Abstract
Variceal hemorrhage may cause high rebleeding and mortality rates. Preventing the first episode of variceal bleeding is mandatory in patients with high-risk esophageal varices (EV). This study aimed to identify factors that predict the recurrence of EV after endoscopic treatment (ET), and to develop a reasonable therapeutic strategy for EV in cirrhosis. From January 2012 to December 2014, 45 patients with cirrhosis and high-risk EV underwent ET, including sclerotherapy and/or ligation. Statistical analyses identified factors associated with the recurrence of EV after ET, and the Kaplan-Meier method determined the cumulative variceal recurrence rates. The 1-, 2-, and 3-year cumulative posttreatment recurrence rates for EV were 13.3%, 29.5%, and 32.2%, respectively. No significant differences were evident between the patients with and without variceal recurrences at 1-year posttreatment. The multivariate regression analyses identified a history of partial splenic embolization (PSE) and the pretreatment Child-Pugh classification as independent predictors of variceal recurrences at 2 years (p < 0.05) and 3 years (p < 0.05) posttreatment. While EV did not recur after ET and splenic artery embolization in cases with Child-Pugh class A, the overall posttreatment variceal recurrence rates were 0% and 66.7% when PSE was performed before and after ET, respectively, in those with Child-Pugh class B or C. Splenic artery embolization significantly reduced the hepatic venous pressure gradient and markedly lowered the Child-Pugh score in 15 patients. Adjunctive PSE and pretreatment Child-Pugh class A could be independently associated with reduced cumulative recurrence rates of EV post-ET. From the perspectives of portal hemodynamics and hepatic function, splenic artery embolization before or after ET could prevent posttreatment variceal recurrence in patients with Child-Pugh class A, and PSE before ET could achieve the long-term eradication of EV following ET in those with Child-Pugh class B or C.
Highlights
Esophageal varices (EV) may be present in about 50% of patients with cirrhosis [1]
This study aimed to identify predictive factors associated with variceal recurrence post-endoscopic treatment (ET), and to develop a reasonable therapeutic strategy for EV in cirrhotic patients with portal hypertension
No significant differences were evident between the patients with and without variceal recurrences at 1-year post-ET regarding age, sex, the cause of cirrhosis, the CP classification, the estimated glomerular filtration rate (eGFR), the platelet count, the number of ETs, including initial treatment or retreatment, the therapeutic procedure, namely, endoscopic injection sclerotherapy (EIS)-based therapy or endoscopic variceal ligation (EVL) alone, the EV form, the red color (RC) signs, a history of partial splenic embolization (PSE), or concomitant hepatocellular carcinomas (HCCs)
Summary
Esophageal varices (EV) may be present in about 50% of patients with cirrhosis [1]. Since variceal hemorrhage may cause high rebleeding and mortality rates, preventing the first episode of variceal bleeding is mandatory in patients with high-risk EV. Endoscopic procedures, including endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS), are widely used to arrest and prevent bleeding. EVL is the gold standard treatment for variceal eradication, because of its unequivocal efficacy, greater convenience, and safety, and lower level of invasiveness compared with EIS. While EVL is plagued by high variceal recurrence rates caused by the mechanical effects of the rubber bands located within the submucosa, the chemical effect of sclerotherapy reaches the perforating veins and the paraesophageal collateral veins. The effectiveness of EIS combined with EVL, which augments the effect of the sclerosant on the deeper vessels and maintains the band ligation efficacy that quickly obliterates the varices, has been reported [2,3,4,5,6]. Despite using procedural techniques and follow-up systems of the same quality, a range of postoperative clinical courses have occurred, including the early recurrence or long-term eradication of EV, after endoscopic treatment (ET)
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