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

Background Global research on endoscopic therapies in combination with partial splenic embolization (PSE) for variceal hemorrhage (VH) is limited. Therefore, we aimed to evaluate the efficacy and safety of endoscopy plus PSE (EP) treatment in comparison to endoscopic (E) treatment for the secondary prophylaxis of VH in cirrhosis patients with hypersplenism. Methods Cirrhosis patients with hypersplenism (platelet count < 100, 000/µL) and those who had recovered from an episode of VH were enrolled in a multicenter randomized controlled trial. The participants were randomly assigned into EP and E groups in a 1:1 ratio. The primary endpoint was variceal rebleeding, and the secondary endpoints were severe variceal recurrence and mortality during the 2-year follow-up. Hematological indices, serum biochemical parameters, and the Child–Pugh score were measured at each time point. Results From June 2016 to December 2019, 108 patients were enrolled in the study, among which 102 patients completed the protocol (51 in EP and 51 in E group). The rebleeding rate of the varices was significantly reduced in the EP group compared to that in the E group during the 2 years (16% vs. 31%, p < 0.001). The EP group showed a significantly lower variceal recurrence rate than the E group (22% vs. 67%, p < 0.001). The COX proportional hazard models revealed that grouping was an independent predictor for variceal rebleeding (H = 0.122, 95% CI 0.055–0.270, p < 0.001) and variceal recurrence (hazard ratio, H = 0.160, 95% CI 0.077–0.332, p < 0.001). The peripheral blood cell count, Child–Pugh class/score, albumin concentration, and coagulation function in the EP group improved significantly compared to the values observed in the E group at any time point (p < 0.05). Conclusions The EP treatment was more effective in preventing variceal rebleeding and variceal recurrence than the conventional E treatment during the secondary prophylaxis of VH in cirrhosis patients with hypersplenism. Furthermore, the EP treatment could significantly increase the peripheral blood cell count and albumin concentration and also improved the coagulation function and the Child–Pugh score. Clinical trials registration Trial registration number ClincialTrials.gov: NCT02778425. The URL of the clinical trial: https://clinicaltrials.gov/

Esophageal collateral veins in predicting esophageal variceal recurrence and rebleeding after endoscopic treatment: a systematic review and meta-analysis

Background Endoscopic treatment is recommended for the management of esophageal varices. However, variceal recurrence or rebleeding is common after endoscopic variceal eradication. Our study aimed to systematically evaluate the prevalence of esophageal collateral veins (ECVs) and the association of ECVs with recurrence of esophageal varices or rebleeding from esophageal varices after endoscopic treatment. Methods We searched the relevant literature through the PubMed, EMBASE, and Cochrane Library databases. Prevalence of paraesophageal veins (para-EVs), periesophageal veins (peri-EVs), and perforating veins (PVs) were pooled. Risk ratio (RR) and odds ratio (OR) with 95% confidence intervals (CIs) were calculated for cohort studies and case–control studies, respectively. A random-effects model was employed. Heterogeneity among studies was calculated. Results Among the 532 retrieved papers, 28 were included. The pooled prevalence of para-EVs, peri-EVs, and PVs in patients with esophageal varices was 73%, 88%, and 54%, respectively. The pooled prevalence of para-EVs and PVs in patients with recurrence of esophageal varices was 87% and 62%, respectively. The risk for recurrence of esophageal varices was significantly increased in patients with PVs (OR = 9.79, 95% CI: 1.95–49.22, P = 0.006 for eight case–control studies), but not in those with para-EVs (OR = 4.26, 95% CI: 0.38–38.35, P = 0.24 for four case–control studies; RR = 1.81, 95% CI: 0.83–3.97, P = 0.14 for three cohort studies). Patients with para-EVs had a significantly higher incidence of rebleeding from esophageal varices (RR = 13.00, 95% CI: 2.43–69.56, P = 0.003 for two cohort studies). Statistically significant heterogeneity was notable across the meta-analyses. Conclusions ECVs are common in patients with esophageal varices. Identification of ECVs could be helpful for predicting the recurrence of esophageal varices or rebleeding from esophageal varices after endoscopic treatment.

A transparent cap assisted endoscopic injection sclerotherapy for the treatment of patients with esophageal varices

Aim: The aim of this study was to compare the efficacy and safety of cap assisted endoscopic injection sclerotherapy(EIS) versus direct endoscopic injection sclerotherapy(EIS) in the management of patients with cirrhosis after esophageal variceal bleeding . Methods: Patients with cirrhosis suffering from esophageal variceal bleeding who underwent EIS with or without the help of a transparent cap in Shandong Provincial Hospital between Novermber December 2014 and April 2017 were included in this retrospective study. All of the cases included in the study were divided into two groups: Group A (EIS with a transparent cap, n=50), Group B (direct EIS, n=45). Data collected included patients’ demographics, details of the procedure, variceal eradication, variceal rebleeding, variceal recurrence and survival during the follow-up period. All data were expressed as mean ± SD. Quantitative variables were compared by Student t test, and qualitative variables were compared by the Fisher exact test or the chi-square test. A P value less than 0.05 was considered significant. Results: The mean duration of follow-up was similar in both groups(16.3±10.2 mo and 15.5±9.5 mo, respectively). To achieve the eradication of varices, the volume of sclerosant (64.86±10.62 ml vs 104.73±21.25 ml, P =0.044), the mean number of sessions (2.37±1.15 times vs 5.70±1.57 times, p =0.042), the time required to perform endoscopic treatment(6.57±1.50 minutes vs 11.22±2.29 minutes, P =0.049) and the time for the initial esophageal varices eradication were significantly reduced in the cap assisted EIS group than in the direct EIS group(5.43±1.38 weeks vs 8.93±1.5 weeks, P =0.041). The probability of variceal recurrence and rebleeding was significantly higher in the direct EIS group than in cap assisted EIS group. Only 22 patients (44%) developed complications in the cap assisted EIS group as compared to 30 patients ( P =0.039) in the EIS group. The probability of survival was similar in both groups ( P =0.133). Conclusion: EIS with a transparent cap is an effective and safe treatment for esophageal varices.

Use of nonselective β blockers after variceal eradication in cirrhotic patients undergoing secondary prophylaxis of esophageal variceal bleeding: a critical review of current evidence

Nonselective β blockers (NSBBs) combined with esophageal variceal ligation (EVL) are recommended for secondary prophylaxis of esophageal variceal bleeding (EVB) in cirrhotic patients according to the current practice guidelines and consensus. However, until now, there is a paucity of recommendations regarding the use of NSBBs in cirrhotic patients who achieved variceal eradication. In this review paper, we firstly introduced a case who achieved variceal eradication after additional use of NSBBs for secondary prophylaxis of EVB and then did not require further endoscopic therapy during repeated endoscopic surveillance, and subsequently discuss the importance of NSBBs for secondary prophylaxis of EVB, the effect of NSBBs after variceal eradication, adherence to NSBBs, screening for variceal recurrence, and timing of endoscopic surveillance after variceal eradication.

Ankstyvas stemplės venų varikozės atsinaujinimas po endoskopinio perrišimo yra susijęs su specifiniais endoskopiniu ultragarsiniu tyrimu diagnozuojamais pakitimais: prospektyvusis tyrimas

Įvadas / tikslasPagrindinis stemplės venų varikozės gydymo metodas yra endoskopinis jų perrišimas guminiais žiedais (toliau – endoskopi­nis perrišimas). Stemplės venų varikozės atsinaujinimas po endoskopinio gydymo yra dažnas ir jam būdingas didelis krau­javimo pavojus. Sergant kepenų ciroze su portine hipertenzija, aplink stemplę išsiplečia kolateralinės venos, kurias galima matyti ir įvertinti atliekant endoskopinį ultragarsinį tyrimą. Šio darbo tikslas – nustatyti, ar endoskopinio ultragarsinio tyrimo metu matomas kolateralinių venų tipas ir dydis gali padėti prognozuoti ankstyvą stemplės venų varikozės atsinaujinimą po endoskopinio perrišimo.Ligoniai ir metodaiĮ prospektyvųjį tyrimą įtraukti ligoniai, kuriems buvo atliktas stemplės varikozinių venų endoskopinis perrišimas. Prieš perrišimą visiems pacientams buvo atliktas endoskopinis ultragarsinis tyrimas ir įvertintas aplink stemplę esančių venų ti­pas ir dydis. Po endoskopinio stemplės varikozinių venų perrišimo ligoniai buvo stebimi vienerius metus siekiant nustatyti stemplės venų varikozės atsinaujinimą. Atsinaujinimas, kuris išsivystė per 6 mėnesius po gydymo, buvo vadinamas ankstyvu. Siekiant nustatyti ankstyvo stemplės venų varikozės atsinaujimo rizikos veiksnius, buvo įvertintas kolateralinių venų ryšys su atsinaujinimu. Tyrimui atlikti buvo gautas regioninio biomedicininių tyrimų etikos komiteto leidimas.RezultataiPo endoskopinio perrišimo 30 % pacientų (12 iš 40) išsivystė ankstyvas stemplės venų varikozės atsinaujimas. Didelės ar­timosios (peri) kolateralinės venos, diagnozuojamos atliekant endoskopinį ultragarsinį tyrimą, buvo statistiškai reikšmingai susijusios su didesne ankstyvo stemplės venų varikozės atsinaujimo rizika (p=0,041). Didelės tolimosios (para) kolateralinės venos, diagnozuojamos atliekant endoskopinį ultragarsinį tyrimą, nebuvo statistiškai reikšmingai susijusios su didesne ankstyvo atsinaujimo rizika (p=0,149).IšvadosŠiuo tyrimu nustatyta, kad didelės artimosios kolateralinės venos yra susijusios su ankstyvu stemplės venų varikozės atsinau­jimu po endoskopinio perrišimo.Reikšminiai žodžiai: endoskopinis ultragasinis tyrimas, stemplės venų varikozės atsinaujimas, endoskopinis perrišimas Endoscopic ultrasound predicts early recurrence of esophageal varices after endoscopic band ligation: a prospective cohort studyLaura Mašalaite, Jonas Valantinas, Juozas Stanaitis BackgroundVariceal recurrence following endoscopic treatment is very common and associated with the variceal bleeding or rebleeding risk. Esophageal collateral veins are observed by endoscopic ultrasound (EUS) in patients with portal hypertension. The aim of the study was to identify whether EUS findings could predict the early variceal recurrence after endoscopic band ligation (EBL).Patients and methodsThe prospective cohort study was performed, including consecutive patients, undergoing EBL for esophageal varices. EUS was performed before ligation, and the type and grade of esophageal collateral veins (ECV) were described. After all EBL ses­sions had been completed, patients were examined every three months for a 12-month period to detect variceal recurrence. Patients in whom varices reoccurred within six months were noted as the early recurrence group. The relationship between the type and grade of ECV and the early variceal recurrence was analysed to detect the possible risk factors. The study was approved by the local ethics committee.ResultsForty patients were included in the study over the study period. Twelve of the forty patients (30%) had early variceal recur­rence within six months, and nineteen of the forty patients (47.5%) had variceal recurrence within twelve months after EBL. Overall, the mean number of months from the end of EBL until recurrence was 7.26 ± 3.05 (3–12)). Severe peri-ECV were statis­tically significantly associated with the higher variceal recurrence risk within six months (p = 0.041), whereas severe para-ECV had no statistically significant risk related to the early variceal recurrence risk (p = 0.149).ConclusionsA positive association between early variceal recurrence following endoscopic band ligation and specific findings on EUS was demonstrated. Severe-grade peri-ECV predict early variceal recurrence following EBL.Key words: endoscopic ultrasound, variceal recurrence, endoscopic band ligation