Published online Aug 27, 2022. doi: 10.4254/wjh.v14.i8.1584
Peer-review started: March 30, 2022
First decision: June 8, 2022
Revised: June 22, 2022
Accepted: July 26, 2022
Article in press: July 26, 2022
Published online: August 27, 2022
Acute severe variceal bleeding (AVB) refractory to medical and endoscopic therapy is infrequent but associated with high mortality. Historical cohort studies from 1970-1980s no longer represent the current population as balloon tamponade is no longer first-line therapy for variceal bleeding; treatments including vasoactive therapies, intravenous antibiotics, endoscopic variceal band ligation are routinely used, and there is improved access to definitive treatments including transjugular intrahepatic portosystemic shunts. However, only a few studies from the current era exist to describe the practice of balloon tamponade, its outcomes, and predictors with a requirement for further updated information.
To describe current management of AVB requiring balloon tamponade and identify the outcomes and predictors of mortality, re-bleeding and complications.
A retrospective multi-centre cohort study of 80 adult patients across two large tertiary health networks from 2008 to 2019 in Australia who underwent balloon tamponade using a Sengstaken-Blakemore tube (SBT) were included for analysis. Patients were identified using coding for balloon tamponade. The primary outcome of this study was all-cause mortality at 6 wk after the index AVB. Secondary outcomes included re-bleeding during hospitalisation and complications of balloon tamponade. Predictors of these outcomes were determined using univariate and multivariate binomial regression.
The all-cause mortality rates during admission and at 6-, 26- and 52 wk were 48.8%, 51.2% and 53.8%, respectively. Primary haemostasis was achieved in 91.3% and re-bleeding during hospitalisation occurred in 34.2%. Independent predictors of 6 wk mortality on multivariate analysis included the Model for Endstage Liver disease (MELD) score (OR 1.21, 95%CI 1.06-1.41, P = 0.006), advanced hepatocellular carcinoma (OR 11.51, 95%CI 1.61-82.20, P = 0.015) and re-bleeding (OR 13.06, 95%CI 3.06-55.71, P < 0.001). There were no relevant predictors of re-bleeding but a large proportion in which this occurred did not survive 6 wk (76.0% vs 24%). Although mucosal trauma was the most common documented complication after SBT insertion (89.5%), serious complications from SBT insertion were uncommon (6.3%) and included 1 patient who died from oesophageal perforation.
In refractory AVB, balloon tamponade salvage therapy is associated with high rates of primary haemostasis with low rates of serious complications. Re-bleeding and mortality however, remain high.
Core Tip: Acute severe variceal bleeding requiring balloon tamponade remains associated with high mortality rates of approximately 50%. Sengstaken-Blakemore tube achieves excellent primary haemostasis rates in > 90% however re-bleeding is common at approximately 30% with subsequent death in approximately 75%. Predictors of all-cause mortality at 6 wk included a greater Model for Endstage Liver disease score, re-bleeding and advanced hepatocellular carcinoma. The most commonly reported complication from SBT was mucosal trauma, which was conservatively managed, with only a small proportion resulting in serious complications (6.3%). There was significant variability amongst technical aspects of balloon tamponade insertion which may result from the infrequent need to perform this procedure.