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1
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You Y, Wang W, Zhong J, Chen S. BRTO for ectopic small intestinal varices bleeding via dilated superior mesenteric veins and left ovarian vein: A case report. Radiol Case Rep 2025; 20:1058-1063. [PMID: 39659689 PMCID: PMC11629471 DOI: 10.1016/j.radcr.2024.10.160] [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: 05/28/2024] [Revised: 10/28/2024] [Accepted: 10/30/2024] [Indexed: 12/12/2024] Open
Abstract
Ectopic Variceal Bleeding is a rare complication of portal hypertension, often difficult to manage and potentially life-threatening. However, established guidelines directing treatment are lacking. This report presents a 51-year-old female with hepatitis B-related cirrhosis, who experienced rare small intestinal bleeding due to varicose veins in the superior mesenteric vein and left ovarian vein. The bleeding was successfully resolved by Balloon-occluded Retrograde Transvenous Obliteration. This report discusses the feasibility of BRTO compared to Transjugular Intrahepatic Portosystemic Shunt for certain patients with EctVB.
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Affiliation(s)
- Yu You
- Departments of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Weicheng Wang
- Departments of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jiawei Zhong
- Departments of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Sihai Chen
- Departments of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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2
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Florencio de Mesquita C, Antunes VLJ, Milioli NJ, Fernandes MV, Correa TL, Martins OC, Chavan R, Baraldo S. EUS-guided coiling plus glue injection compared with endoscopic glue injection alone in endoscopic treatment for gastric varices: a systematic review and meta-analysis. Gastrointest Endosc 2025; 101:331-340.e8. [PMID: 39389435 DOI: 10.1016/j.gie.2024.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 09/02/2024] [Accepted: 10/02/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND AND AIMS EUS-guided coil plus glue injection has emerged as a safe and effective modality for gastric varices (GVs). Very few studies have compared EUS embolization with the direct endoscopic glue injection (EGI) technique for its safety and effectiveness. In this systematic review and meta-analysis, we compared the outcomes of EUS-guided coil plus glue injection versus EGI. METHODS MEDLINE, EMBASE, and Cochrane databases were searched for studies that compared EUS and EGI for GVs, and 1454 articles were screened following the Preferred Reporting Items for Systematic reviews and Meta-Analyses protocol. Endpoints were pulmonary embolism, recurrent bleeding rate, reintervention rate, technical success, abdominal pain, and mortality rate. A restricted maximum likelihood random-effects model with odds ratios (ORs) and 95% confidence intervals (CIs) was used for binary endpoints. Heterogeneity was evaluated through Cochrane's Q statistic and Higgins and Thompson's I2 statistic. Significance was defined as P < .05. RESULTS We included 6 studies with 445 patients treated for GVs. Mean patient age was 49 years, and 43% were women. EUS was associated with a reduction in recurrent bleeding rate (OR, .22; 95% CI, .11-.45; P < .001; I2 = 0) and reintervention rate (OR, .29; 95% CI, .09-.89; P = .03; I2 = 49%) compared with EGI. There were no differences between groups in pulmonary embolism (OR, .34; 95% CI, .10-1.18; P = .09; I2 = 0%), mortality rate (OR, .78; 95% CI, .28-2.13; P = .63; I2 = 0%), technical success (OR, 3.50; 95% CI, .60-20.49; P = .16; I2 = 0%), fever (OR, 1.49; 95% CI, .42-5.21 days; P = .5; I2 = 0%), and abdominal pain (OR, .96; 95% CI, .31-2.95; P = .94; I2 = 32%). CONCLUSIONS In patients with GVs, EUS-guided coil plus glue injection is associated with lower recurrent bleeding and reintervention rates than EGI with no difference in pulmonary embolization rate, abdominal pain, technical success, and mortality rate.
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Affiliation(s)
| | - Vanio L J Antunes
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | | | | | - Tulio L Correa
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Radhika Chavan
- Department of Gastroenterology and Advanced Endoscopy, Ansh Clinic, Gujarat, India
| | - Stefano Baraldo
- Department of Endoscopy, Barretos Cancer Hospital, Barretos, Brazil
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3
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Wahba G, Lee JH. Updates on therapeutic endoscopic ultrasound. Curr Opin Gastroenterol 2025; 41:16-28. [PMID: 39560626 DOI: 10.1097/mog.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2024]
Abstract
PURPOSE OF REVIEW Multiple endoscopic ultrasound (EUS) guided therapeutic interventions have been developed for the management of benign and malignant pancreaticobiliary and gastrointestinal luminal pathology. Recent high-quality evidence is increasingly validating these interventions and positioning them within evidence-based therapeutic algorithms. RECENT FINDINGS Here we review therapeutic EUS-guided interventions including pancreatic fluid collection drainage, gastroenterostomy, biliary drainage, pancreatic duct drainage and gallbladder drainage. The most up-to-date high-quality evidence supporting these interventions is presented including comparative data with other conventional treatment options. Newer emerging interventions such as tumor ablation are also reviewed. Current controversies and future avenues for research are discussed. The key role of EUS-guided interventions in managing pancreaticobiliary pathology in patients with a surgically altered anatomy is highlighted. SUMMARY Multiple EUS therapeutic interventions have evolved from experimental or rescue options to now well established first- and second-line interventions over other endoscopic, percutaneous and surgical alternatives with the support of high-quality data. Further research is needed to better optimize patient selection and guide long term postintervention follow-up.
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Affiliation(s)
- George Wahba
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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4
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Rai P, Kumar P, Hoda US, Balankhe K. Endoscopic ultrasound-guided vascular interventions: A review (with videos). Indian J Gastroenterol 2024; 43:927-942. [PMID: 39352686 DOI: 10.1007/s12664-024-01681-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 08/19/2024] [Indexed: 10/10/2024]
Abstract
Endoscopic ultrasound (EUS) has evolved from a diagnostic to an interventional modality, allowing precise vascular access and therapy. EUS-guided vascular access of the portal vein has received increasing attention in recent years as a diagnostic and therapeutic tool. EUS-guided portal pressure gradient directly measures the hepatic vein portal pressure gradient and is crucial for understanding of liver function and prognostication of liver disease. EUS facilitates the sampling of portal venous blood to obtain circulating tumor cells (CTCs) in pancreatobiliary malignancies. This technique aids in the diagnosis and staging of cancers. EUS-guided interventions have a substantial potential for diagnosing portal vein tumor thrombus (PVTT) in patients with hepatocellular carcinoma. EUS-guided coil and glue embolization have higher efficacy for the treatment of gastric varices than direct endoscopic glue. Pseudoaneurysm (PsA), a rare vascular complication of acute and chronic pancreatitis, is typically managed with interventional radiology (IR)-guided embolization and surgery. EUS is increasingly used in specialized centers for non-variceal gastrointestinal bleeding, particularly for pseudoaneurysm-related bleeding. There is limited data on EUS-guided intervention for bleeding ectopic varices, rectal varices and Dieulafoy lesions, but it is becoming more widely accepted. In this extensive review, we evaluated both current and potential future applications of EUS-guided vascular interventions, including EUS-guided gastric variceal bleed therapy, rectal and ectopic varices, pseudoaneurysmal bleeding, splenic artery embolization, portal pressure gradient measurement, portal vein sampling for CTCs, fine needle aspiration of PVTT, intrahepatic portosystemic shunt placement, liver tumor ablation and EUS-guided cardiac intervention.
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Affiliation(s)
- Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India.
| | - Pankaj Kumar
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Umair Shamsul Hoda
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Kartik Balankhe
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
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5
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Dragomir I, Pojoga C, Hagiu C, Seicean R, Procopet B, Seicean A. Endoscopic ultrasound in portal hypertension: navigating venous hemodynamics and treatment efficacy. Gastroenterol Rep (Oxf) 2024; 12:goae082. [PMID: 39281269 PMCID: PMC11398876 DOI: 10.1093/gastro/goae082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/23/2024] [Accepted: 06/07/2024] [Indexed: 09/18/2024] Open
Abstract
Portal hypertension-related complications increase mortality in patients, irrespective of its etiology. Classically, endoscopic ultrasound (EUS) was used to assess the portal venous system and collaterals, considering size and hemodynamic parameters, which correlate with portal hypertension (PH) and related complications. Furthermore, therapeutic EUS guides treatment interventions, such as embolization of the gastric varices through coil placement and tissue adhesive injection, yielding encouraging clinical results. Recently, the direct measurement of portal pressure, emerging as an alternative to hepatic venous pressure gradient, has shown promise, and further research in this area is anticipated. In this review, we aimed to provide a detailed description of various possibilities for diagnosing vascular anatomy and hemodynamics in PH and actual knowledge on the EUS usefulness for PH vessel-related complications. Also, future promises for this field of endo-hepatology are discussed.
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Affiliation(s)
- Irina Dragomir
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
| | - Cristina Pojoga
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
- UBB Med, Babeş-Bolyai University, Department of Clinical Psychology and Psychotherapy, International Institute for Advanced Study of Psychotherapy and Applied Mental Health, Cluj Napoca, Romania
| | - Claudia Hagiu
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
| | - Radu Seicean
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- First Surgical Clinic, County Emergency Hospital, Cluj Napoca, Romania
| | - Bogdan Procopet
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
| | - Andrada Seicean
- “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj Napoca, Romania
- Regional Institute of Gastroenterology and Hepatology “Prof. Dr. Octavian Fodor”, Cluj Napoca, Romania
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6
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Tang T, Yang L, Yang D, Li X, Zhang W, Xu H, Chen G. Outcomes of endoscopic treatment for acute duodenal ectopic variceal bleeding: a single-center retrospective case series. Acta Gastroenterol Belg 2024; 87:322-325. [PMID: 39210764 DOI: 10.51821/87.2.12100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Duodenal ectopic variceal hemorrhage is a rare portal hypertension complication that can easily be clinically missed. Once hemorrhage occurs, the rebleeding and fatality rates are high. There is no unified standard for its treatment, we reported the endoscopic treatment of eight patients admitted to our department between January 2014 and May 2021, Endoscopic band ligation and endoscopic cyanoacrylate injection were performed in five and three cases, respectively. The hemostasis success rate was 100%, no postoperative bleeding occurred, and there were no serious complications. Duodenal varices disappeared in four cases after 2-12 months. In conclusion, Endoscopic therapy is an ideal treatment method for acute duodenal ectopic variceal hemorrhage.
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Affiliation(s)
- T Tang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - L Yang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - D Yang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - X Li
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - W Zhang
- Department of Interventional Therapy, The First Hospital of Jilin University, Changchun, China
| | - H Xu
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
| | - Geng Chen
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun, China
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7
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Chavan R, Baraldo S, Patel N, Gandhi C, Rajput S. Technical tips for EUS-guided embolization of varices and pseudoaneurysms. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2024; 9:211-219. [PMID: 38618622 PMCID: PMC11009482 DOI: 10.1016/j.vgie.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Backgrounds and Aims EUS-guided vascular intervention has expanded the horizons of diagnostic as well as therapeutic interventions for vascular pathology. EUS-guided embolization is a commonly performed technique for the treatment of gastric varices. However, there is a lack of data on the standardization of the technique. Here, we review the techniques and difficulties encountered during EUS-guided embolization of varices and pseudoaneurysms. Methods This article and accompanying video describe the EUS-guided embolization techniques for various vascular lesions. EUS-guided embolization was achieved by combination therapy using coils and cyanoacrylate. Complete obliteration of the lesions was documented on follow-up. The existing literature of EUS-guided embolization therapy is also reviewed. Results Patients with various vascular lesions, including gastric varices, ectopic duodenal varices, and splenic artery pseudoaneurysms, were successfully treated with EUS-guided coil plus cyanoacrylate injection. Patients with gastric varices underwent treatment with 2 EUS-guided techniques: (1) direct puncture of the varix and embolization and (2) feeder vessel embolization. Following embolization, the absence of Doppler flow within the varix and pseudoaneurysm was documented. Conclusions Techniques of EUS-guided embolization of varices and pseudoaneurysms are demonstrated. Understanding the techniques and the challenges encountered during therapy is crucial to optimize outcomes and reduce adverse events.
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Affiliation(s)
| | | | - Nishant Patel
- Arnold Palmer Hospital for Children, Orlando Health, Orlando, Florida, USA
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8
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Bazaga S, García-Alonso FJ, Aparicio Tormo JR, Martinez Moreno B, Sanchiz V, Gornals JB, Loras C, Terán Á, Vazquez-Sequeiros E, Pedraza Sanz R, Súbtil JC, Pérez-Millan A, Uceda Porta F, Vila JJ, de la Serna-Higuera C, Couto-Worner I, Guarner-Argente C, Perez-Miranda M. Endoscopic ultrasound-guided gallbladder drainage with long-term lumen-apposing metal stent indwell: 1-year results from a prospective nationwide observational study. J Gastroenterol Hepatol 2024; 39:360-368. [PMID: 37920889 DOI: 10.1111/jgh.16392] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND AND AIM This study aimed to determine safety and risk factors for adverse events (AEs) of endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with long-term indwell of lumen-apposing metal stents (LAMS). METHODS This study is a multicenter prospective observational study on consecutive high surgical-risk patients requiring gallbladder drainage who underwent EUS-GBD with LAMS over 12 months. Centralized telephone follow-up interviews were conducted every 3 months for 1 year. Patients were censored at LAMS removal, cholecystectomy, or death. AE-free survival was determined using log-rank tests. Cumulative risks were estimated using life-table analysis. RESULTS Eighty-two patients were included (53.7% male, median [interquartile range] age of 84.6 [76.5-89.8] years, and 85.4% with acute cholecystitis). Technical success was achieved in 79 (96.3%), and clinical success in 73 (89%). No patient was lost to follow-up; 45 patients (54.9%) completed 1-year follow-up with in situ LAMS. Median (interquartile range) LAMS indwell time was 364 (47-367) days. Overall, 12 (14.6%) patients presented 14 AEs, including 5 (6.1%) recurrent biliary events (3 acute cholangitis, 1 mild acute pancreatitis, and 1 acute cholecystitis). Patients with pancreatobiliary malignancy had an increased risk of recurrent biliary events (33% vs 1.5%, P = 0.001). The overall 1-year cumulative risk of recurrent biliary events was 9.7% (4.1-21.8%). The 1-year risk of AEs and of severe AEs was 18.8% (11-31.2%) and 7.9% (3.3-18.2%), respectively. Pancreatobiliary malignancy was the single risk factor for recurrent biliary events; LAMS misdeployment was the strongest risk factor for AEs. CONCLUSIONS Long-term LAMS indwell does not increase the risk of delayed AEs following EUS-GBD.
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Affiliation(s)
- Sergio Bazaga
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
- Department of Medicine, Universitat Autónoma de Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | | | - Joan B Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Carme Loras
- Department of Gastroenterology, Hospital Universitari Mútua Terrassa, Fundació per la Recerca Mútua Terrassa, Terrassa, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
| | - Álvaro Terán
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Enrique Vazquez-Sequeiros
- Endoscopy Unit, Department of Gastroenterology and Hepatology, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | - José Carlos Súbtil
- Department of Gastroenterology, Endoscopy Unit, University of Navarra Clinic, University of Navarra, Pamplona, Spain
| | | | | | - Juan J Vila
- Complejo Hospitalario de Navarra, Pamplona, Spain
| | | | | | - Carlos Guarner-Argente
- Department of Medicine, Universitat Autónoma de Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manuel Perez-Miranda
- Department of Gastroenterology, Hospital Universitario Rio Hortega, Valladolid, Spain
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9
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Ryou M, DeWitt JM, Das KK, Shami VM. AGA Clinical Practice Update on Interventional EUS for Vascular Investigation and Therapy: Commentary. Clin Gastroenterol Hepatol 2023; 21:1699-1705.e2. [PMID: 37162434 DOI: 10.1016/j.cgh.2023.03.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 05/11/2023]
Abstract
DESCRIPTION The purpose of this AGA Institute Clinical Practice Update is to review the available evidence supporting and examine opportunities for future research in endoscopic ultrasound-guided vascular investigation and therapies. METHODS This Clinical Practice Update was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in endoscopic ultrasound-guided vascular investigation and therapy.
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Affiliation(s)
- Marvin Ryou
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts.
| | - John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health, Indianapolis, Indiana
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Vanessa M Shami
- Division of Gastroenterology and Hepatology, University of Virginia Medical Center, Charlottesville, Virginia
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10
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Dhar J, Samanta J. Endoscopic ultrasound-guided vascular interventions: An expanding paradigm. World J Gastrointest Endosc 2023; 15:216-239. [PMID: 37138933 PMCID: PMC10150286 DOI: 10.4253/wjge.v15.i4.216] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/09/2023] [Accepted: 03/15/2023] [Indexed: 04/14/2023] Open
Abstract
Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.
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Affiliation(s)
- Jahnvi Dhar
- Gastroenterology, Sohana Multispeciality Hospital, Mohali 140308, India
| | - Jayanta Samanta
- Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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11
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Sun L, Long L, Wang Q, Xiang H. Expert consensus on emergency procedures for portal hypertension bleeding (2022). J Interv Med 2023; 6:1-9. [PMID: 37180370 PMCID: PMC10167519 DOI: 10.1016/j.jimed.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/10/2022] [Accepted: 10/31/2022] [Indexed: 01/13/2023] Open
Abstract
Expert consensus proposes an emergency treatment protocol for portal hypertension bleeding. Herein, the emergency treatment procedures, which include first aid, medical, interventional, and surgical treatments, are described. In addition, the indications, contraindications, operating norms, precautions, and prevention of complications of portal hypertension are described to optimize the first aid process.
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Affiliation(s)
- Lin Sun
- Chinese Society of Emergency Medicine, Interventional Physician Branch of Chinese Medical Doctor Association, China
- Interventional Group of Radiology Society of Chinese Medical Association, China
- Haemorrhage Professional Committee of Chinese Research Hospital Association, China
- China Haemorrhage Center Alliance, China
- Hunan Provincial People′s Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, 410005, China
| | - Lin Long
- Chinese Society of Emergency Medicine, Interventional Physician Branch of Chinese Medical Doctor Association, China
- Interventional Group of Radiology Society of Chinese Medical Association, China
- Haemorrhage Professional Committee of Chinese Research Hospital Association, China
- China Haemorrhage Center Alliance, China
- Hunan Provincial People′s Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, 410005, China
| | - Qing Wang
- Chinese Society of Emergency Medicine, Interventional Physician Branch of Chinese Medical Doctor Association, China
- Interventional Group of Radiology Society of Chinese Medical Association, China
- Haemorrhage Professional Committee of Chinese Research Hospital Association, China
- China Haemorrhage Center Alliance, China
- Hunan Provincial People′s Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, 410005, China
| | - Hua Xiang
- Chinese Society of Emergency Medicine, Interventional Physician Branch of Chinese Medical Doctor Association, China
- Interventional Group of Radiology Society of Chinese Medical Association, China
- Haemorrhage Professional Committee of Chinese Research Hospital Association, China
- China Haemorrhage Center Alliance, China
- Hunan Provincial People′s Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, 410005, China
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12
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Altonbary AY. Endoscopic ultrasound-guided vascular interventions: An overview of current and emerging techniques. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2023; 12:16-21. [DOI: 10.18528/ijgii220030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 04/14/2025] Open
Affiliation(s)
- Ahmed Youssef Altonbary
- Department of Gastroenterology and Hepatology, Mansoura Specialized Medical Hospital, Mansoura University, Mansoura, Egypt
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13
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Jamwal KD, Padhan RK, Sharma A, Sharma MK. Endoscopic ultrasound-guided coiling and glue is safe and superior to endoscopic glue injection in gastric varices with severe liver disease: a retrospective case control study. Clin Endosc 2023; 56:65-74. [PMID: 36594180 PMCID: PMC9902678 DOI: 10.5946/ce.2021.119] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 10/04/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND/AIMS Gastric varices (GV) are present in 25% of cirrhotic patients with high rates of rebleeding and mortality. Data on endoscopic ultrasound (EUS)-guided treatment in severe liver disease (model for end stage liver disease sodium [MELD-Na] >18 and Child-Turcotte-Pugh [CTP] C with GV) are scarce. Thus, we performed a retrospective comparison of endoscopic glue injection with EUS-guided therapy in cirrhotic patients with large GV. METHODS A retrospective study was performed in the tertiary hospitals of India. A total of 80 patients were recruited. The inclusion criteria were gastroesophageal varices type 2, isolated gastric varices type 1, bleeding within 6 weeks, size of GV >10 mm, and a MELD-Na >18. Treatment outcomes and complications of endoscopic glue injection and EUS-guided GV therapy were compared. RESULTS In this study, the patients' age, sex, liver disease severity (CTP, MELD-Na) and clinical parameters were comparable. The median number of procedures, injected glue volume, complications, and GV obturation were better in the EUS group, respectively. On subgroup analysis of the EUS method (e.g., direct gastric fundus vs. paragastric collateral [PGC] coil placement), PGC coil placement showed decreased coil requirement, less injected glue volume, decreased luminal coil extrusion, and increased successful GV obturation. CONCLUSION EUS-guided treatment is more efficient and safer, and requires a smaller number of treatment sessions, as compared to endoscopic treatment in severe liver disease patients with large GV. Furthermore, PGC coil placement increases the complete obliteration of GV.
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Affiliation(s)
- Kapil D. Jamwal
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India,Institute of Liver and Biliary Sciences, New Delhi, India,Correspondence: Kapil D. Jamwal Department of Gastroenterology, Artemis Hospitals, Sector 51, Gurugram, Haryana 122001, India E-mail:
| | - Rajesh K. Padhan
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India
| | - Atul Sharma
- Department of Gastroenterology, Artemis Hospitals, Gurugram, India
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14
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Yang J, Zeng Y, Zhang JW. Endoscopic ultrasound-guided diagnosis and treatment of gastric varices. World J Gastrointest Endosc 2022; 14:748-758. [PMID: 36567822 PMCID: PMC9782569 DOI: 10.4253/wjge.v14.i12.748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
Gastric varices (GV) represent a common and severe complication in patients with portal hypertension, commonly seen in patients with cirrhosis and severe pancreatic disease. Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa, portal vein and its tributaries, and collateral circulations during direct endoscopic observation. Recently, various studies have been published about endoscopic ultrasound (EUS)-guided management of GV, mainly including diagnosis, treatment, and prognostic analysis. This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.
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Affiliation(s)
- Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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15
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Chooklin S, Chuklin S, Posivnych M, Krystopchuk S. Ендоваскулярне лікування варикозно розширених вен шлунка під контролем ендосонографії. EMERGENCY MEDICINE 2022; 18:39-47. [DOI: 10.22141/2224-0586.18.6.2022.1519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Шлункова варикозна кровотеча супроводжується високою летальністю. Ендоскопічна ін’єкція ціаноакрилату є стандартною терапією, однак рецидивна кровотеча та побічні ефекти, такі як виразки в місці ін’єкції та дистальна емболія, є підводним каменем цієї терапії. Ендоскопічне лікування варикозного розширення вен шлунка під ендосонографічним контролем має кілька можливих переваг перед сучасними методами лікування. Воно дозволяє детально оцінити анатомію судин, подібну ефективність і безпеку поточних методів лікування, а також дає змогу оцінити ефект лікування за допомогою ультразвукової допплерівської візуалізації. Ми розглядаємо методи лікування варикозного розширення вен шлунка, включаючи ендоскопічну ін’єкцію ціаноакрилату та спіралей під контролем ендосонографії, окремо або в комбінації, ін’єкцію тромбіну та желатинової губки, що розсмоктується. Відповідний відбір пацієнтів для цих процедур має першорядне значення для забезпечення отримання корисних клінічних даних і безпеки пацієнтів. Ми шукали літературу в базі даних MedLine на платформі PubMed.
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16
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Jearth V, Sundaram S, Rana SS. Diagnostic and interventional EUS in hepatology: An updated review. Endosc Ultrasound 2022; 11:355-370. [PMID: 36255023 PMCID: PMC9688142 DOI: 10.4103/eus-d-22-00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
EUS has become an increasingly used diagnostic and therapeutic modality in the armamentarium of endoscopists. With ever-expanding indications, EUS is being used in patients with liver disease, for both diagnosis and therapy. EUS is playing an important role in providing additional important information to that provided by cross-sectional imaging modalities such as computerized tomography and magnetic resonance imaging. Domains of therapy that were largely restricted to interventional radiologists have become accessible to endosonologists. From liver biopsy and sampling of liver lesions to ablative therapy for liver lesions and vascular interventions for varices, there is increased use of EUS in patients with liver disease. In this review, we discuss the various diagnostic and therapeutic applications of EUS in patients with various liver diseases.
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Affiliation(s)
- Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence Prof. Surinder Singh Rana, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India. E-mail:
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17
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Sallout D, Tatro E, Adler DG. Managing gastric varices. Frontline Gastroenterol 2022; 13:535-542. [PMID: 36250174 PMCID: PMC9559633 DOI: 10.1136/flgastro-2021-101834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023] Open
Abstract
Gastric varices (GV) are a type of ectopic varix, which is a natural portosystemic shunt occurring in response to an increase in intrahepatic vascular resistance, mostly commonly from portal hypertension. GV are present in up to 20% of patients with portal hypertension. Although oesophageal varices are more common than GV, and oesophageal variceal bleeding (EVB) happens more often than gastric variceal bleeding (GVB), GVB tends to be more severe, to have higher associated hospital costs, length of stay, higher rebleeding rates and have higher mortality. Mortality rates associated with variceal bleeding range from 6% in EVB to 20%-55% in GVB. Risk factors for GV haemorrhage include location, size, severity of liver failure, presence of variceal red spots, and presence of HCC (hepatocellular carcinoma). This manuscript will review endoscopic and non-endoscopic treatment of GV.
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Affiliation(s)
- Deema Sallout
- The University of Utah Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Eric Tatro
- The University of Utah Department of Internal Medicine, Salt Lake City, Utah, USA
| | - Douglas G Adler
- Endoscopy, Center for Advanced Therapeutic Endoscopy, Denver, Colorado, USA
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18
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Fugazza A, Khalaf K, Colombo M, Carrara S, Spadaccini M, Koleth G, Troncone E, Maselli R, Repici A, Anderloni A. Role of endoscopic ultrasound in vascular interventions: Where are we now? World J Gastrointest Endosc 2022; 14:354-366. [PMID: 35978714 PMCID: PMC9265255 DOI: 10.4253/wjge.v14.i6.354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/08/2022] [Accepted: 05/17/2022] [Indexed: 02/06/2023] Open
Abstract
From a mere diagnostic tool to an imperative treatment modality, endoscopic ultrasound (EUS) has evolved and revolutionized safer efficient options for vascular interventions. Currently it is an alternative treatment option in the management of gastrointestinal bleeding, primarily variceal type bleeding. Conventional treatment option prior to EUS incorporation had limited efficiency and high adverse events. The characterization and detail provided by EUS gives a cutting edge towards a holistically successful management choice. Data indicates that EUS-guided combination therapy of coil embolization and glue injection has the higher efficacy for the treatment of varices. Conversely, similar treatment options that exist for esophageal and other ectopic variceal bleeding was also outlined. In conclusion, many studies refer that a combination therapy of coil and glue injection under EUS guidance provides higher technical success with fewer recurrence and adverse events, making its adaptation in the guideline extremely favorable. Endo-hepatology is a novel disciple with a promising future outlook, we reviewed topics regarding portal vein access, pressure gradient measurement, and thrombus biopsy that are crucial interventions as alternative of radiological procedures. The purpose of this review is to provide an update on the latest available evidence in the literature regarding the role of EUS in vascular interventions. We reviewed the role of EUS in variceal bleeding in recent studies, especially gastric varices and novel approaches aimed at the portal vein.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Kareem Khalaf
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Italy
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Glenn Koleth
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Edoardo Troncone
- Department of Systems Medicine, University of Rome "Tor Vergata", Roma 00133, Italy
| | - Roberta Maselli
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Italy
| | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, Humanitas Research Hospital, Rozzano 20089, Italy
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19
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Li G, Xu L, Wang X. Antitumor Proliferation and Related Mechanism of Ultrasound Irradiation Combined with Safflower Yellow. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:5168886. [PMID: 35755741 PMCID: PMC9225832 DOI: 10.1155/2022/5168886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/25/2022] [Accepted: 05/09/2022] [Indexed: 01/03/2023]
Abstract
Ultrasound irradiation is now the best method for evaluating benign and malignant tumor nodules. Chemotherapy has always played an important role in the treatment of malignant tumors. With the large-scale application of chemotherapy drugs, the problem of multidrug resistance of tumors has become more and more prominent, which has become one of the difficulties in tumor chemotherapy. This study mainly explores the antitumor proliferation and related mechanisms of ultrasound irradiation combined with safflower yellow. The breast cancer cell line 4T1 derived from BALB/c mice was selected. BALB/c is an albino laboratory mouse, which, like many commonly used sublines, originated from Mus musculus. BALB/c mice have been bred for more than 200 generations in research institutions around the world and are widely used in animal experiments in immunology and physiology. When the cell proliferation reached 80%-90% of the bottom area of the culture flask, it was resuspended, passaged, frozen, and resuscitated according to experimental needs. The 4T1 breast cancer cell line was cultured by conventional methods. 4T1 breast cancer cells in the logarithmic proliferation phase were collected. After 0.25% was digested with pancreatin, it was washed twice with PBS to adjust the concentration to 1 × 107/mL. A 0.1 mL tumor cell suspension was subcutaneously inoculated on the edge of the mouse chest, thereby establishing a breast cancer model of BALB/c mice. After 6-15 days, the tumor volume grew rapidly and became larger. When the length of the tumor is 2.5 × 2.5, the modeling is successful. Ultrasound-targeted microbubble destruction technology, as a novel drug delivery method with high efficiency and low toxicity, can form transient pores (sonoporation effect) on the cell surface, widen the intercellular space, and increase the membrane permeability, and thus effectively. The transport of drugs, genes, proteins, etc., is promoted to target organs and tissues. Tumor-forming mice were randomly divided into the following four groups: control group, safflower yellow group, ultrasound irradiation group, and ultrasound irradiation combined with safflower yellow group. From the second day of inoculation to the end of the experiment, the body weight of the mice successfully inoculated with 4T1 cells was measured every day; from the 5th day, tumors in each group were calculated body volume and tumor inhibition rate (TIR) of each group. The combined treatment group has a higher tumor inhibition rate than the ultrasound irradiation group, and the difference is statistically significant (P < 0.05). Ultrasound irradiation combined with safflower yellow pigment can effectively inhibit tumor proliferation, maintain, or even improve the efficacy of chemotherapy, thereby improving the patient's tolerance to chemotherapy.
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Affiliation(s)
- Gen Li
- Division of Cardiothroracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
| | - Lijun Xu
- Division of Cardiothroracic and Vascular Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
| | - Xiaoli Wang
- Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
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20
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Safety and efficacy of endoscopic ultrasound-guided combination therapy for treatment of gastric varices: a systematic review and meta-analysis. Clin J Gastroenterol 2022; 15:310-319. [PMID: 35133625 DOI: 10.1007/s12328-022-01600-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND EUS-guided combination therapy (coil and hemostatic glue) for bleeding and non-bleeding gastric varices has recently attracted considerable attention after promising results were published in multiple small studies. We performed a meta-analysis to investigate the safety and efficacy of EUS-guided combination therapy in the treatment of GVs. METHODS Publications investigating the safety and efficacy of EUS-guided combination therapy in patients with gastric varices were searched in Medline, Ovid Journals, Medline non-indexed citations and Cochrane Central Register of Controlled Trials. Pooling was conducted by both fixed and random effects model. RESULTS In pooled analysis of 10 studies (N = 323), the technical success of EUS-guided combination therapy was 98.66% (95% CI 97.14-99.62). The pooled variceal obliteration rate after first session of treatment was 78.31% (95% CI 73.05-83.14). In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.79% (95% CI 94.28-98.60). The pooled rate of hemorrhage from treated gastric varices was 4.92% (95% CI 2.85-7.52). After EUS-guided combination therapy, the pooled percentage of patients developing abdominal pain was 9.79% (95% CI 6.82-13.24), pulmonary embolism was 2.20% (95% CI 0.89-4.06), febrile episodes was 1.17% (95% CI 0.30-2.61), and procedure-related bleeding was noted in 2.62% (95% CI 1.18-4.63) of the patients. Subgroup analysis of studies using coil embolization and cyanoacrylate injection showed pooled variceal obliteration rate of 77.92% (95% CI 72.35-83.01) after first session of treatment. In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.76% (95% CI 94.11-98.65). The pooled rate of re-bleeding from treated gastric varices was 5.09% (95% CI 2.90-7.83). CONCLUSIONS This meta-analysis suggests that EUS-guided combination therapy is safe and effective for patients with gastric varices and should be considered in the clinical management of these patients.
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21
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Bazerbachi F, Levy MJ, WongKeeSong LM. Endoscopic Treatment of Portal Hypertension and Its Complications. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:76-89. [DOI: 10.1016/j.tige.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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22
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Sbeit W, Kadah A, Mahamid M, Mari A, Khoury T. A state-of-the-art comprehensive review summarizing the emerging data on endoscopic ultrasound-guided liver diseases management. Eur J Gastroenterol Hepatol 2021; 33:e13-e20. [PMID: 32804852 DOI: 10.1097/meg.0000000000001893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Liver diseases are among the most common diseases worldwide accounting for substantial morbidity and mortality. Most liver diseases necessitate radiological evaluation or accurate diagnosis and recently for management as well. In the last decade, the application of therapeutic endoscopic ultrasound (EUS) procedure has been increasingly utilized for the management of various liver diseases. In this comprehensive narrative review article, we provide systematic overview on EUS-guided therapeutic interventions in various liver diseases summarizing most updated data regarding technical success, outcomes and safety profiles. Overall, 35 articles have reported on the use of EUS in the treatment of liver diseases with excellent technical success, favorable radiological response and high safety profiles for EUS-guided treatment of solid and cystic liver lesion and for EUS-guided angiotherapy for gastric varices, except for EUS-guided cyanoacrylate glue injection which was associated with life-threatening fatal systemic embolization adverse events. This suggests that EUS-guided intervention is a new promising therapeutic intervention for the treatment of various liver diseases with durable effect and a limited potential for adverse events.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed
| | - Anas Kadah
- Department of Gastroenterology, Galilee Medical Center, Nahariya
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed
| | - Mahmud Mahamid
- Gastroenterology Department, Sharee Zedek Medical Center, Jerusalem
| | - Amir Mari
- Gastroenterology and Endoscopy Units, The Nazareth Hospital, EMMS, Nazareth
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed
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23
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Pavic T, Mikolasevic I, Kralj D, Blazevic N, Skrtic A, Budimir I, Lerotic I, Hrabar D. Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand? Diagnostics (Basel) 2021; 11:2021. [PMID: 34829368 PMCID: PMC8618190 DOI: 10.3390/diagnostics11112021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 12/13/2022] Open
Abstract
As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.
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Affiliation(s)
- Tajana Pavic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Ivana Mikolasevic
- Department of Gastroenterology, University Hospital Center Rijeka, 51000 Rijeka, Croatia;
| | - Dominik Kralj
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Nina Blazevic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Anita Skrtic
- Department of Pathology, Merkur University Hospital, 10000 Zagreb, Croatia;
| | - Ivan Budimir
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Ivan Lerotic
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
| | - Davor Hrabar
- Department of Gastroenterology and Hepatology, University Hospital Center Sestre Milosrdnice, 10000 Zagreb, Croatia; (D.K.); (N.B.); (I.B.); (I.L.); (D.H.)
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24
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Abstract
PURPOSE OF REVIEW To update on recent advances in interventional endoscopic ultrasound (INVEUS) techniques. RECENT FINDINGS The introduction of linear echoendoscopes with larger instrument channels and the combined development of new tools and devices have enabled various new applications of minimally invasive endoscopic ultrasound (EUS)-guided transluminal interventions of the pancreas, biliary system and peri-gastrointestinal structures. In this review, EUS-guided interventions are discussed and evaluated: drainage of peripancreatic fluid collections, access and drainage of bile ducts, gallbladder and pancreatic duct, treatment of gastrointestinal haemorrhage, coeliac plexus block and coeliac plexus neurolysis, fiducial placement, solid and cystic tumour ablation, drug delivery and brachytherapy, gastroenterostomy, angiotherapy and other EUS-guided applications. The EUS-guided interventions are classified based on the available evidence as established or experimental, standardized or nonstandardized procedures in common or rare diseases with well or little known complications and their established or nonestablished treatment. SUMMARY Some EUS-guided interventions have sparse published evidence with only single-centre studies, case series or individual case reports, others like drainage of peripancreatic fluid collections have become widely accepted practice. INVEUS has been accepted as an alternative to several surgical approaches, EUS-guided techniques result in faster recovery times, shorter hospital stay and lower costs.
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Affiliation(s)
- Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, Switzerland
| | - Barbara Braden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Maerkisch-Oderland, D-15344 Strausberg and Brandenburg Institute of Clinical Ultrasound at Medical University Brandenburg, Germany
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25
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Hogan DE, Ma M, Kadosh D, Menon A, Chin K, Swaminath A. Endo-hepatology: An emerging field. World J Gastrointest Endosc 2021; 13:296-301. [PMID: 34512877 PMCID: PMC8394184 DOI: 10.4253/wjge.v13.i8.296] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/13/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroenterologists have long been spearheading the care of patients with various forms of liver disease. The diagnosis and management of liver disease has traditionally been a combination of clinical, laboratory, and imaging findings coupled with percutaneous and intravascular procedures with endoscopy largely limited to screening for and therapy of esophageal and gastric varices. As the applications of diagnostic and therapeutic endoscopic ultrasound (EUS) have evolved, it has found a particular niche within hepatology now coined endo-hepatology. Here we discuss several EUS-guided procedures such as liver biopsy, shear wave elastography, direct portal pressure measurement, paracentesis, as well as EUS-guided therapies for variceal hemorrhage.
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Affiliation(s)
- Daniel E Hogan
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
| | - Michael Ma
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
| | - David Kadosh
- Department of Internal Medicine, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
| | - Alisha Menon
- Department of Internal Medicine, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
| | - Kana Chin
- Department of Internal Medicine, Long Island Jewish Forest Hills, Northwell Health, Forest Hills, NY 11375, United States
| | - Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, Northwell Health, New York, NY 10075, United States
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Clinical Manifestations of Ultrasonic Virtual Reality in the Diagnosis and Treatment of Cardiovascular Diseases. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:1746945. [PMID: 34257848 PMCID: PMC8253629 DOI: 10.1155/2021/1746945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 12/26/2022]
Abstract
On a global scale, cardiovascular disease has become one of the most serious diseases that endangers human health and causes death and seriously threatens human life and health. If we can make accurate, timely, and effective judgments on cardiovascular-related parameters and take corresponding effective measures, the incidence of cardiovascular diseases can be reduced to a large extent. Based on this, this paper proposes the clinical application research of ultrasound virtual reality technology in the diagnosis and treatment of cardiovascular diseases. This article uses literature methods, experimental research methods, mathematical statistical analysis methods, and other research methods and in-depth study of virtual reality technology, cardiovascular disease, and other theoretical knowledge and briefly introduces ultrasound image denoising algorithms, such as bilateral filtering and PM model. And on this basis, it establishes clinical trials of ultrasound virtual reality technology in the diagnosis and treatment of cardiovascular diseases. This article mainly analyzes the application of virtual reality technology, technology comparison, and the experimental results carried out in this article. From the survey results, the total prevalence of hypertension was 25.1%, and the prevalence of males and females was 25.9% and 24.4%, respectively; the diagnostic accuracy rate of the experimental group reached 85.39%, while the diagnostic accuracy rate of the control group was 76.8%. It shows that the use of ultrasound virtual reality technology for disease diagnosis can effectively improve the accuracy of cardiovascular disease diagnosis and reduce the proportion of misdiagnosis and missed detection.
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Affiliation(s)
- Firas Bahdi
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Rollin George
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Kalpesh Patel
- Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
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Thiruvengadam SS, Sedarat A. The Role of Endoscopic Ultrasound (EUS) in the Management of Gastric Varices. Curr Gastroenterol Rep 2021; 23:1. [PMID: 33389241 PMCID: PMC7778619 DOI: 10.1007/s11894-020-00801-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Gastric varices (GV) are an important complication of portal hypertension, and the current recommendation for management is beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt (TIPS) for active bleeding or secondary prophylaxis. Direct endoscopic injection of cyanoacrylate (CYA) glue has been investigated but has drawbacks including limited endoscopic characterization of GV and possible distal glue embolism. To this end, endoscopic ultrasound (EUS) has been pursued to help in characterization of GV, visualization of treatment in real time, and confirmation of obliteration with Doppler. RECENT FINDINGS In this paper, we review treatments for GV involving EUS, including EUS-guided injection of CYA and coils, either alone or in combination. We also discuss less common methods, including EUS-guided injection of thrombin and absorbable gelatin sponge. We then review literature comparing EUS-guided methods with direct endoscopic therapy and comparing individual EUS-guided methods with one another. We conclude by highlighting drawbacks of EUS in this field, including the unproven benefit over conventional therapy, lack of a standardized approach, and limited availability of expertise and necessary materials. Novel EUS-based methods offer a unique opportunity to directly visualize and access gastric varices for treatment and obliteration. This may provide key advantages over current endoscopic or angiographic treatments. Comparative studies investigating the benefit of EUS over conventional therapy are needed.
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Affiliation(s)
| | - Alireza Sedarat
- Division of Digestive Diseases, UCLA Vatche and Tamar Manoukian, Los Angeles, CA USA
- Santa Monica, USA
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Tang RSY, Kyaw MH, Teoh AYB, Lui RNS, Tse YK, Lam TYT, Chan SL, Wong VWS, Wu JCY, Lau JYW, Sung JJY. Endoscopic ultrasound-guided cyanoacrylate injection to prevent rebleeding in hepatocellular carcinoma patients with variceal hemorrhage. J Gastroenterol Hepatol 2020; 35:2192-2201. [PMID: 32602261 DOI: 10.1111/jgh.15168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/25/2020] [Accepted: 06/27/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Secondary prophylaxis (SP) of variceal rebleeding was reported to improve outcomes of hepatocellular carcinoma (HCC) patients, but the optimal endoscopic approach is not well defined. We compared outcomes in HCC patients who underwent SP by endoscopic ultrasound-guided cyanoacrylate obturation (EUS-CYA) versus no SP. METHODS Between 2014 and 2018, 30 consecutive patients with inoperable HCC and recent endoscopically controlled variceal bleeding were prospectively recruited. Twenty-seven patients with persistent varices ≥ 3 mm on endoscopic ultrasound underwent EUS-CYA for SP. Thirty-three HCC patients treated by esophagogastroduodenoscopy-guided CYA obturation (EGD-CYA) alone for acute variceal bleeding between 2009 and 2013 were identified from a prospective gastrointestinal bleed registry as standard of care controls for comparison. Outcome measures were death-adjusted cumulative incidence of rebleeding, bleeding-free survival, technical success, and procedure-related adverse events of EUS-CYA. RESULTS The majority of patients in both groups had advanced HCC, portal vein thrombosis, and Child-Pugh B cirrhosis. EUS-CYA was successful in all 27 patients with no radiographic evidence of cyanoacrylate-lipiodol embolization. Significantly lower 30- and 90-day death-adjusted cumulative incidence of rebleeding (14.8% vs 42.4%, P = 0.023 and 18.5% vs 60.6%, P = 0.002, respectively) and significantly higher variceal bleeding-free survival at 3 and 6 months (51.9% vs 21.2%, P = 0.009, 40.7% vs 15.2%, P = 0.010, respectively) were observed in the EUS-CYA group when compared with standard of care group. CONCLUSIONS Secondary prophylaxis by EUS-CYA reduced rebleeding rate and improved variceal bleeding-free survival in patients with inoperable HCC and variceal bleeding when compared with no SP. Randomized studies are needed to confirm the benefits of EUS-CYA for this difficult-to-treat population.
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Affiliation(s)
- Raymond S Y Tang
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Moe H Kyaw
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Anthony Y B Teoh
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Rashid N S Lui
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Yee-Kit Tse
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Thomas Y T Lam
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Stephen L Chan
- State Key Laboratory of Translational Oncology, Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong
| | - Vincent W S Wong
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Justin C Y Wu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - James Y W Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Joseph J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
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Irisawa A, Shibukawa G, Hoshi K, Yamabe A, Sato A, Maki T, Yoshida Y, Yamamoto S, Obara K. Endoscopic ultrasound-guided coil deployment with sclerotherapy for isolated gastric varices: Case series of feasibility, safety, and long-term follow-up. Dig Endosc 2020; 32:1100-1104. [PMID: 32147871 DOI: 10.1111/den.13666] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 03/05/2020] [Indexed: 02/08/2023]
Abstract
The purpose of the present study is to report our experience of endoscopic ultrasound-guided coil deployment with sclerotherapy (EUS-CS) for isolated gastric varices (IGV) through a case series. Eight consecutive patients who had risky IGV were prospectively enrolled. EUS-CS was performed according to the following procedures: (i) several coils were first deployed in the IGV under EUS guidance; (ii) contrast medium was subsequently injected without removing the needle; (iii) if the infused contrast medium stayed in the IGV and feeding vein, sclerosant was then injected to obliterate the IGV and feeders. Coil deployment in the IGV was successfully performed in all cases. Sclerosant was injected both into the IGV and feeders in seven patients (87.5%). There was no adverse event during the procedure. During a median follow-up of 57 months, one patient who could not inject the sclerosant into IGV and feeders had an early hemorrhagic recurrence. Our case series showed that EUS-CS could be a feasible and safe procedure for the treatment of IGV.
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Affiliation(s)
- Atsushi Irisawa
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Goro Shibukawa
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Koki Hoshi
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Akane Yamabe
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Ai Sato
- Department of Gastroenterology, Dokkyo Medical University School of Medicine, Tochigi, Japan
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Takumi Maki
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Yoshitsugu Yoshida
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Shogo Yamamoto
- Department of Gastroenterology, Aizu Medical Center, Fukushima Medical University, Fukushima, Japan
| | - Katsutoshi Obara
- Department of Advanced Gastrointestinal Endoscopy, Fukushima Medical University School of Medicine, Fukushima, Japan
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Sharma K, Sharma M, Singh S. Endoscopic Ultrasound-Guided Angiotherapy for Gastric Varices—A Small Retrospective Study. JOURNAL OF DIGESTIVE ENDOSCOPY 2020. [DOI: 10.1055/s-0040-1717823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Introduction Conventional n-butyl-cyanoacrylate (CYA) recommended for secondary prophylaxis of gastric varices (GV) is associated with significant rebleeding and glue embolism. Limited data are available on more successful and less risky endoscopic ultrasound-guided coils and CYA (EUS-Coils-CYA) injection in GV.
Methods We present a retrospective case series of 12 patients with GV bleeding managed successfully with EUS-Coils-CYA injection leading to variceal eradication in 11 patients.
Results From January 2018 to June 2019, 12 cases of GV, which were either bleeding or bled recently, were included. Complete obliteration was achieved in 91.6% of patients with 100% technical success. Mean number of deployed coils and volume of injected CYA glue were 1.16 and 1.58 mL, respectively.
Conclusions EUS-guided angiotherapy is an effective and safe intervention for managing GV bleeding with high technical success rate.
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Affiliation(s)
- Kapil Sharma
- Department of Gastroenterology, Batra Hospital and Medical Research Centre, New Delhi, India
| | - Mamta Sharma
- Department of Preventive and Social Medicine, Al-Falah Medical College, Faridabad, Haryana, India
| | - Sanchit Singh
- Department of Gastroenterology, Batra Hospital and Medical Research Centre, New Delhi, India
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El-Sherif Y, Harrison P, Courtney K, Lewis D, Devlin J, Reffitt D, Joshi D. Management of portal cavernoma-associated cholangiopathy: Single-centre experience. Clin Res Hepatol Gastroenterol 2020; 44:181-188. [PMID: 31255533 DOI: 10.1016/j.clinre.2019.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/23/2019] [Accepted: 06/07/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Portal cavernoma associated cholangiopathy (PCC) is an uncommon disease in western countries. We describe our experience in seven patients with PCC, in particular the endoscopic management. We describe the mode of presentation, frequent symptoms and the outcome of different treatment modalities of patients with symptomatic PCC. METHODS Prospectively maintained database was reviewed at a large tertiary referral unit in London, UK. Data included therapeutic interventions, outcomes and complications. RESULTS Seven patients with PCC were followed for a median of 87 months [interquartile range (IQR), 62-107.5]. Causes of EHPVO included (hypercoagulable status, n=2, peritoneal tuberculosis n=1, neonatal sepsis, n=1, idiopathic, n=3). Acute cholangitis constituted the most recurring complications in all patients during the disease course. Endoscopic intervention was deemed required in all patients for biliary decompression, with 5 out 7 patients managed with repeat endoscopic sessions, (total=23 ERCPs). Surgical portal decompression (meso-caval shunt) was successfully performed in one patient and another patient underwent liver transplantation for decompensated liver cirrhosis. When endoscopic intervention was indicated, a fully covered self expanding metal stent (FcSEMS) provided a longer "symptoms free" period when compared to plastic stent, 7.5 (IQR, 4.75-18.25) and 4 (IQR, 3.5-7) months respectively, P=0.03. Bile duct bleeding occurred in two patients during ERCP procedure, however none of the patients had spontaneous haemobilia. Both patients were successfully treated by FcSEMS. CONCLUSION Acute cholangitis is a common presentation and recurrent complication during the disease course. Spontaneous haemobilia seems to be uncommon, however it is a significant potential hazard during endoscopic intervention. Insertion of FcSEMS may remodel choledochal varices and provide a longer "symptoms free" period compared to plastic stents.
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Affiliation(s)
- Yasser El-Sherif
- SE5 9RS, Institute of Liver Studies, King's College Hospital, London, United Kingdom; National Liver institute, Menoufia University, Egypt.
| | - Philip Harrison
- SE5 9RS, Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Kenneth Courtney
- SE5 9RS, Department of Radiology, King's College Hospital, London, United Kingdom
| | - Dylan Lewis
- SE5 9RS, Department of Radiology, King's College Hospital, London, United Kingdom
| | - John Devlin
- SE5 9RS, Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - David Reffitt
- SE5 9RS, Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Deepak Joshi
- SE5 9RS, Institute of Liver Studies, King's College Hospital, London, United Kingdom
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Braden B, Gupta V, Dietrich CF. Therapeutic EUS: New tools, new devices, new applications. Endosc Ultrasound 2019; 8:370-381. [PMID: 31417067 PMCID: PMC6927146 DOI: 10.4103/eus.eus_39_19] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/02/2019] [Indexed: 12/11/2022] Open
Abstract
Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years.
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Affiliation(s)
- Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vipin Gupta
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Kozieł S, Pawlak K, Błaszczyk Ł, Jagielski M, Wiechowska-Kozłowska A. Endoscopic Ultrasound-Guided Treatment of Gastric Varices Using Coils and Cyanoacrylate Glue Injections: Results after 1 Year of Experience. J Clin Med 2019; 8:1786. [PMID: 31731504 PMCID: PMC6912414 DOI: 10.3390/jcm8111786] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 10/18/2019] [Accepted: 10/23/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND AIMS Gastric varices (GVs) occur in 20% of patients with portal hypertension. GVs are associated with a 65% risk of bleeding over the course of 2 years and have a mortality rate of up to 20%. The standard treatment for GVs is obliteration with cyanoacrylate (CYA). This study presents our experience with combined therapy (vascular coils and CYA) under endoscopic ultrasound (EUS) guidance. METHODS 16 patients (9 male and 7 female) were included into our study. Etiology of portal hypertension included: portal vein thrombosis (PVT) (31.0%), isolated splenic vein thrombosis (SVT) (25.0%), alcoholic cirrhosis (12.5%), hepatitis C cirrhosis (19.0%), and alcoholic cirrhosis with PVT (12.5%). Varices type GOV-2 were diagnosed in 8 patients, type IGV-1 and IGV-2 in 6 and 2 patients, respectively. Indications for treatment were based on endoscopic and endosonographic evaluations of GVs. Inclusion and exclusion criteria were also specified. Technique depended on the size of varices (different size of coils + CYA additionally). The results were based on the achievement of technical success, therapeutic effects, and number of adverse events. Average follow-up period was 327 days. RESULTS From January to August 2017, 16 patients were treated with EUS-guided obliteration of GVs using vascular coils only or coils with CYA injections. 6 (37.5%) and 10 (62.5%) patients underwent primary and secondary prophylaxis for hemorrhage, respectively. Technical success was achieved in 15 patients (94.0%). Mean numbers of implanted coils and CYA volume during one procedure were 1.7 and 2 mL, respectively. Therapeutic success was achieved in all patients treated with the combination. There were no serious complications such as embolization or death due to the procedure. Three patients (19.0%) had transient abdominal pain and two (12.5%) had transient fever. 1 patient had clinical symptoms of gastrointestinal bleeding. CONCLUSIONS Based on our retrospective research we have concluded, that EUS-guided implantation of intravascular coils combined with cyanoacrylate injections is an effective method of treatment with an acceptable number of complications.
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Affiliation(s)
- Sławomir Kozieł
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Katarzyna Pawlak
- Department of Gastroenterology, Hospital of the Ministry of Internal Affairs in Szczecin, 70-382 Szczecin, Poland (A.W.-K.)
| | - Łukasz Błaszczyk
- Department of Gastroenterology, Hospital of the Ministry of Internal Affairs in Szczecin, 70-382 Szczecin, Poland (A.W.-K.)
| | - Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, 87-100 Torun, Poland;
| | - Anna Wiechowska-Kozłowska
- Department of Gastroenterology, Hospital of the Ministry of Internal Affairs in Szczecin, 70-382 Szczecin, Poland (A.W.-K.)
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Campos S, Poley JW, van Driel L, Bruno MJ. The role of EUS in diagnosis and treatment of liver disorders. Endosc Int Open 2019; 7:E1262-E1275. [PMID: 31579708 PMCID: PMC6773586 DOI: 10.1055/a-0958-2183] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/07/2019] [Indexed: 02/06/2023] Open
Abstract
Background and aim Transabdominal ultrasound (US), computed tomographic scanning (CT) and magnetic resonance imaging (MRI) are established diagnostic tools for liver diseases. Percutaneous transhepatic cholangiography is used to perform hepatic interventional procedures including biopsy, biliary drainage procedures, and radiofrequency ablation. Despite their widespread use, these techniques have limitations. Endoscopic ultrasound (EUS), a tool that has proven useful for evaluating the mediastinum, esophagus, stomach, pancreas, and biliary tract, has an expanding role in the field of hepatology complementing the traditional investigational modalities. This review aimed to assess the current scientific evidence regarding diagnostic and therapeutic applications of EUS for hepatic diseases.
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Affiliation(s)
- Sara Campos
- Department of Gastroenterology, Hospital Garcia da Orta, Portugal
- Department of Gastroenterology and Hepatology, Erasmus MC, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, The Netherlands
| | - Lydi van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, The Netherlands
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Goral V, Yılmaz N. Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:335. [PMID: 31277322 PMCID: PMC6681371 DOI: 10.3390/medicina55070335] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/28/2019] [Accepted: 06/28/2019] [Indexed: 12/21/2022]
Abstract
Gastric varices are less common than esophageal varices, and their treatment is quite challenging. Gastric varix bleedings (GVB) occur less frequently than esophageal varix (EV) bleedings and represent 10% to 30% of all variceal bleedings. They are; however, more severe and are associated with high mortality. Re-bleeding may occur in 35% to 90% of cases after spontaneous hemostasis. GV bleedings represent a serious clinical problem compared with esophageal varices due to their location. Sclerotherapy and band ligation, in particular, are less effective. Based on the anatomic site and location, treatment differs from EV and is categorized into two groups (i.e., endoscopic or radiologic treatment). Surgical management is used less frequently. Balloon-occluded retrograde transvenous obliteration (BRTO) and cyanoacrylate are safe but there is a high risk of re-bleeding. Portal pressure elevates following BRTO and leads to worsening of esophageal varix pressure. Other significant complications may include hemoglobinuria, abdominal pain, fever, and pleural effusion. Shock and atrial fibrillation are major complications. New and efficient treatment modalities will be possible in the future.
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Affiliation(s)
- Vedat Goral
- Istanbul Medipol University, School of Medicine Department of Gastroenterology, 34214 Istanbul, Turkey.
| | - Nevin Yılmaz
- Department of Gastroenterology, School of Medicine, Near East University, 99138 Nicosia, Cyprus
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Mazzawi T, Markhus CE, Havre RF, Do-Cong Pham K. EUS-guided coil placement for acute gastric variceal bleeding induced by non-EUS-guided variceal glue injection (with video). Endosc Int Open 2019; 7:E380-E383. [PMID: 30834298 PMCID: PMC6395176 DOI: 10.1055/a-0826-4253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/22/2018] [Indexed: 01/15/2023] Open
Abstract
Background and study aims Endoscopic ultrasound (EUS)-guided coil placement is a new emerging technique for management of gastric varices. In this video case report, we describe an EUS-guided coil placement for managing acute bleeding of gastric varices, following an unsuccessful glue injection to achieve hemostasis.
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Affiliation(s)
- Tarek Mazzawi
- Section of Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway,,Department of Clinical Medicine 1, University of Bergen, Bergen, Norway.,Corresponding author Tarek Mazzawi, MD, PhD Section of GastroenterologyDepartment of MedicineHaukeland University HospitalJonas Lies vei 655020 BergenNorway+4755974785
| | - Carl Erik Markhus
- Department of Radiology, Haukeland University Hospital, Bergen, Norway,
| | - Roald F. Havre
- Section of Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway,,Department of Clinical Medicine 1, University of Bergen, Bergen, Norway.
| | - Khanh Do-Cong Pham
- Section of Gastroenterology, Department of Medicine, Haukeland University Hospital, Bergen, Norway,,Department of Clinical Medicine 1, University of Bergen, Bergen, Norway.
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Wang X, Yu S, Chen X, Duan L. Endoscopic ultrasound-guided injection of coils and cyanoacrylate glue for the treatment of gastric fundal varices with abnormal shunts: a series of case reports. J Int Med Res 2019; 47:1802-1809. [PMID: 30819006 PMCID: PMC6460599 DOI: 10.1177/0300060519830207] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Gastric varices are found in approximately 20% of patients with portal hypertension. Endoscopic procedures involving the injection of cyanoacrylate (CYA) have proven to be the therapies of choice for primary treatment of gastric varices and have resulted in higher hemostasis rates and lower recurrent bleeding rates compared with band ligation and sclerotherapy. Nevertheless, serious adverse events associated with CYA injection, including glue embolization, have been reported in numerous articles and have occasionally led to fatal adverse events. Gastric fundal varices with abnormal shunts are higher-risk than those without abnormal shunts, and their treatment is more challenging. Endoscopic ultrasound (EUS)-guided puncture is an important technique in the field of digestive endoscopy. EUS has advantages that include improved therapeutic targeting, enhanced variceal detection, the ability to confirm varix obliteration with Doppler examination, and the ability to perform accurate observations of gastric varices that are not affected by blood in the stomach. The coils currently used for intravascular embolization can be precisely delivered into a varix through fine-needle puncture under EUS guidance, and this technique has provided a new approach for varix obliteration. We herein describe two patients with severe gastric fundal varices who were treated with EUS-guided coil injection and CYA embolization.
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Affiliation(s)
- XiaoMing Wang
- Department of Gastroenterology, Panzhihua Central Hospital, Sichuan, People's Republic of China
| | - Shan Yu
- Department of Gastroenterology, Panzhihua Central Hospital, Sichuan, People's Republic of China
| | - Xin Chen
- Department of Gastroenterology, Panzhihua Central Hospital, Sichuan, People's Republic of China
| | - Lei Duan
- Department of Gastroenterology, Panzhihua Central Hospital, Sichuan, People's Republic of China
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Bick BL, Al-Haddad M, Liangpunsakul S, Ghabril MS, DeWitt JM. EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding. Surg Endosc 2018; 33:1837-1845. [PMID: 30259158 DOI: 10.1007/s00464-018-6462-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic injection of cyanoacrylate into gastric varices may be performed by EUS-guided fine needle injection (EUS-FNI) or direct endoscopic injection (DEI). The aim of this study is to compare the rate of recurrent GV bleeding and adverse events between DEI and EUS-FNI for treatment of GV. METHODS In a single-center study, a retrospective cohort of patients with actively/recently bleeding or high-risk GV treated with DEI were compared with a prospective cohort of similar patients treated with EUS-FNI. Repeat endoscopy after index treatment was performed 3 months later or earlier if rebleeding occurred. The main outcomes assessed were rates of GV or overall rebleeding and adverse events. RESULTS Forty patients (mean age 57.2 ± 9.1 years, 73% male) and 64 patients (mean age 58.0 ± 12.5 years, 52% male) underwent DEI and EUS-FNI, respectively. Compared to the DEI group, the frequency of isolated gastric varices type 1 (IGV1) were higher (p < 0.001) but MELD scores were lower (p = 0.004) in the EUS-FNI group. At index endoscopy, EUS-FNI utilized a lower mean volume of cyanoacrylate (2.0 ± 0.8 mL vs. 3.3 ± 1.3 mL; p < 0.001) and injected a greater number of varices (1.6 ± 0.7 vs. 1.1 ± 0.4; p < 0.001) compared to DEI. Overall, GV rebleeding [5/57 (8.8%) vs. 9/38 (23.7%); p = 0.045] and non-GV-related gastrointestinal bleeding [7/64 (10.9%) vs. 11/40 (27.5%); p = 0.030] were less frequent in the EUS-FNI group compared to the DEI group, respectively. Adverse event rates were similar (20.3% vs. 17.5%, p = 0.723). CONCLUSIONS EUS-guided CYA injection of active or recently bleeding GV in patients with portal hypertension appears to decrease the rate of GV rebleeding despite injection of more varices and less CYA volume during the initial endoscopic procedure. Adverse events are similar between the two groups. EUS-FNI appears to be the preferred strategy for treatment of these patients.
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Affiliation(s)
- Benjamin L Bick
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | - Suthat Liangpunsakul
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | - Marwan S Ghabril
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA
| | - John M DeWitt
- Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA.
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Liu X, Wang AJ, Li BM. Progress in endoscopic treatment of gastric varices in patients with liver cirrhosis. Shijie Huaren Xiaohua Zazhi 2018; 26:1355-1359. [DOI: 10.11569/wcjd.v26.i22.1355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis is defined as diffuse or prolonged hepatic damage caused by one or more etiologies. When liver cirrhosis progresses to decompensation stage, hepatic dysfunction and portal hypertension are the main manifestations. Main symptoms of portal hypertension include collateral circulation, splenomegaly, and ascites. Gastric varices (GV) is one of the most common manifestations of collateral circulation. Gastric variceal bleeding (GVB) is one of the most common complications of cirrhosis, with a high mortality rate. In recent years, there are many studies on GV, but the choice of endoscopic treatments for different types of GV is still controversial. Compared with esophageal variceal bleeding, GVB is associated with large volume of bleeding, high risk, and high mortality. Therefore, selecting an appropriate endoscopic treatment can effectively reduce mortality and improve the prognosis. This article reviews the type of GV and endoscopic treatment of different types of GV.
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Affiliation(s)
- Xia Liu
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - An-Jiang Wang
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Bi-Min Li
- Department of Gastroenterology, the First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Chandra S, Holm A, El Abiad RG, Gerke H. Endoscopic Cyanoacrylate Glue Injection in Management of Gastric Variceal Bleeding: US Tertiary Care Center Experience. J Clin Exp Hepatol 2018; 8:181-187. [PMID: 29892182 PMCID: PMC5992314 DOI: 10.1016/j.jceh.2017.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/09/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as first-line treatment for bleeding gastric varices (GV) there is still limited experience with this method in the US. Our aim was to analyze our 10-year experience of ECGI for treatment and prophylaxis of gastric variceal bleeding. METHODS Records of patients undergoing ECGI of GV at our US tertiary care center between 6/2005 and 5/2015 were reviewed. Assessed outcomes were primary hemostasis, early rebleeding during hospitalization, recurrent bleeding during follow-up, eradication and recurrence of GV. RESULTS Prophylactic ECGI was performed in 16 patients with large GV. Eradication was achieved in 15 (94%). During the median follow-up of 27 (IQR 7-47) months, 4 patients (26.6%) had variceal bleeding; all were treated successfully with ECGI. Fifty-seven patients underwent ECGI for GV bleeding. Primary hemostasis was achieved in all. Early rebleeding occurred in 2 (3.5%) and durable hemostasis could not be achieved. Follow-up beyond initial hospitalization was available in 41 patients. Bleeding recurred in 8 (19.5%) patients during a median follow-up of 12 (IQR, 3-51) months. Eradication of GV was achieved in 92% of patients but recurrent varices were found in 44% during a median follow up period of 33 months. CONCLUSION ECGI is effective in achieving hemostasis of bleeding GV and their eradication. Recurrent bleeding and recurrence of varices after complete obliteration however are not infrequent and continued surveillance is advisable.
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Key Words
- BRTO, balloon-occluded retrograde transvenous obliteration
- CT, computed tomography
- ECGI, endoscopic cyanoacrylate glue injection
- GV, gastric varices
- ICD-9CM, International Classification of Diseases, Ninth Revision, Clinical Modification
- IQR, interquartile range
- TIPS, transjugular intrahepatic portosystemic shunt
- US, United States
- endoscopic cyanoacrylate glue injection
- gastric varices
- hemostasis
- variceal bleeding
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Affiliation(s)
| | | | | | - Henning Gerke
- Address for correspondence: Henning Gerke, Clinical Professor, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Hospital and Clinics, Iowa City, IA 52242, United States. Tel.: +1 319 356 2197; fax: +1 319 353 6399.
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Frost JW, Hebbar S. EUS-guided thrombin injection for management of gastric fundal varices. Endosc Int Open 2018; 6:E664-E668. [PMID: 29868631 PMCID: PMC5979194 DOI: 10.1055/a-0599-0440] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/18/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Cyanoacrylate glue is recommended first-line endoscopic therapy for gastric fundal varices but it is difficult to use and carries a risk of embolization. Thrombin is preferred by many in the UK, but its effectiveness can be difficult to establish at endoscopy and the rate of re-bleeding is higher. Endoscopic ultrasound (EUS) can help assess variceal blood flow and has the potential to improve both targeting and effectiveness of injection therapy. Whereas there is already some data for its use with glue, little data currently exist in relation to its use with thrombin. PATIENTS AND METHODS We present a series of patients treated with EUS-guided thrombin injection over the last 4 years. Thrombin was injected under EUS guidance with the intention of obliterating flow within the fundal varices. Outcomes reviewed included whether haemostasis was achieved, the dose of thrombin required for endosonographic variceal obliteration, the incidence of re-bleeding, and procedural related adverse events. RESULTS Eight patients received EUS-guided thrombin: 3 with active bleeding and 5 as elective prevention. In 2/3 (66 %) patients with active bleeding haemostasis was achieved after a single dose with complete variceal obliteration. 1/3 (33 %) had no alteration in blood flow despite 10 000 IU. None of the elective prevention group had further bleeding and obliteration was observed in 4/5 (80 %). A range of 600 to 10 000 IU of thrombin was used and there were no adverse procedure-related outcomes. CONCLUSIONS Our results are promising and suggest that EUS-guided thrombin injection may have a role in managing bleeding from gastric fundal varices.
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Affiliation(s)
- John W. Frost
- Royal Stoke University Hospital – Gastroenterology, Stoke-on-Trent, United Kingdom of Great Britain and Northern Ireland,Corresponding author John W. Frost Royal Stoke University Hospital – GastroenterologyNewcastle RoadStoke-on-Trent ST4 6QGUnited Kingdom of Great Britain and Northern Ireland
| | - Srisha Hebbar
- Royal Stoke University Hospital – Gastroenterology, Stoke-on-Trent, United Kingdom of Great Britain and Northern Ireland
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Siddiqui UD, Levy MJ. EUS-Guided Transluminal Interventions. Gastroenterology 2018; 154:1911-1924. [PMID: 29458153 DOI: 10.1053/j.gastro.2017.12.046] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/24/2017] [Accepted: 12/08/2017] [Indexed: 12/13/2022]
Abstract
The role of endoscopic ultrasound (EUS) has transitioned from a diagnostic to a therapeutic one over the past 40 years. With the advent of curvilinear array echoendoscopes in the 1990s with an accessory channel, multiple tools and devices have been developed and used for a variety of transluminal interventions. EUS provides a viable option and is becoming the procedure of choice for many interventions, including bile and pancreatic duct drainage, guiding angiotherapy, pancreatic fluid collection management, gallbladder drainage, and creating a gastrojejunostomy. Although reports demonstrate the technical success of these interventions, there is tremendous study heterogeneity and a relative lack of controlled randomized trials, which may limit our understanding of their role and utility. Furthermore, adverse events are relatively common and occasionally severe. Despite the limitations, available data strongly indicate the efficacy of EUS interventions when performed by well-trained endosonographers in carefully selected patients and managed in a multidisciplinary setting.
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Affiliation(s)
- Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics (CERT), The University of Chicago Medicine, Chicago, Illinois.
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Mukkada RJ, Antony R, Chooracken MJ, Francis JV, Chettupuzha AP, Mathew PG, Augustine P, Koshy A. Endoscopic ultrasound-guided coil or glue injection in post-cyanoacrylate gastric variceal re-bleed. Indian J Gastroenterol 2018; 37:153-159. [PMID: 29629510 DOI: 10.1007/s12664-018-0844-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/10/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS N-butyl-cyanoacrylate injection is recommended in bleeding/recently bled gastric varices. However, cyanoacrylate injection is associated with re-bleed in 25% to 50% of patients. Endoscopic ultrasound (EUS)-guided coil application is an emerging treatment modality for bleeding gastric varices. The aim of this study was to compare EUS-guided coil application combined with or without cyanoacrylate glue injection to injection alone in post-glue gastric variceal re-bleed. METHODS A retrospective analysis of a prospectively maintained database was performed. Thirty patients who re-bled after cyanoacrylate injection and who had EUS-guided coil application to gastric varices were included. The comparison was done with data of 51 patients who had only repeat cyanoacrylate injection. Both groups had a follow up for 12 months. EUS-guided coil application was done under endosonographic guidance. A single coil was placed in 7, two coils in each of 13 patients, three in 5, four in 3, five in one, and 6 coils in one patient. In addition, cyanoacrylate glue injection was given in 15 patients. Eight patients had repeat EUS-guided coil application 1 month later. Re-bleed and mortality were assessed. RESULTS Coilng: Six out of 30 (20%) patients re-bled during follow up of 9 to 365 days. Three out of 30 (10%) died. One patient died 9 days after the procedure due to acute respiratory distress syndrome, one died 4 months after the procedure due to a re-bleed and one 5 months after the procedure due to spontaneous bacterial peritonitis. Glue only: 26/51 (51%) re-bled during follow up of 45 to 365 days. EUS-guided coil application resulted in significantly less re-bleed than glue-only (Kaplan-Meir survival analysis with log-rank test, z = 5.4, p < 0.001). Two out of 51 (4%) died 59 and 186 days after the procedure. CONCLUSION EUS-guided coil application with/without cyanoacrylate injection for the obliteration of gastric varices is effective for post-cyanoacrylate gastric variceal re-bleed.
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Affiliation(s)
- Roy J Mukkada
- Departments of Gastroenterology and Radiology, VPS Lakeshore Hospital and Research Centre, Kochi, 682 304, India
| | - Rajesh Antony
- Departments of Gastroenterology and Radiology, VPS Lakeshore Hospital and Research Centre, Kochi, 682 304, India
| | - Mathew J Chooracken
- Departments of Gastroenterology and Radiology, VPS Lakeshore Hospital and Research Centre, Kochi, 682 304, India
| | - Jose V Francis
- Departments of Gastroenterology and Radiology, VPS Lakeshore Hospital and Research Centre, Kochi, 682 304, India
| | - Antony P Chettupuzha
- Departments of Gastroenterology and Radiology, VPS Lakeshore Hospital and Research Centre, Kochi, 682 304, India
| | - Pradeep G Mathew
- Departments of Gastroenterology and Radiology, VPS Lakeshore Hospital and Research Centre, Kochi, 682 304, India
| | - Philip Augustine
- Departments of Gastroenterology and Radiology, VPS Lakeshore Hospital and Research Centre, Kochi, 682 304, India
| | - Abraham Koshy
- Departments of Gastroenterology and Radiology, VPS Lakeshore Hospital and Research Centre, Kochi, 682 304, India.
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Affiliation(s)
- Idan Levy
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California
| | - Kenneth F Binmoeller
- Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California
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Yu Y, Qi SL, Zhang Y. Role of combined propofol and sufentanil anesthesia in endoscopic injection sclerotherapy for esophageal varices. World J Gastroenterol 2017; 23:7875-7880. [PMID: 29209128 PMCID: PMC5703916 DOI: 10.3748/wjg.v23.i44.7875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 09/04/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the efficacy and safety of a combination of sufentanil and propofol injection in patients undergoing endoscopic injection sclerotherapy (EIS) for esophageal varices (EVs).
METHODS Patients with severe EVs who underwent EIS with sufentanil and propofol anesthesia between April 2016 and July 2016 at our hospital were reviewed. Although EIS and sequential therapy were performed under endotracheal intubation, we only evaluated the efficacy and safety of anesthesia for the first EIS procedure. Patients were intravenously treated with 0.5-1 μg/kg sufentanil. Anesthesia was induced with 1-2 mg/kg propofol and maintained using 2-5 mg/kg per hour of propofol. Information, regarding age, sex, weight, American Association of Anesthesiologists (ASA) physical status, Child-Turcotte-Pugh (CTP) classification, indications, preanesthetic problems, endoscopic procedure, successful completion of the procedure, anesthesia time, recovery time, and anesthetic agents, was recorded. Adverse events, including hypotension, hypertension, bradycardia, and hypoxia, were also noted.
RESULTS Propofol and sufentanil anesthesia was provided in 182 procedures involving 140 men and 42 women aged 56.1 ± 11.7 years (range, 25-83 years). The patients weighed 71.4 ± 10.7 kg (range, 45-95 kg) and had ASA physical status classifications of II (79 patients) or III (103 patients). Ninety-five patients had a CTP classification of A and 87 had a CTP classification of B. Intravenous anesthesia was successful in all cases. The mean anesthesia time was 33.1 ± 5.8 min. The mean recovery time was 12.3 ± 3.7 min. Hypotension occurred in two patients (1.1%, 2/182). No patient showed hypertension during the endoscopic therapy procedure. Bradycardia occurred in one patient (0.5%, 1/182), and hypoxia occurred in one patient (0.5%, 1/182). All complications were easily treated with no adverse sequelae. All endoscopic procedures were completed successfully.
CONCLUSION The combined use of propofol and sufentanil injection in endotracheal intubation-assisted EIS for EVs is effective and safe.
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Affiliation(s)
- Yang Yu
- Department of Anesthesiology, the Sixth People’s Hospital of Dalian, Dalian 116000, Liaoning Province, China
| | - Sheng-Lin Qi
- Endoscopy Center, the Sixth People’s Hospital of Dalian, Dalian 116000, Liaoning Province, China
| | - Yong Zhang
- President Office, the Sixth People’s Hospital of Dalian, Dalian 116000, Liaoning Province, China
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Guo YW, Miao HB, Wen ZF, Xuan JY, Zhou HX. Procedure-related complications in gastric variceal obturation with tissue glue. World J Gastroenterol 2017; 23:7746-7755. [PMID: 29209115 PMCID: PMC5703934 DOI: 10.3748/wjg.v23.i43.7746] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/12/2017] [Accepted: 10/28/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To focus on procedure-related complications, evaluate their incidence, analyze the reasons and discuss the solutions.
METHODS Overall, 628 endoscopic gastric variceal obturation (EGVO) procedures (case-times) with NBC were performed in 519 patients in the Department of Endoscopy of the Third Affiliated Hospital of Sun Yat-Sen University from January 2011 to December 2016. The clinical data of patients and procedure-related complications of EGVO were retrospectively analyzed.
RESULTS In the 628 EGVO procedures, sticking of the needle to the varix occurred in 9 cases (1.43%), including 1 case that used lipiodol-diluted NBC and 8 cases that used undiluted NBC (P = 0.000). The needle was successfully withdrawn in 8 cases. Large spurt bleeding occurred in one case, and hemostasis was achieved by two other injections of undiluted glue. The injection catheter became blocked in 17 cases (2.71%) just during the injection, and 4 cases were complicated with the needle sticking to the varix. Large glue adhesion to the endoscope resulted in difficulty withdrawing the endoscope in 1 case. Bleeding from multiple sites was observed in the esophagus and gastric cardia after the endoscope was withdrawn. Hemostasis was achieved by 1% aethoxysklerol injection and intravenous somatostatin. The ligation device stuck to the varices in two cases during the subsequent endoscopic variceal ligation. In one case, the ligation device was successfully separated from the esophageal varix after all bands were released. In another case, a laceration of the vein and massive bleeding were observed. The bleeding ceased after 1% aethoxysklerol injection.
CONCLUSION Although EGVO with tissue glue is usually safe and effective, a series of complications can occur during the procedure that may puzzle endoscopists. There is no standard operating procedure for addressing these complications. The cases described in the current study can provide some reference for others.
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Affiliation(s)
- Yun-Wei Guo
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Hui-Biao Miao
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Zhuo-Fu Wen
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Jie-Ying Xuan
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
| | - Hao-Xiong Zhou
- Department of Gastroenterology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510630, Guangdong Province, China
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Friedberg SR, Lachter J. Endoscopic ultrasound: Current roles and future directions. World J Gastrointest Endosc 2017; 9:499-505. [PMID: 29085560 PMCID: PMC5648992 DOI: 10.4253/wjge.v9.i10.499] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 05/20/2017] [Accepted: 06/13/2017] [Indexed: 02/05/2023] Open
Abstract
Endoscopic ultrasound (EUS), developed in the 1980s, was initially predominantly used for guidance of fine needle aspiration; the last 25 years, however, have witnessed a major expansion of EUS to various applications, both diagnostic and therapeutic. EUS has become much more than a tool to differentiate different tissue densities; tissue can now be characterized in great detail using modalities such as elastography; the extent of tissue vascularity can now be learned with increasing precision. Using these various techniques, targets for biopsy can be precisely pinpointed. Upon reaching the target, tissue can then be examined microscopically in real-time, ensuring optimal targeting and diagnosis. This article provides a comprehensive review of the various current roles of EUS, including drainage of lesions, visualization and characterization of lesions, injection, surgery, and vascular intervention. With EUS technology continuing to develop exponentially, the article emphasizes the future directions of each modality.
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Affiliation(s)
- Scott R Friedberg
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Jesse Lachter
- Rambam Healthcare Campus, Technion Israel Institute of Technology, Haifa 3109601, Israel
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Artifon ELDA, Marson FP, Khan MA. Endoscopic Ultrasonography-Guided Hemostasis Techniques. Gastrointest Endosc Clin N Am 2017; 27:741-747. [PMID: 28918809 DOI: 10.1016/j.giec.2017.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic ultrasonography (EUS)-guided hemostasis is an evolving technique that has the potential to improve the care of patients with refractory variceal and nonvariceal gastrointestinal bleeding. EUS-guided treatment of fundal varices with coil and/or cyanoacrylate seems to be highly effective in active bleeding, as well as for primary and secondary bleeding prophylaxis. Reports of EUS-guided treatment of refractory nonvariceal sources of bleeding are more scarce, but show high success rates. The procedures involve a medium to high technical difficulty level, and this has been replicated worldwide.
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Affiliation(s)
- Everson Luiz de Almeida Artifon
- Department of Surgery, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 255 - Cerqueira César, São Paulo, São Paulo 05403-000, Brazil.
| | - Fernando Pavinato Marson
- Department of Surgery, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 255 - Cerqueira César, São Paulo, São Paulo 05403-000, Brazil
| | - Muhammad Ali Khan
- Department of Gastroenterology and Hepatology, University of Tennessee Health Science Center, 956 Court Avenue, Suite H 314, Memphis, TN 38163, USA
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50
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Endoscopic ultrasound access, therapy, and treatment of gastrointestinal bleeding. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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