Adding embolization to TIPS implantation: A better therapy to control bleeding from ectopic varices?

Investigation report on endoscopic management of esophagogastric variceal bleeding by Chinese endoscopists

BACKGROUND

Esophagogastric variceal bleeding (EGVB) is a potentially life-threatening complication of portal hypertension. Endoscopic treatment combined with pharmacotherapy remains the mainstay in the management of acute variceal bleeding.

AIM

This article intends to highlight the potential differences in the endoscopic management of EGVB in China.

METHODS

A cross-sectional descriptive study was conducted. Endoscopists from 85 hospitals in 62 cities from 26 provinces were contacted by email. The items in questionnaire involved academic experience, screening, esophagogastric varices (EGV) classification, emergency treatment, and primary and secondary prophylaxis of EGVB by endoscopists with different lengths of experience.

RESULTS

A total of 85 questionnaires were collected. There was no statistical difference in the selection of items (P < .05 indicated statistical significance). The majority of endoscopists (95.29%) offered EGV screening for patients with liver cirrhosis. The location, diameter, and risk factor classification was selected by 82.35% of endoscopists. Endoscopy + medication was preferred (42.35%) for the primary prophylaxis of moderate-to-severe EGVs. There was no statistical difference in emergency intervention time for active EGVB (P > .05). The response "patients receive emergency endoscopic intervention within 12 hours" was selected by 61.2% of the endoscopists. The preferred emergency treatment for EGVB was combination treatment (40%). Tissue adhesive embolization was selected for the treatment of gastric variceal bleeding by 74.12% of endoscopists; transjugular intrahepatic portosystemic stent shunt/percutaneous transhepatic variceal embolization were selected as remedial measures by 48.23% to 52.94% of endoscopists. In addition, 67.06% of endoscopists elected to perform secondary prophylaxis and treatment within 1 week after hemostasis. Endoscopy and endoscopy + medication were selected by 44.71% and 49.41% of endoscopists, respectively, for secondary prophylaxis. The choice of laboratory indicators did not differ with length of experience.

CONCLUSIONS

There was no statistical difference in the endoscopic management of EGVB among Chinese endoscopists. The selection of diagnosis/treatment schemes was mainly based on guidelines and physician experience.

Embolization of parastomal and small bowel ectopic varices utilizing a transhepatic antegrade approach: A case series

Background

The ideal approach to managing parastomal and small bowel ectopic varices (EVs) is yet to be established.

Purpose

To evaluate outcomes following percutaneous antegrade transhepatic venous obliteration (PATVO) in patients presenting with bleeding from parastomal or small bowel EVs.

Material and Methods

A case series of 12 patients presenting with active or recurrent bleeding from parastomal or small bowel EVs who underwent 17 PATVO interventions at our tertiary care institution was performed. Data extraction from electronic medical records included baseline characteristics and procedural details. Endpoints included technical success, early clinical success, and re-bleeding.

Results

Technical success was 100% ( n = 17), and early clinical success was 82.3% ( n = 14). No patient experienced any intra- or post-operative complications. Rebleed rates after initial PATVO in patients who achieved early clinical success was as follows: 3-month, 0% ( n = 0); 6-month, 20% ( n = 2); 12-month, 20% ( n = 2). Rebleed rates after all PATVO procedures (including patients undergoing repeat procedures) that achieved early clinical success were as follows: 3-month, 0% ( n = 0); 6-month, 14% ( n = 2; 12-month, 14% ( n = 2). All patients with re-bleeding required reintervention with either PATVO, transjugular intrahepatic portosystemic shunt (TIPS) or both.

Conclusion

PATVO can be safely performed to treat bleeding from parastomal and small bowel EVs. In patients who present with recurrent bleeding despite PATVO, TIPS with/without embolization of bleeding varices remains a valid option as described by the literature.

Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

We performed a systematic review and meta-analysis of published studies to assess the efficacy, safety, and outcomes of N-butyl cyanoacrylate (NBCA) injection for the treatment of variceal gastrointestinal bleeding (GIB). The MEDLINE/PubMed, EMBASE, and SCOPUS databases were searched for English-language studies published from January 1980 to December 2019 and including patients who had injection of NBCA for variceal GIB. Two independent reviewers extracted and evaluated the data from eligible studies. Exclusion criteria were sample size < 5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. NBCA was injected during endoscopy in 42 studies and through a direct percutaneous approach for stomal varices in 1 study. The study’s endpoints were: Technical success, 30-day rebleeding, and 30-day overall and major complications. The estimated overall rates were computed with 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. In total, 43 studies with 3484 patients were included. The technical success rate was 94.1% (95% CI: 91.6–96.1%), the 30-day rebleeding rate was 24.2% (18.9–29.9%), and 30-day overall and major complications occurred in 15.9% (11.2–21.3%) and 5.3% (3.3–7.8%) of patients, respectively. For treating variceal GIB, NBCA injection is a safe and effective method that demonstrates high technical success rate and very low major complication rate.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis

BACKGROUND & AIMS

Spontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that the presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, the presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcomes in patients with liver cirrhosis.

METHODS

In this retrospective international multicentric study, CT scans of 908 cirrhotic patients with SPSS were evaluated for TSA. Clinical and laboratory data were recorded. Each detected SPSS radius was measured and TSA calculated. One-year survival was the primary endpoint and acute decompensation (oHE, variceal bleeding, ascites) was the secondary endpoint.

RESULTS

A total of 301 patients (169 male) were included in the training cohort. Thirty percent of all patients presented with >1 SPSS. A TSA cut-off of 83 mm2 was used to classify patients with small or large TSA (S-/L-TSA). Patients with L-TSA presented with higher model for end-stage liver disease score (11 vs. 14) and more commonly had a history of oHE (12% vs. 21%, p <0.05). During follow-up, patients with L-TSA experienced more oHE episodes (33% vs. 47%, p <0.05) and had lower 1-year survival than those with S-TSA (84% vs. 69%, p <0.001). Multivariate analysis identified L-TSA (hazard ratio 1.66; 95% CI 1.02-2.70, p <0.05) as an independent predictor of mortality. An independent multicentric validation cohort of 607 patients confirmed that patients with L-TSA had lower 1-year survival (77% vs. 64%, p <0.001) and more oHE development (35% vs. 49%, p <0.001) than those with S-TSA.

CONCLUSION

This study suggests that TSA >83 mm2 increases the risk for oHE and mortality in patients with cirrhosis. Our results support the clinical use of TSA/SPSS for risk stratification and decision-making in the management of patients with cirrhosis.

LAY SUMMARY

The prevalence of spontaneous portosystemic shunts (SPSS) is higher in patients with more advanced chronic liver disease. The presence of more than 1 SPSS is common in advanced chronic liver disease and is associated with the development of hepatic encephalopathy. This study shows that total cross-sectional SPSS area (rather than diameter of the single largest SPSS) predicts survival in patients with advanced chronic liver disease. Our results support the clinical use of total cross-sectional SPSS area for risk stratification and decision-making in the management of SPSS.

Hemoperitoneum in cirrhotic patients in the absence of abdominal trauma

Introduction: Hemoperitoneum can be a life-threating condition in cirrhotic patients who have a limited compensatory reserve during hemorrhagic shock. We aim to review the literature on the different etiologies associated with non-traumatic hemoperitoneum (NTH), summarizing the most relevant conditions associated with spontaneous and iatrogenic peritoneal and retroperitoneal bleeding that may occur in cirrhotic patients and to illustrate the most relevant diagnostic strategies and optimal management. Area covered: This review encompasses the current literature in hemoperitoneum in cirrhotic patients in the absence of abdominal trauma. Established diagnostic procedures, therapeutic interventions and potential novel targets are reported and discussed. Expert opinion: To ensure the optimal management regardless of the underlying etiology of NTH, the first goal for the clinician is to obtain immediate hemodynamic stabilization with supportive measures and to control the source of bleeding. The latter can be achieved with angiographic embolization, which is usually the first choice, or with open surgery. Other therapeutic options according to specific etiologies include transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), balloon-occluded anterograde transvenous obliteration (BATO) or intra operative radio frequency (RF).