Reinforcing the management of type 1 gastric esophageal varices

Variceal bleed represents an important complication of cirrhosis, with its presence reflecting the severity of liver disease. Gastric varices, though less frequently seen than esophageal varices, present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality. Based upon the Sarin classification, GOV1 is the most common subtype of gastric varices seen in clinical practice.

Endoscopic submucosal dissection for early esophageal squamous cell carcinoma after ligation and sclerotherapy of esophageal and gastric varices

Esophageal cancer ranked ten of the most common cancers in China. With the advancement of high-quality endoscopy and chromoendoscopic technique, early esophageal cancer can be diagnosed more easily, even combined with esophageal-gastric fundal varices. Endoscopic resection of early esophageal cancer is a minimally invasive treatment method for early esophageal cancer, and endoscopic submucosal dissection (ESD) is one of the standard treatments for early esophageal cancer in view of the risk of bleeding, the patient in this study successfully received ESD treatment after using endoscopic variceal ligation and endoscopic injection of tissue glue and sclerosing agent before ESD surgery. ESD treatment is safe and feasible for early esophageal cancer patients with cirrhosis of esophageal-gastric fundal varices.

Predicting the risk of early bleeding following endoscopic variceal ligation in cirrhotic patients with computed tomography

BACKGROUND

Life-threatening bleeding following endoscopic variceal ligation (EVL) in patients with cirrhosis rarely can occur. The present study aimed to evaluate the performance of computed tomography (CT) in predicting the risk of early bleeding following EVL in cirrhotic patients.

METHODS

We retrospectively investigated 285 cirrhotic patients who had undergone EVL. EVL was performed for prophylaxis or acute variceal bleeding. The patients were classified into 2 groups: early bleeding (< 14 days after EVL) and non-early bleeding. We compared baseline characteristics including CT findings between the patient groups.

RESULTS

Among the 285 patients who underwent EVL treatment, 19 patients (6.7%) experienced early bleeding. On average, these bleeding occurred 9.3 ± 3.5 days after the EVL, with a range of 3 to 13 days. Patients who experience early bleeding had a higher six-week bleeding-related mortality rate compared to those in the non-early bleeding group (31.6% vs. 10.2%; p = 0.014). There was a correlation between the grade of esophageal varix observed during endoscopy and the diameter of esophageal varix observed on CT (p < 0.001). The diameter of esophageal varix on CT was identified as the only significant predictive factor for early bleeding (p = 0.005).

CONCLUSION

A larger esophageal varix diameter observed on CT is associated with an increased risk of early bleeding after EVL treatment. Early identification of this high-risk group can provide a change of treatment strategies to improve patient outcomes.

Maternal and perinatal outcome in pregnancies complicated with portal hypertension: a systematic review and meta-analysis

BACKGROUND

Portal hypertension is secondary to either cirrhotic or non-cirrhotic causes, and complicating pregnancy poses a challenge to the treating team. A systematic review was performed to determine maternal and perinatal outcomes in women with portal hypertension. Outcomes were compared among those with cirrhotic (CPH) with non-cirrhotic portal hypertension (NCPH) as well as non-cirrhotic portal fibrosis (NCPF) with extra-hepatic portal vein obstruction (EHPVO).

METHODS

Medline and EMBASE databases were searched for studies reporting outcomes among pregnant women with portal hypertension. Reference lists from relevant papers and reviews were hand-searched for appropriate citations. Data were extracted to describe maternal complications, obstetric and neonatal outcomes. A random-effects model was used to derive pooled estimates of various outcomes, and final estimates were reported as percentages with a 95% confidence interval (CI). Cumulative, sequential and sensitivity analysis was studied to assess the temporal trends of outcomes over the period.

RESULTS

Information on 895 pregnancies among 581 patients with portal hypertension was included from 26 studies. Portal hypertension was diagnosed during pregnancy in 10% (95% CI 4-24%). There were 22 maternal deaths (0%, 95% CI 0-1%), mostly following complications from variceal bleeding or hepatic decompensation. Variceal bleeding complicated in 14% (95% CI 9-20%), and endoscopic interventions were performed in 12% (95% CI 8-17%) during pregnancy. Decompensation of liver function occurred in 7% (95% CI 3-12%). Thrombocytopenia was the most common complication (41%, 95% CI 23-60%). Miscarriages occurred in 14% (95% CI 8-20%), preterm birth in 27% (95% CI 19-37%), and low birth weights in 22% (95% CI 15-30%). Risk of postpartum hemorrhage was higher (RR 5.09, 95% CI 1.84-14.12), and variceal bleeding was lower (RR 0.51, 95% CI 0.30-0.86) among those with CPH compared to NCPH. Risk of various outcomes was comparable between NCPF and EHPVO.

CONCLUSION

One in ten pregnancies complicated with portal hypertension is diagnosed during pregnancy, and thrombocytopenia is the most common complication. Hepatic decompensation and variceal bleeding remain the most common cause of maternal deaths, with reduced rates of bleeding and its complications reported following the introduction of endoscopic procedures during pregnancy. CPH increases the risk of postpartum hemorrhage, whereas variceal bleeding is higher among NCPH.

Vagus Nerve-Preserving Laparoscopic Splenectomy and Azygoportal Disconnection with Versus Without Intraoperative Endoscopic Variceal Ligation: a Randomized Clinical Trial

BACKGROUND

Esophagogastric variceal bleeding is the most common lethal factor for patients with cirrhotic portal hypertension. We firstly developed a laparoscopic splenectomy and azygoportal disconnection (LSD) with intraoperative endoscopic variceal ligation (LSDL) technique. In this study, we aimed to evaluate whether LSDL is feasible and safe and whether LSDL can effectively prevent esophagogastric variceal re-bleeding (EVR), as compared with single LSD.

METHODS

In this randomized controlled single-center study, 88 patients with cirrhosis who had esophagogastric variceal bleeding and hypersplenism were randomly assigned to receive either LSD (n = 44) or LSDL (n = 44) between January 2020 and December 2021. The primary outcome was EVR.

RESULTS

No patients withdrew from the study. There were no significant differences in estimated blood loss, incidence of blood transfusion, time to first flatus and off-bed activity, or postoperative hospital stay between the two groups. Compared with that in the LSD group, operation time was significantly longer in the LSDL group (138.5 ± 19.4 min vs. 150.3 ± 19.0 min, P < 0.05); however, LSDL was associated with a significantly decreased EVR rate at 1-year follow-up (8/44 vs. 1/44, P < 0.05). Univariate analysis and multivariate logistic regression revealed that LSDL was a significant independent protective factor against EVR in comparison with LSD (relative risk: 0.105, 95% confidence interval 0.012-0.877; P = 0.037).

CONCLUSIONS

Our newly developed LSDL procedure is not only technically feasible and safe; it also contributed to lowering the EVR risk more so than single LSD.

TRIAL REGISTRATION

We registered our research at https://www.

CLINICALTRIALS

gov/ . The name of research registered is "Laparoscopic Splenectomy and Azygoportal Disconnection with Intraoperative Endoscopic Variceal Ligation." The trial registration identifier at clinicaltrials.gov is NCT04244487.

Novel balloon compression-assisted endoscopic injection sclerotherapy and endoscopic variceal ligation in the treatment of esophageal varices: a prospective randomized study

Background

Herein, our group designed a novel technology, termed balloon compression-assisted endoscopic injection sclerotherapy (bc-EIS), which was applied to improve the efficiency of eradicating esophageal varices (EVs). The present study aimed to compare the rate of eradication and efficacy between bc-EIS and endoscopic variceal ligation (EVL) in the management of EVs.

Methods

Ninety-five patients with esophageal variceal bleeding (EVB) were randomly assigned to receive bc-EIS or ligation alone. Additional treatment sessions were held 1 month later and then at 3-month intervals until eradication of the varices was achieved. Endoscopic follow-up examinations were carried out at 6-month intervals in the absence of recurrence or immediately if there was any recurrent bleeding.

Results

The mean physical injection points per session were 2.89 ± 0.79, and the mean volume of lauromacrogol used per session was 17.74 ± 7.09 ml in the bc-EIS group. The mean band per session was 6.13 ± 0.86. The rate of eradication after one to three rounds of bc-EIS was obviously higher than that of the EVL group (89.36%, 97.87%, and 100% vs. 37.5%, 43.75%, and 47.92%, respectively). Retrosternal pain or discomfort in the bc-EIS group was slightly lower than that in the EVL group (23.4%, 11/47 vs. 31.25%, 15/48). Two and five patients showed mild abdominal bloating and distension between the bc-EIS and EVL groups, respectively (2/47, 4.26% vs. 5/48, 10.42% P > 0.05). Nausea and vomiting were reported in one patient (1/47, 2.13%) in the bc-EIS group and three patients (3/48, 6.25%) in the EVL group. However, there were no statistically significant differences between the two groups (P > 0.05). No fatal or severe complications, such as esophageal perforation, esophageal stricture or ectopic embolism, were observed.

Conclusion

The bc-EIS method was effective in eradicating EVs and was accompanied by fewer complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09412-6.

Management of Thrombocytopenia and Coagulopathy in Patients with Chronic Liver Disease Undergoing Therapeutic Endoscopic Interventions

Management of coagulopathy in patients with advanced liver disease undergoing therapeutic endoscopic procedures is complex. Improvements in the understanding of hemostasis at a physiologic level have highlighted the inaccuracy of currently available clinical tests, like platelet count and prothrombin time, in estimating hemostasis in patients with cirrhosis. With identification of novel factors that contribute to bleeding risk in patients with cirrhosis, there is a dearth of clinical trial data that account for all potentially relevant factors and that examine interventions to reduce bleeding risk. Precise recommendations regarding transfusion strategies based on hemostatic test results in patients with cirrhosis are impractical.

Effect of aluminum phosphate gel on prevention of early rebleeding after ligation of esophageal variceal hemorrhage

BACKGROUND

Liver cirrhosis is the main cause of portal hypertension. The leading cause of death in patients with liver cirrhosis is its most common complication, esophageal variceal bleeding (EVB). Endoscopic variceal ligation (EVL) is recommended by many guidelines to treat EVB and prevent rebleeding; however, esophageal ulcers occur after treatment. Delayed healing of ulcers and unhealed ulcers lead to high rebleeding and mortality rates. Thus, the prevention of early postoperative rebleeding is of great significance in improving the quality of life and prognosis of patients.

AIM

To evaluate the efficacy of aluminum phosphate gel (APG) plus a proton pump inhibitor (PPI) in the prevention of early rebleeding after EVL in patients with EVB.

METHODS

The medical records of 792 patients who were diagnosed with EVB and in whom bleeding was successfully stopped by EVL at Shenzhen People’s Hospital, Guangdong Province, China from January 2015 to December 2020 were collected. According to the study inclusion and exclusion criteria, 401 cases were included in a PPI-monotherapy group (PPI group), and 377 cases were included in a PPI and APG combination therapy (PPI + APG) group. We compared the incidence rates of early rebleeding and other complications within 6 wk after treatment between the two groups. The two-sample t-test, Wilcoxon rank-sum test, and chi-squared test were adopted for statistical analyses.

RESULTS

No significant differences in age, sex, model for end-stage liver disease score, coagulation function, serum albumin level, or hemoglobin level were found between the two groups. The incidence of early rebleeding in the PPI + APG group (9/337; 2.39%) was significantly lower than that in the PPI group (30/401; 7.48%) (P = 0.001). Causes of early rebleeding in the PPI group were esophageal ulcer (3.99%, 16/401) and esophageal varices (3.49%, 14/401), while those in the PPI + APG group were also esophageal ulcers (5/377; 1.33%) and esophageal varices (4/377; 1.06%); such causes were significantly less frequent in the PPI + APG group than in the PPI group (P = 0.022 and 0.024, respectively). The early mortality rate within 6 wk in both groups was 0%, which was correlated with the timely rehospitalization of all patients with rebleeding and the conduct of emergency endoscopic therapy. The incidence of adverse events other than early bleeding in the PPI + APG group (28/377; 7.43%) was significantly lower than that in the PPI group (63/401; 15.71%) (P < 0.001). The incidence of chest pain in the PPI + APG group (9/377; 2.39%) was significantly lower than that in the PPI group (56/401; 13.97%) (P < 0.001). The incidence of constipation in the PPI + APG group (16/377; 4.24%) was significantly higher than that in the PPI group (3/401; 0.75%) (P = 0.002) but constipation was relieved after patients drank more water or took lactulose. In the PPI and PPI + APG groups, the incidence rates of spontaneous peritonitis within 6 wk after discharge were 0.50% (2/401) and 0.53% (2/377), respectively, and those of hepatic encephalopathy were 0.50% (2/401) and 0.27% (1/377), respectively, presenting no significant difference (P > 0.999).

CONCLUSION

PPI + APG combination therapy significantly reduces the incidence of early rebleeding and chest pain in patients with EVB after EVL.

Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies

Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. Patients are deemed at high risk of bleeding when they present with medium or large-sized varices, when they have red signs on varices of any size and when they are classified as Child-Pugh C and have varices of any size. In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). The superiority of one of these alternatives over the others is controversial. While EVL might be superior to pharmacological therapy regarding the prevention of the first bleeding episode, either traditional NSBBs or carvedilol seem to play a more prominent role in mortality reduction, probably due to their capacity of preventing other complications of cirrhosis through the decrease in portal hypertension. A sequential strategy, in which patients unresponsive to pharmacological therapy would be submitted to endoscopic treatment, or the combination of pharmacological and endoscopic strategies might be beneficial and deserve further investigation.

Comparative study for predictability of type 1 gastric variceal rebleeding after endoscopic variceal ligation: High-frequency intraluminal ultrasound study

BACKGROUND

The efficacy of endoscopic ultrasonography for the follow-up of gastric varices treated with endoscopic variceal ligation (EVL) has not been established.

AIM

To evaluate the diagnostic correlation of esophagogastroduodenoscopy (EGD) and high-frequency intraluminal ultrasound (HFIUS) for type 1 gastric varices (GOV1) after EVL and to identify the predictability for rebleeding of EGD and HFIUS.

METHODS

In liver cirrhosis patients with GOV1, we performed endoscopic follow-up using EGD and HFIUS synchronously after EVL for hemorrhage from GOV1. Endoscopic grading and red color signs were analyzed using EGD, and the largest variceal cross-sectional areas were measured using HFIUS. In addition, 1-year follow-up was performed. Variceal rebleeding was defined as the presence of hematemesis, hematochezia, or melena without other evidence of bleeding on endoscopic follow-up.

RESULTS

In 26 patients with GOV1, variceal cross-sectional areas on HFIUS of GOV1 was poorly correlated with EGD grading of GOV1 (r = 0.36). In 17 patients who completed the 1-year follow-up, variceal cross-sectional areas on HFIUS was a good predictor of subsequent rebleeding, whereas EGD grading was not a predictor of subsequent rebleeding.

CONCLUSION

HFIUS measurement is more predictive of GOV1 rebleeding than EGD grading, so HFIUS measurement may be necessary for endoscopic follow-up after EVL in patients with GOV1.

Exacerbation of Portal Hypertensive Enteropathy after Endoscopic Injection Sclerotherapy for Esophageal Varices

INTRODUCTION

Portal hypertensive enteropathy (PHE) is a well-known small-bowel lesion that occurs with liver cirrhosis (LC) and is associated with increased hepatic venous pressure. However, it is unclear how esophageal varices (EV) treatment actually affects PHE. We aimed to analyze the effects of EV treatment on PHE.

METHODS

Among LC patients who underwent capsule endoscopy (CE) more than twice to confirm PHE at our hospital from February 2009 to September 2018, we targeted those with no change in the Child-Pugh classification after EV treatment for the prevention of bleeding. Patients were assigned to groups based on the EV treatment method (endoscopic injection sclerotherapy [EIS] group or endoscopic variceal ligation [EVL] group). We analyzed the PHE findings before and after treatment, and we investigated changes in the collateral vein using computed tomography imaging.

RESULTS

We analyzed 42 LC patients (27 men; mean age, 65.3 years); 20 were in the EIS group and 22 were in the EVL group. Exacerbation of PHE was significantly prevalent in the EIS group (90%) compared to that in the EVL group (50%). CE of PHE showed significantly prevalent exacerbation of villous edema in the EIS group (65%) compared to that in the EVL group (23%). Stenosis or disappearance of the feeding vessel (55%) and exacerbation of the hepatofugal collateral vein (35%) were significantly prevalent in the EIS group.

CONCLUSIONS

EIS exacerbates PHE, especially villous edema, in LC patients with changes in collateral circulation.

Gastroesophageal varices in a patient presenting with essential thrombocythemia: A case report

BACKGROUND

Gastroesophageal varices are a rare complication of essential thrombocythemia (ET). ET is a chronic myeloproliferative neoplasm (MPN) characterized by an increased number of blood platelets.

CASE SUMMARY

A 46-year-old woman, who denied a history of liver disease, was admitted to our hospital on presentation of hematemesis. Laboratory examination revealed a hemoglobin level of 83 g/L, and a platelet count of 397 × 10⁹/L. The appearance of gastric and esophageal varices with red colored signs as displayed by an urgent endoscopy was followed by endoscopic variceal ligation and endoscopic tissue adhesive. Abdominal computed tomography revealed cirrhosis, marked splenomegaly, portal vein thrombosis and portal hypertension. In addition, bone marrow biopsy and evidence of mutated Janus kinase 2, substantiated the onset of ET. The patient was asymptomatic with regular routine blood testing during the 6-mo follow-up period. Therefore, in this case, gastroesophageal varices were induced by ET.

CONCLUSION

MPN should be given considerable attention when performing differential diagnoses in patients with gastroesophageal varices. An integrated approach such as laboratory tests, radiological examination, and pathological biopsy, should be included to allow optimal decisions and management.

Partial splenic embolization combined with endoscopic therapies and NSBB decreases the variceal rebleeding rate in cirrhosis patients with hypersplenism: a multicenter randomized controlled trial

Background

Global research on endoscopic therapies in combination with partial splenic embolization (PSE) for variceal hemorrhage (VH) is limited. Therefore, we aimed to evaluate the efficacy and safety of endoscopy plus PSE (EP) treatment in comparison to endoscopic (E) treatment for the secondary prophylaxis of VH in cirrhosis patients with hypersplenism.

Methods

Cirrhosis patients with hypersplenism (platelet count < 100, 000/µL) and those who had recovered from an episode of VH were enrolled in a multicenter randomized controlled trial. The participants were randomly assigned into EP and E groups in a 1:1 ratio. The primary endpoint was variceal rebleeding, and the secondary endpoints were severe variceal recurrence and mortality during the 2-year follow-up. Hematological indices, serum biochemical parameters, and the Child–Pugh score were measured at each time point.

Results

From June 2016 to December 2019, 108 patients were enrolled in the study, among which 102 patients completed the protocol (51 in EP and 51 in E group). The rebleeding rate of the varices was significantly reduced in the EP group compared to that in the E group during the 2 years (16% vs. 31%, p < 0.001). The EP group showed a significantly lower variceal recurrence rate than the E group (22% vs. 67%, p < 0.001). The COX proportional hazard models revealed that grouping was an independent predictor for variceal rebleeding (H = 0.122, 95% CI 0.055–0.270, p < 0.001) and variceal recurrence (hazard ratio, H = 0.160, 95% CI 0.077–0.332, p < 0.001). The peripheral blood cell count, Child–Pugh class/score, albumin concentration, and coagulation function in the EP group improved significantly compared to the values observed in the E group at any time point (p < 0.05).

Conclusions

The EP treatment was more effective in preventing variceal rebleeding and variceal recurrence than the conventional E treatment during the secondary prophylaxis of VH in cirrhosis patients with hypersplenism. Furthermore, the EP treatment could significantly increase the peripheral blood cell count and albumin concentration and also improved the coagulation function and the Child–Pugh score.

Clinical trials registration

Trial registration number ClincialTrials.gov: NCT02778425. The URL of the clinical trial: https://clinicaltrials.gov/

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-021-10155-0.

Early rebleeding increases mortality of variecal bleeders on secondary prophylaxis with β-blockers and ligation

BACKGROUND/AIMS

Despite secondary-prophylaxis with β-blockers and endoscopic-variceal-ligation rebleeding is frequent, particularly within the first-6-weeks. Early-rebleeding may have greater impact on death-risk than late rebleeding, which may affect therapy. We assessed whether the influence of rebleeding on long-term survival of patients on secondary-prophylaxis is greater in patients with early-rebleeding.

METHODS

369 patients with cirrhosis were consecutively included once recovered from first variceal-bleeding. The impact of rebleeding on survival was investigated according to whether it occurred within 6-weeks (early-rebleeding) or later (late-rebleeding).

RESULTS

During 46-months of follow-up (IQR: 14-61), 45 patients (12%) had early-rebleeding, 74(20%) had late-rebleeding and 250(68%) had not rebleeding. Mortality risk was higher in early-rebleeding group vs. late-rebleeding (HR = 0.476, 95%CI = 0.318-0.712, p < 0.001) and was similar in late-rebleeding group vs. no-rebleeding (HR = 0.902, 95%CI = 0.749-1.086, p = 0.271). Adjusting for baseline risk-factors, early-rebleeding was independently associated with mortality-risk (HR = 1.58, 95%CI = 1.02-2.45; p = 0.04). Child-Pugh&MELD scores improved at 3rd-4th-week only in patients without early-rebleeding (p < 0.05). Presence of ascites or encephalopathy, MELD-score>12 and HVPG>20 mmHg identified patients at risk of early-rebleeding.

CONCLUSIONS

Patients with early-rebleeding have higher risk of death than patients without rebleeding and even than those rebleeding later. Our results suggest that patients at risk of early rebleeding might benefit from preemptive therapies such as early-TIPS.

Evaluation and Management of Esophageal and Gastric Varices in Patients with Cirrhosis

Variceal bleeding is a complication of cirrhosis that defines decompensation. Important advances in the management of gastroesophageal varices have led to a significant decrease in the morbidity and mortality. Achieving these results in clinical practice is contingent on clinicians applying the best practice strategies and appropriate referral to a tertiary center. Several quality metrics were developed by the American Association for the Study of Liver Diseases. This article aims to update outpatient and inpatient strategies to include the latest recommendations on variceal screening and surveillance, primary and secondary prophylaxis of variceal bleeding, and therapy for patients with acute variceal bleeding.

Maternal-fetal outcome in pregnancies complicated with non-cirrhotic portal hypertension: experience from a Tertiary Centre in South India

OBJECTIVE

To assess the maternal and perinatal outcomes of pregnant women with non-cirrhotic portal hypertension (NCPH).

METHODS

This was an observational study done by retrieving the records of pregnant women with non-cirrhotic portal hypertension admitted to a tertiary hospital in South India, over a 9-year study period. Data regarding the clinical course, complications during pregnancy, labor, and delivery details were reviewed. We also compared the outcomes among women with non-cirrhotic portal fibrosis (NCPF) with extrahepatic portal vein obstruction (EHPVO).

RESULTS

During the study period, portal hypertension was noted in 0.07%(n = 108) of the pregnancies and 74.1% of them had NCPH. The diagnosis was made for the first time in 54.7% of them when presented with pancytopenia or splenomegaly. Variceal bleeding complicated 25% of the pregnancies in women with NCPH pregnancies, with three among them having a massive bleed. Eighteen among them underwent endoscopy following bleeding; variceal banding procedure was performed in nine of them without any complications. Preterm birth was the most common (20.6%) obstetric complication. There was one maternal death from severe sepsis, acute kidney injury, and disseminated intravascular coagulation, following a massive variceal bleed. Obstetric outcomes and medical complications were similar in women with NCPF and EHPVO. Perinatal loss was comparable in both the groups (14.3% vs. 9.6%, p = 0.417) CONCLUSION: Multidisciplinary team approach, with optimal and timely intervention with intensive monitoring, can reduce the morbidity and help achieve an optimal maternal-perinatal outcome in pregnancies complicated with portal hypertension.

Removal of a Trigger Cord Stuck between Bands during Endoscopic Multiple-Band Ligation for Treating Esophageal Variceal Hemorrhage

Endoscopic variceal ligation is the preferred endoscopic treatment method for esophageal variceal bleeding. The incidence of complications such as chest pain, bleeding, stricture formation, and aspiration pneumonia is low. We report a case wherein a malfunctioning multiple-band ligator could have potentially caused damage to the esophageal varices and massive bleeding. The equipment was safely removed using scissors and forceps. To the best of our knowledge, this is the first published report detailing the management of a case of esophageal variceal bleeding.

A case of early colorectal cancer with rectal varices treated with endoscopic variceal ligation

Rectal varices are ectopic varices that occur in patients with portal hypertension and cause abrupt gastrointestinal bleeding. Endoscopic variceal ligation is a minimally invasive treatment used for patients with bleeding from rectal varices. Endoscopic treatment of colorectal tumors accompanied by rectal varices has been rarely reported. It is very important to control bleeding during treatment. The patient was a 76-year-old man who had a chief complaint of bloody stools. A flat-elevated-type neoplastic lesion measuring about 20 mm was found above the rectal varices. After performing endoscopic variceal ligation for rectal varices around the lesion, the lesion was resected en bloc by endoscopic submucosal dissection. Bleeding was controlled during the procedure; the patient was discharged 7 days after the endoscopic treatment, and there was no postoperative bleeding. Colonoscopy performed 90 days after the procedure showed scar formation in the wound area and no remnant lesion. The implementation of preoperative endoscopic variceal ligation enabled us to control bleeding during endoscopic treatment in a case of early colorectal cancer accompanied by rectal varices.

Effect of endoscopic variceal obliteration by band ligation on portal hypertensive gastro-duodenopathy: endoscopic and pathological study

INTRODUCTION AND AIM

A few studies have shown that the degree of portal hypertensive gastropathy (PHG) and duodenopathy (PHD) has been worsening after the introduction of therapeutic endoscopic interventions. This study aimed to determine the impact of esophageal variceal eradication by endoscopic variceal ligation (EVL) on PHG and PHD using endoscopic and histopathologic assessment.

METHODS

Fifty patients with esophageal varices for which EVL was indicated were included. EVL was carried out until complete variceal eradication was achieved. The degree of severity of PHG and PHD were recorded before and 4 weeks after variceal eradication. Biopsies were taken from various parts of the stomach and duodenum before and 4 weeks after variceal eradication.

RESULTS

The whole Baveno score (4 vs. 2.5) increased significantly after variceal eradication when compared to those before eradication (p < 0.05). After obliteration, only 19 (38 %) patients had mild PHG versus 37 (74 %) before EVL, while severe PHG was found in 31 (62 %) patients versus 11 (22 %) before EVL and the difference was highly statistically significant. No significant changes were found regarding endoscopic PHD lesions before and after variceal eradication. Pathological changes as average blood vessel count, angiogenesis, ectasia and blood extravasation in stomach and duodenum significantly increased after EVL. Large esophageal varices (III-IV) and Baveno score (>1) at baseline endoscopy were independent risk factors for development of severe PHG after variceal obliteration (p < 0.05).

CONCLUSION

PHG increased significantly, endoscopically and pathologically, after variceal obliteration by EVL. Although PHD did not significantly change as documented by endoscopy, pathological examination documented statistically significant changes in the duodenum after EVL.

Laparoscopic RFA with splenectomy for hepatocellular carcinoma

BACKGROUND

The treatment of hepatocellular carcinoma (HCC) is complicated and challenging because of the frequent presence of cirrhosis. Therefore, we propose a novel surgical approach to minimize the invasiveness and risk in patients with HCC, hypersplenism, and esophagogastric varices.

METHODS

This was a retrospective study carried out in 25 patients with HCC and hypersplenism and who underwent simultaneous laparoscopic-guided radio-frequency ablation and laparoscopic splenectomy with endoscopic variceal ligation. Tumor size was restricted to a single nodule of <3 cm. Characteristics of the patients (cirrhosis etiology, liver function, tumor size, spleen size), surgery (complications, blood loss, time of stay), and follow-up (recurrence and survival) were examined.

RESULTS

Mean operative time was 128 ± 18 min. Mean blood loss was 206 ± 57 mL. Length of stay was 7.0 ± 1.5 days. Mean total costs were 8064 USD. Cytopenia and thrombocytopenia recovered quickly after surgery. No procedure was converted to open surgery. Two patients showed worsening liver function after surgery, three patients showed worsening of ascites, and five patients suffered from portal vein thrombosis. The 1-year tumor-free survival was 78.8 %, and the 21-month tumor-free survival was 61.4 %. According to a literature review, these outcomes were comparable to those of simultaneous open hepatic resection and splenectomy.

CONCLUSIONS

Laparoscopic-guided radio-frequency ablation with laparoscopic splenectomy and endoscopic variceal ligation could be an available technique for patients with HCC <3 cm, hypersplenism, and esophagogastric varices. This approach may help to minimize the surgical risks and results in a fast increase in platelet counts with an acceptable rate of complications.

Challenges of banding jejunal varices in an 8-year-old child

Endoscoic variceal ligation (EVL) by the application of bands on small bowel varices is a relatively rare procedure in gastroenterology and hepatology. There are no previously reported paediatric cases of EVL for jejunal varices. We report a case of an eight-year-old male patient with a complex surgical background leading to jejunal varices and short bowel syndrome, presenting with obscure but profound acute gastrointestinal bleeding. Wireless capsule endoscopy and double balloon enteroscopy (DBE) confirmed jejunal varices as the source of bleeding. The commercially available variceal banding devices are not long enough to be used either with DBE or with push enteroscopes. With the use of an operating gastroscope, four bands were placed successfully on the afferent and efferent ends of the leads of the 2 of the varices. Initial hemostasis was achieved with obliteration of the varices after three separate applications. This case illustrates the feasibility of achieving initial hemostasis in the pediatric population.

Esophageal variceal pressure influence on the effect of ligation

AIM: To explore the effect of in vitro porcine esophageal variceal pressure on complete ligation degree for polycyclic ligators.

METHODS: An in vitro model of experimental porcine venous vessels was used to test various venous pressures. Three treatment groups were designated according to the preset pressure range: P1 = 25-30 cmH₂O; P₂ = 35-40 cmH₂O; P₃ = 45-50 cmH₂O. The effect of pressure on ligation was assessed and compared among the groups.

RESULTS: Complete ligation was achieved at a rate of 56.25% (18/32) in group P₁, 37.5% (12/32) in group P₂, and 33.33% (11/33) in group P₃ (χ² = 3.6126; P = 0.0573).

CONCLUSION: Higher variceal pressures impair the ligation completion rate. Therefore, measuring variceal pressure may help predict the effect of endoscopic ligation and guide treatment choice.

Effect of intravariceal sclerotherapy combined with esophageal mucosal sclerotherapy using small-volume sclerosant for cirrhotic patients with high variceal pressure

AIM: To explore the effect of intravariceal-mucosal sclerotherapy using small dose of sclerosant on the recurrence of esophageal varices.

METHODS: We randomly assigned 38 cirrhotic patients with previous variceal bleeding and high variceal pressure (> 15.2 mmHg) to receive endoscopic variceal ligation (EVL) and combined intravariceal and esophageal mucosal sclerotherapy (combined group) using small-volume sclerosant. The end-points of the study were rebleeding and recurrence of esophageal varices.

RESULTS: During a median follow-up period of 16 mo, varices recurred in 1 patient in the combined group as compared with 7 patients in the EVL group (P = 0.045). Rebleeding occurred in 3 patients in the EVL group as compared with 1 patient in the combined group (P = 0.687). No patient died in the two groups. No significant differences were observed between the two groups with respect to serious adverse events.

CONCLUSION: Intravariceal-mucosal sclerotherapy using small dose of sclerosant is more effective than EVL in decreasing the incidence of variceal recurrence for cirrhotic patients.

Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage: A meta-analysis

AIM: To compare the effect of endoscopic variceal ligation (EVL) with that of endoscopic injection sclerotherapy (EIS) in the treatment of patients with esophageal variceal bleeding.

METHODS: We performed a systematic literature search of multiple online electronic databases. Meta-analysis was conducted to evaluate risk ratio (RR) and 95% confidence interval (CI) of combined studies for the treatment of patients with esophageal variceal bleeding between EVL and EIS.

RESULTS: Fourteen studies comprising 1236 patients were included in the meta-analysis. The rebleeding rate in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group (RR = 0.68, 95%CI: 0.57-0.81). The variceal eradication rate in actively bleeding varices patients in the EVL group was significantly higher than that in the EIS group (RR = 1.06, 95%CI: 1.01-1.12). There was no significant difference about mortality rate between the EVL group and EIS group (RR = 0.95, 95%CI: 0.77-1.17). The rate of complications in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group (RR = 0.28, 95%CI: 0.13-0.58).

CONCLUSION: Our meta-analysis has found that EVL is better than EIS in terms of the lower rates of rebleeding, complications, and the higher rate of variceal eradication. Therefore, EVL is the first choice for esophageal variceal bleeding.

Clinical effects of endoscopic submucosal dissection combined with variceal ligation in treatment of patients with gastrointestinal stromal tumors

AIM: To analyze the clinical effects of endoscopic submucosal dissection combined with variceal ligation in the treatment of patients with gastrointestinal stromal tumors.

METHODS: Ninety-eight patients with gastrointestinal stromal tumors treated at our hospital from August 2010 to July 2014 were selected and divided into either a control group or a treatment group. The control group received endoscopic variceal ligation, and the treatment group received endoscopic submucosal dissection combined with variceal ligation. Clinical effects were observed and compared for the two groups.

RESULTS: The operative time was significantly longer in the treatment group than in the control group (57.6 min ± 9.3 min vs 67.9 min ± 9.1 min, P < 0.05), while hospital stay time and treatment cost were significantly lower in the treatment group (6.4 d ± 1.1 d vs 4.9 d ± 1.0 d, 4324.8 yuan ± 231.2 yuan vs 3780.9 yuan ± 214.3 yuan, P < 0.05). The rate of complete excision was significantly higher and the incidences of perforation and bleeding were significantly lower in the treatment group (P < 0.05).

CONCLUSION: Endoscopic submucosal dissection combined with variceal ligation is effective in the treatment of patients with gastrointestinal stromal tumors.

Epidemiology, diagnosis and early patient management of esophagogastric hemorrhage

Acute variceal bleeding (AVB) is a potentially life-threatening complication of cirrhosis and portal hypertension. Combination therapy with vasoactive drugs and endoscopic variceal ligation is the first-line treatment in the management of AVB after adequate hemodynamic resuscitation. Short-term antibiotic prophylaxis, early resuscitation, early use of lactulose for prevention of hepatic encephalopathy, targeting of conservative goals for blood transfusion, and application of early transjugular intrahepatic portosystemic shunts in patients with AVB have further improved the prognosis of AVB. This article discusses the epidemiology, diagnosis, and nonendoscopic management of AVB.

Emergency endoscopic cyanoacrylate injection combined with sclerotherapy-ligation for treatment of esophageal and gastric variceal bleeding

AIM: To explore the clinical efficacy and complications of emergency endoscopic cyanoacrylate injection combined with sclerotherapy-ligation for esophageal and gastric variceal bleeding.

METHODS: Clinical data for 58 patients with acute esophageal or gastric variceal bleeding who were treated by emergency endoscopic cyanoacrylate injection combined with sclerotherapy-ligation and followed for 6 mo after the procedure were retrospectively analyzed.

RESULTS: Immediate hemostasis was achieved in all cases, and the success rate of immediate hemostasis was 100.0% (58/58). The early re-bleeding rate and short-term re-bleeding rate were both 1.7% (1/58). The remission rate of gastric fundus varices was 70.7% (41/58), the effective rate was 22.4% (13/58), and the total effective rate was 93.1% (54/58); the remission rate of esophageal varices was 74.1% (43/58), the effective rate was 17.2% (10/58), and the total effective rate was 91.4% (53/58). The total effective rate for GOV1 varices was significantly higher than that for GOV2 varices [95.8% (23/24) vs 82.2% (30/34), P < 0.05). Three patients received endoscopic injection sclerotherapy again four weeks later, and two patients with liver cancer had recurrence of variceal bleeding and died from hepatic encephalopathy within 1 mo. Substernal chest discomfort or pain in the setting of eating or fever was observed in some patients, but ectopic embolism and treatment-related serious complications did not occur.

CONCLUSION: Emergency endoscopic cyanoacrylate injection combined with sclerotherapy-ligation is a safe and effective technique for the treatment of patients with esophageal or gastric variceal bleeding, in terms of high immediate hemostasis rate and varices remission rate and minor side effects.

Carvedilol vs. esophageal variceal band ligation in the primary prophylaxis of variceal hemorrhage: a multicentre randomized controlled trial

BACKGROUND & AIMS

Esophageal variceal bleed is a major problem in patients with cirrhosis. Endoscopic variceal ligation (EVL) has been shown to be equal to or better than propranolol in preventing first bleed. Carvedilol is a non-selective β blocker with alpha-1 adrenergic blocker activity. Hemodynamic studies have shown carvedilol to be more effective than propranolol at reducing portal pressure. We compared efficacy of carvedilol with EVL for primary prophylaxis of esophageal variceal bleed.

METHODS

Cirrhotic patients with esophageal varices were randomized to carvedilol 12.5mg daily or EVL at three university hospitals of Pakistan. End points were esophageal variceal bleeding, death or liver transplant.

RESULTS

Two hundred and nine patients were evaluated. Eighty two and eighty six patients were randomized in carvedilol and EVL arms respectively. Mean age was 48 ± 12.2 years; 122 (72.7%) were males; 89.9% had viral cirrhosis; mean Child-Pugh score was 7.3 ± 1.6 and mean follow up was 13.3 ± 12.1 months (range 1-50 months). Both EVL and carvedilol groups had comparable variceal bleeding rates (8.5% vs. 6.9%), bleed related mortality (4.6% vs. 4.9%) and overall mortality (12.8% vs. 19.5%) respectively. Adverse events in carvedilol group were hypotension (n=2), requiring cessation of therapy, while transient nausea (n=18) and dyspnea (n=30) resolved spontaneously. In the EVL arm, post banding ulcer bleed (n=1) and chest pain (n=17), were termed as serious adverse events while transient dysphagia (n=58) resolved without treatment.

CONCLUSIONS

Although our study is underpowered, the findings suggest that carvedilol is probably not superior to EVL in preventing first variceal bleed in patients with viral cirrhosis.

Efficacy and safety of three different methods for primary prophylaxis of variceal bleeding in cirrhosis

AIM: To compare the efficacy and safety of endoscopic variceal ligation (EVL), propranolol and EVL plus propranolol for the primary prophylaxis of first variceal bleeding in cirrhosis.

METHODS: We chose 90 patients with cirrhosis and esophageal varices at a high risk of bleeding and divided them into EVL (n = 30), propranolol (n = 30) and combination (n = 30) groups. Treatment effectiveness and side effects in the 3 groups were compared.

RESULTS: The three groups of patients had comparable baseline characteristics and follow-up time (EVL: 19.9 mo ± 7.2 mo; propranolol: 19.3 mo ± 6.7 mo; combination: 21.4 mo ± 5.3 mo). There were no significant differences in average ligation times between the EVL group and combination group (2.2 ± 1.2 vs 2.0 ± 0.9, P > 0.05), mean daily propranolol dose between the propranolol group and combination group(75.6 mg ± 23.4 mg vs 68.8 mg ± 30.5 mg, P > 0.05), rate of first variceal bleeding and bleeding-related mortality (10.0%, 16.7% vs 6.6%, both P > 0.05) or incidence of portal hypertensive gastropathy between the three groups (16.7%, 6.6% vs 10.0%, both P > 0.05). The incidence of complications and adverse reactions was significantly different between the three groups (50.0%, 26.7% vs 56.7%, both P < 0.05), but no serious complications or adverse reactions occurred. The difference in variceal recurrence rate was significant between the EVL group and combination group (26.7% vs 6.6%, P = 0.04).

CONCLUSION: EVL, propranolol and EVL plus propranolol are effective and safe in primary prophylaxis of bleeding due to high-risk varices. The adverse effects caused by propranolol are minimal. The recurrence of varices is lower if propranolol is added to EVL, but without much more adverse reactions.

Three-dimensional Doppler ultrasonographic evaluation of hemodynamic changes in the left gastric vein of patients after esophageal variceal ligation

AIM: To determine the hemodynamic effects of endoscopic variceal band ligation (EVL) on the left gastric vein (LGV) using three-dimensional Doppler ultrasonography (TD-DUS).

METHODS: One hundred and ten patients with pathologically confirmed cirrhosis, portal hypertension and esophageal varices who underwent esophageal variceal ligation at our hospital from January 2009 to December 2012 were divided into either a non-hemorrhage group (n = 50) or a hemorrhage group (n = 60). TD-DUS measurements of hemodynamic indexes of the LGV including vein diameter, mean blood flow velocity, blood flow and blood flow were performed.

RESULTS: Before and after EBL, LGV diameter, mean flow velocity, and blood flow were significantly higher in the hemorrhage group than in the non-hemorrhage group (t = 3.2, 2.8; 4.7, 6.0; 3.6, 3.8, all P < 0.01). After EVL treatment, hemodynamic indexes were significantly reduced in both groups. The direction of blood flow of the left gastric vein to the liver (4.55% vs 70.91%), from the liver (87.27% vs 19.09%), and bidirectional blood flow (8.18% vs 10%) differed significantly between before and after treatment. There was also a significant difference between the two groups (χ² = 16.82, P < 0.01).

CONCLUSION: EVL can reduce hemodynamic indexes (LGV diameter, mean blood flow velocity and blood flow) of the LGV.

Curative effect of endoscopic variceal ligation versus oral propranolol in management of esophageal varices

AIM: To compare the curative effect of endoscopic variceal ligation (EVL) versus oral propranolol in the management of esophageal varices (EV).

METHODS: One hundred patients with liver cirrhosis and EV were divided into either an observation group or a treatment group. The observation group underwent EV, while the control group was given oral propranolol. The curative effect and side effects were compared between the two groups.

RESULTS: The patients were followed for a period of 18-36 mo. There were no significant differences in the rate of hemorrhage (22.86% vs 20.0%, P > 0.05), overall mortality (22.86% vs 17.14%, P > 0.05), and bleeding-related mortality (11.43% vs 8.57%, P > 0.05) between the control group and observation group. However, the incidence of side effects was significantly lower in the observation group than in the control group (20.0% vs 51.43%, P < 0.05).

CONCLUSION: Both EVL and oral propranolol have good curative effect on liver cirrhosis-associated EV. The side effects associated with propranolol are much less than those with EVL.

Transjugular intrahepatic portosystemic shunt vs endoscopic therapy in preventing variceal rebleeding

AIM: To compare early use of transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic treatment (ET) for the prophylaxis of recurrent variceal bleeding.

METHODS: In-patient data were collected from 190 patients between January 2007 and June 2010 who suffured from variceal bleeding. Patients who were older than 75 years; previously received surgical treatment or endoscopic therapy for variceal bleeding; and complicated with hepatic encephalopathy or hepatic cancer, were excluded from this research. Thirty-five cases lost to follow-up were also excluded. Retrospective analysis was done in 126 eligible cases. Among them, 64 patients received TIPS (TIPS group) while 62 patients received endoscopic therapy (ET group). The relevant data were collected by patient review or telephone calls. The occurrence of rebleeding, hepatic encephalopathy or other complications, survival rate and cost of treatment were compared between the two groups.

RESULTS: During the follow-up period (median, 20.7 and 18.7 mo in TIPS and ET groups, respectively), rebleeding from any source occurred in 11 patients in the TIPS group as compared with 31 patients in the ET group (Kaplan-Meier analysis and log-rank test, P = 0.000). Rebleeding rates at any time point (6 wk, 1 year and 2 year) in the TIPS group were lower than in the ET group (Bonferroni correction α’ = α/3). Eight patients in the TIPS group and 16 in the ET group died with the cumulative survival rates of 80.6% and 64.9% (Kaplan-Meier analysis and log-rank test χ² = 4.864, P = 0.02), respectively. There was no significant difference between the two groups with respect to 6-wk survival rates (Bonferroni correction α’ = α/3). However, significant differences were observed between the two groups in the 1-year survival rates (92% and 79%) and the 2-year survival rates (89% and 64.9%) (Bonferroni correction α’ = α/3). No significant differences were observed between the two treatment groups in the occurrence of hepatic encephalopathy (12 patients in TIPS group and 5 in ET group, Kaplan-Meier analysis and log-rank test, χ² = 3.103, P = 0.08). The average total cost for the TIPS group was higher than for ET group (Wilcxon-Mann Whitney test, 52 678 RMB vs 38 844 RMB, P < 0.05), but hospitalization frequency and hospital stay during follow-up period were lower (Wilcxon-Mann Whitney test, 0.4 d vs 1.3 d, P = 0.01; 5 d vs 19 d, P < 0.05).

CONCLUSION: Early use of TIPS is more effective than endoscopic treatment in preventing variceal rebleeding and improving survival rate, and does not increase occurrence of hepatic encephalopathy.

Efficacy of endoscopic intervention alone versus endoscopic intervention plus propranolol in the prophylaxis of esophageal variceal rebleeding

AIM: To compar e the efficacy of endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS) alone versus EVL or EIS plus propranolol in the prophylaxis of esophageal variceal rebleeding.

METHODS: Sixty-nine cirrhotic patients were divided randomly into endoscopic intervention group (EIG, n = 40; EVL or EIS) and combination intervention group (CIG, n = 29; EVL or EIS plus propranolol). The mortality, mortality due to rebleeding, and rate of rebleeding were compared between the two groups. All patients were followed for more than one year. In addition, changes in endoscopic characteristics of esophageal varices were evaluated according to the criterion of the Japan Society for Portal Hypertension.

RESULTS: There were no significantly differences in liver function, routine blood parameters, and serum electrolytes between the two groups. After intervention, the diameter of varices decreased significantly in the EIG group (10.92 ± 2.91 vs 8.45 ± 2.26, P < 0.05), but showed no significance in the CIG group (10.14 ± 2.46 vs 8.95 ± 2.21, P > 0.05). The distance from the proximal end of varices to the fore-tooth (22.79 ± 2.83 vs 24.85 ± 3.96, P < 0.05) and the rate of recurrence of red signs in varices (100% vs 76.19%, P < 0.05) decreased significantly after intervention in the CIG group. The morbidity of gastric varices and portal hypertensive gastropathy were both higher after intervention in the CIG group (10.34% vs 28.10%, P < 0.05; 10.34% vs 42.86%, P < 0.05). The appearance of varices in both groups changed from rosary-like to earthworm-like pattern. The rate of rebleeding between two groups displayed no significant difference (50.00% vs 51.71%, P > 0.05). However, the mortality in the CIG group was significantly lower than that in the EIG group (27.50% vs 7.41%, P < 0.05), and the main cause of death in both groups was upper gastrointestinal bleeding.

CONCLUSION: Endoscopic intervention combined with propranolol can decrease the risk of death and reduce endoscopic re-bleeding in the prevention of esophageal variceal re-bleeding.

Risk factors for predicting early variceal rebleeding after endoscopic variceal ligation

AIM: To analyze the clinical risk factors for early variceal rebleeding after endoscopic variceal ligation (EVL).

METHODS: 342 cirrhotic patients with esophageal varices who received elective EVL to prevent bleeding or rebleeding at our endoscopy center between January 2005 and July 2010. were included in this study. The early rebleeding cases after EVL were confirmed by clinical signs or endoscopy. A case-control study was performed comparing the patients presenting with early rebleeding with those without this complication.

RESULTS: The incidence of early rebleeding after EVL was 7.60%, and the morbidity of rebleeding was 26.9%. Stepwise multivariate logistic regression analysis showed that four variables were independent risk factors for early rebleeding: moderate to excessive ascites [odds ratio (OR) 62.83, 95% CI: 9.39-420.56, P < 0.001], the number of bands placed (OR 17.36, 95% CI: 4.00-75.34, P < 0.001), the extent of varices (OR 15.41, 95% CI: 2.84-83.52, P = 0.002) and prothrombin time (PT) > 18 s (OR 11.35, 95% CI: 1.93-66.70, P = 0.007).

CONCLUSION: The early rebleeding rate after EVL is mainly affected by the volume of ascites, number of rubber bands used to ligate, severity of varices and prolonged PT. Effective measures for prevention and treatment should be adopted before and after EVL.

Efficacy and safety of endoscopic variceal ligation and endoscopic injection sclerotherapy in patients with cirrhosis and esophageal varices: a prospective study

AIM: To prospectively determine the efficacy and safety of endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS) in patients with esophageal varices.

METHODS: Sixty-three patients with liver cirrhosis and esophageal varices were divided into two groups: EIS group (n = 36) and EVL group (n = 27). To compare the rates of hemostatic success, early rebleeding, delayed rebleeding, mortality, and other complications between the two groups, a 6-month prospective follow-up study was performed in patients after endoscopic therapy.

RESULTS: The patients treated by EVL had a higher rate of hemostatic success than those by EIS though the difference was not significant (P = 0.137). The EVL group had significantly lower rates of early rebleeding (44.4% vs 12%, P = 0.007), delayed rebleeding (52.8% vs 16%, P = 0.004), and better survival (19.4% vs 4%, P = 0.125) than the EIS group. Furthermore, the patients treated by EVL also had a lower probability of fever (63.9% vs 25.9%, P = 0.003), retrosternal pain (69.4% vs 40.7%, P = 0.023), bleeding esophageal ulcer (19.4% vs 0%, P = 0.017), and abdominal distention (47.2% vs14.8%, P = 0.007) than those by EIS.

CONCLUSION: EVL is more effective and safer than EIS in the treatment of esophageal varices because the former is associated with a lower probability of rebleeding and other complications.

Endoscopic therapy for hemorrhage from gastric varices: an analysis of 97 cases

AIM: To study the selection of methods and the curative effects of endoscopic therapy in hemorrhage from gastric varices.

METHODS: Ninety seven patients with hemorrhage from gastric varices were randomly divided into 3 groups. One group received endoscopic injection of tissue adhesives (Cyanoacrylate group, n = 31 cases), the second group was given sclerotic agents (EIS group, n = 37 cases) and group 3 had endoscopic band ligation (EVL group, n = 29 cases). An average of 6 months' follow-up was conducted to understand short-term and long-term efficacy of patients treated with endoscopic therapy.

RESULTS: The rates of haemostasis in the three groups were 91.9%-96.6%. The incidence of local ulcer, short-term rehaemorrhagia and mortality in the three groups were 22.5%,16.1%, 12.9% in cyanoacrylate group, 29.7%, 18.9%, 13.5% in EIS group, and 58.6%, 31.0%, 37.9% in EVL group. Incidence rate of local ulcer, short-term rehaemorrhagia and mortality were significantly higher in EVL group than either cyanoacrylate group or than EIS group (χ² = 9.485, 6.574, 7.579, all P < 0.05). However, there were not significant differences in long-term therapeutic efficacy among the three groups.

CONCLUSION: Endoscopic scherotherapy and endoscopic injection of cyanoacrylate are more effective and safer than endoscopic ligation for gastric varices.

Development of digestive endoscopic ligator and advances in application of ligation

Great progress has been made in the development of both endoscopic variceal ligator and ligation application in the past 20 years. In clinical practice, endoscopic variceal ligation (EVL) has been recognized as the first choice to treat esophageal variceal hemorrhage by the domestic and foreign experts because of its good efficacy as well as milder and fewer complications. The application category of endoscopic ligation has been expanded to other fields of digestive endoscopic therapy. Endoscopic ligation has become a simple and safe as well as generalized ligation technique with a high efficacy.

Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices

AIM: To detect the hemodynamic alterations in collateral circulation before and after combined endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization by ultrasonography, and to evaluate their effect using hemodynamic parameters.

METHODS: Forty-three patients with esophageal varices received combined EVL and splenectomy with pericardial devascularization for variceal eradication. The esophageal vein structures and azygos blood flow (AZBF) were detected by endoscopic ultrasonography and color Doppler ultrasound. The recurrence and rebleeding of esophageal varices were followed up.

RESULTS: Patients with moderate or severe varices in the esophageal wall and those with severe peri-esophageal collateral vein varices had improvements after treatment, while the percentage of patients with severe para-esophageal collateral vein varices decreased from 54.49% to 2.33%, and the percentage of patients with detectable perforating veins decreased from 79.07% to 4.65% (P < 0.01). Color Doppler flowmetry showed a significant decrease both in AZBF (43.00%, P < 0.05) and in diameter of the azygos vein (28.85%, P < 0.05), while the blood flow rate was unchanged. The recurrence rate of esophageal varices was 2.5% (1/40, mild), while no re-bleeding cases were recorded.

CONCLUSION: EVL in combination with splenectomy with pericardial devascularization can block the collateral veins both inside and outside of the esophageal wall, and is more advantagious over splenectomy in combination with pericardial devascularization or EVL in preventing recurrence and re-bleeding of varices.