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A novel therapeutic strategy for esophageal varices using endoscopic treatment combined with splenic artery embolization according to the Child-Pugh classification.

ABSTRACT: Variceal hemorrhage may cause high rebleeding and mortality rates. Preventing the first episode of variceal bleeding is mandatory in patients with high-risk esophageal varices (EV). This study aimed to identify factors that predict the recurrence of EV after endoscopic treatment (ET), and to develop a reasonable therapeutic strategy for EV in cirrhosis. From January 2012 to December 2014, 45 patients with cirrhosis and high-risk EV underwent ET, including sclerotherapy and/or ligation. Statistical analyses identified factors associated with the recurrence of EV after ET, and the Kaplan-Meier method determined the cumulative variceal recurrence rates. The 1-, 2-, and 3-year cumulative posttreatment recurrence rates for EV were 13.3%, 29.5%, and 32.2%, respectively. No significant differences were evident between the patients with and without variceal recurrences at 1-year posttreatment. The multivariate regression analyses identified a history of partial splenic embolization (PSE) and the pretreatment Child-Pugh classification as independent predictors of variceal recurrences at 2 years (p < 0.05) and 3 years (p < 0.05) posttreatment. While EV did not recur after ET and splenic artery embolization in cases with Child-Pugh class A, the overall posttreatment variceal recurrence rates were 0% and 66.7% when PSE was performed before and after ET, respectively, in those with Child-Pugh class B or C. Splenic artery embolization significantly reduced the hepatic venous pressure gradient and markedly lowered the Child-Pugh score in 15 patients. Adjunctive PSE and pretreatment Child-Pugh class A could be independently associated with reduced cumulative recurrence rates of EV post-ET. From the perspectives of portal hemodynamics and hepatic function, splenic artery embolization before or after ET could prevent posttreatment variceal recurrence in patients with Child-Pugh class A, and PSE before ET could achieve the long-term eradication of EV following ET in those with Child-Pugh class B or C.

SUBMITTER: Ishikawa T

PROVIDER: S-EPMC6762126 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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A novel therapeutic strategy for esophageal varices using endoscopic treatment combined with splenic artery embolization according to the Child-Pugh classification.

Ishikawa Tsuyoshi T Sasaki Ryo R Nishimura Tatsuro T Aibe Yuki Y Saeki Issei I Iwamoto Takuya T Hidaka Isao I Takami Taro T Sakaida Isao I

PloS one 20190926 9

Variceal hemorrhage may cause high rebleeding and mortality rates. Preventing the first episode of variceal bleeding is mandatory in patients with high-risk esophageal varices (EV). This study aimed to identify factors that predict the recurrence of EV after endoscopic treatment (ET), and to develop a reasonable therapeutic strategy for EV in cirrhosis. From January 2012 to December 2014, 45 patients with cirrhosis and high-risk EV underwent ET, including sclerotherapy and/or ligation. Statistic ...[more]

PMID: 31557230

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Project description:Video 1Balloon-compression endoscopic injection sclerotherapy for the treatment of esophageal varices. A 50-year-old man with schistosomiasis-induced liver fibrosis presented with melena and hematemesis. The bleeding stopped after intravenous administration of somatostatin and ceftriaxone for 4 days. Balloon-compression endoscopic injection sclerotherapy (bc-EIS) was performed with the patient under general anesthesia to prevent rebleeding. The novel device for bc-EIS is composed of a syringe, a stopcock, a catheter, and an inflatable balloon. In the majority of patients with cirrhosis, the blood flow from the coronary vein drains into the azygos and hemiazygos venous system through esophageal and para-esophageal varices, and eventually back to the inferior vena cava. With compression of proximal esophageal and para-esophageal varices via an inflated balloon, sclerosant can be retained at the injection site, rather than flowing back to the inferior vena cava. Endoscopy revealed the presence of moderately enlarged, beady esophageal varices with red wale signs in the middle and lower esophagus. An inflatable balloon was fixed to an endoscope at a distance of 3 cm from its distal end. When the end of the endoscope was introduced to the target varices, 20 mL of air was injected into the balloon through a thin catheter, making its outer diameter expand to 3.5 cm. A disposable endoscopic injection needle then entered the base of the variceal columns near the cardia. When blood flowed back into the needle, a mixture of Lauromacrogol and methylene blue was intravariceally administered. Minor bleeding at the injection site was stopped through brief compression with the needle sheath. The second injection was performed following the aforementioned procedure. Follow-up endoscopy at 1 month, 4 months, and 7 months revealed the progression from thrombosed blue varices to complete eradication of esophageal varices. Endoscopic ultrasonography also showed the absence of blood flow in the varices after treatment. To date, bc-EIS has been performed successfully on 28 patients with esophageal varices. Variceal eradication was obtained in 17 patients with 1 session, 10 patients with 2 sessions, and 1 patient with 3 sessions. Two patients showed recurrence of esophageal varices on routine follow-up endoscopy and were re-treated with bc-EIS successfully. There were no severe complications during the follow-up period. With the sclerosant retained at injection sites after balloon compression, bc-EIS enables complete eradication of esophageal varices and lowers the risk of recurrence. The blockade of sclerosant also decreases the incidence of complications related to large-volume injection of sclerosant, such as embolization, ulceration, and perforation. In conclusion, bc-EIS appears to be an effective and safe approach for the treatment of esophaeal varices. Further research is underway to determine its suitability for large-scale clinical application.

Project description:The results of endoscopic treatment with elastic band ligation for esophageal variceal bleeding in patients with Child-Pugh class C cirrhosis remain poor. In comparison with treatment with elastic band ligation, we have found lower rates of rebleeding and mortality with n-butyl-2-cyanoacrylate injections. Thus, the aim of the current study was to describe our unit's 10 years of experience with injection of n-butyl-2-cyanoacrylate to control esophageal variceal ruptures in patients with Child-Pugh class C cirrhosis.A single-center, retrospective study was conducted. Sixty-three patients with Child-Pugh class C cirrhosis had been admitted to the center with an acute episode of esophageal variceal bleeding. All were treated with injection of n-butyl-2-cyanoacrylate. The patients were assigned to 1 of 2 groups according to their Child-Pugh class C cirrhosis scores: group I (score range, 10 through 13 points) and group II (score, 14 or 15 points). The 3 variables studied were rates of initial failure to control bleeding, failure to prevent rebleeding (secondary prophylaxis), and mortality. Patients in the 2 groups (group I, n = 50; group II, n = 13) had similar characteristics.Bleeding was successfully controlled in almost 75 % of the patients during the first 5 days after treatment, with no significant differences observed between groups I and II. There were no significant differences between the 2 groups with respect to mortality rate for the first 5 days after treatment. Thirty-four patients (54 %) were free of bleeding at 6 weeks after treatment, with a significant difference noted between the groups: group I, 64 %, versus group II, 15.4 % (P < 0.001). The overall mortality rate was 44.4 %, with a significant difference noted between the groups: group I, 34 %, versus group II, 84.6 % (P < 0.001).Endoscopic injection of n-butyl-2-cyanoacrylate is a valid treatment option to control esophageal variceal bleeding in patients with a Child-Pugh class C cirrhosis score in the range of 10 through 13 points.

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A novel therapeutic strategy for esophageal varices using endoscopic treatment combined with splenic artery embolization according to the Child-Pugh classification.

Publications

A novel therapeutic strategy for esophageal varices using endoscopic treatment combined with splenic artery embolization according to the Child-Pugh classification.

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