Three years experience with endoscopic variceal ligation for treatment of bleeding varices

Complete Esophageal Obstruction after Endoscopic Variceal Band Ligation in a Patient with a Sliding Hiatal Hernia

Complete esophageal obstruction is a rare complication of endoscopic variceal banding, with only 6 cases in the English literature since the introduction of endoscopic variceal banding in 1986. We report a case of complete esophageal obstruction following esophageal banding due to entrapment of part of a sliding hiatal hernia. To our knowledge, our case is one of few with esophageal obstruction post-banding, and the first associated with a hiatal hernia. We recommend caution when performing esophageal banding on patients with a hiatal hernia.

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.

Splenectomy with endoscopic variceal ligation is superior to splenectomy with pericardial devascularization in treatment of portal hypertension

AIM: To investigate the therapeutic efficacy and complications of splenectomy with endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization (i.e. Hassab’s operation) in patients with portal hypertension.

METHODS: A total of 103 patients with liver cirrhosis and portal hypertension were randomly selected to receive either splenectomy with EVL (n = 53, group A) or Hassab’s operation (n = 50, group B).

RESULTS: The portal blood flow volume, the presence of portal vein thrombosis, gastric emptying time and free portal venous pressure (FPP) before and after the operation were determined. Patients were followed up for up to 64 mo with an average of 45 mo, and the Dagradi classification of variceal veins and the grading of portal hypertension gastropathy (PHG) were evaluated. It was found that all esophageal varices were occluded or decreased to grade II or less in both groups. There was little difference in the recurrence rate of esophageal varices (11.9% vs 13.2%) and the re-bleeding rate (7.1% vs 5.3%) between groups A and B. The incidence of complications and the percentage of patients with severe PHG after the operation were significantly higher in group B (60.0% and 52.0%) than in group A (32.1% and 20.8%, P < 0.05). No patients died of operation-related complications. There was no significant difference in gastric emptying time, FPP and portal blood flow volume between the two groups.

CONCLUSION: The results suggest that splenectomy with EVL achieves similar therapeutic efficacy to that of Hassab’s operation in terms of the recurrence rate of esophageal varices and the re-bleeding rate, but the former results in fewer and milder complications.

A cost-utility analysis of secondary prophylaxis for variceal hemorrhage

BACKGROUND

Secondary prophylaxis for esophageal variceal hemorrhage (VH) is recommended, but there has never been a cost-utility analysis of its implementation.

OBJECTIVE

The objective was to compare the cost utility of various strategies for the secondary prophylaxis of VH including (a) observation alone, (b) medical therapy (MED), (c) endoscopic band ligation (EBL), (d) endoscopic band ligation plus medical therapy (EBL + M), and (e) transjugular intrahepatic portosystemic shunt (TIPS), and to examine the effect of adherence on these strategies.

METHODS

A Markov model was developed for all five strategies, and included surveillance, risk of hepatic encephalopathy, complications, and nonadherence.

DATA SOURCES

Published literature and the Health Care Financing Administration.

TARGET POPULATION

People with cirrhosis and a history of controlled VH.

TIME HORIZON

Three years.

PERSPECTIVE

Third-party payer.

OUTCOME MEASURES

Incremental cost-effectiveness ratios for quality-adjusted life-years (QALYs) gained.

RESULTS OF BASE-CASE ANALYSIS

Combination EBL + M was the optimal strategy, dominating all other strategies including observation, meaning that it was more effective and less expensive than the others. In addition, EBL alone dominated observation and TIPS in terms of QALYs, and MED alone dominated the strategy of observation in terms of QALYs.

RESULTS OF SENSITIVITY ANALYSIS

Important variables affecting the optimal strategy were the odds ratio (OR) of VH with EBL compared to MED, the OR of VH with EBL + M compared to EBL, and patients' preferences regarding taking the medication as reflected in the associated toll exacted on the health state utility. Variations in these parameters within the range of clinical plausibility allowed EBL or MED to become the optimal strategy. TIPS was the optimal strategy only if adherence rates for all strategies were less than 12%. RESULTS OF MONTE CARLO ANALYSIS: Neither observation nor TIPS was ever the optimal strategy, and EBL + M was optimal in 62% of cases. If the variables identified in the sensitivity analysis were controlled, then EBL + M was optimal in 95% of cases.

CONCLUSIONS

TIPS should be reserved only for patients with very poor adherence. Otherwise, patients are best served by medications, EBL, or a combination of both, depending on the comparative rates of rebleeding with each and patients' preferences regarding medical therapy. The redundancy of combination band ligation plus medical therapy can improve outcomes, particularly in the setting of poor patient adherence.

The role of endoscopic therapy in the treatment of bleeding varices

The role of endoscopy in bleeding varices is both diagnostic and therapeutic. While sclerotherapy of oesophageal varices remains an established modality, ligation has, in view of its higher safety margin, turned out to be superior in recent years. The excellent initial results of ligation are, however, tainted by a higher recurrence rate in the long term. Since the end-point of treatment is the achievement and maintenance of variceal eradication, the addition of low-dose sclerotherapy following initial eradication by ligation seems to be the optimal method to combine the best of both techniques. In the management of life-threatening bleeding from oesophageal varices and gastric varices, cyanoacrylate remains the only promising non-surgical option. Primary endoscopic prophylaxis is still under evaluation. It is only justified in high-risk patients with large varices bearing red colour signs and in the presence of an intolerance of or contra-indication to propranolol. When indicated, ligation seems to be preferable, and the addition of low-dose sclerotherapy after initial variceal eradication may maintain the benefits accrued in such high-risk patients. The present review examines the available evidence regarding the above issues in the recent literature.

Endoscopic band ligation of oesophageal varices

BACKGROUND

For 25 years the optimal management of bleeding oesophageal varices has included endoscopic injection sclerotherapy (EIS) both to arrest bleeding and to prevent rebleeding. However, the recent innovation of endoscopic variceal ligation (EVL) may be a more effective treatment; this paper reviews its efficacy.

METHODS

All Medline (National Library of Medicine, Washington DC, USA) articles containing the text words 'oesophageal varices', 'sclerotherapy' or 'band ligation' were reviewed. Prospective randomized studies comparing sclerotherapy with band ligation, or combinations thereof, were included.

RESULTS

After an acute variceal bleed EVL is as effective as EIS for control and eradication of oesophageal varices. Initial control of bleeding is similar, but eradication is achieved in fewer sessions with EVL. EVL is associated with lower rebleeding rates and fewer procedure-related complications; it is also more effective for control of active bleeding at initial endoscopy. Combination therapy (EIS plus EVL) confers no advantage over EVL alone.

CONCLUSION

EVL is similar to EIS for control of bleeding varices, but the former has less associated morbidity, lower rebleeding rates and achieves more rapid variceal eradication. EVL should be considered the endoscopic treatment of choice in the management of variceal haemorrhage.

Evaluation of endoscopic variceal ligation in prophylactic therapy for bleeding of oesophageal varices: a prospective, controlled trial compared with endoscopic injection sclerotherapy

BACKGROUND

To evaluate the efficacy of endoscopic variceal ligation (EVL) in prophylactic therapy for oesophageal varices, we performed a randomized prospective trial to compare the recurrence of oesophageal varices treated by EVL with those treated by endoscopic injection sclerotherapy.

METHODS

Fifty patients with liver cirrhosis were divided into two groups at random, after informed consents were obtained, to receive prophylactic therapy for bleeding of oesophageal varices. Group 1 patients underwent sessions of sclerotherapy with 5% ethanolamine oleate used as the sclerosant. Group 2 patients underwent EVL followed by one or two sessions of sclerotherapy.

RESULTS

During the 18 month follow-up period, both the recurrence rate in group 2 (56%) and the incidence of bleeding (20%) were significantly higher compared with group 1 (recurrence rate 16%, bleeding 0%).

CONCLUSIONS

This result indicates that EVL is not effective for prophylactic therapy for oesophageal varices in liver cirrhosis.

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.

New approaches to endoscopic therapy for a haemostasis upper GI bleed

Haematemesis and/or melaena are the most common presentations of upper gastrointestinal bleeding. Endoscopic haemostasis after diagnosis still remains a challenge to the gastroenterologist. Most variceal and peptic ulcer bleeding episodes stop spontaneously, and then prevention of rebleeding might be indicated by endoscopic techniques. In the present article, four less well-known endoscopic haemostasis techniques are discussed and, if available, comparative studies are reviewed.

A new method of endoscopic variceal ligation-injection sclerotherapy (EVLIS) for gastric varices

OBJECTIVES

For esophageal varices, endoscopic variceal sclerotherapy and band ligation have been effectively and frequently used, but these methods were not effective for gastric varices. In gastric varices, because of rich networks of feeding vessels and shunts that may exist in many cases, an effective therapeutic level of sclerosant is difficult to be maintained. Accordingly, we propose a new method called "Endoscopic Variceal Ligation-Injection Sclerotherapy (abbreviated EVLIS)" for gastiric varices, with focus on maintenance of the effective therapeutic level of a sclerosant by partially blocking the blood flow of gastric varices using the band ligation method. The study was undertaken prospectively to evaluate the efficacy and safety of EVLIS for the treatment of gastric varices.

METHODS

EVLIS was performed in a group of 32 patients with gastric varices. Active bleeding varices were 11 and non-bleeding 21. Five cases were grade A, 12 grade B, and 14 grade C of Child's classification. Nine cases were type 1, 22 type 2, and 1 was type 3 of Hosking-Johnson's classification.

RESULTS

The results of EVLIS were excellent, active bleeding of gastric varices in the 11 cases were successfully controlled and all the gastric varices of 32 cases including those bleeding varices were completely eradicated. The bleeding status, the Child's grade and the Hosking-Johnson's class do not appear to correlate in any way with the efficacy of this technique. No perforation or re-bleeding was observed in any of the patients until the mean 10.6 months of the follow-up period.

CONCLUSIONS

EVLIS should be considered as an effective and safe treatment for gastric varices.

New approaches to endoscopic therapy for hemostasis of upper GI bleed

Hematemesis and/or melena are the most common presentations of upper gastrointestinal bleeding. Endoscopic hemostasis after diagnosis still remains a challenge to the gastroenterologist. Most variceal and peptic ulcer bleeding episodes stop spontaneously, and then prevention of rebleeding might be indicated by endoscopic techniques. Four not so well known endoscopic hemostasis techniques are discussed and comparative studies are reviewed.