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Shinkai K, Sakamori R, Yamada R, Tahata Y, Nozaki Y, Matsumoto K, Tawara S, Fukuda K, Yoshida Y, Tanaka S, Ito T, Doi Y, Iio S, Sakakibara M, Nakanishi F, Kodama T, Hikita H, Tatsumi T, Takehara T. Prognostic impact of worsening of esophageal varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 2022; 37:1148-1155. [PMID: 35430734 DOI: 10.1111/jgh.15853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Balloon-occluded retrograde transvenous obliteration (BRTO) is widely performed for treating gastric varices (GVs). However, worsening of esophageal varices (EVs) can be observed after BRTO. This study aimed to investigate the impact of EV worsening on prognosis after BRTO. METHODS Overall, 258 patients who underwent initial BRTO for GV treatment between January 2004 and May 2019 at 12 institutions were retrospectively registered. RESULTS Technical success was achieved in 235 patients (91.1%). Based on the exclusion criteria, 37 patients were excluded, and 198 were evaluated. The cumulative worsening rates of EVs at 1, 2, and 3 years were 39.0%, 59.4%, and 68.4%, respectively. In the univariate Cox proportional hazards model, sex, EV size, history of EV treatment, left gastric vein dilatation, platelet count, aspartate transaminase (AST), alanine aminotransferase (ALT), total bilirubin, albumin, albumin-bilirubin score, prothrombin time-international normalized ratio, fibrosis-4 index, AST to platelet ratio index, and spleen width were significantly associated with worsening of EV after BRTO. Multivariate analysis showed that sex (adjusted hazard ratio [aHR] 1.72; 95% confidence interval [CI] 1.03-2.86; P = 0.04), left gastric vein dilatation (aHR 1.90; 95% CI 1.17-3.10; P = 0.01), ALT (aHR 1.01; 95% CI 1.00-1.03; P = 0.02), albumin (aHR 0.61; 95% CI 0.43-0.87; P < 0.01), and spleen width (aHR 1.02; 95% CI 1.01-1.03; P < 0.01) were independent risk factors for worsening of EV after BRTO. Patients with EV worsening within 1 year after BRTO had a significantly worse prognosis than the other patients (P = 0.007). CONCLUSIONS Early worsening of EV after BRTO was associated with poor prognosis after BRTO.
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Affiliation(s)
- Kazuma Shinkai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ryoko Yamada
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuki Tahata
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | | | | | | | | | | | - Satoshi Tanaka
- National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Toshifumi Ito
- Japan Community Health Care Organization Osaka Hospital, Osaka, Japan
| | | | - Sadaharu Iio
- Hyogo Prefectural Nishinomiya Hospital, Nishinomiya, Japan
| | | | - Fumihiko Nakanishi
- National Hospital Organization Osaka Minami Medical Center, Kawachinagano, Japan
| | - Takahiro Kodama
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hayato Hikita
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
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Left Gastric Vein Width Is an Important Risk Factor for Exacerbation of Esophageal Varices Post Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices in Cirrhotic Patients. Medicina (B Aires) 2022; 58:medicina58020205. [PMID: 35208529 PMCID: PMC8875323 DOI: 10.3390/medicina58020205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Balloon-occluded retrograde transvenous obliteration (BRTO) could be currently one of the best therapies for patients with gastric varices. This study examined the exacerbation rates for esophageal varices following BRTO for gastric varices in patients with hepatic cirrhosis. Materials and Methods: We enrolled 91 cirrhotic patients who underwent BRTO for gastric varices. In total, 50 patients were examined for exacerbation rates of esophageal varices following BRTO. Esophageal varices and their associated exacerbation were evaluated by upper gastrointestinal endoscopy. Patients were allocated into two groups according to the main inflow tract for gastric varices: (1) 36 patients in the left gastric vein (LGV) group with an LGV width of more than 3.55 mm, and (2) 14 patients in the non-LGV group who had short gastric vein or posterior gastric vein. Moreover, treatment outcomes were retrospectively analyzed. Results: LGV width (p < 0.01) was the major risk factor for the deterioration of esophageal varices post BRTO. In addition, LGV was the most common inflow tract, and the LGV group contained 74% (37/50) of patients. The exacerbation rates of esophageal varices at 1, 2, 3, and 4 years post BRTO were 40%, 62%, 65%, and 68%, respectively. The comparison of the exacerbation rates for esophageal varices following BRTO according to inflow tract showed that the exacerbation rates were significantly higher in the LGV group than those of the non-LGV group (p = 0.03). In more than half of the subjects, LGV was the main inflow tract for gastric varices, and this group experienced more frequent exacerbations of esophageal varices following BRTO compared to patients with different inflow tract sources. Conclusion: Careful attention should be paid to the LGV width when BRTO is performed for gastric varices.
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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: 1.7] [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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Ahmed R, Kiyosue H, Mori H, Abdelaziz S, Othman M, Abdel-Aal S, Maruno M, Matsumoto S. Conventional versus selective balloon-occluded retrograde transvenous obliteration of gastric varices. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00228-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Balloon-occluded retrograde transvenous obliteration (BRTO) is a well-established interventional radiological technique for treatment of isolated gastric varices (GV). The aim of this study is to compare outcome after different BRTO techniques, i.e., conventional, selective and superselective techniques.
Fifty-nine consecutive patients underwent BRTO as a primary prophylactic treatment for GV were retrospectively categorized into group A (38 patients underwent conventional BRTO) and group B (21 patients underwent selective or superselective BRTO). Group B was sub-grouped into group B1 (11 patients underwent selective BRTO) and group B2 (10 patients underwent superselective BRTO).
Results
Median volume of ethanol amine oleate iopamidol (EOI) was significantly higher in group A than in group B2 (14.8 Vs 7.4 ml, p = 0.03). Complete GV thrombosis was significantly lower in group B2 (50%) than in A (89.5%, p = 0.01) and B1 (100%, p = 0.01). GV bleeding rate after BRTO was significantly higher in group B2 than in group A (20% vs 0%, p = 0.04). GV recurrence rate was not significantly different between group A and B (p = 0.5) or between group A, B1 and B2 (p = 0.1). Cumulative ascites exacerbation rate was significantly higher in group A than B (p = 0.005), B1 (p = 0.03), and B2 (p = 0.03). Cumulative esophageal varices (Es.V) aggravation rate was significantly higher in group A than B (p = 0.001), B1 (p = 0.01), and B2 (p = 0.03). Volume of EOI was a significant risk factor for ascites exacerbation (p = 0.008) while shunt occlusion and pre-existing partial portal vein thrombosis were significant risk factors for Es.V aggravation (p = 0.01 and 0.03, respectively).
Conclusion
Selective and super-selective techniques had a lower ascites exacerbation, and Es.V aggravation rates than conventional technique. However, superselective BRTO had a lower GV complete thrombosis and higher GV bleeding rates after BRTO than other techniques.
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Campos S, Poley JW, van Driel L, Bruno MJ. The role of EUS in diagnosis and treatment of liver disorders. Endosc Int Open 2019; 7:E1262-E1275. [PMID: 31579708 PMCID: PMC6773586 DOI: 10.1055/a-0958-2183] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/07/2019] [Indexed: 02/06/2023] Open
Abstract
Background and aim Transabdominal ultrasound (US), computed tomographic scanning (CT) and magnetic resonance imaging (MRI) are established diagnostic tools for liver diseases. Percutaneous transhepatic cholangiography is used to perform hepatic interventional procedures including biopsy, biliary drainage procedures, and radiofrequency ablation. Despite their widespread use, these techniques have limitations. Endoscopic ultrasound (EUS), a tool that has proven useful for evaluating the mediastinum, esophagus, stomach, pancreas, and biliary tract, has an expanding role in the field of hepatology complementing the traditional investigational modalities. This review aimed to assess the current scientific evidence regarding diagnostic and therapeutic applications of EUS for hepatic diseases.
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Affiliation(s)
- Sara Campos
- Department of Gastroenterology, Hospital Garcia da Orta, Portugal
- Department of Gastroenterology and Hepatology, Erasmus MC, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, The Netherlands
| | - Lydi van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, The Netherlands
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Jogo A, Nishida N, Yamamoto A, Kageyama K, Nakano M, Sohgawa E, Hamamoto S, Hamuro M, Miki Y. Selective Balloon-occluded Retrograde Transvenous Obliteration for Gastric Varices. Intern Med 2019; 58:2291-2297. [PMID: 31118379 PMCID: PMC6746652 DOI: 10.2169/internalmedicine.2356-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices (GV) is associated with drawbacks including a postoperative increase in portal pressure and the risk of subsequent worsening of esophageal varices (EV). Selective B-RTO that embolizes only the varices may have the potential to minimize such risks. The aim of this study is to retrospectively compare the postoperative course of patients after selective B-RTO (Group S) and conventional B-RTO (Group B). Methods One hundred four patients treated from January 2007 to April 2012 were classified into Groups S (n=5) and B (n=99). In the univariate analysis, the volume of 5% ethanolamine oleate iopamiodol (EOI) administered at baseline and the GV blood flow on endoscopic ultrasound after B-RTO were considered as covariates. The rates of GV recurrence and EV aggravation was also compared between Groups B and S. Results In Group S, the volume of 5% EOI was significantly lower (Group S vs. Group B: 14.6±5.5 vs. 28.5±16.4 mL; p=0.0012) and the rate of EV aggravation was lower in comparison to Group B (p=0.045). However, in Group S, the rate of complete eradication of GV blood flow was significantly lower (Group S vs. Group B: 0% vs. 89.9%; p<0.001) and the rate of re-treatment for GV was higher in comparison to Group B (Group S vs. Group B: 60% vs. 1.0%; p<0.001). Conclusion Selective B-RTO for GV could minimize the risk of a worsening of EV or reduce the amount of sclerosants; however, the rate of recurrence was high in comparison to conventional B-RTO.
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Affiliation(s)
- Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Norifumi Nishida
- Department of Radiology, Osaka Saiseikai Nakatsu Hospital, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Mariko Nakano
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Shinichi Hamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Masao Hamuro
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Japan
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Ahmed R, Kiyosue H, Maruno M, Matsumoto S, Mori H. Coexistence of "extra-gastric afferent-efferent direct connection" with gastric varices: CT evaluation and clinical significance. Abdom Radiol (NY) 2019; 44:2699-2707. [PMID: 31030246 DOI: 10.1007/s00261-019-02033-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the prevalence of extra-gastric direct connection between afferent and efferent veins of gastric varices (GVs) (i.e., EAEDC) and its clinical significance during balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS 57 patients who underwent BRTO for GVs obliteration were retrospectively enrolled in this study. Pre-procedural CT images were reviewed for the presence of EAEDC. Patients were categorized into group A (patients with EAEDC) and group B (Patients with no detectable EAEDC). Intraprocedural images were reviewed to see if EAEDCs could be seen and if additional techniques were used to preserve or occlude them. Post-procedural CT images were reviewed for GVs obliteration, portal/splenic vein thrombosis, EAEDC patency, and ascites exacerbation. Post-procedural esophageal varices aggravation was evaluated by upper endoscopy. RESULTS 39 EAEDCs were identified in CT images of 35 patients (i.e., group A = 61.4%). Among them, only 20 EAEDCs were visualized during BRTO. In the remaining 22 patients, EAEDC was not identified in CT images or during BRTO (i.e., group B = 38.6%). There was no statistically significant difference between group A and B regarding post-BRTO GVs obliteration and portal/splenic vein thrombosis. Use of additional techniques to preserve EAEDC patency had significantly reduced the incidence of ascites and esophageal varices exacerbation (p = 0.036 and 0.028, respectively). In patients with EAEDC diameter ≥ 5 mm, EAEDC preservation or obliteration by coils or balloon had significantly reduced the injected sclerosant volume (p = 0.003). CONCLUSION CT is very useful for EAEDC detection. EAEDC preservation may decrease the incidence of post-BRTO ascites and esophageal varices exacerbation.
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Affiliation(s)
- Ramy Ahmed
- Department of Radiology, Faculty of Medicine, Assuit University, Assuit, 71515, Egypt.
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan.
| | - Hiro Kiyosue
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan
| | - Miyuki Maruno
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan
| | - Shunro Matsumoto
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan
| | - Hiromu Mori
- Department of Radiology, Faculty of Medicine, Oita University, Oita, Japan
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Kim SK, Lee KA, Sauk S, Korenblat K. Comparison of Transjugular Intrahepatic Portosystemic Shunt with Covered Stent and Balloon-Occluded Retrograde Transvenous Obliteration in Managing Isolated Gastric Varices. Korean J Radiol 2017; 18:345-354. [PMID: 28246514 PMCID: PMC5313522 DOI: 10.3348/kjr.2017.18.2.345] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/27/2016] [Indexed: 12/11/2022] Open
Abstract
Objective Although a transjugular intrahepatic portosystemic shunt (TIPS) is commonly placed to manage isolated gastric varices, balloon-occluded retrograde transvenous obliteration (BRTO) has also been used. We compare the long-term outcomes from these procedures based on our institutional experience. Materials and Methods We conducted a retrospective review of patients with isolated gastric varices who underwent either TIPS with a covered stent or BRTO between January 2000 and July 2013. We identified 52 consecutive patients, 27 who had received TIPS with a covered stent and 25 who had received BRTO. We compared procedural complications, re-bleeding rates, and clinical outcomes between the two groups. Results There were no significant differences in procedural complications between patients who underwent TIPS (7%) and those who underwent BRTO (12%) (p = 0.57). There were also no statistically significant differences in re-bleeding rates from gastric varices between the two groups (TIPS, 7% [2/27]; BRTO, 8% [2/25]; p = 0.94) or in developing new ascites following either procedure (TIPS, 4%; BRTO, 4%; p = 0.96); significantly more patients who underwent TIPS developed hepatic encephalopathy (22%) than did those who underwent BRTO (0%, p = 0.01). There was no statistically significant difference in mean survival between the two groups (TIPS, 30 months; BRTO, 24 months; p = 0.16); median survival for the patients who received TIPS was 16.6 months, and for those who underwent BRTO, it was 26.6 months. Conclusion BRTO is an effective method of treating isolated gastric varices with similar outcomes and complication rates to those of TIPS with a covered stent but with a lower rate of hepatic encephalopathy.
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Affiliation(s)
- Seung Kwon Kim
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA.; Department of Radiology, Kyung Hee University College of Medicine, Seoul 02447, Korea
| | - Kristen A Lee
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Steven Sauk
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA
| | - Kevin Korenblat
- Division of Gastroenterology, Department of Internal Medicine, Washington University St. Louis School of Medicine, St. Louis, MO 63110, USA
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Prajapati R, Ranjan P, Gupta A, Yadav AK. Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature. J Clin Exp Hepatol 2016; 6:326-330. [PMID: 28003724 PMCID: PMC5157881 DOI: 10.1016/j.jceh.2016.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 08/12/2016] [Indexed: 12/12/2022] Open
Abstract
Bleeding gastric varices (GV) are managed by cyanoacrylate glue injection with transjugular intrahepatic portosystemic shunt (TIPSS) as modality for treatment failure. Ulcer can form at the site of glue injection over GV and it can cause bleeding. Treatment approach for such bleed is not well described. Balloon-occluded retrograde transvenous obliteration (BRTO), TIPSS, and devascularization remain the treatment options in this scenario. BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of GV, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. BRTO has the benefit of increasing portal hepatic blood flow and can also be useful in patients who may not tolerate TIPSS. We report two cases where BRTO was done for control of bleeding from ulcers formed over previously injected GV.
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Affiliation(s)
- Ritesh Prajapati
- Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India
| | - Piyush Ranjan
- Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India,Address for correspondence: Piyush Ranjan, Consultant, Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India.Consultant, Department of Gastroenterology, Sir Ganga Ram HospitalNew DelhiIndia
| | - Arun Gupta
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ajit K. Yadav
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India
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Yamamoto A, Nishida N, Morikawa H, Jogo A, Kageyama K, Sohgawa E, Hamamoto S, Takeshita T, Sakai Y, Matsuoka T, Kawada N, Miki Y. Prediction for Improvement of Liver Function after Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices to Manage Portosystemic Shunt Syndrome. J Vasc Interv Radiol 2016; 27:1160-7. [PMID: 27234486 DOI: 10.1016/j.jvir.2016.03.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 03/12/2016] [Accepted: 03/15/2016] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To investigate predictive factors and cutoff value of transient elastography (TE) measurements for assessing improvement in liver function after balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices (GV). MATERIALS AND METHODS Retrospective analysis was performed of 50 consecutive patients followed for > 3 months after BRTO, who had undergone TE before BRTO between January 2011 and February 2015. The correlation between change in liver function (total bilirubin, albumin, and prothrombin time) and baseline liver function values and liver stiffness measurement (LSM) by TE was evaluated by Pearson correlation test. Receiver operating characteristic curves were used to determine cutoff values for discriminating between patients who had improved liver function and patients who did not. The time interval from BRTO to aggravation of esophageal varices (EV) (worsening morphology, development of new varices, or variceal rupture) grouped by cutoff values was also analyzed. RESULTS Serum albumin was significantly improved at 3 months after BRTO (3.57 g/dL vs 3.74 g/dL, P < .001). There was a significant negative correlation between change in albumin and baseline LSM (r = -0.50, P < .001). The best cutoff point for LSM was ≤ 22.9 kPa, with sensitivity and specificity of 78.4% and 69.2%, respectively, for predicting which patients would have improved albumin after BRTO. Among 33 patients, 29 (88%) patients had improved albumin. The 1-year progression rate of EV after BRTO was 13.6% in patients with LSM ≤ 22.9 kPa. CONCLUSIONS The predictive factor for improvement in albumin after BRTO was lower LSM (≤ 22.9 kPa) using TE.
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Affiliation(s)
- Akira Yamamoto
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Norifumi Nishida
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan.
| | - Hiroyasu Morikawa
- Premier Preventive Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Atsushi Jogo
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Ken Kageyama
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Etsuji Sohgawa
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Shinichi Hamamoto
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Toru Takeshita
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Yukimasa Sakai
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Toshiyuki Matsuoka
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Norifumi Kawada
- Hepatology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
| | - Yukio Miki
- Departments of Radiology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka 545-8585, Japan
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Waguri N, Osaki A, Ikarashi S, Ogawa M, Kuraoka N, Ogawa K, Sato M, Aiba T, Yoneyama O, Furukawa K, Sugimura K, Igarashi K. Simultaneous combined balloon-occluded retrograde transvenous obliteration and partial splenic embolization for gastric fundal varices. United European Gastroenterol J 2015; 4:62-9. [PMID: 26966524 DOI: 10.1177/2050640615581966] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 03/22/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We previously reported the techniques and usefulness of simultaneous combined balloon-occluded retrograde transvenous obliteration (B-RTO) and partial splenic embolization (PSE), based on the hypothesis that concomitant PSE can diminish the increase in portal venous pressure after B-RTO. OBJECTIVE After experiencing more cases and performing longer-term follow-up, we re-evaluated the efficacy of simultaneous combined B-RTO and PSE for gastric fundal varices (GVs). METHODS We performed B-RTO in 36 consecutive patients treated for GVs from 2005 to 2013. Twenty-three patients underwent simultaneous combined B-RTO and PSE (Group 1) and 13 underwent B-RTO monotherapy (Group 2). The outcomes were retrospectively evaluated. RESULTS There were no significant differences in baseline characteristics between the two groups except that the splenic volumes were larger in Group 1 than 2. B-RTO was technically successful in 21 of 23 patients (91.3%) in Group 1 and in 12 of 13 patients (92.3%) in Group 2. In all patients with ruptured GVs (six in Group 1 and five in Group 2), complete hemostasis was obtained by B-RTO. Exacerbation of esophageal varices was significantly less frequent in Group 1 than 2 (p = 0.0017). CONCLUSION Concomitant PSE with B-RTO may contribute to prevention of the exacerbation of esophageal varices after B-RTO.
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Affiliation(s)
- Nobuo Waguri
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Akihiko Osaki
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Shunzo Ikarashi
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Masahiro Ogawa
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Naosuke Kuraoka
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Kohei Ogawa
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Munehiro Sato
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Tsuneo Aiba
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Osamu Yoneyama
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Koichi Furukawa
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Kazuhito Sugimura
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
| | - Kentarou Igarashi
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Niigata, Japan
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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: 0.9] [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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13
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Naeshiro N, Aikata H, Kakizawa H, Hyogo H, Kan H, Fujino H, Kobayashi T, Fukuhara T, Honda Y, Ohno A, Miyaki D, Kawaoka T, Tsuge M, Hiraga N, Hiramatsu A, Imamura M, Kawakami Y, Takahashi S, Awai K, Chayama K. Long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 2014; 29:1035-42. [PMID: 24372807 DOI: 10.1111/jgh.12508] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM To assess the short- and long-term outcome of patients with gastric varices (GV) after balloon-occluded retrograde transvenous obliteration (B-RTO) by comparing bleeding cases with prophylactic cases. METHODS Consecutive 100 patients with GV treated by B-RTO were enrolled in this retrospective cohort study. We compared the technical success, complications, and survival rates between bleeding and prophylactic cases. RESULTS Of 100 patients, 61 patients were bleeding cases and 39 patients were prophylactic cases. Technical success was achieved in 95% of bleeding case and in 100% of prophylactic case, with no significant difference between these groups (overall technical success rate, 97%). The survival rates at 5 and 10 years were 50% and 22% in bleeding case, and 49% and 36% in prophylactic case, respectively. There was also no significant difference (P = 0.420). By multivariate analysis, survival rates correlated significantly with liver function (hazard ratio 2.371, 95% CI 1.457-3.860, P = 0.001) and hepatocellular carcinoma development (HR 4.782, 95% CI 2.331-9.810, P < 0.001). The aggravating rates of esophageal varices (EV) were 21%, 50%, and 54% at 12, 60, and 120 months after B-RTO. By multivariate analysis, aggravating rates significantly correlated with EV existing before B-RTO (HR 18.114, 95% CI 2.463-133.219, P = 0.004). CONCLUSION B-RTO for GV could provide the high rate of complete obliteration and favorable long-term prognosis even in bleeding cases as well as prophylactic cases. Management of EV after B-RTO, especially in coexisting case of GV and EV, would be warranted.
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Affiliation(s)
- Noriaki Naeshiro
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital
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14
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Factors associated with aggravation of esophageal varices after B-RTO for gastric varices. Cardiovasc Intervent Radiol 2013; 37:1243-50. [PMID: 24322305 PMCID: PMC4156781 DOI: 10.1007/s00270-013-0809-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 11/10/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE To retrospectively evaluate risk factors for aggravation of esophageal varices (EV) within 1 year after balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices (GV) and to clarify suitable timing for upper endoscopy to detect EV aggravation after B-RTO. METHODS Participants included 67 patients who underwent B-RTO for GV between January 2006 and December 2010. Whether EV aggravation occurred within 1 year was evaluated, and the time interval from B-RTO to aggravation was calculated. Factors potentially associated with EV aggravation were analyzed. RESULTS B-RTO was successfully performed in all patients. EV aggravation at 1 year after B-RTO was found in 38 patients (56.7 %). Multivariate logistic regression analysis showed that total bilirubin (T-bil) (P = 0.032) and hepatic venous pressure gradient (HVPG) (P = 0.011) were significant independent risk factors for EV aggravation after B-RTO. Cutoff values of T-bil and HVPG yielding maximal combined sensitivity and specificity for EV aggravation were 1.6 mg/dL and 13 mmHg, respectively. The patients with T-bil ≥ 1.6 mg/dL or HVPG ≥ 13 mmHg had a median aggravation time of 5.1 months. All five patients with ruptured EV belonged to this group. In contrast, patients with T-bil < 1.6 mg/dL and HVPG < 13 mmHg had a median aggravation time of 21 months. CONCLUSION T-bil and HVPG were significant independent risk factors for EV aggravation after B-RTO. The patients with T-bil ≥ 1.6 mg/dL or HVPG ≥ 13 mmHg require careful follow-up evaluation, including endoscopy.
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Sonomura T, Ono W, Sato M, Sahara S, Nakata K, Sanda H, Kawai N, Minamiguchi H, Nakai M, Kishi K. Emergency balloon-occluded retrograde transvenous obliteration of ruptured gastric varices. World J Gastroenterol 2013; 19:5125-5130. [PMID: 23964147 PMCID: PMC3746385 DOI: 10.3748/wjg.v19.i31.5125] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 06/14/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effectiveness and safety of emergency balloon-occluded retrograde transvenous obliteration (BRTO) for ruptured gastric varices.
METHODS: Emergency BRTO was performed in 17 patients with gastric varices and gastrorenal or gastrocaval shunts within 24 h of hematemesis and/or tarry stool. The gastric varices were confirmed by endoscopy, and the gastrorenal or gastrocaval shunts were identified by contrast-enhanced computed tomography (CE-CT). A 6-Fr balloon catheter (Cobra type) was inserted into the gastrorenal shunt via the right internal jugular vein, or into the gastrocaval shunt via the right femoral vein, depending on the varices drainage route. The sclerosant, 5% ethanolamine oleate iopamidol, was injected into the gastric varices through the catheter during balloon occlusion. In patients with incomplete thrombosis of the varices after the first BRTO, a second BRTO was performed the following day. Patients were followed up by endoscopy and CE-CT at 1 d, 1 wk, and 1, 3 and 6 mo after the procedure, and every 6 mo thereafter.
RESULTS: Complete thrombosis of the gastric varices was not achieved with the first BRTO in 7/17 patients because of large gastric varices. These patients underwent a second BRTO on the next day, and additional sclerosant was injected through the catheter. Complete thrombosis which led to disappearance of the varices was achieved in 16/17 patients, while the remaining patient had incomplete thrombosis of the varices. None of the patients experienced rebleeding or recurrence of the gastric varices after a median follow-up of 1130 d (range 8-2739 d). No major complications occurred after the procedure. However, esophageal varices worsened in 5/17 patients after a mean follow-up of 8.6 mo.
CONCLUSION: Emergency BRTO is an effective and safe treatment for ruptured gastric varices.
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Sonomura T, Ono W, Sato M, Sahara S, Nakata K, Sanda H, Kawai N, Minamiguchi H, Nakai M, Kishi K. Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices. World J Gastroenterol 2012; 18:1373-8. [PMID: 22493551 PMCID: PMC3319964 DOI: 10.3748/wjg.v18.i12.1373] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Revised: 02/20/2012] [Accepted: 02/26/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the usefulness of the microcatheter techniques in balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices.
METHODS: Fifty-six patients with gastric varices underwent BRTOs using microcatheters. A balloon catheter was inserted into gastrorenal or gastrocaval shunts. A microcatheter was navigated close to the varices, and sclerosant was injected into the varices through the microcatheter during balloon occlusion. The next morning, thrombosis of the varices was evaluated by contrast enhanced computed tomography (CE-CT). In patients with incomplete thrombosis of the varices, a second BRTO was performed the following day. Patients were followed up with CE-CT and endoscopy.
RESULTS: In all 56 patients, sclerosant was selectively injected through the microcatheter close to the varices. In 9 patients, microcoil embolization of collateral veins was performed using a microcatheter. In 12 patients with incomplete thrombosis of the varices, additional injection of sclerosant was performed through the microcatheter that remained inserted overnight. Complete thrombosis of the varices was achieved in 51 of 56 patients, and the remaining 5 patients showed incomplete thrombosis of the varices. No recurrence of the varices was found in the successful 51 patients after a median follow up time of 10.5 mo. We experienced one case of liver necrosis, and the other complications were transient.
CONCLUSION: The microcatheter techniques are very effective methods for achieving a higher success rate of BRTO procedures.
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Usefulness of endoscopic ultrasonography in hepatology. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 25:621-5. [PMID: 22059170 DOI: 10.1155/2011/367643] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Endoscopic ultrasonography (EUS) is used to evaluate patients with hepatobiliary diseases. The technique is useful for the diagnosis of esogastric varices in selected cases of portal hypertension, and to evaluate the pathogenic role and prognostic value of the collateral circulation in patients with this condition. When coupled with the Doppler technique, EUS can be used to guide injection sclerotherapy and to verify the obliteration of varices (particularly fundal varices) after endoscopic treatment. Hemodynamic changes induced in the collateral circulation by vasoactive drugs can also be measured with Doppler-EUS. Fine-needle aspiration under EUS guidance is useful in the diagnosis of focal liver lesions and perihepatic adenopathy, and in the evaluation of biliary tract diseases. New indications can be developed in the future after adequate experimental validation.
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