Combination Of Endoscopic Band Ligation Research Articles

Screening and management of portal hypertension in advanced hepatocellular carcinoma: A French practice survey

BackgroundPortal hypertension (PHT) and hepatocellular carcinoma (HCC) are two major complications of cirrhosis that are closely linked and impact patients prognosis, particularly acute variceal bleeding (AVB). Therefore, PHT screening and AVB prophylaxis are major issues to improve the outcome of the patients, but practices may vary among physicians. MethodsWe submitted hepatologists, gastroenterologists and digestive oncologists to a questionnaire of 70 items about PHT screening and management to evaluate their practice. Results95 out of 847 physicians responded to the questionnaire (hepatologists 63.2%, Oncologists/gastroenterologists 36.8%). In patients with advanced HCC, PHT was assessed by endoscopy in 80.0% of cases. HCC progression motivated a new for 12.6% of respondents while no intent to control was declared for 49.5% of them.AVB primary prophylaxis for large size esophageal varices (EV) was impacted by the presence of red marks at endoscopy. In the absence of a red mark, prophylaxis with non-selective betablockers (NSSB) was proposed in 70.5% of cases for patients undergoing TKI and 63.2% undergoing Atezolizumab/Bevacizumab, whereas the combination of endoscopic band ligation (EBL) and NSBB was preferred in 41.1% of patients undergoing TKI versus 53.7% undergoing Atezolizumab/Bevacizumab in case of a red mark.The initiation of a systemic treatment was lower in patients with an history of AVB <6 months, which was even more significant for Atezolizumab/Bevacizumab combination (51.6%) compared to tyrosine kinase inhibitors (72.6%) (p<0.001). Atezolizumab/Bevacizumab was initiated in 43% of participants in case of AVB <6 months versus 95% if >6 months (p<0.001).In case of AVB on Atezolizumab/Bevacizumab, 43.2% continued the treatment after regression of EV, 24.2% continued Atezolizumab alone and 14.7% permanently stopped the treatment. ConclusionStrategies for screening and management of PHT in advanced HCC remain very heterogeneous among physicians, suggesting the need to improve PHT knowledge and dedicated studies for advanced HCC.

Survival benefits of adding simvastatin to standard therapy for secondary prevention of bleeding esophageal varices in patients with hepatitis C-related liver cirrhosis

BackgroundThe combination of endoscopic band ligation and beta-blockers is the standard of care treatment for secondary prevention of variceal bleeding; however, rebleeding still occurs with associated high mortality. Simvastatin (a lipid-lowering agent) was found to reduce portal hypertension and decrease hepatic fibrosis. This study aimed to assess the effect of adding simvastatin to the standard therapy to prevent variceal rebleeding and its impact on survival in patients with liver cirrhosis.ResultsThis single-center randomized controlled clinical trial included 80 patients with cirrhosis receiving the standard secondary prophylaxis for variceal bleeding composed of endoscopic variceal ligation and non-selective β-blockers (either propranolol or carvedilol). Two weeks after the first attack of hematemesis, patients were randomized into two groups: group I who received the standard therapy (40 patients) and group II who administered simvastatin (20 mg daily for 2 weeks and 40 mg daily after that). Patients were followed up for 1 year. The primary endpoints were rebleeding and overall survival. Thirty patients of group I completed the study while ten patients died during the follow-up period. The simvastatin group showed a significantly better overall 1-year survival (3 deaths during follow-up) compared to the control group (37/40, 92.5% vs. 30/40; 75%) (p-value 0.034); however, this was lacking in Child C patients. No similar difference was present in rebleeding rates between the two groups (5/40, 12.5% vs. 3/40, 7.5%) (p-value 0.456) in groups I and II, respectively.ConclusionsAdding simvastatin to the standard therapy in secondary prevention of variceal bleeding could be associated with survival benefits in patients with Child A and B cirrhosis, while was incapable of reducing rebleeding.

Patients Whose First Episode of Bleeding Occurs While Taking a β-Blocker Have High Long-term Risks of Rebleeding and Death

Patients who have their first episode of variceal bleeding despite primary prophylaxis with a nonselective β-adrenergic receptor antagonist (also called a nonselective β-blocker [NSBB]) receive additional treatment by endoscopic band ligation to prevent further bleeding. However, little is known about their long-term outcomes. We collected data on 89 consecutive patients with cirrhosis who were admitted to the Liver Unit of Hospital Clínic, Barcelona, with acute esophageal variceal bleeding between June 2007 and February 2011. Thirty-four patients were receiving primary prophylaxis with NSBBs when they had their first episode of variceal bleeding, whereas 55 were not receiving NSBBs (controls). All patients were subsequently treated with a combination of endoscopic band ligation and NSBBs. Patients were examined after 1, 3, and 6 months and every 6 months thereafter until 2 years. After 2 years, a greater proportion of patients who had their first episode of bleeding while on NSBBs had further bleeding, compared with controls (48% vs 24%; P = .01). Primary prophylaxis with NSBBs and serum levels of bilirubin were independent predictors of rebleeding. Overall, 11 patients died, and 5 underwent liver transplantation. Liver transplantation-free survival was lower among patients who had their first episode of bleeding while taking NSBBs (66% vs 88% for controls; P = .02). Primary prophylaxis with NSBBs and Child-Pugh class were independently associated with liver transplantation-free survival. Patients who have their first episode of variceal bleeding while on primary prophylaxis with a β-blocking agent have an increased risk of further bleeding and death, despite adding endoscopic band ligation. These patients possibly require alternative treatment approaches.

Terlipressin: An Asset for Hepatologists!

Terlipressin: An Asset for Hepatologists!

Combination of Endoscopic Band Ligation With Terlipressin Is Better Than That With Octreotide in Shortening Hospital Stay?

Combination of Endoscopic Band Ligation With Terlipressin Is Better Than That With Octreotide in Shortening Hospital Stay?

Microwave coagulation versus sclerotherapy after band ligation to prevent recurrence of high risk of bleeding esophageal varices in Child-Pugh’s A and B patients

The combination of endoscopic band ligation (EBL) with either endoscopic injection sclerotherapy (EIS) or thermal therapy has been shown to reduce recurrence of esophageal varices compared to EBL alone. The aim of this prospective trial was twofold: 1) to evaluate the safety and efficacy of EBL used in association with microwave coagulation (MC), a thermal endoscopic therapy method, for treating esophageal varices and preventing recurrence; and 2) to compare these results to the joint application of EBL and EIS. Seventy cirrhotic patients with bleeding esophageal varices were treated with EBL until only thin vessels remained. Thirty-six randomly selected patients received EIS (group A) and 34 received MC (group B) until complete eradication had been achieved. Endoscopic follow-up was performed to detect recurrence. The effectiveness of the treatment was measured using variceal recurrence, rebleeding, intervention complications, and recurrence factors. During follow-up evaluations averaging 34.9 +/- 11.4 months, no significant differences were found between groups A and B in variceal recurrence (27.7 vs. 17.6%, P = 0.31) or rebleeding (8.3 vs. 0%, P = 0.23). Complications were rare, with no difference detected between groups. The presence of gastric varices influenced recurrence with an odds ratio of 3.9 (95% CI 1.14-13.1, P = 0.029). Application of MC to esophageal varices after band ligation is safe. The post-MC recurrence rate may be comparable to that observed following the combined treatment of EBL and EIS. The presence of gastric varices increases the risk of esophageal variceal recurrence.

Angiodysplasias Successfully Treated with A Combination of Endoscopic Band Ligation and Argon Plasma Coagulation: A Case Report

A 74-year-old Japanese man was admitted to our hospital due to repeated episodes of upper gastrointestinal (GI) bleeding, anemia and melena, which he had suffered for the preceding two years. We performed several panendoscopic and angiographic examinations, but could not discover the cause of his anemia. In addition, we performed jejunectomy because arteriovenous malformation (AVM) was suspected to exist in the jejunum. However, we found no evidence of AVM in the resected portion of the jejunum. During an endoscopic GI study on his seventh admission, we found hemorrhaging gastric angiodysplasia (AGD) in the upper body of the stomach. Moreover, we found another small AGD in the lower body of the stomach. We treated these lesions endoscopically using a combination of hemoclip, endoscopic band ligation and argon plasma coagulation. When diagnosing patients presenting with the symptoms described herein, the physician should consider small AGDs and check the GI tract accordingly, to prevent unnecessary resections. In the present subject, there has been no further bleeding and no other lesions have been detected in his upper GI on endoscopic examination during a 12-month follow up.

Injection Therapy for Variceal Bleeding

The role of injection therapies in the management of esophageal and gastric varices are reviewed. Available radiographic, pharmacologic and alternative endoscopic methods are compared and contrasted with sclerotherapy. Recent studies regarding a combination of endoscopic band ligation and low volume sclerotherapy to achieve best eradication of esophageal varices are reviewed.