Balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices using foam sclerosant and a reduced balloon inflation time: Feasibility and efficacy

INTRODUCTION

Balloon-occluded retrograde transvenous obliteration (BRTO) is recommended for secondary prevention of gastric variceal bleeding in the American Association for the Study of Liver Disease (AASLD) guidelines, as an alternative to Transjugular intrahepatic portosystemic shunt (TIPS). However, there is significant heterogeneity in how BRTO is performed, including how and how long to occlude the outflow venous shunt amongst other variables such as variceal size, flow rate, agent used, and preparation technique. We propose a method using foam sclerotherapy and reducing balloon occlusion to as little as 30 min, with assessment of the efficacy of this shorter balloon inflation time.

METHODS

Retrospective single-centre analysis of BRTO procedures between July 2015 and February 2019 for isolated gastric varices in a non-acute setting, where inflation time was 2 h or less.

RESULTS

Six patients underwent BRTO with a short inflation time, with a mean age of 66 years. The median balloon inflation and thus 3% athoxysclerol foam contact time was 30 min (range 30-60 min). Four of the 6 patients showed complete resolution of varices, while 2 of the 6 showed a partial response. Mean follow-up was 27 months. There were no patients who did not show a response to treatment and no episodes of clinically significant upper gastrointestinal bleeding.

CONCLUSIONS

This technique using a shortened balloon occlusion time resulted in complete or partial clinical and technical success in all patients and suggests that the threshold for initiation of gastric variceal thrombosis may be below 30 min. This timepoint may provide a balance between adequate balloon inflation, angiography room efficiency and hospital resource allocation with resultant procedural cost implications.

Balloon-Assisted Percutaneous Transhepatic Antegrade Embolization with 2-Octyl Cyanoacrylate for the Treatment of Isolated Gastric Varices with Large Gastrorenal Shunts

Aims

To evaluate the safety and effectiveness of percutaneous transhepatic antegrade embolization (PTAE) with 2-octyl cyanoacrylate assisted with balloon occlusion of the left renal vein or gastrorenal shunts (GRSs) for the treatment of isolated gastric varices (IGVs) with large GRSs.

Methods

Thirty patients with IGVs associated with large GRSs who had underwent PTAE assisted with a balloon to block the opening of the GRS in the left renal vein were retrospectively evaluated and followed up. Clinical and laboratory data were collected to evaluate the technical success of the procedure, complications, changes in the liver function using Child-Pugh scores, worsening of the esophageal varices, the rebleeding rate, and survival. Laboratory data obtained before and after PTAE were compared (paired-sample t-test).

Results

PTAE was technically successful in all 30 patients. No serious complications were observed except for one nonsymptomatic pulmonary embolism. During a mean follow-up of 30 months, rebleeding was observed in 4/30 (13.3%) patients, worsening of esophageal varices was observed in 4/30 (13.3%) patients, and newly developed or aggravated ascites were observed on CT in 3/30 (10%) patients. Significant improvement was observed in Child-Pugh scores (p=0.009) and the international normalized ratio (INR) (p=0.004) at 3 months after PTAE. The cumulative survival rates at 1, 2, 3, and 5 years were 96.3%, 96.3%, 79.9%, and 79.9%, respectively.

Conclusion

Balloon-assisted PTAE with 2-octyl cyanoacrylate is technically feasible, safe, and effective for the treatment of IGV associated with a large GRS.

Recent development of balloon-occluded retrograde transvenous obliteration

Gastric varices (GVs) are a major complication of portal hypertension in patients with liver cirrhosis. The mortality rate associated with the bleeding from GVs is not low. Balloon-occluded retrograde transvenous obliteration (BRTO) was first introduced by Kanagawa et al. as a treatment for isolated GVs in 1994. It has been performed most frequently in Asia, especially in Japan. Ethanolamine oleate was the original sclerosant used in the therapy. Since the late 2000s, BRTO using sodium tetradecyl sulfate foam or polidocanol foam as a sclerosant has been performed in many countries other than Japan. Then, early in the 2010s, modified BRTO techniques including vascular plug-assisted retrograde transvenous obliteration and coil-assisted retrograde transvenous obliteration were developed as an alternative treatment for GVs. This article provides a historical overview of BRTO using various sclerosants and modified BRTO techniques, such as plug-assisted retrograde transvenous obliteration and coil-assisted retrograde transvenous obliteration.

Safety and Efficacy of a Novel Shunt Surgery Combined with Foam Sclerotherapy of Varices for Prehepatic Portal Hypertension: A Pilot Study

OBJECTIVES

This pilot study investigated the safety and efficacy of a novel shunt surgery combined with foam sclerotherapy of varices in patients with prehepatic portal hypertension.

METHODS

Twenty-seven patients who were diagnosed with prehepatic portal hypertension and underwent shunt surgeries were divided into three groups by surgery type: shunt surgery alone (Group A), shunt surgery and devascularization (Group B), and shunt surgery combined with foam sclerotherapy (Group C). Between-group differences in operation time, intraoperative blood loss, portal pressure decrease, postoperative complications, rebleeding rates, encephalopathy, mortality rates and remission of gastroesophageal varices were compared.

RESULTS

Groups A, B and C had similar operation times, intraoperative bleeding, and portal pressure decrease. The remission rates of varices differed significantly (p<0.001): one patient in Group A and 6 patients in Group B had partial response, and all 9 patients in Group C had remission (2 complete, 7 partial). Two Group A patients and one Group B patient developed recurrent gastrointestinal bleeding postoperatively within 12 months. No postoperative recurrence or bleeding was observed in Group C, and no sclerotherapy-related complications were observed.

CONCLUSIONS

Shunt surgery combined with foam sclerotherapy obliterates varices more effectively than shunt surgery alone does, decreasing the risk of postoperative rebleeding from residual gastroesophageal varices. This novel surgery is safe and effective with good short-term outcomes.

Endoscopic treatment or balloon-occluded retrograde transvenous obliteration is safe for patients with esophageal/gastric varices in Child-Pugh class C end-stage liver cirrhosis

Background/Aims

There is a controversy about the availability of invasive treatment for esophageal/gastric varices in patients with Child-Pugh class C (CP-C) end-stage liver cirrhosis (LC). We have evaluated the validity of invasive treatment with CP-C end-stage LC patients.

Methods

The study enrolled 51 patients with CP-C end-stage LC who had undergone invasive treatment. The treatment modalities included endoscopic variceal ligation in 22 patients, endoscopic injection sclerotherapy in 17 patients, and balloon-occluded retrograde transvenous obliteration (BRTO) in 12 patients. We have investigated the overall survival (OS) rates and risk factors that contributed to death within one year after treatment.

Results

The OS rate in all patients at one, three, and five years was 72.6%, 30.2%, and 15.1%, respectively. The OS rate in patients who received endoscopic treatment and the BRTO group at one, three, and five years was 67.6%, 28.2% and 14.1% and 90.0%, 36.0% and 18.0%, respectively. The average of Child-Pugh scores (CPS) from before treatment to one month after variceal treatment significantly improved from 10.53 to 10.02 (P=0.003). Three significant factors that contributed to death within one year after treatment included the presence of bleeding varices, high CPS (≥11), and high serum total bilirubin levels (≥4.0 mg/dL).

Conclusions

The study demonstrated that patients with a CPS of up to 10 and less than 4.0 mg/dL of serum total bilirubin levels may not have a negative impact on prognosis after invasive treatment for esophageal/gastric varices despite their CP-C end-stage LC.

Comparison of Ultrasound-Guided Percutaneous Polidocanol Injection Versus Percutaneous Ethanol Injection for Treatment of Benign Cystic Thyroid Nodules

OBJECTIVES

We compared the efficacy, safety, and cost-effectiveness of ultrasound-guided percutaneous polidocanol injection and percutaneous ethanol injection for the treatment of benign cystic and predominantly cystic thyroid nodules.

METHODS

A total of 135 cystic thyroid nodules treated by percutaneous ethanol injection and 136 cystic thyroid nodules treated by percutaneous polidocanol injection were enrolled retrospectively in this study from May 2010 to March 2016. The nodules were followed after 1, 3, 6, and 12 months. Nodule volumes, symptoms scores, and cosmetic scores were assessed before treatment and at follow-up. The therapeutic success rate, safety, and cost-effectiveness between the groups were also compared.

RESULTS

No significant differences in the reduction of the nodule volume, volume reduction rate, and therapeutic success were observed between the groups with cystic and predominantly cystic thyroid nodules during follow-up (P > .05). Neither the cosmetic scores (P = .59; P = .42) nor the symptom scores (P = .32; P = .73) in the cystic and predominantly cystic nodules were significantly different between the groups at the last follow-up. The complication rates for ethanol were higher than those for polidocanol (P < .05). However, the cost of polidocanol injection was higher than that of ethanol injection for cystic thyroid nodules (mean ± SD, US$97.18 ± US$22.17 versus US$43.36 ± US$5.51; P < .01).

CONCLUSIONS

Ultrasound-guided percutaneous polidocanol injection can be an alternative for sclerotherapy of cystic or predominantly cystic thyroid nodules. However, its cost was higher than that of percutaneous ethanol injection.

Overview of small bowel angioectasias: clinical presentation and treatment options

Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.

Foam Sclerotherapy during Shunt Surgery for Portal Hypertension and Varices

Objective

This preliminary study investigated the clinical safety and efficacy of foam sclerotherapy during shunt surgery to treat portal hypertension and gastroesophageal varices.

Methods

Seven patients with confirmed portal hypertension and a variceal bleeding history underwent mesocaval shunt with simultaneous polidocanol foam injection into the varices. Computed tomography and endoscopic reviews were conducted within two weeks following the procedures and around six months later.

Results

Six patients underwent side-to-side mesocaval shunt. One received a prosthetic mesocaval shunt. Polidocanol foam was injected into the gastric varices or the inferior mesenteric vein during the surgery. Surgical success and survival was achieved in all patients. Gastric ulcer formation and thrombocytopenia occurred in one patient respectively, which were ameliorated by conservative treatment. During 12 to 24 months’ follow-up, three patients had obvious decrease or eradication of gastroesophageal varices; four patients had obvious decrease of gastric varices but residual esophageal varices; and all patents had unobstructed shunts. Encephalopathy occurred in one patient two months postoperatively. No sclerosant-related complications were observed and no postoperative recurrent variceal bleeding occurred.

Conclusions

Foam sclerotherapy during shunt surgery is safe and effective for portal hypertension and varices treatment.

Efficacy and Safety of Ultrasound-Guided Percutaneous Polidocanol Sclerotherapy in Benign Cystic Thyroid Nodules: Preliminary Results

OBJECTIVE

To evaluate the efficacy and safety of percutaneous polidocanol injection (PPI) in treating cystic thyroid nodules.

MATERIALS AND METHODS

A total of 158 cystic or predominantly cystic thyroid nodules (>80% cystic component) in 143 patients were evaluated. 114 patients with compressive symptoms or aesthetic complaints were offered PPI. 44 individuals without compressive symptoms and aesthetic complaints who were only followed up clinically were used as the control group. The efficacy and safety of PPI were evaluated for 1 month, 3 months, 6 months, 9 months, and 12 months of follow-up.

RESULTS

In the PPI group, the mean baseline volume of 15.6 ± 18.9 cm³ reduced at the 1-month follow-up to 5.1 ± 5.6 cm³ (p < 0.001) and 0.6 ± 0.9 (p < 0.001), and nodules shrunk according to the time after PPI (p < 0.001). A complete response (if ≥70% decrease) to PPI at the 12-month follow-up occurred in 100% of the cystic or predominant cystic nodules. None of the nodules recurred at the 12-month follow-up after PPI. The side effects were mild. Twenty patients (17.5%) developed mild localized pain, and fourteen cases (12.3%) experienced mild or moderate fever after PPI.

CONCLUSIONS

PPI is a safe and effective alternative to treat benign cystic or predominant cystic thyroid nodules.

BRTO assisted endoscopic Histoacryl injection in treating gastric varices with gastrorenal shunt

AIMS

We evaluated the feasibility, efficacy and safety of a novel technique of balloon-occluded retrograde transvenous obliteration (BRTO) assisted endoscopic Histoacryl (N-buthyl-2-cyanoacrylate) injection.

MATERIAL AND METHODS

A total with 11 patients were enrolled and analyzed in this single center, open-label, prospective study. Patients with high-risk gastric varices (defined as fundal varices, large GV (>5 mm), presence of a red spot, and Child-Pugh score C) and concurrent gastrorenal shunt underwent endoscopic Histoacryl injection while the gastrorenal shunt was temporarily occluded with an occlusion balloon. Feasibility, hemostatic effect, intra- and postoperative complications, and varices recurrence were evaluated.

RESULTS

All procedures were successfully done per protocol. Except for one patient who underwent rescue Histoacryl injection due to residual varices, single therapy was sufficient to eliminate gastric varices in ten patients. Intra-operative hemorrhage occurred in one case and was stopped after additional Histoacryl injection. One patient was confirmed to have treatment-related fungemia. No death or major complications occurred, including ectopic embolism, worsening of hepatic and renal function, etc. No recurrence of the varices was found during a median follow-up time (mean ± SD) of 228 ± 153 days.

CONCLUSIONS

BRTO assisted endoscopic Histoacryl injection is effective and safe for patients with high-risk gastric varices and concurrent gastrorenal shunt.

Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: A meta-analysis

BACKGROUND AND AIM

The aim of this study was to compare the feasibility and safety of both balloon-occluded retrograde transvenous obliteration (BRTO) versus transjugular intrahepatic portosystemic shunt (TIPS) for treatment of gastric varices due to portal hypertension through the method of meta-analysis.

METHODS

PubMed, Embase, and Cochrane Library were searched for both randomized controlled trials and cohort studies concerning BRTO compared with TIPS in the treatment of gastric varices from their inception to April 26, 2015. The Cochrane network RevMan 5.3 software was used for statistic analysis. The primary markers that need to be evaluated contained technical success rate, hemostasis rate, incidence rate of postoperative rebleeding, incidence rate of hepatic encephalopathy, and postoperative procedure-related complication. Study-specific odds ratios (ORs) were combined to calculate pooled value by using random effects model.

RESULTS

Five original studies were included in total. Meta-analysis showed that BRTO and TIPS had no difference in aspects of technical success rate (OR, 0.19; 95% confidence interval [CI], 0.03-1.08; P = 0.06), hemostasis rate (OR, 3.41; 95% CI, 0.33-35.40; P = 0.30), and incidence rate of postoperative procedure-related complication (OR, 1.98; 95% CI, 0.44-8.84; P = 0.37). However, BRTO had a lower incidence rate of post-operative rebleeding (OR, 0.27; 95% CI, 0.09-0.81; P = 0.02) and a lower incidence rate of postoperative encephalopathy (OR, 0.05; 95% CI, 0.02-0.13; P < 0.00001).

CONCLUSIONS

Balloon-occluded retrograde transvenous obliteration was a technically feasible as well as a secure method for the treatment of gastric varices originated from portal hypertension. It may have the potential to be an alterative shunt approach of TIPS, when suitable patients selected.

Percutaneous transvenous embolization for portosystemic shunts associated with encephalopathy: Long-term outcomes in 14 patients

AIM

To evaluate the clinical outcomes of percutaneous transvenous embolization (PTE) for portosystemic shunt (PSS) associated with encephalopathy

METHODS

Fourteen patients with portosystemic encephalopathy (PSE) were enrolled in this retrospective cohort study. We evaluated technical success, clinical success, complication and outcomes.

RESULTS

In cases in which PSS was one of main causes of PSE, three also had splenorenal shunts, four gastrorenal shunts, four superior mesenteric vein systemic shunts, one inferior mesenteric vein systemic shunt and two main trunk of portal vein inferior vena cava shunts. We used only ethanolamine oleate (EO) in five; EO and coils in five; EO, coils and n-butyl 2-cyanoacrylate (NBCA) in two; and coils and NBCA in two patients as embolic materials. The rate of primary and secondary technical success was 93% (13/14 patients) and 100%, respectively. No major complications were encountered related to PTE. Follow-up period was a median of 27 months (range, 12-79). All patients had sustained disappearance of PSE. PSE recurred in one patient because of another PSS development. Thus, clinical success was achieved in 93% (13/14 patients). The ammonia levels 1 year after PTE were significantly improved compared with pre-PTE (median, 102 vs 41 μmol/L) and maintained lower levels 2 and 3 years later. Child-Pugh scores did not change significantly. Esophageal varices were aggravated in 29% (4/14 patients). Five patients died, but no death of hepatic failure related to PTE was encountered.

CONCLUSION

PTE could be one of the useful treatment options for PSE.

Management of gastric varices

According to their location, gastric varices (GV) are classified as gastroesophageal varices and isolated gastric varices. This review will mainly focus on those GV located in the fundus of the stomach (isolated gastric varices 1 and gastroesophageal varices 2). The 1-year risk of GV bleeding has been reported to be around 10%-16%. Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. Limited data suggest that tissue adhesives, mainly cyanoacrylate (CA), may be effective and better than propranolol in preventing bleeding from GV. General management of acute GV bleeding must be similar to that of esophageal variceal bleeding, including prophylactic antibiotics, a careful replacement of volemia, and early administration of vasoactive drugs. Small sample-sized randomized controlled trials have shown that tissue adhesives are the therapy of choice for acute GV bleeding. In treatment failures, transjugular intrahepatic portosystemic shunt (TIPS) is considered the treatment of choice. After initial hemostasis, repeated sessions with CA injections along with nonselective beta-blockers are recommended as secondary prophylaxis; whether CA is superior to TIPS in this scenario is not completely clear. Balloon-occluded retrograde transvenous obliteration (BRTO) has been introduced as a new method to treat GV. BRTO is also effective and has the potential benefit of increasing portal hepatic blood flow and therefore may be an alternative for patients who may not tolerate TIPS. However, BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension and its related complications. The role of BRTO in the management of acute GV bleeding is promising but merits further evaluation.

Long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration

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.

Variceal and other portal hypertension related bleeding

Variceal bleeding is one of the commonest and most severe complications of liver cirrhosis. Even with the current best medical care, mortality from variceal bleeding is still around 20%. When cirrhosis is diagnosed, varices are present in about 30-40% of compensated patients and in 60% of those who present with ascites. Once varices have been diagnosed, the overall incidence of variceal bleeding is in the order of 25% at two years. Variceal size is the most useful predictor for variceal bleeding, other predictors are severity of liver dysfunction (Child-Pugh classification) and the presence of red wale marks on the variceal wall. The current consensus is that every cirrhotic patient should be endoscopically screened for varices at the time of diagnosis to detect those requiring prophylactic treatment. Non-selective beta-adrenergic blockers (NSBB) and endoscopic band ligation (EBL) have been shown effective in the prevention of first variceal bleeding. The current recommendation for treating acute variceal bleeding is to start vasoactive drug therapy early (ideally during the transferral or to arrival to hospital, even if active bleeding is only suspected) and performing EBL. Once bleeding is controlled, combination therapy with NSBB + EBL should be used to prevent rebleeding. In patients at high risk of treatment failure despite of using this approach, an early covered-TIPS within 72 h (ideally 24 h) should be considered. Data on management of gastric variceal bleeding is limited. No clear recommendation for primary prophylaxis can be done. In acute cardiofundal variceal bleeding, vasoactive agents together with cyanoacrylate (CA) injection seem to be the treatment of choice. Further CA injections and/or NSBB may be used to prevent rebleeding. TIPS or Balloon-occluded retrograde transvenous obliteration when TIPS is contraindicated may be used as a rescue therapy.