Endoscopic injection sclerotherapy for esophageal varices associated with concomitant portal venous thrombus of hepatocellular carcinoma

Emergency endoscopic variceal ligation following variceal rupture in patients with advanced hepatocellular carcinoma and portal vein tumor thrombosis: a retrospective study

BACKGROUND

The outcomes of treatment of ruptured varices in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT) are unclear. We therefore evaluated the long- (rebleeding and death) and short-term (immediate death within 24 h of variceal bleeding diagnosis) outcomes of patients with PVTT who underwent emergency variceal band ligation.

METHODS

Data on 62 patients with PVTT and endoscopically proven esophageal or gastric variceal bleeding from 2007 to 2012 were studied. In most cases, the varices were treated using endoscopic variceal band ligation (EVL). We assessed the patients' rebleeding-free and overall survival using the Kaplan-Meier method, and a Cox proportional hazard model was used to analyze effect of independent factors on rebleeding-free and overall survival times.

RESULTS

Most patients had decompensated cirrhosis and were classified as Child-Pugh class B (56%) or C (36%). A total of 35 patients (56%) had PVTT in the main portal trunk. Among all patients, 58 (94%) and 4 (6%) had esophageal and gastric variceal bleeding, respectively. Bleeding was managed using EVL in all, but one patient (98%) who was treated with a Sengstaken-Blakemore tube. A total of 24 patients (39.3%) experienced rebleeding, and these patients had a median overall survival time of 36 days. A PVTT in the main portal trunk was predictive of rebleeding (hazard ratio 3.706, p = .0223), and α-fetoprotein-L3 levels <37.4% (hazard ratio 0.464, p = 0.015) and Child-Pugh class A/B (hazard ratio 0.398, p = 0.007) were associated with overall survival. We observed 95 bleeding events in 62 patients. EVL achieved hemostasis in 92 of the 95 bleeding events, whereas seven immediate deaths occurred due to variceal bleeding (7/92, 7.6%). All three bleeding events treated with modalities other than EVL resulted in immediate deaths.

CONCLUSIONS

EVL is a safe and effective treatment of variceal ruptures in patients with HCC and PVTT. After successful hemostasis, alleviation of the underlying liver function impairment and tumor control are equally important for a good prognosis.

Merits of prophylactic sclerotherapy for esophageal varices concomitant unresectable hepatocellular carcinoma: prospective randomized study

BACKGROUND

Several clinical studies of prophylactic therapy for esophageal varices have led to the conclusion that prophylactic therapy is of no value, and it is generally not accepted in the Western world. However, this is not the case in Japan. The present study evaluated the efficacy of prophylactic endoscopic injection sclerotherapy (EIS) in patients with unresectable hepatocellular carcinoma (HCC) and risky esophageal varices.

PATIENTS AND METHODS

Twenty-seven patients with 'likely-to-bleed' esophageal varices concomitant with unresectable HCC were randomly allocated to two groups. Thirteen patients underwent prophylactic EIS (EIS group), whereas the remaining 14 patients were observed conservatively (control group).

RESULTS

No bleeding from esophageal varices occurred in the EIS group during the entire period of this study, whereas in thecontrol group the cumulative bleeding rate was 44.8% in 6 months. Cumulative survival rates of patients in the EIS group and in the control group were 48.8% and 7.7% in 2 years, respectively. There was a statistically significant difference between the two groups in cumulative bleeding rate and survival rate (P < 0.01).

CONCLUSION

This prospective study demonstrated that prophylactic EIS could prolong the survival of the patients with esophageal varices concomitant with unresectable HCC. Prophylactic EIS for patients with unresectable HCC may be, in part, justified according to the present study.

Predictors of in-hospital mortality after acute variceal bleeding in patients with hepatocellular carcinoma and concurrent main portal vein thrombosis

BACKGROUND AND AIM

Risk factors for acute variceal bleeding in patients with hepatocellular carcinoma (HCC) and concurrent main portal vein thrombosis (PVT) remain unclear. We aimed to determine risk factors of in-hospital mortality after acute variceal bleeding for HCC patients with concurrent main PVT.

METHODS

We conducted a retrospective analysis of 102 HCC patients (83% men and 17% women) with concurrent main PVT and acute variceal bleeding. All patients received emergent endoscopy to define the bleeding source. Multivariable Cox proportional hazard regression analysis consisting of clinical, laboratory, and endoscopic parameters was performed to identify predictive factors for intrahospital mortality.

RESULTS

Twenty-eight (27.5%) patients died within admission. The median survival of all patients was 56 days. Multivariable Cox proportional hazard regression analyses revealed Child-Pugh score (adjusted hazard ratio [aHR]: 1.29 for each point; 95% confidence interval [CI]: 1.11-1.50), active bleeding on index endoscopy (aHR: 7.50; 95% CI: 3.05-18.4), esophageal varices as the bleeder (compared with gastric varices, aHR: 14.3; 95% CI: 3.12-66.1), failure to control bleeding (aHR: 38.0; 95% CI: 7.44-194), and serum creatinine (aHR: 1.28 for each increase of 1 mg/dL; 95% CI: 1.09-1.50) independently predicted in-hospital mortality.

CONCLUSIONS

Hepatic reserve, active bleeding on index endoscopy, failure to control bleeding, esophageal varices as the bleeder when compared with gastric varices, and renal function were independent predictive factors for in-hospital mortality in HCC patients with acute variceal bleeding and concurrent main PVT.

Endoscopic injection sclerotherapy for esophageal varices in cirrhotic patients with hepatocellular carcinoma: risk factors for survival

GOALS

We previously showed that endoscopic injection sclerotherapy (EIS) prolonged survival in patients with esophageal varices complicated by hepatocellular carcinoma (HCC) and liver cirrhosis. Here, we evaluated risk factors that affect EIS outcomes. Among factors, the difference between prophylactic and emergency EIS was of interest, and we analyzed precisely.

STUDY

Subjects were 134 patients with esophageal varices complicated by HCC and liver cirrhosis: 38 underwent emergent therapy for bleeding varices and 96 underwent prophylactic sclerotherapy.

RESULTS

During 2-year observation, 22 of the 38 (57.9%) and 38 of the 96 (39.6%) died. Analysis by univariate Cox's proportional hazard model indicated that prognosis of patients receiving emergency EIS was inferior to those with prophylactic EIS. However, multivariate Cox's analysis showed that emergency EIS itself extended survivals of those with esophageal varices complicated by HCC and liver cirrhosis. Patients' hepatic function (Child-Pugh classes) and tumor sizes were also statistically significant factors for survival. Neither prophylactic nor emergency EIS prolonged survival of patients with Child C hepatic function or those with HCCs larger than 5 cm.

CONCLUSIONS

The prophylactic sclerotherapy for esophageal varices prolongs long-term survival of patients with liver cirrhosis and HCC, better than emergency therapy. However, EIS itself had no beneficial effect on patients with poor disease status.

Endoscopic injection sclerotherapy for esophageal varices prolonged survival of patients with hepatocellular carcinoma complicating liver cirrhosis

BACKGROUND

A prospective controlled study was performed between 1982 and 1991 to evaluate the efficacy of endoscopic injection sclerotherapy (EIS) in patients with esophageal varices complicated by hepatocellular carcinoma and liver cirrhosis.

METHODS

The study included 83 patients with esophageal varices, hepatocellular carcinoma, and liver cirrhosis. Forty-three patients (group 1) underwent prophylactic EIS or emergent EIS for bleeding varices. EIS was performed weekly 4 to 6 times until the varices disappeared. The remaining 40 patients (group 2) underwent conservative therapy and did not undergo EIS. Survival rates were compared between the 2 groups.

RESULTS

During the 5-year observational period, all patients who did not undergo EIS died. Sixteen in group 2 (40.0%) died of gastrointestinal bleeding including ruptured esophageal varices. In contrast, patients treated with EIS survived significantly longer (p<0.001). Nine patients (20.9%) treated with EIS experienced gastrointestinal bleeding as a result of which 5 (11.6%) died. EIS prolonged survival in patients classified as Child's A or B but did not affect survival in patients with Child's C hepatic function. EIS was effective in prolonging survival in patients with hepatocellular carcinomas smaller than 5 cm. However, EIS had no effect in patients with hepatocellular carcinomas that were larger than 5 cm. EIS prolonged survival only for patients with nodular hepatocellular carcinoma and had no effect in patients with massive and diffuse hepatocellular carcinoma. Further, EIS prolonged survival only for patients who did not have portal vein thrombosis.

CONCLUSION

Based on this prospective study, we concluded that EIS was effective in prolonging the survival period of a select subset of patients with hepatocellular carcinoma.

Surgical treatment for hepatocellular carcinoma and concomitant esophagogastric varices

Preventing a rupture of esophagogastric varices (EGV) is very important in aggressively treating hepatocellular carcinoma (HCC) in cirrhotic patients. We therefore performed simultaneous partial hepatic resection and direct interruption procedure on nine patients with HCC and concomitant EGV. Patients were selected on the basis of their stages of HCC and hepatic functional reserve. Postoperative hospital courses of all patients were uneventful. Six patients had recurrence of HCC and received non-surgical anti-tumor treatments. Only one patient had upper gastrointestinal bleeding at 18 months after operation, and the other eight patients have had no episodes of upper gastrointestinal bleeding during the follow-up period. The 5-year survival rate of these patients was 48%. This operative procedure is quite effective and is one of the treatments of choice for patients with less advanced HCC and concomitant risk of EGV.