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Yue X, Wang Z, Li J, Guo X, Zhang X, Li S, Lv H, Hu D, Ji X, Li S, Lu W. Esophageal variceal ligation plus sclerotherapy vs. ligation alone for the treatment of esophageal varices. Front Surg 2022; 9:928873. [PMID: 36311923 PMCID: PMC9614367 DOI: 10.3389/fsurg.2022.928873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the efficacy and adverse events of esophageal variceal ligation (EVL) vs. EVL combined with endoscopic injection sclerosis (EIS) in the therapy of esophageal varices. METHODS Patients from January 2017 to August 2021 who received EVL alone (control group) or EVL plus EIS (intervention group) were enrolled in this retrospective study. Efficacy, including rebleeding (clinically hematemesis or melena, confirmed by endoscopy as esophagogastric varices bleeding), variceal recurrence rate (the presence of esophagogastric varices which is needed to be treated again) the number of sessions performed to complete eradication of varices, and safety (adverse events) were compared. The variceal recurrence-associated factors were derived by univariate and multivariate logistic regression analyses. RESULTS The variceal recurrence and rebleeding rate in the intervention group showed significantly lower than the control group (2.6% vs 10.3%, P = 0.006 and 20.7% vs 37.5%, P = 0.029, P = 0.006, respectively, in the 12-month follow-up). The adverse events (fever, chest pain, swallowing, and esophageal stricture) showed no significant difference between the two groups (P > 0.05). Further research showed that the efficacy of the intervention group was better than the control group only achieved in prophylactically endoscopic treatment patients. The diameter of esophageal varices and gastric varices co-exist showed significant effects on variceal recurrence in intervention group [odds ratio (OR) = 15.856; 95% confidence interval (CI), 1.709-160.143; P = 0.016 and OR = 4.5; 95% CI, 1.42-20.028; P = 0.021; respectively]. CONCLUSIONS The intervention group may obtain lower recurrence, rebleeding rate, and fewer sessions performed to complete eradication of varices (number of sessions) and similar incidence of adverse events, especially for prophylactically treatment. Among the intervention group, the diameter of esophageal varices and gastric varices were closely associated with variceal recurrence.
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Affiliation(s)
- Xiaofen Yue
- Department of Hepatobiliary Oncology, Liver Cancer Center, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University, Tianjin, China,Department of Hepatology, Tianjin Second People’s Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Zeyu Wang
- Department of Hepatobiliary Oncology, Liver Cancer Center, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University, Tianjin, China
| | - Jianbiao Li
- Department of Clinical Laboratory, The Third Central Hospital of Tianjin, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin, China
| | - Xiaoling Guo
- Department of Hepatology, Tianjin Second People’s Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Xiehua Zhang
- Department of Infectious Diseases, The First Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Shengnan Li
- Department of Hepatobiliary Oncology, Liver Cancer Center, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University, Tianjin, China,Department of Hepatology, Tianjin Second People’s Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Hongcheng Lv
- Department of Oncology, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin, China
| | - Dongsheng Hu
- Department of Hepatology, Tianjin Second People’s Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Xiangjun Ji
- Department of Hepatology, Tianjin Second People’s Hospital, Tianjin Institute of Hepatology, Tianjin, China
| | - Shuang Li
- Department of Hepatology, Tianjin Second People’s Hospital, Tianjin Institute of Hepatology, Tianjin, China,Correspondence: Shuang Li Wei Lu
| | - Wei Lu
- Department of Hepatobiliary Oncology, Liver Cancer Center, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin Medical University, Tianjin, China,Correspondence: Shuang Li Wei Lu
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Esophageal Variceal Ligation Monotherapy versus Combined Ligation and Sclerotherapy for the Treatment of Esophageal Varices. Can J Gastroenterol Hepatol 2021; 2021:8856048. [PMID: 33859966 PMCID: PMC8024074 DOI: 10.1155/2021/8856048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 11/27/2022] Open
Abstract
Currently, endoscopic variceal ligation (EVL) monotherapy is the standard therapy for managing esophageal variceal hemorrhage. Patients generally need several sessions of endoscopy to achieve optimal variceal ablation, and the varices can recur afterward. Endoscopic injection sclerotherapy (EIS) is an older technique, associated with certain complications. This study aimed to evaluate the clinical efficacy of EVL alone versus combined EVL and EIS in the treatment of esophageal varices. This retrospective study included 84 patients, of which 40 patients were treated with EVL monotherapy and 44 patients were treated with combined EVL + EIS. The main outcomes were rebleeding rates, recurrence at six months, number of treatment sessions, length of hospital stay, cost of hospitalization, and procedural complications. At six months, the rebleeding rate and recurrence were significantly lower in the EVL + EIS group compared to the EVL group (2.3% versus 15.0%; and 9.1% versus 27.5%, respectively). The number of treatment sessions, length of hospital stay, and cost of hospitalization were significantly lower in the EVL + EIS group compared to those in the EVL group (2.3 ± 0.6 versus 3.2 ± 0.8 times; 14.5 ± 3.4 versus 23.5 ± 5.9 days; and 23918.6 ± 4220.4 versus 26165.2 ± 4765.1 renminbi, respectively). Chest pain was significantly lower in the EVL + EIS group compared to that in the EVL group (15.9% versus 45.0%). There were no statistically significant differences in the presence of fever or esophageal stricture in both groups. In conclusion, combined EVL + EIS showed less rebleeding rates and recurrence at six months and less chest pain and was more cost effective compared to EVL alone in the treatment of gastroesophageal varices.
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Mansour L, El-Kalla F, El-Bassat H, Abd-Elsalam S, El-Bedewy M, Kobtan A, Badawi R, Elhendawy M. Randomized controlled trial of scleroligation versus band ligation alone for eradication of gastroesophageal varices. Gastrointest Endosc 2017; 86:307-315. [PMID: 28082116 DOI: 10.1016/j.gie.2016.12.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 12/27/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Gastric varices develop in 5% to 33% of patients with portal hypertension. Their most common form is concomitant gastroesophageal varices. Scleroligation (combined sclerotherapy and band ligation) has been used successfully in management of esophageal varices but has not been evaluated previously in the management of gastroesophageal varices. The aim of this work was evaluation of a new scleroligation technique for management of bleeding gastroesophageal varices regarding efficacy, adverse events, variceal recurrence, and survival. METHODS This study was conducted on 120 cirrhotic patients with bleeding gastroesophageal varices, whom we divided randomly into 2 groups of 60 patients each-a band ligation group and a scleroligation group. RESULTS The mean number of sessions was lower in the scleroligation group than in the band ligation group (2.22 ± 0.92 and 3.43 ± 0.67, respectively) (P < .001), as were the duration of treatment and total number of bands used. Cost and survival were comparable in the 2 groups. There was no significant difference between the 2 maneuvers regarding adverse events, recurrence rates, or rebleeding rates after obliteration. Recurrence was significantly higher in patients with larger varices, ulceration, and postprocedure pyrexia. Rebleeding was significantly higher among those who experienced postprocedure pyrexia and developed or had worsening of gastric antral vascular ectasia. CONCLUSIONS Scleroligation appears to achieve a faster rate of eradication with fewer treatment sessions and total number of bands deployed to achieve variceal obliteration than band ligation and is comparable in cost and in adverse event and recurrence rates. (Clinical trial registration number: NCT02646202.).
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Affiliation(s)
- Loai Mansour
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Ferial El-Kalla
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Hanan El-Bassat
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Sherief Abd-Elsalam
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | | | - Abdelrahman Kobtan
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Rehab Badawi
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
| | - Mohamed Elhendawy
- Tropical Medicine and Infectious Diseases Department, Tanta University, Tanta, Egypt
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Ali SM, Wu S, Xu H, Liu H, Hao J, Qin C. A Prospective Study of Endoscopic Injection Sclerotherapy and Endoscopic Variceal Ligation in the Treatment of Esophageal Varices. J Laparoendosc Adv Surg Tech A 2016; 27:333-341. [PMID: 28221819 DOI: 10.1089/lap.2016.0436] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The aim of this study was to compare the effectiveness and safety of endoscopic injection sclerotherapy (EIS) with endoscopic variceal ligation (EVL) in the management of esophageal variceal bleeding (EVB). PATIENTS AND METHODS In this prospective study, we compared the EIS and EVL in 124 patients who had endoscopically proved bleeding from esophageal varices. According to different treatment methods, they were randomly divided into the EIS and the EVL groups. Sixty-four patients were treated with sclerotherapy and 60 with ligation. The patients were followed for a mean of 2 years, during which we determined the incidence of complications and recurrences of bleeding and the number of treatment sessions needed to eradicate varices, mortality, and survival. RESULTS Active bleeding at the first treatment was controlled by EIS in 19 of 19 patients and by EVL in 16 of 16 patients. The likelihood of early rebleeding was slightly smaller in the patients treated with EIS (7.8% versus 11.7%, P = .47). However, late rebleeding rate was slightly more in EIS patients (28.1% versus 23.3%, P = .54) without statistical significance. The rate of eradication of varices in the EIS group was slightly lower than in the EVL group (79.7% versus 86.7%, P = .30). There were also no statistically significant differences in mortality (1.6% versus 3.3%, P = .61) or survival rate (71.9% versus 78.3%, P = .41) (all P > .05) after EIS and EVL. However, fever in the EIS group was significantly higher compared to that of in the EVL group (n = 17, 26.6% versus n = 6, 10.0%, P = .02). CONCLUSIONS Both EIS and EVL produce excellent results, are safe, effective, feasible, and acceptable for EVB with minimum complications and obviate need for subsequent procedures in the short term. To make better choice, we should consider the hospital conditions, operator experience, and the characteristics of esophageal varices.
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Affiliation(s)
- Syed Mohsin Ali
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Shanbin Wu
- 2 Qianfoshan Hospital Affiliated to Shandong University , Jinan, China
| | - Hongwei Xu
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Hui Liu
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Jinghua Hao
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
| | - Chengyong Qin
- 1 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University , Jinan, China
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Yoshida H, Mamada Y, Taniai N, Yoshioka M, Hirakata A, Kawano Y, Mizuguchi Y, Shimizu T, Ueda J, Uchida E. Risk factors for bleeding esophagogastric varices. J NIPPON MED SCH 2014; 80:252-9. [PMID: 23995567 DOI: 10.1272/jnms.80.252] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Bleeding from gastric varices (GVs) is generally considered more severe than that from esophageal varices (EVs) but occurs less frequently. We review the risk factors for bleeding EVs and GVs. GVs were divided into 2 groups: cardiac varices (CVs, Lg-c) and fundal varices (FVs), i.e., varices involving the fundus alone (Lg-f) or varices involving both the cardia and fundus (Lg-cf). Elevated pressure in the portal vein is a risk factor for bleeding EVs. The portal pressure in patients with GVs and a gastrorenal shunt is lower than that in patients with EVs. The large size of varices is a risk factor for bleeding EVs. Red color signs are elevated red areas that are important for predicting the risk of variceal bleeding, and red wale markings, dilated venules oriented longitudinally on the mucosal surface, have been considered to be the sign with the highest risk. Red color signs are rare in FVs, possibly because of the pronounced thickness of the mucosal layer. Bleeding EVs are not associated with use of antiulcer drugs or nonsteroidal anti-inflammatory drugs (NSAIDs). Although, in patients with bleeding GVs, "occasional" use of an oral NSAID is an important step leading to variceal hemorrhage, especially from FVs, even if the mucosa is protected by antiulcer drugs. Constipation, vomiting, severe coughing, and excessive consumption of alcohol may precipitate rupture of EVs.
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Affiliation(s)
- Hiroshi Yoshida
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan.
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Akhter NM, Haskal ZJ. Diagnosis and management of ectopic varices. GASTROINTESTINAL INTERVENTION 2012. [DOI: 10.1016/j.gii.2012.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Yoshida H, Mamada Y, Taniai N, Yoshioka M, Hirakata A, Kawano Y, Mizuguchi Y, Shimizu T, Ueda J, Uchida E. Treatment Modalities for Bleeding Esophagogastric Varices. J NIPPON MED SCH 2012; 79:19-30. [DOI: 10.1272/jnms.79.19] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Hiroshi Yoshida
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital
| | - Yasuhiro Mamada
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Nobuhiko Taniai
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Masato Yoshioka
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Atsushi Hirakata
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital
| | - Youichi Kawano
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Yoshiaki Mizuguchi
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Tetsuya Shimizu
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Junji Ueda
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Eiji Uchida
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
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Takahashi T, Yoshida H, Mamada Y, Taniai N, Tajiri T. Balloon-occluded Retrograde Transvenous Obliteration for Gastric Varices in a Child with Extrahepatic Portal Venous Obstruction. J NIPPON MED SCH 2009; 76:173-8. [DOI: 10.1272/jnms.76.173] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Tsubasa Takahashi
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Hiroshi Yoshida
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Yasuhiro Mamada
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Nobuhiko Taniai
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
| | - Takashi Tajiri
- Surgery for Organ Function and Biological Regulation, Graduate School of Medicine, Nippon Medical School
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Abstract
Partial splenic embolization (PSE) is a non-surgical procedure developed to treat hypersplenism as a result of hepatic disease and thus avoid the disadvantages of splenectomy. A femoral artery approach is used for selective catheterization of the splenic artery. Generally, the catheter tip is placed as distally as possible in an intrasplenic artery. After an injection of antibiotics and steroids, embolization is achieved by injecting 2-mm gelatin sponge cubes suspended in a saline solution containing antibiotics. PSE can benefit patients with thrombocytopenia, esophagogastric varices, portal hypertensive gastropathy, encephalopathy, liver dysfunction, splenic aneurysm, and splenic trauma. The contraindications of PSE include secondary splenomegaly and hypersplenism in patients with terminal-stage underlying disease; pyrexia or severe infections are associated with a high risk of splenic abscess after PSE. Complications of PSE include daily intermittent fever, abdominal pain, nausea and vomiting, abdominal fullness, appetite loss, and postembolization syndrome. Decreased portal-vein flow and a rapid increase in the platelet count after excessive embolization may cause portal-vein or splenic-vein thrombosis.
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Abstract
Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow-up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients’ quality of life. Recently, we have performed EVL at 2-mo (bi-monthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.
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Abstract
Bleeding from gastric varices has been successfully treated by endoscopic modalities. Once the bleeding from the gastric varices is stabilized, endoscopic treatment and/or interventional radiology should be performed to eradicate varices completely. Partial splenic artery embolization is a supplemental treatment to prolong the obliteration of the veins feeding and/or draining the varices. The overall incidence of bleeding from gastric varices is lower than that from esophageal varices. No studies to date have definitively characterized the causal factors behind bleeding from gastric varices. The initial episodes of bleeding from esophageal varices or gastric varices without prior treatment may be at least partly triggered by a violation of the mucosal barrier overlying varices. This is especially likely in the case of varices of the fundus. In view of the high rate of hemostasis achieved among bleeding gastric varices, treatment should be administered in selective cases. Among untreated cases, steps to prevent gastric mucosal injury confer very important protection against gastric variceal bleeding.
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Farooq FT, Wong RC. Injection sclerotherapy for the management of esophageal and gastric varices. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2005; 7:8-17. [DOI: 10.1016/j.tgie.2004.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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