strongly satisfied' with the procedure when interviewed at their 12 month follow-up examination. LIMITATIONS There were a limited number of participants in this study across an extensive timeframe. CONCLUSION Phenol-based total nail ablation with specific gauze application is safe, inexpensive and has a high rate of patient satisfaction.
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Affiliation(s)
- R Becerro de Bengoa Vallejo
- Escuela Universitaria de Enfermería, Fisioterapia y Podología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Akahoshi T, Hashizume M, Tomikawa M, Kawanaka H, Yamaguchi S, Konishi K, Kinjo N, Maehara Y. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience. J Gastroenterol Hepatol 2008; 23:1702-9. [PMID: 18713295 DOI: 10.1111/j.1440-1746.2008.05549.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Balloon-occluded retrograde transvenous obliteration (B-RTO) is a new alternative treatment for gastric varices (GVx), but the long-term efficacy is not known. We investigated the long-term effects of B-RTO on rebleeding, prevention of first bleeding, mortality and occurrence of risky esophageal varices (EVx). METHODS B-RTO was performed in 68 cirrhotic patients with GVx. Twenty patients had recent bleeding, transiently treated by endoscopic Histoacryl injection or balloon tamponade. Forty-eight patients had varices likely to bleed, but no bleeding. After B-RTO, the recurrent bleeding, occurrence of EVx and mortality over the long-term were evaluated. RESULTS B-RTO was successfully performed in 63 of 68 patients (92.6%). Varices eradication was confirmed by endoscopy in 61 of 63 patients (96.6%). During follow up, GVx bleeding occurred in two patients (3.2%). The 8-year cumulative rebleeding rates of patients with bleeding and risky GVx were 14% and 0%, respectively. Risky EVx occurred in 10 patients (17%) and the cumulative occurrence rate was 22% in 8 years. The cumulative occurrence rate of risky EVx was higher in GVx with EVx (GOV2-GVx) compared to GVx without EVx (IGV1, P < 0.05). No ectopic variceal bleeding occurred. No patients died from variceal bleeding. Hepatocellular carcinoma was the only significant prognostic factor (P < 0.05). CONCLUSION B-RTO is beneficial over the long-term, despite worsening EVx in some patients, because of excellent treatment efficacy and improved mortality. We believe that B-RTO can become a first-choice radical treatment following hemostasis for gastric variceal bleeding and prophylactic treatment for risky GVx.
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Affiliation(s)
- Tomohiko Akahoshi
- Departments of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Gastric varices with gastrorenal shunt: combined therapy using transjugular retrograde obliteration and partial splenic embolization. AJR Am J Roentgenol 2008; 191:555-9. [PMID: 18647931 DOI: 10.2214/ajr.07.3356] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study was prospectively conducted to evaluate the effectiveness of the combination of transjugular retrograde obliteration and partial splenic embolization in the treatment of gastric varices with gastrorenal shunt. SUBJECTS AND METHODS Between November 2002 and December 2006, 14 patients with gastric varices and gastrorenal shunt were treated by combining transjugular retrograde obliteration and partial splenic embolization (group 1). These patients were compared with 19 patients with gastric varices and gastrorenal shunt treated by only transjugular retrograde obliteration (group 2) for the disappearance rate of gastric varices, the cumulative survival rate, and the occurrence rate of esophageal varices after transjugular retrograde obliteration. Partial splenic embolization was performed 7-14 days before transjugular retrograde obliteration. No significant differences were seen between the two groups in terms of demographic data, including age, sex, and Child-Pugh classification. RESULTS The disappearance rate of gastric varices after transjugular retrograde obliteration was 100% in both groups. The 3-year cumulative survival rate after transjugular retrograde obliteration was 92% in group 1 and 95% in group 2. The 3-year cumulative occurrence rate of esophageal varices after transjugular retrograde obliteration was 9% in group 1 and 45% in group 2, a significant difference (p < 0.05). CONCLUSION The findings of this study indicate that partial splenic embolization contributed to preventing portal congestion after transjugular retrograde obliteration. We conclude that the combination of transjugular retrograde obliteration and partial splenic embolization for gastric varices is more effective than transjugular retrograde obliteration only in the long-term prevention of esophageal varices after transjugular retrograde obliteration.
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Development of thrombus in the major systemic and portal veins after balloon-occluded retrograde transvenous obliteration for treating gastric variceal bleeding: its frequency and outcome evaluation with CT. J Vasc Interv Radiol 2008; 19:529-38. [PMID: 18375297 DOI: 10.1016/j.jvir.2007.10.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 10/03/2007] [Accepted: 10/08/2007] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To investigate the frequency and outcome of the thrombus that developed in the major systemic and portal veins after balloon-occluded retrograde transvenous obliteration (BRTO) by comparing the computed tomographic (CT) scans obtained before and after BRTO treatment. MATERIALS AND METHODS Sixty patients with liver cirrhosis who underwent BRTO to treat gastric variceal bleeding were included in this study. The pre- and postprocedural CT scans in these patients were retrospectively compared to evaluate thrombus development in the major systemic and portal veins after BRTO. Thrombus was classified as having a high attenuation (ie, containing iodized oil), combined attenuation, or low attenuation. The outcome of the thrombus that developed in those veins after BRTO was evaluated by reviewing the serial follow-up CT scans. RESULTS After BRTO, 14 thrombi developed in 13 systemic and portal veins of nine of the 60 patients (15%). Eleven of the 14 thrombi had high attenuation, two thrombi had low attenuation, and one thrombus had a combined attenuation. The 13 affected veins included six splenic veins, four left renal veins, and three main portal veins. On the serial follow-up CT scans (range of the follow-up period, 5-25 months), all 11 high-attenuation thrombi were completely resolved without sequelae in the affected veins. One of the two low-attenuation thrombi disappeared with severe slitlike collapse of the affected left renal vein; the other low-attenuation thrombus had progressed and it caused complete occlusion of the affected main portal vein. One thrombus with a combined attenuation was almost completely resolved without sequelae in the affected splenic vein, despite the transient enlargement of the low-attenuation component. CONCLUSIONS In this study, the frequency of thrombus development in the major systemic and portal veins after BRTO was 15%. Although iodized oil deposited in those veins appears to be of no great importance, the low-attenuation thrombus can be associated with occlusion of the affected vein. These tendencies, however, require validation in a larger series.
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Sugimoto N, Watanabe K, Watanabe K, Ogata S, Shimoda R, Sakata H, Eguchi Y, Mizuta T, Tsunada S, Iwakiri R, Nojiri J, Mizuguchi M, Kudo S, Miyazaki K, Fujimoto K. Endoscopic hemostasis for bleeding gastric varices treated by combination of variceal ligation and sclerotherapy with N-butyl-2-cyanoacrylate. J Gastroenterol 2007; 42:528-32. [PMID: 17653647 DOI: 10.1007/s00535-007-2041-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2007] [Accepted: 03/05/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Bleeding from esophagogastric varices is a serious complication of portal hypertension. The aim of the present study was to determine whether endoscopic sclerotherapy with injection of N-butyl-2-cyanoacrylate combined with variceal ligation was useful for hemostasis of bleeding gastric varices. METHODS Twenty-seven patients with bleeding gastric varices underwent endoscopic treatment with variceal ligation followed by sclerotherapy with N-butyl-2-cyanoacrylate from November 1995 to November 2000. Patients underwent endoscopic variceal ligation only for the bleeding spot just before sclerotherapy. Injection was continued until varices were engorged. After these therapies, patients were followed for at least for 5 years. Retreatment was applied as necessary. RESULTS Among these patients, 11 had active bleeding and 16 had recent bleeding within 24 h with white or red plaques on gastric varices. All varices presented as nodular or tumorous forms. The hemostasis rate at 1 week after treatment with N-butyl-2-cyanoacrylate was 88.9% (24/27). Among the patients achieving hemostasis at 1 week, 33.3% (8/24) experienced recurrent bleeding between 5 and 53 months after the initial treatment. Five patients with rebleeding were treated with N-butyl-2-cyanoacrylate, and the other three patients were treated by other procedures. The final hemostasis rate was 81.5% (22/27). The 5-year survival rate after initial hemostasis was 63.0% (17/27). CONCLUSIONS This study showed that endoscopic variceal ligation combined with sclerotherapy might become a recommended choice for effective treatment of bleeding gastric varices.
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Affiliation(s)
- Nozomi Sugimoto
- Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical School, 5-1-1 Nabeshima, Saga, 849-8501, Japan
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Yamamoto J, Nagai M, Smith B, Tamaki S, Kubota T, Sasaki K, Ohmori T, Maeda K. Hand-assisted laparoscopic splenectomy and devascularization of the upper stomach in the management of gastric varices. World J Surg 2006; 30:1520-5. [PMID: 16855808 PMCID: PMC7102344 DOI: 10.1007/s00268-005-0243-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Bleeding from esophagogastric varices is the major cause of death in patients with portal hypertension. Although esophageal varices can be treated with endoscopic procedures, the treatment for gastric varices is still controversial. The aim of this study was to describe a surgical technique and our preliminary results of hand-assisted laparoscopic Hassab's procedure. METHODS Between February 2002 and May 2005, we performed 7 cases of gastric varices with this type of operation. The patients included 4 men and 3 women who ranged in age from 23 to 74 years (underlying liver disease: 5 case of liver cirrhosis, 1 case of polycystic disease, 1 case of extrahepatic portal vein obstruction). After splenctomy was performed, we devascularized the vessels of the upper stomach and the esophagus 5 cm away from the esophago-cardia junction. RESULTS The operative time ranged from 132 to 290 minutes. Intraoperative blood loss was estimated to be from 50 ml to 475 ml. The weight of removed spleen ranged from 110 g to 800 g. During the follow-up period, all gastric varices disappeared and no bleeding from varicose veins was observed. All patients had hypersplenism with thrombocytopenia before surgery (mean: 11.1+/-7.4x10(4)/ml), which was improved postoperatively (mean: 30.8+/-19.0x10(4)/ml). This data were statistically significant (P=0.033). One patient died of aspiration pneumonia related to postoperative pyloric stricture. CONCLUSIONS Although there is no agreement concerning the best treatment of gastric varices, the hand-assisted laparoscopic Hassab's operation is a safe, moderately invasive method, and its outcome appears to be equal to that of other open procedures.
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Affiliation(s)
- Joji Yamamoto
- Department of Surgery, Chibanishi General Hospital, Chiba, Japan.
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Arai H, Abe T, Takagi H, Mori M. Efficacy of balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration and combined techniques for the management of gastric fundal varices. World J Gastroenterol 2006; 12:3866-73. [PMID: 16804972 PMCID: PMC4087935 DOI: 10.3748/wjg.v12.i24.3866] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of three interventional treatments involving transvenous obliteration for the treatment of gastric varices, and to compare the efficacy and adverse effects of these methods.
METHODS: From 1995 to 2004, 93 patients with gastric fundal varices underwent interventional radiologic embolotherapy at our hospital. Of the 93 patients, 75 were treated with the balloon-occluded retrograde transvenous obliteration (BRTO) procedure; 8 were with the percutaneous transhepatic obliteration (PTO) procedure; and 10 were with the combined BRTO and PTO therapy. A follow-up evaluation examined the rates of survival, recurrence and rebleeding of the gastric varices, worsening of esophageal varices and complications in each group.
RESULTS: The BRTO, PTO, and combined therapy were technically successful in 81% (75/93), 44% (8/18), and 100% (10/10) patients, respectively. Recurrence of gastric varices was found in 3 patients in the BRTO group and in 3 patients in the PTO group. Rebleeding was observed in 1 patient in the BRTO group and in 1 patient in the PTO group. The 1- and 3-year survival rates were 98% and 87% in the patients without hepatocellular carcinoma (HCC) in the BRTO group, 100% and 100% in the PTO group, and 90% and 75% in the combined therapy group, respectively.
CONCLUSION: Combined BRTO and PTO therapy may rescue cases with uncontrollable gastric fundal varices that remained even after treatment with BRTO and/or PTO, though there were limitations of our study, including retrospective nature and discrepancy in sample size between the BRTO, PTO and combined therapy groups.
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Affiliation(s)
- Hirotaka Arai
- Department of Gastroenterology, Maebashi Red Cross Hospital, Japan.
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Arai H, Abe T, Shimoda R, Takagi H, Yamada T, Mori M. Emergency balloon-occluded retrograde transvenous obliteration for gastric varices. J Gastroenterol 2005; 40:964-71. [PMID: 16261433 DOI: 10.1007/s00535-005-1654-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2005] [Accepted: 05/11/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND We evaluated the efficacy of emergency balloon-occluded retrograde transvenous obliteration (B-RTO) performed within 24 h after initial hemostasis for the prevention of rebleeding from ruptured gastric varices. METHODS From December 1995 to March 2003, 11 patients who had undergone B-RTO within 24 h after the control of gastric variceal bleeding at Maebashi Red Cross Hospital were investigated. They were followed up for complete eradication, recurrence of varices, and rebleeding. Efficacy was determined by endoscopic examination and computed tomography. RESULTS The 4 patients with acute bleeding from ruptured gastric varices were treated with endoscopic therapy-endoscopic variceal ligation (EVL) in 2 patients, and clipping treatment in 2. Initial hemostasis was achieved in all 4; the other 7 patients had already stopped bleeding at endoscopy. After hemostasis was achieved, emergency B-RTO was immediately performed within 24 h and was successful in all 11 patients. Ten (90.9%) of the 11 gastric varices were obliterated and the other 1 (9.1%) was diminished in size. During the mean follow-up period of 1136 days, no rebleeding or recurrence as found. Four patients died during the follow-up period, but none died from variceal bleeding. Survival rates were 90.9% and 70.7%, respectively, at 1 year and 3 years. In 6 patients, development of esophageal varices appeared during the follow-up period, all of which were controlled by usual endoscopic therapy. No severe side effects were found after the B-RTO treatment. CONCLUSIONS Emergency B-RTO is an effective treatment for the prevention of rebleeding from ruptured gastric varices.
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Affiliation(s)
- Hirotaka Arai
- Department of Gastroenterology, Maebashi Red Cross Hospital, 3-20-14 Asahi-cho, and Department of Medicine and Molecular Science, Gunma University School of Medicine, Maebashi, 371-0014, Japan
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Poddar U, Thapa BR, Singh K. Frequency of gastropathy and gastric varices in children with extrahepatic portal venous obstruction treated with sclerotherapy. J Gastroenterol Hepatol 2004; 19:1253-6. [PMID: 15482531 DOI: 10.1111/j.1440-1746.2004.03470.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND There are limited reports of the effect of endoscopic sclerotherapy (EST) on portal hypertensive gastropathy (PHG) and gastric varices (GV) in children with extrahepatic portal venous obstruction (EHPVO). We have studied the prevalence of PHG and GV in children with EHPVO and assessed the effect of EST on them on long-term follow-up. METHODS From January 1992 to June 2002, consecutive children presenting with variceal bleeding due to EHPVO were included in this study. All children underwent EST at presentation and at 2-3 week intervals thereafter. During each session of endoscopy, gastric mucosa and fundus of the stomach was screened carefully to detect PHG and GV. Gastric varices were classified as gastroesophageal (GOV) and isolated gastric varices (IGV). RESULTS In total, 274 cases of EHPVO were managed during the study period. The mean age was 7.4 +/- 3.5 years with a male to female ratio of 2.3:1. Of these 274 cases, 186 completed the EST program (study population), 60 were lost to follow-up, five died and 23 underwent surgery. At presentation (n = 274) 27% cases had PHG (3.6% severe) and 68.6% had GV (GOV 66.8%, IGV 1.8%). Following EST (n = 186) there was a significant (P < 0.001) decrease in GOV (45% from 64%) but an increase in IGV (14% from 1%) and PHG (51.6% from 24.7%). There was also a significant increase in severe PHG (15.6% from 3.2%, P < 0.05). On follow-up (mean follow-up 38 +/- 30 months) 19% children with IGV bled while none with PHG bled. CONCLUSIONS Portal hypertensive gastropathy and gastric varices are quite common in children with EHPVO. Following EST, there is a chance of developing isolated gastric varices.
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Affiliation(s)
- Ujjal Poddar
- Division of Pediatric Gastroenterology, Department of Gastroenterology, PGIMER, Chandigarh, India.
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Hsieh JS, Wang WM, Perng DS, Huang CJ, Wang JY, Huang TJ. Modified devascularization surgery for isolated gastric varices assessed by endoscopic ultrasonography. Surg Endosc 2004; 18:666-671. [PMID: 15026927 DOI: 10.1007/s00464-003-8196-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2003] [Accepted: 10/23/2003] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study aimed to assess the role of endoscopic ultrasonography (EUS) in the surgical management of isolated gastric varices (IGV), and to report the authors' experience in the treatment of IGV with modified devascularization surgery. METHODS In this study, 26 cirrhotic patients with IGV were treated with devascularization surgery for variceal hemorrhage. Preoperatively, percutaneous transhepatic portography (PTP) and EUS were used to determine the mode of therapy for IGV. Fundectomy was performed for 14 patients with fundic IGV, whereas 12 patients with cardiac IGV underwent proximal gastrectomy. RESULTS A significantly higher proportion of patients with cardiac varices showed grade 3 IGV on preoperative EUS than those who had fundic varices (p < 0.05). No major complications were observed during or after the operation, and only one patient died of prolonged shock and massive transfusion. Postoperatively, gastric varices had been eradicated completely in 25 of 26 patients, as determined by EUS study. During a mean follow-up period of 50 months, two patients had recurrent varices without bleeding, as demonstrated by EUS. The overall 5-year survival rate for the fundic IGV group was 67.9%, whereas that for the cardiac IGV group was 64.3% (p > 0.05). CONCLUSIONS This study showed that devascularization surgery is highly effective for the prevention of recurrent bleeding from IGV and provides an alternative treatment method. Preoperatively, EUS is very helpful in detailed devascularization of patients with specific IGV, and may be used also for postoperative follow-up evaluation.
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Affiliation(s)
- J-S Hsieh
- Department of Surgery, Kaohsiung Medical University, No. 100, Shih Chuan 1st Road, 807, Kaohsiung City, Taiwan
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Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices. Part 1. Anatomic classification. Radiographics 2003; 23:911-20. [PMID: 12853665 DOI: 10.1148/rg.234025044] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Since its introduction in the mid-1990s, balloon-occluded retrograde transvenous obliteration (BRTO) has become widely accepted in Japan as a minimally invasive, highly effective treatment for gastric varices. Sufficient filling and stagnation of the sclerosing agent in the entire variceal complex is essential for successful BRTO of gastric varices. However, the success of BRTO in this context also requires familiarity with the hemodynamic features of the varices, including the patterns of their afferent and draining veins, which affect the degree of difficulty in performing BRTO. Thus, accurate assessment of the hemodynamic pattern before and during each procedure is essential for successful treatment. Sixty cases of gastric varices that were successfully treated with transcatheter techniques over the past 5 years were reviewed and analyzed. From this study, a classification system for gastric varices was developed that is based on the hemodynamic pattern of the varices.
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Affiliation(s)
- Hiro Kiyosue
- Department of Radiology, Oita Medical University, 1-1 Hasama, Oita 879-55, Japan.
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Akahoshi T, Hashizume M, Shimabukuro R, Tanoue K, Tomikawa M, Okita K, Gotoh N, Konishi K, Tsutsumi N, Sugimachi K. Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience. Surgery 2002; 131:S176-81. [PMID: 11821807 DOI: 10.1067/msy.2002.119501] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The long-term efficacy and safety of endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) were evaluated as the initial treatment for bleeding gastric varices. PATIENTS AND METHODS Fifty-two patients with bleeding gastric varices underwent endoscopic injections of Histoacryl for hemostasis over a 10-year period. Histoacryl was injected intravariceally. Among these 52 patients, 32 had active bleeding and 20 had recent bleeding. Most of the varices were large (F2 or F3, 48 cases). After Histoacryl injection, the patients were followed endoscopically with retreatment administered as necessary. The patients were followed for a mean 28.1 months. RESULTS The rate of initial hemostasis (no bleeding occurred for 48 hours after sclerotherapy) was 96.2%. Cumulative nonbleeding rates were 64.7%, 52.7%, and 48.2% at 1, 5, and 10 years, respectively. When rebleeding occurred, 80.0% was within 1 year after initial injection. Recurrent bleeding was easily stopped with the reinjection of Histoacryl in most patients. The treatment failure-related mortality rate was 4.0% (2 of 52). The cumulative survival rates were 66.9%, 60.4%, and 55.5% at 1, 5, and 10 years, respectively. The mortality depended on either malignancy or liver function (Child-Pugh classification). CONCLUSIONS These results suggest that Histoacryl injection sclerotherapy is highly effective for the treatment of bleeding gastric varices, with rare complications occurring both acutely and long-term. Therefore, Histoacryl injection sclerotherapy is considered to be the first choice of treatment for bleeding gastric varices, but the rate of recurrent bleeding is so high that further methods or devices still need to be developed in order to prevent gastric variceal rebleeding.
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Affiliation(s)
- Tomohiko Akahoshi
- Department of Disaster and Emergency Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Abstract
Gastric varices and portal hypertensive gastropathy (PHG) are an important complication of both generalized and segmental portal hypertension. The natural history and risk factors for bleed from GV are not extensively studied as that for esophageal varices. Recently, effective therapy for gastric variceal bleed in form of tissue adhesives, balloon-occluded retrograde transvenous obliteration of gastric varices (BRTO) has been developed. Further advances are still needed regarding natural history, risk factors, bleeding, and mechanism of GV rupture.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G. B. Pant Hospital, New Delhi, India.
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Han SW, Joo YE, Kim HS, Choi SK, Rew JS, Kim JK, Kim SJ. Clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of variceal bleeding. Korean J Intern Med 2000; 15:179-86. [PMID: 11242805 PMCID: PMC4531767 DOI: 10.3904/kjim.2000.15.3.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) has been popularized for the treatment of refractory variceal bleeding. The aim of this study was to assess the safety and long-term effect of TIPS in the treatment of variceal bleeding that is not controlled with pharmacological and endoscopic treatment. METHODS Thirty-six patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) due to refractory variceal bleeding were included in the study. The effectiveness of portal decompression and bleeding control was evaluated. Upper gastrointestinal endoscopy was performed to analyse the degree of varices and portal hypertensive gastropathy (PHG) before TIPS procedure and one to three weeks after TIPS. Angiography was performed in surviving patients, if bleeding recurred, or if ultrasonography or endoscopy suggested stent dysfunction. RESULTS TIPS were successfully placed in 36 of 38 patients (94.6%). TIPS achieved hemostasis of variceal bleeding in 34 patients (94.4%). Portal venous pressure decreased from an initial average of 28.7 +/- 7.9 to 23.2 +/- 9.4 mmHg after TIPS (p < 0.05). The portosystemic pressure gradient was significantly decreased from 15.5 +/- 6.3 to 7.8 +/- 4.1 mmHg (p < 0.01). The degree of esophagogastric varices and PHG was significantly improved after TIPS. The total length of follow-up was from one day to 54 months (mean: 355 days). The actuarial probability of survival was 83% at one year and 74% at two years. Overall, 16 episodes of stent dysfunction were diagnosed during follow-up. Stent revision by means of angioplasty was successfully performed in 14 of these episodes. CONCLUSION TIPS is an effective and reliable nonoperative means of lowering portal pressure. This procedure has proved useful in the management of acute variceal bleeding refractory to endoscopic treatment. Surveillance by ultrasonography, endoscopy, and angiographic intervention is useful for the maintenance of shunt patency.
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Affiliation(s)
- S W Han
- Department of Internal Medicine and Radiology, Chonnam National University Medical School, Kwangju, Korea
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Tomikawa M, Hashizume M, Saku M, Tanoue K, Ohta M, Sugimachi K. Effectiveness of gastric devascularization and splenectomy for patients with gastric varices. J Am Coll Surg 2000; 191:498-503. [PMID: 11085729 DOI: 10.1016/s1072-7515(00)00735-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bleeding from gastric varices is difficult to control and has a high mortality rate. Recently, newly developed treatments for this serious lesion have been used, but surgical intervention is still advocated by several studies. We report our experience with gastric devascularization and splenectomy and its effectiveness for patients with gastric varices. STUDY DESIGN Gastric devascularization and splenectomy was successfully performed to treat patients with isolated gastric varices (n = 42). The patients included 27 men and 15 women who ranged from 29 to 73 years of age (average 53.7 years). We analyzed the findings of gastric varices using endoscopy, the results of gastric devascularization and splenectomy, and survival after the operation. RESULTS No patient had tortuous varices (F1). Twenty-seven patients (64.3%) had nodular varices (F2) and 15 (35.7%) had tumorous varices (F3). Twenty-five patients (59.5%) had large varices that occupied two or more areas. Twenty-nine patients (69.0%) had varices with a positive red color sign. No major complications during or after the operation were observed, and peri-operative death did not occur. Gastric varices were eradicated in all 42 patients. Survival rates were 97.6% after 1 year, 88.1% after 3 years, 76.2% after 5 years (mean followup period, 46 months). CONCLUSIONS This study showed that gastric devascularization and splenectomy provides satisfactory results for patients with gastric varices that are likely to bleed and that it can be performed even on patients who have had other treatments.
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Affiliation(s)
- M Tomikawa
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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30
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Matsumoto A, Hamamoto N, Nomura T, Hongou Y, Arisaka Y, Morikawa H, Hirata I, Katsu K. Balloon-occluded retrograde transvenous obliteration of high risk gastric fundal varices. Am J Gastroenterol 1999; 94:643-9. [PMID: 10086645 DOI: 10.1111/j.1572-0241.1999.00928.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Balloon-occluded retrograde transvenous obliteration is an effective new method for treating gastric fundal varices, but subsequent occurrence of esophageal varices creates a problem. The relationship between portal hemodynamics and the occurrence of esophageal varices after prophylactic balloon-occluded retrograde transvenous obliteration was investigated. METHODS Ten cirrhotic patients considered to have high risk gastric fundal varices underwent angiography. Six patients showed a communication between blood flow in gastric wall vessels and that in the gastrorenal shunt (type I), whereas the others (type II) did not. Depending on the flow direction in the left gastric vein, the two groups were further divided into hepatopetal (a) and hepatofugal (b) subgroups. The therapeutic effect on portal hemodynamics and the relationship between pretreatment portal hemodynamics and posttreatment occurrence of esophageal varices were investigated. RESULTS Fundal varices disappeared endoscopically in all 10 patients and the gastrorenal shunt was also occluded after the procedure. No patient showed worsening of liver function or systemic complications during follow-up. The increase in portal blood flow was more significant in type Ib patients than in the others. Esophageal varices occurred in all type I patients, and as to those in type Ib, high risk varices developed within 6 months after treatment. On the other hand, esophageal varices did not occur in type II patients. CONCLUSIONS This procedure was effective for treating gastric fundal varices. However, type Ib patients are likely to develop high risk esophageal varices after occlusion of the gastrorenal shunt.
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Affiliation(s)
- A Matsumoto
- The Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Japan
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31
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Affiliation(s)
- W S Helton
- Department of Surgery, University of Washington School of Medicine, Seattle 98195, USA
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32
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Kollias J, Jeans PL, Padbury RT, Toouli J. Gastric devascularization and splenectomy for bleeding gastric varices. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1995; 65:804-7. [PMID: 7487731 DOI: 10.1111/j.1445-2197.1995.tb00565.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Gastric varices may be associated with oesophageal varices in patients with portal hypertension. Control of haemorrhage from gastric varices is often difficult. Between June 1988 and February 1990, six patients underwent gastric devascularization in an effort to control life-threatening haemorrhage from bleeding gastric varices after non-operative measures failed. In all six patients the bleeding was controlled. There was one peri-operative death due to hepatic failure. Four patients experienced postoperative respiratory or urinary tract infections that responded to appropriate antibiotic and respiratory support measures. After a mean follow-up period of 44 months, eradication of gastric varices was achieved in all five survivors. Gastric devascularization is an effective surgical measure for good palliation and control of life-threatening haemorrhage from bleeding gastric varices.
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Affiliation(s)
- J Kollias
- Department of Surgery, Flinders Medical Centre, Flinders University of South Australia, Bedford Park, Adelaide, Australia
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Abstract
In patients with bleeding gastric varices from causes other than splenic vein thrombosis, endoscopic sclerotherapy and ablative surgery have yielded poor results. Over a 3-year period starting in June 1989, a total of 30 distal splenorenal shunts were performed prospectively on 19 paediatric and 11 adult patients with bleeding gastric varices and good liver function. The mean (s.d.) age was 17(12) (range 6-50) years; there were 20 male and ten female patients of whom six had cirrhosis, four non-cirrhotic portal fibrosis and 20 portal vein thrombosis. Two patients died and two more had shunt thrombosis; all four were considered failures of treatment. Hypersplenism was present in 15 patients but reverted to normal in 13. In 26 patients the gastric varices disappeared. Concomitant oesophageal varices were present in 22 patients and showed marked regression, with no rebleeding over a mean (s.d.) follow-up of 21(10) (range 7-39) months. A distal splenorenal shunt was effective in controlling gastric variceal haemorrhage in 26 of 30 patients in whom liver function was well preserved.
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Affiliation(s)
- P G Thomas
- Department of General Surgery, St John's Medical College Hospital, Bangalore, India
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Abstract
Bleeding from esophageal varices exacts a high mortality and extraordinary societal costs. Prophylaxis--medication, sclerotherapy, or shunt surgery to prevent an initial bleeding episode--is ineffective. In patients who have bled from varices, endoscopic injection sclerotherapy can control acute bleeding in more than 90% of patients. Because recurrent bleeding frequently occurs and survival without definitive therapy is dismal, selection of a permanently effective treatment is mandatory once variceal bleeding has been controlled. Long-term injection sclerotherapy can be performed in compliant patients; it is relatively safe but is associated with a 30-50% rebleeding rate. Beta-blockers significantly reduce portal pressure and recurrent bleeding but have not been shown to diminish mortality from BEV. Portal decompressive surgery permanently halts bleeding in more than 90% of patients; the risk of operative mortality is high in decompensated cirrhotics, and long-term complications of encephalopathy and accelerated liver failure may limit indications for shunt surgery to good-risk cirrhotics who are not liver transplant candidates. Devascularization procedures have a low operative mortality and encephalopathy rate but unacceptably high rates of recurrent bleeding. Liver transplantation is curative therapy for bleeding esophageal varices and the associated underlying hepatic dysfunction; cost and availability of donor organs generally limit its use in this setting to variceal bleeders with end-stage liver disease not associated with active alcoholism.
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Affiliation(s)
- K Johansen
- Department of Surgery, University of Washington School of Medicine, Seattle 98195
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Nakamura H, Inoue H, Kawano T, Goseki N, Endo M, Sugihara K. Selection of the treatment for esophagogastric varices. Analyses of collateral structures by endoscopic ultrasonography. Surg Endosc 1992; 6:228-34. [PMID: 1465729 DOI: 10.1007/bf02498809] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In 57 cases with portal hypertensive disease, we investigated the intramural and extramural structure of the stomach and the esophagus by endoscopic ultrasonography (EUS). Variously developed intra- and extramural vascular structures had a relationship to the endoscopic variceal form, and communicating (inflow) vessels to varices were found in 28 of the 43 primary cases treated (65%). We then classified the esophagogastric varices into three types according to the vascular structure, such as the esophageal type, esophagogastric type, and solitary gastric type. Based on the analysis of these collateral structures, we selected the treatment as follows. In the esophageal type, which has a few inflow vessels, it is easy to eliminate the varices by obturating the inflow vessels by endoscopic injection sclerotherapy (EIS). In the esophagogastric type, which has many enlarged inflow vessels, the Hassab operation is effective in devascularizing the extramural inflow vessels, and the combination of EIS is necessary to sclerose the intramural varices. In the solitary gastric type, which is a part of the downward portosystemic shunt, the Hassab operation is recommended to prevent rupture of the varices for the subtype with intramural running vessels, but conservative therapy is enough for the subtype without.
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Affiliation(s)
- H Nakamura
- First Department of Surgery, Tokyo Medical and Dental University, Japan
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36
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Taylor I. General surgery. Postgrad Med J 1991; 67:876-91. [PMID: 1758797 PMCID: PMC2399165 DOI: 10.1136/pgmj.67.792.876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- I Taylor
- University Surgical Unit, Southampton General Hospital, UK
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