Management Of Bleeding Esophageal Varices Research Articles

Gastric variceal obstruction improves the efficacy of endoscopic management of esophageal variceal bleeding in GOV type I.

Background and study aims Limited data exist regarding endoscopic obstruction of type I gastroesophageal (GOV I) in managing bleeding from esophageal varices. In this multicenter retrospective cohort study, we aimed to access the efficacy of blocking gastric varices in management of bleeding from esophageal varices in patients with GOV1. Patients and methods Cirrhotic patients experiencing bleeding from esophageal varices and having GOV I gastric varices in four centers were screened. All included patients were followed up for 180 days, or until death. Results A total of 93 cirrhotic patients with GOV I and bleeding esophageal varices were included. Among them, 58 patients underwent endoscopic cyanoacrylate injection (ECI) for gastric varices in addition to treatment for esophageal varices (EV), while the remaining 35 patients received treatment for EV only. Kaplan-Meier analysis demonstrated that the cumulative 180-day rebleeding rate was significantly lower in the ECI plus EV treatment group (7.9%) compared with the EV treatment group (30.7%) ( P = 0.0031). The cumulative incidence of 180-day mortality was 1.9% in the ECI plus EV treatment group and 23.9% in the EV treatment group ( P = 0.0010). Multivariable Cox regression analysis revealed that concomitant ECI treatment was an independent protective factor against 180-day rebleeding and overall mortality. Conclusions In conclusion, obstruction of gastric varices in addition to endoscopic treatment for bleeding from esophageal varices in patients with GOV 1 proved superior to endoscopic treatment alone for esophageal variceal bleeding.

Comparison of transjugular intrahepatic portosystemic with endoscopic treatment plus anticoagulation for esophageal variceal bleeding and portal vein thrombosis in liver cirrhosis

Background and aim The optimal management of esophageal variceal bleeding (EVB) and portal vein thrombosis (PVT) in liver cirrhosis has not been well-established. The aim of the present study was to compare the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic treatment (ET) plus anticoagulation in cirrhotic patients with EVB and PVT. Patients and methods A total of 66 cirrhotic patients with PVT and EVB (31 in the TIPS group and 35 in the ET plus anticoagulation group) were evaluated retrospectively between January 2016 and January 2022. Results During the follow-up period, 85.5% of patients in the TIPS group achieved complete recanalization of the portal vein, as compared with 19.6% in the ET plus anticoagulation group (p < .001). The cumulative 5-year rate of variceal rebleeding in the TIPS group was significantly lower than that in the ET plus anticoagulation group (31.0 vs. 50.1%; p = .017). The TIPS group exhibited a significantly higher incidence of overt hepatic encephalopathy (HE) than the ET plus anticoagulation group (25.8 vs. 5.7%; p = .037). No difference in the 5-year survival rate (74.1 vs. 85.7%; p = .692) and probability of other complications was observed between the two groups. Conclusion TIPS was superior to ET plus anticoagulation in preventing variceal rebleeding and achieving recanalization of PVT but increased the incidence of overt HE without improving the survival rate.

George Weir Johnston

With a twinkle in his eye, George Weir Johnston liked to describe himself as a gunrunner who imported guns from Russia to Belfast at the height of the Troubles. The...

Comparative Efficacy of Terlipressin and Octreotide along with Endoscopic Band Ligation in the Management of Esophageal Variceal Bleeding

Esophageal variceal bleeding is a medical emergency that carries a high mortality rate despite appropriate management. Terlipressin and Octreotide are two common agents used as adjuvant agents in the management of variceal bleeding. The objective of this study is to compare the effectiveness of Terlipressin with Octreotide along with endoscopic band ligation in the management of esophageal variceal bleeding in cirrhotic patients. This randomized control study was carried out at the Department of General Medicine, Fatima Memorial Hospital, Lahore, for six months extending from February 2019 to July 2019. A total of 100 cirrhotic patients were selected /based on predetermined inclusion and exclusion criteria. The patients were randomly divided into two groups of equal strength. Hence, 50 patients were included in Group A and 50 patients were included in Group B along with banding. Group A received Terlipressin whereas Group B received Octreotide. The two groups were monitored for variceal bleeding for 72 hours. The mean age of the patients in Group A was 55.9±7.3 years and for the patients in Group B it was 56.8±7.4 years. In Group A, 36 (72.0%) male and 14 (28.0%) female patients were included. In Group B, there were 34 (68.0%) male and 16 (32.0%) female patients. In Group A, the treatment was effective for 46 (92.0%) patients and in Group B, 36 (72.0%) patients had an effective treatment. It is concluded from this study that Terlipressin is statistically more effective than Octerotide in terms of preventing esophageal variceal bleeding.

S2225 Novel Hemostatic Stenting in the Esophageal Cancer Patient

INTRODUCTION: This is a case of unconventional stent placement to achieve hemostasis of upper GI bleeding due to esophageal adenocarcinoma. CASE DESCRIPTION/METHODS: An 81-year-old woman with a history of metastatic esophageal adenocarcinoma, coronary artery disease status post CABG and non-insulin-dependent diabetes mellitus presented to the emergency department with a 24-hour history of intermittent lightheadedness and auditory and visual hallucinations. Patient also reported dyspnea, nausea, hemoptysis and melena. She was receiving chemotherapy with capecitabine and monthly esophageal dilations to maintain patency and relieve dysphagia. Her vital signs were within normal limits. Pertinent findings on physical exam included acute distress and pallor of the conjunctivae and mucosa. She had maroon-colored coffee ground output from her PEG tube. Labs showed an elevated BUN and creatinine, mildly elevated troponin, and trace ketones in her urine. She was profoundly anemic with an H&H of 5.2/18.5 and an MCV of 95.9. On endoscopic evaluation, a hemorrhagic exophytic mass measuring 4 cm was seen in the distal esophagus. Following gastric lavage, a fully covered self-expanding metal stent (SEMS) was successfully placed over the length of the mass achieving complete hemostasis. She was volume resuscitated over several days and discharged home with an H&H of 10.5/32. DISCUSSION: Over half of esophageal cancers are unresectable at the time of diagnosis due to distant metastasis and involvement of local structures. Consequently, diagnosis currently confers a 5-year survival rate of less than 20% and treatment is often palliative rather than curative. The use of SEMS in the treatment of dysphagia, maintenance of patency, and management of esophageal variceal bleeding is well-documented. It was this last application that inspired off-label use of SEMS for hemostasis in this case. Other available hemostatic techniques provide effective short-term hemostasis, but have higher rates of rebleeding. A future rebleed would be potentially catastrophic to this patient with stage IV esophageal adenocarcinoma which highlighted the importance of a more long-term solution in order to avoid future need for intervention. A search of the medical literature revealed another case report from 2016 which achieved similar satisfactory results indicating a promising venue for further research in this area. The compassionate use of SEMS in this case may represent a favorable alternative to the present technologies which have many limitations.Figure 1.: Retroflexed view of tumor with active bleed extending beyond GE junction.Figure 2.: Successful stent placement.Figure 3.: Patient's hemoglobin levels before and after stent placement. Orange arrow indicates time of stent placement.

Comparative Efficacy of Terlipressin and Octreotide along with Endoscopic Band Ligation in the Management of Esophageal Variceal Bleeding

Esophageal variceal bleeding is a medical emergency that carries a high mortality rate despite appropriate management. Terlipressin and Octreotide are two common agents used as adjuvant agents in the management of variceal bleeding. The objective of this study is to compare the effectiveness of Terlipressin with Octreotide along with endoscopic band ligation in the management of esophageal variceal bleeding in cirrhotic patients. This randomized control study was carried out at the Department of General Medicine, Fatima Memorial Hospital, Lahore, for six months extending from February 2019 to July 2019. A total of 100 cirrhotic patients were selected /based on predetermined inclusion and exclusion criteria. The patients were randomly divided into two groups of equal strength. Hence, 50 patients were included in Group A and 50 patients were included in Group B along with banding. Group A received Terlipressin whereas Group B received Octreotide. The two groups were monitored for variceal bleeding for 72 hours. The mean age of the patients in Group A was 55.9±7.3 years and for the patients in Group B it was 56.8±7.4 years. In Group A, 36 (72.0%) male and 14 (28.0%) female patients were included. In Group B, there were 34 (68.0%) male and 16 (32.0%) female patients. In Group A, the treatment was effective for 46 (92.0%) patients and in Group B, 36 (72.0%) patients had an effective treatment. It is concluded from this study that Terlipressin is statistically more effective than Octerotide in terms of preventing esophageal variceal bleeding.

Management of acute variceal hemorrhage.

Gastrointestinal bleeding is one of the major causes of death in patients with cirrhosis, and gastroesophageal varices represent the main source of hemorrhage. Even though in the last decades survival has been improved because of the widespread adoption of effective treatments and optimization of general medical care, mortality is still significantly high, and decompensated patients pose a complex challenge requiring a multidisciplinary approach that is crucial to improve survival. The aims of this commentary are to review the most recent advances in the management of esophageal variceal bleeding and to highlight useful information to aid hepatologists in clinical practice.

Reprocessing of single-use endoscopic variceal band ligation devices: a pilot study.

Background and study aims The preferred management of bleeding esophageal varices includes endoscopic band ligation. Endoscopic ligation devices (ELDs) are expensive and designed for single use, limiting their uptake in developing countries. We aimed to assess the efficacy of reprocessing ELDs using terminal microbial cultures and adenosine triphosphate (ATP) testing. Materials and methods ELDs were recovered after clinical use and their components (cap, handle, and cord) were subjected to reprocessing. This included manual cleaning, automated high-level disinfection (HLD), and drying with forced air. Using sterile technique, ELD components were sampled for ATP at three stages: before manual cleaning, after manual cleaning, and after HLD. Components were sent to an external laboratory for culturing. Cultures were interpreted as positive upon identification of Gram-negative bacilli. Results A total of 14 clinically used ELDs were studied, and 189 ATP tests and 41 cultures were evaluated. Overall, 95 % (39/41) of components and 86 % (12/14) of ELDs were culture-negative or did not yield Gram-negative bacilli. Two components (5 %; one handle and one cord) harbored Gram-negative bacilli in quantities of 1 CFU per component. There was no apparent correlation between ATP at any juncture of reprocessing and terminal cultures. Conclusions Reprocessing of ELDs is effective, resulting in infrequent and minimal microbial contamination. Microbial culturing can be used to ensure adequacy of ELD reprocessing if pursued. Until reusable ELDs are commercially available, continued efforts to better define the adequacy and long-term effects of reprocessing ELDs are needed.

Terlipressin Administered Only Prior To Endoscopic Therapy in The Management of Bleeding Esophageal Varices Does Not Increase the Risk of Re-bleeding Compared to Standard 3-5 Days Regime

Background & Aims: Terlipressin is recommended therapy for 3-5 days in esophageal variceal bleeding. The aim of this study was to determine the feasibility of administering terlipressin only prior to band ligation. Methods: Patients with esophageal variceal bleeding received terlipressin 2mg intravenous bolus followed by 1mg 6 hourly until undergoing endoscopic band ligation. They were monitored for re-bleeding for 5 days. Results: 67 patients, 38 (57%) male and 29 (43%) female, mean age 50+4 years, received terlipressin until undergoing endoscopic band-ligation. Etiology of liver disease was HCV in 62 (92.5%), HBV & HCV in 2 (3%), HCV & ethanol in 2 (3%) and unknown in 1 (1.5%) patient. 13 (19%) patients underwent band ligation after a single 2 mg dose of terlipressin, 16 (24%) after two doses (6 hours therapy), 11 (16%) after 3 (12 hours therapy), 6 (9%) after 4 (18 hours therapy), 6 (9%) after 5 doses (24 hours therapy) and 15 (22%) after more than 24 hours therapy. Banding was done within 12 hours in 40 (60%) patients and within 24 hours in 12 (18%) patients. Endoscopy was delayed beyond 24 hours in 15 (22%) patients due to Sengstaken-Blakemore tube placement, encephalopathy and blood transfusion requirements. 3 (4.9%) patients had rebleeding. Repeat endoscopy showed post-banding ulcers in 2 patients (managed with I.V omeprazole and oral sucralfate). One patient had varices with red signs requiring repeat band ligation. Two patients died due to hepatorenal syndrome and persistent encephalopathy. No drug related adverse effects were noted. Conclusion: Once band-ligation has been performed, terlipressin may be safely discontinued. This can result in reduction in cost of treatment with no significant increase in morbidity and mortality.

PTH-127 Endoscopic Variceal Band Ligation (EVBL) at The 37 Military Hospital, Accra-Ghana: Our Experience with The Euro-Ligator-Universal (Euro Multiband Ligator)

Introduction Bleeding gastro-eosophageal varices are the 3 rd commonest cause of UGI bleeding in Ghana and have a high mortality. EVBL is an effective, safe treatment for oesophageal varices but single use, preloaded ligators are unaffordable in developing countries. We report our early experience of the re-usable Euro-Ligator for variceal banding. Methods The Euro-Ligator is the first re-usable multiple band ligator. It operates on a different principle to other ligators. A rotating driver is locked into the instrument channel and pre-loaded bands are deployed as an inner cylinder is withdrawn. Training in the use of the Euro-Ligator was provided by a visiting team from the University Hospitals of Leicester, funded by the British Society of Gastroenterology. During a one day course (October ‘15) the endoscopy team at 37 Military received instruction in loading the bands, intubation, band deployment and disinfection. An instruction video of each step was produced. During the course 5 patients were successfully banded under the supervision of the visiting team. Dedicated lists for variceal banding were established. Results To date, 15 EVBL sessions have been performed on 7 patients (6 males, age range 16 to 62). In all, 60 bands have been deployed with a successful band deployment rate of 55/60 (91.6%). The mean number of bands used per session was 3.7. All procedures were elective day cases after an index bleed & performed under conscious sedation. No mortality was recorded during the procedures & all patients were discharged home the same day. We have not seen deep ulceration, perforation or aspiration pneumonia. One patient was lost to follow up after the index procedure and 1 patient died 2 weeks after the initial session from Hepatic Failure (Child Pugh C). In the remaining 5 patients under follow-up, haemostatic control has been achieved with no further bleeding episodes reported. Complete eradication has now been achieved in 1 patient. Conclusion This preliminary case report gives us some insight and working experience into the use of the multiband Euro-Ligator. We found the equipment easy to use and technically effective in the endoscopic treatment of oesophageal varices. We need to adhere to stringent disinfection and cleaning protocols to ensure long term safety in our patients and evaluate the clinical and cost effectiveness over a longer period. However, the Euroligator is a major advance in the management of bleeding oesophageal varices in the developing world Disclosure of Interest None Declared

English

BACKGROUND: Varices are expanded blood vessels that develop most commonly in the esophagus. Esophageal varices is responsible for 5-11% of all cases of upper GI bleeding. Endoscopic injection sclerotherapy (EST) is a valuable therapeutic modality for the management of variceal bleeding. Other options for treatment such as variceal band ligation are either expensive or unavailable. AIM: To study the common causes for development of portal hypertension to present as esophageal varices and its different clinical mode of presentation and to know the effect of endoscopic sclerotherapy with absolute alcohol particularly in acute bleeding varices of different grades. MATERIALS AND METHODS: A clinical study of esophageal varices who presented to casualty in Basaveshwar Teaching and General Hospital, Gulbarga; from May 2012 to May 2014. Etiology, presentation, outcome from EST was evaluated. RESULTS: Common affected age group was 30-50yrs, common presentation is haematemesis (90%), melena (55%), distension of abdomen (70%), haemorrhoids (20%) and all cases of esophageal varices were due to portal hypertension, the common pathological condition was cirrhosis (alcoholic, cryptogenic, posthepatitis cirrhosis) and next common was portal vein thrombosis followed by splenic vein thrombosis. 70% cases of bleeding varices were very well controlled with EST alone and some needed initial sengstaken balloon tamponade treatment to control the bleeding followed by EST (30%). Recurrence of bleeding and complications of EST is less. CONCLUSION: This study provides evidence that endoscopic injection sclerotherapy is an important component in the management of bleeding oesophageal varices caused by portal hypertension. It is a safe and effective procedure.

Non-Cirrhotic Portal Hypertension of Unknown Etiology, May Be from Thrombosis of the Extrahepatic Portal Vein

Purpose: 55-year-old adult female with h/o colon cancer 3 years ago had right hemicolectomy and chemotherapy, presented with GERD symptoms and found to have large esophageal varices. Liver function is preserved. Screening tests for specific liver diseases including HBsAg, autoantibodies, serum ferritin, ceruloplasmin were all normal. CT of abdomen revealed extra hepatic portal vein thrombosis; hematology evaluation to evaluate other causes of hypercoaguable state is negative. She has multiple cysts throughout the liver on imaging and later patient developed esophageal variceal hemorrhage. After ultrasonographic and biopy evaluation, a diagnosis of idiopathic non-cirrhotic portal hypertension was made. Percutaneous liver biopsy showed non-specific changes and did not provide definitive diagnostic histologic evidence of either hepatic venous outflow obstruction or of pathology involving the major portal vein. Endoscopy showed extensive oesophageal varices with stigmata of bleeding. She has undergone esophageal variceal ligation several times electively and another time for a bleed. She saw a liver surgeon regarding whether she might be a candidate for a shunt procedure such as a distal splenorenal shunt. Conclusion: Noncirrhotic portal hypertension results from thrombosis of the extrahepatic portal vein. Multiple etiologies may cause the disorder, although nearly half are idiopathic. In this case, it's not certain whether or not the large number of liver cysts decreased liver parenchyma contributed to increased portal pressure and esophageal varices. Endoscopic management of esophageal variceal bleeding is the preferred therapy. However, when endoscopic treatment fails to control variceal hemorrhage, a distal splenorenal shunt is likely to be the most successful operation.

Terlipressin: An Asset for Hepatologists!

Terlipressin: An Asset for Hepatologists!

Endoscopic Sclerotherapy for Bleeding Oesophageal Varices: Experience in Gezira State, Sudan

Introduction Bleeding due to oesophageal varices is the most common cause of upper gastrointestinal tract haemorrhage in Gezira State, Central Sudan. Endoscopic injection sclerotherapy (EST) is a valuable therapeutic modality for the management of variceal bleeding. Other options for treatment such as variceal band ligation are either expensive or unavailable. Objectives A retrospective study to evaluate the outcome of (EST) in the management of bleeding oesophageal varices due to portal hypertension in Gezira State, the centre of a developing country, Sudan. Methods A total of 1073 patients, during 2001-2010, were carefully selected particularly those with bleeding oesophageal varices consequent to portal hypertension. EST was performed using a standard technique and ethanolamine oleate (5%) was utilized as sclerosing agent. Results There were 777 males (72.4%) and 296 females (27.6%) in a ratio of 2.6. The causes of portal hypertension were found to be schistosomal periportal fibrosis (PPF) in 1001 (93.3%) patients, liver cirrhosis in 60 (5.5%) mixed PPF and cirrhosis in seven (0.7%) and portal vein thrombosis in five (0.5%) patients. Full obliteration of varices required a mean of four sessions with a range of 2-6. In the present study 350 (32.6%) patients have been followed up until complete sclerosis of varices. Conclusion This study provides evidence that endoscopic injection sclerotherapy is an important component in the management of bleeding oesophageal varices caused by hypertension. It is a safe and effective procedure.

Management of gastric varices

Although the incidence of bleeding from gastric varices is relatively low (10%-36%), the bleeding is massive once it has occurred and it increases the patient's mortality. The management of esophageal variceal bleeding is highly differentiated with several effective treatments available. In contrast, bleeding from gastric varices continues to be a therapeutic challenge. In the last decade, there have been increasing reports regarding the management of gastric varices. In this article we review recent progress in the management of gastric varices and discuss further expected studies.

Octreotide

Octreotide

Cyanoacrylate glue injection for acutely bleeding oesophageal varices: Is it ready for prime time?

Gastroesophageal varices are present in approximately 50% of patients with cirrhosis and bleeding from these is the most common lethal complication of cirrhosis [ [1] Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar ]. Cirrhotic patients without varices can develop them at a rate of 8% per year, and the ones with small varices can develop large varices at a similar rate [ 2 Groszmann R.J. Garcia-Tsao G. Bosch J. et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005; 353: 2254-2261 Crossref PubMed Scopus (712) Google Scholar , 3 Merli M. Nicolini G. Angeloni S. et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol. 2003; 38: 266-272 Abstract Full Text Full Text PDF PubMed Scopus (377) Google Scholar ]. Among these, variceal hemorrhage occurs at a yearly rate of 5–15%, with most important risk factors for bleeding being the size of varices, decompensated cirrhosis (Child B/C) and the endoscopic presence of red wale marks [ 1 Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar , 4 The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988; 319: 983-989 Crossref PubMed Scopus (1060) Google Scholar ]. The current guidelines by the American Association for the Study of Liver Diseases (AASLD) recommend combination of pharmacological therapy (somatostatin or its analogues octreotide and vapreotide; terlipressin) and endoscopic therapy (endoscopic variceal ligation or sclerotherapy) to control active variceal bleeding [ [1] Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar ]. These recommendations, based on the results of two randomized trials, demonstrate the superiority of combined therapy versus endoscopic variceal ligation alone. Although these advances in the management of bleeding oesophageal varices over the last two decades have led to significant reduction in mortality, mortality rates are still at least 20% at 6 weeks [ [5] Bendtsen F. Krag A. Møller S. Treatment of acute variceal bleeding. Dig Liver Dis. 2008; 40: 328-336 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar ]. The major cause of this mortality is the initial failure to control bleeding or the early rebleeding within the first week of admission [ [1] Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar ]. Most of these high risk patients are the ones with very high (>20 mmHg) hepatic venous pressure gradient. If no treatment is administered, late rebleeding occurs in approximately 60% of untreated patients, mostly within 1–2 years of the index haemorrhage [ [1] Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar ]. Hence, can we perform a better therapy which is easy to use, has less rebleeding rates and more importantly decreases mortality compared to the current recommended management?

Management of bleeding esophageal varices in public and private institutions in Chile

The better treatment modalities for bleeding esophageal varices have improved the prognosis of cirrhosis. To inquire about diagnostic and treatment modalities for esophageal bleeding in Chile. An enquiry about diagnosis and treatment of esophageal bleeding was designed and electronically sent to public and private health institutions that could admit patients and were located in cities with more than 100,000 inhabitants. The enquiry was answered by 31 of 35 public and 17 of 19 private health institutions that were consulted. Emergency endoscopy was available in 6 of 27 public and in the 16 private institutions that had an emergency room. Rubber band was available in 16 public (52%) and in all private institutions. Cyanoacrylate injections were done in 10 public (32%) and 11 (65%) private institutions. No public institution installed transjugular intrahepatic portosystemic shunts, but 8 had occasional access to this technique. This procedure was done in 7 (41%) private institutions and all had access to it. Surgical treatment was feasible in 20 public (65%) and all private institutions. Primary prophylaxis was done in 18 public (58%) and 14 private (82%) institutions. Secondary prophylaxis was carried out in 26 public (84%) and 16 private (94%) institutions. Public health institutions have poor access to adequate diagnostic and treatment methods for esophageal bleeding. The primary and secondary prophylaxis of esophageal varices must be improved in both types of institutions.

Recent Advances in Surgery 30

The Recent Advances in Surgery series, edited once more by Irving Taylor and Colin Johnson, has now reached its 30th edition and will be familiar to many surgical trainees and consultants. In recent years, the series has been published annually and the book consists of sections dedicated to some of the subspecialities within general surgery; a section entitled ‘Surgery in General’, which pertains to topics relevant to all practitioners of surgery; and finally a chapter reviewing recent randomised clinical trials. This edition includes sections dedicated to breast, gastrointestinal and vascular surgery. Contributors include both surgical trainees and leading consultants in their respective fields, including a number from overseas and those in other specialties where their expertise relates to the topic under consideration. The information in the individual chapters is presented in a concise and readable format, with useful summary boxes containing key points. Relevant photographs, imaging and other illustrations are presented, with colour plates included in the section on vascular surgery. The ‘Surgery in General’ section contains a thought-provoking chapter on risk management and, among other things, examines how this issue is addressed in a more systematic way by anaesthetists and the airline industry. The chapter on the surgical significance of MRSA is topical but consists largely of personal opinion and lacks a firm evidence-base. We were disappointed with the emphasis given to the role of medical staff's clothing in the dissemination of MRSA while neglecting significance of high bed-occupancy rates prevalent in many NHS institutions. Other chapters in this section discuss the emerging field of tissue engineering of blood vessels and newer procedures for day-case surgery. Further highlights include a useful review of the management of acute gallbladder disease and a review of the evidence for the surgical management of haemorrhoids. There is also a useful update on the multidisciplinary approach to the modern management of bleeding oesophageal varices, with contributions from a physician, surgeon and radiologist practising at the University of Cape Town. The increasingly difficult task of staying up-to-date with new developments in the practice of general surgery is made easier to some degree by this series. We would recommend it to all basic and higher trainees within the increasingly superspecialised field of general surgery as well as consultants with an interest in the relevant sections of the book. In particular, this book is ideal for candidates preparing for final examinations prior to completion of training in general surgery. We hope the series continues in the future.

Two-Stage Transjugular Intrahepatic Porta-Systemic Shunt for Patients With Cirrhosis and a High Risk of Portal-Systemic Encephalopathy Patients as a Bridge to Orthotopic Liver Transplantation: A Preliminary Report

Aim Placement of a transjugular intrahepatic porta-systemic shunt (TIPS) is a therapeutic option for the management of bleeding esophageal varices. However, the procedure is associated with an increased risk of portal-systemic encephalopathy (PSE). In this study, a two-stage modification of the standard TIPS technique was introduced for the management of variceal bleeding in cirrhotic patients with a high risk of PSE before liver transplantation. Methods The modified procedure was applied to four patients with cirrhosis, portal hypertension, and ascites. Two had a history of encephalopathy after variceal bleeding; the other two were encephalopathic at the time of the first stage of the modified procedure. In the first stage, a 6-mm diameter intrahepatic shunt was created using a Palmaz-Schatz stent. One month later, in the second stage, the lumen of the shunt was expanded to a diameter of 10 mm. Results Both stages of this TIPS procedure were undertaken without any associated adverse events. In particular, neither stage was followed by a deterioration of neurologic status. From completion of the second stage to undertaking orthotopic liver transplantation (a period of 2 to 6 months), no rebleeding from esophageal varices occurred. Conclusions A two-stage TIPS procedure to reduce portal hypertension enables a more gradual adaptation to post-TIPS hemodynamic and metabolic changes than occurs after creation of a conventional TIPS. A two-stage TIPS procedure may be the method of choice for treating bleeding from esophageal varices in patients who have a high risk of developing PSE and give them a chance for liver transplantation.