Recurrence Of Varices Research Articles

Pediatric non-cirrhotic portal fibrosis: role of endoscopic management in determining long-term outcome.

Non-cirrhotic portal fibrosis (NCPF) is a rare cause of pediatric portal hypertension. There is abundant literature in adults but paucity of data in children. We aimed to evaluate and compare the endoscopic and long-term outcomes of children with NCPF. Consecutive children (≤ 18years) diagnosed with NCPF evaluated for clinical and endoscopic profile and outcome. The cohort underwent 3weekly endoscopic sessions until esophageal variceal eradication followed by 6-12monthly endoscopic surveillance. Non-bleeders and bleeders were compared for endoscopic outcome. Forty-five NCPF children with median age of 14.5 (6-18) years and symptom duration 12 (1-120) months presented with spleen-related issues (78%), esophageal varices (96%), primary gastric varices (56%), and portal hypertensive gastropathy (89%). Thirty-three patients undergoing endotherapy (secondary prophylaxis n = 22, primary prophylaxis n = 11) showed primary eradication of varices after 5 (2-12) sessions. 36% showed recurrence of esophageal varices in 11 (6-42) months and secondary gastric varices developed in 12%. Overall 87% patients required endoscopic intervention at onset or follow-up. Poor outcome was observed in ten patients (n = 9 bleeders). Three children died of variceal bleeding before endoscopic eradication of esophageal varices. Three developed decompensation after a median follow-up of 48 (3-120) months and referred for liver transplantation. Four patients required surgery for portal hypertension. Overall, endoscopic outcome of NCPF is favorable. One-third patients have recurrence of esophageal varices. Small proportion of bleeders have poor outcome.

The endoscopic ultrasound probe findings in prediction of esophageal variceal recurrence after endoscopic variceal eradication therapies in cirrhotic patients: a cohort prospective study

BackgroundThe recurrence of esophageal varices remains high in patients with hepatic portal hypertension after the endoscopic esophageal variceal eradication therapies, including endoscopic variceal band ligation (EVL), injection sclerotherapy (EIS) or EVL plus EIS. The aim of this study was to evaluate the endoscopic ultrasound probe examinations (EUP) findings in the prediction of recurrence following esophageal variceal eradication in a prospective cohort.MethodsA total of 206 cirrhotic portal hypertension patients with esophageal variceal eradication, who underwent endoscopic variceal therapy (EVL or EIS or EVL plus EIS) were initially enrolled. All patients were scheduled for a follow-up every 6 months for up to 3 years. EUP was performed to evaluate peri-esophageal collateral veins (peri-ECVs), perforating veins (PFV) and para-esophageal collateral veins (para-ECVs). In addition, computed tomography (CT) were conducted to detect portal vein diameter, portal vein embolus, and major portosystemic collateral shunts. The relationship between esophageal variceal recurrence and EUP findings were analyzed.ResultsWe found that as high as 93.5% of patients developed esophageal variceal recurrence in the 3-year follow-up. The time of esophageal variceal recurrence after variceal eradication was 13.4 months (13.4 ± 9.2 months). Furthermore, the median time of recurrence in patients who were undertaken EVL,EIS and EVL plus EIS was 10, 13 and 12 months, respectively. We identified that the risk factors, including EVL (OR 0.23, 95% CI 0.08–0.71, p < 0.01), Child-Pugh score (OR 3.32,95% CI 1.31–35.35, p < 0.05), large peri-ECVs (OR 4.56, 95% CI 2.17–9.58, p < 0.0001), and existence of PFV (OR 2.14, 95% CI 1.44–3.16, p < 0.001), were significantly associated with the recurrence of esophageal varices. The peri-ECVs and PFV showed better ability to predict esophageal variceal recurrence. When cut-off value of peri-ECVs diameter was 3.5 mm, the specificity of prediction 1-year variceal recurrence was 86% and the sensitivity was 45%.ConclusionsThe EUP appears to be very effective, convenient and economical examinations to predict esophageal varices recurrence after variceal eradication by endoscopic therapies. The high Child-pugh score, large peri-ECVs, and PFV are independent risk factors related to esophageal varices recurrence.

Long-term outcome of endoscopic variceal band ligation of esophageal varices in patients with chronic liver disease.

There are scanty data on the long-term outcome of endoscopic variceal band ligation (EVL) for esophageal varices. Adult patients suffering from a chronic liver disease (CLD) undergoing EVL of esophageal varices of grade 2 and above between January 2006 andDecember 2015 were followed upfor the recurrence of varices, worsening of portal hypertensive gastropathy (PHG), rebleeding, and mortality. EVL was done as primary prophylaxis of bleeding in 72 and as secondary prophylaxis in 175 patients. All received propranolol after EVL if there was no contraindication. Two hundred and forty-seven CLD patients (mean age 51.83 ± 11.28years, 179 males) underwent 306 EVL sessions. The most common etiology was alcohol (53%). Sixty-eight percent of patients had grade 3 esophageal varices 76.5%had PHG. There was no immediate post-EVL bleeding or 30-day mortality. Variceal obliteration was achieved in 100% with 19% recurrence within amean period of53.74 ± 27.2months. PHG worsened in 49.7%. Overall, rebleeding occurred in 13.8%, 4.3% from recurrent varices. There was no difference in variceal recurrence (16.7% vs. 20%) and incidence of rebleeding (9.7% vs. 13.7%) between patients undergoing EVL for primary and secondary prophylaxis. Cumulative rebleeding rates after 1, 5, and 9years were 1.6%, 9.2%, and 11.4%, respectively. The overall mortality was 85%, mostly from progressive CLD, and only 8.6% was due to rebleeding. On subgroup analysis, the factors significantly associated with rebleeding was Child-Pugh class C and worsened PHG those with mortality were alcohol and Child-Pugh class C. EVL is effective in the long-term for both primary and secondary prophylaxis of esophageal variceal bleeding.

Update on the management of gastrointestinal varices.

Cirrhosis of liver is a major problem in the western world. Portal hypertension is a complication of cirrhosis and can lead to a myriad of pathology of which include the development of porto-systemic collaterals. Gastrointestinal varices are dilated submucosal veins, which often develop at sites near the formation of gastroesophageal collateral circulation. The incidence of varices is on the rise due to alcohol and obesity. The most significant complication of portal hypertension is life-threatening bleeding from gastrointestinal varices, which is associated with substantial morbidity and mortality. In addition, this can cause a significant burden on the health care facility. Gastrointestinal varices can happen in esophagus, stomach or ectopic varices. There has been considerable progress made in the understanding of the natural history, pathophysiology and etiology of portal hypertension. Despite the development of endoscopic and medical treatments, early mortality due to variceal bleeding remains high due to significant illness of the patient. Recurrent variceal bleed is common and in some cases, there is refractory variceal bleed. This article aims to provide a comprehensive review of the management of gastrointestinal varices with an emphasis on endoscopic interventions, strategies to handle refractory variceal bleed and newer endoscopic treatment modalities. Early treatment and improved endoscopic techniques can help in improving morbidity and mortality.

Outcome of Esophageal Variceal Ligation in Cirrhotic Patients: Experience in a Tertiary Care Hospital in Dhaka

Background: Bleeding from esophageal varices in cirrhosis is an emergency condition. Esophageal varices band ligation has shown better results in terms of variceal obliteration as well as having fewer side effects like ulceration, perforation and stricture formation.&#x0D; Methods: This observational study was conducted at the gastroenterology department of BIRDEM general hospital, from September 2014 to March 2015. Subjects were eligible if they had a diagnosis of cirrhosis based on history, physical examination, biochemical parameters and presence of esophageal varices in upper gastrointestinal endoscopy. All patients were tested to determine the cause of liver cirrhosis. All patients under-went upper gastrointestinal endoscopy after consent. Esophageal variceal ligation was done at appropriate situation and patients were followed up later on. SPSS 23 was used for statistical analysis.&#x0D; Results: The sample size was 69. The cumulative mean age was 55.58±14.462 years (range: 20-90), with gender-based mean age of 54.76±15.704 years for males and 57.22±11.739 years for female. Mild portal hypertensive gastropathy (PHG) was found 31 (44.9%) patient and severe PHG 36 (52.2%). Patients were followed up for mean period of 8.52±3.6 months. Variceal obliteration was achieved in 25 (36.2%) patients, while 06 (8.7%) cases developed re-bleeding during the study period and this type of patients were managed by other modalities or combination therapies. Recurrence of varices occurred in 13 (18.8%). 25 (36.2%) patients reduction of varix size occured after esophageal variceal ligation (EVL), 32 (46.4%) required second session and 12 (17.4%) required more than second session (Table-2). Thirty nine (56.5%) patients experienced minor adverse events like GI discomfort (retrosternal pain or dysphagia), while severe adverse events were noticed in 13 (18.8%) patients. Fundal varix was found among 8 (11.6%) patient on follow up endoscopy and GAVE found in 6 (8.69%) patients. All patient developed PHG during follow up endoscopy.&#x0D; Conclusion: Band ligation eradicates esophageal varices with less complications and a lower re-bleeding rate, but at the same time eradication is associated with more frequent development of PHG and fundal varices.&#x0D; Birdem Med J 2019; 9(1): 63-69

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.

LEV 9. Causes of Recurrent Varicose Vein After Endovenous Laser Ablation Therapy Confirmed by Three-Dimensional Computed Tomography Venography and Duplex Ultrasound

The objective of this study was to determine the cause and anatomic patterns of recurrent varices after endovenous laser ablation (EVLA). Patients who were treated for recurrent varicose vein after EVLA between January 2010 and December 2017 were enrolled. Pathophysiologic patterns of recurrence were assessed using three-dimensional computed tomography venography and later confirmed by surgery. Among 1694 patients who were treated for varicose vein, symptomatic recurrence of varicose vein after EVLA was observed in 12 patients (0.7%). Median period to recurrence was 4.3 (interquartile range, 2.4-10.6) years. Especially in four patients (33%), the recurrence was observed >10 years after the EVLA. The main anatomic source of recurrence was recurrent or remaining reflux at the saphenofemoral junction (SFJ; n = 6) or saphenopopliteal junction (SPJ; n = 4); in three of these cases, there was coexisting reflux from pelvic veins or perforators. Sources of the other two cases were perforator and untreated saphenous vein. The pathophysiologic mechanism underlying recurrent or remaining reflux at the SFJ or SPJ was either recanalization of treated saphenous vein (n = 6) or incompetent branches at the junction (n = 4). Recurrent varicose vein after EVLA was mainly caused by the recanalized saphenous vein or incompetent tributaries of the SFJ or SPJ. Three-dimensional computed tomography venography along with duplex ultrasound was useful in assessing the extent and the pathophysiologic mechanism of recurrent varicose vein.

Clinical efficacy of pericardial devascularization combined with splenectomy and partial gastric fundus resection in the treatment of portal hypertension-induced severe gastric varices complicated with gastrorenal shunt

Objective To investigate the clinical efficacy of pericardial devascularization (PCDV) combined with splenectomy and partial gastric fundus resection (PGFR) in the treatment of portal hypertension-induced severe gastric varices complicated with gastrorenal shunt (GRS). Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 18 patients with portal hypertension-induced severe gastric varices complicated with GRS who were admitted to the Fujian Provincial Hospital from January 2010 to December 2015 were collected. According to the stage of technical development, open surgery or laparoscopic surgery was selected based on patients′ and their family's wishes. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative pathological examination; (3) follow-up and survival. The follow-up using outpatient examination and telephone interview was performed once every 3 months within 1 year postoperatively and once every 6 months after 1 year to detect long-term complications and survival up to June 2017. The reexaminations of gastroscopy, enhanced scan of X-ray computed tomography (CT) on the epigastric region or magnetic resonance imaging (MRI) were done at 1 month postoperatively for detecting resection of fundus ventriculi varicosity. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). The survival rate was calculated by the Kaplan-Meier method. Results (1) Surgical and postoperative recovery situations: 18 patients underwent successful PCDV combined with splenectomy and PGFR, including 12 with open surgery and 6 with laparoscopic surgery (1 with conversion to open surgery due to intraoperatively uncontrollable bleeding). There was no perioperative death. The operation time, volume of intraoperative blood loss, recovery time of gastrointestinal function, time of postoperative drainage-tube removal and duration of hospital stay were (192±20)minutes, (280±30)mL, (33±6)hours, 8 days (range, 5-9 days), 8 days (range, 5-12 days) in 12 patients with open surgery and (208±40)minutes, (210±10)mL, (28±5)hours, 7 days (range, 5-26 days), 7 days (range, 5-10 days) in 6 patients with laparoscopic surgery, respectively. One patient with laparoscopic surgery had intraoperative condensed erythrocyte infusion with 2 U. Seven, 1, 0 patients with open surgery and 4, 1, 1 patients with laparoscopic surgery were respectively complicated with pleural effusion, delayed gastric emptying and pancreatic leakage in level A, and they were cured by conservative treatment. (2) Postoperative pathological examination: results of postoperative pathological examination in 18 patients showed that a large number of varicose veins in the mucous and serosal layers of gastric fundus and moderate or severe hepatic cirrhosis. (3) Follow-up and survival: 18 patients were followed up for 8-78 months with a median time of 39 months. The gastroscopy and enhanced scan of X-ray CT at 1 month postoperatively showed that no varicose veins in the gastric fundus. During the follow-up, there was no recurrence of gastric varices with GRS and esophageal stenosis. Of 4 patients with portal vein thrombosis, 1 died of portal hypertensive gastropathy-induced upper gastrointestinal bleeding due to stop taking warfarin, and other 3 patients had portal vein patency by warfarin therapy. One patient was complicated with liver cancer at 32 months postoperatively and received radiofrequency ablation therapy. Two patients died, including 1 dying of hepatic failure at 35 months postoperatively and 1 dying of advanced liver cancer at 54 months postoperatively. The 1-, 3- and 5-year overall survival rates of 18 patients were respectively 93.8%, 84.4% and 70.3%. Conclusion The PCDV combined with splenectomy and PGFR is safe and effective in the treatment of portal hypertension-induced severe gastric varices with GRS, with a dissemination value for appropriate patients. Key words: Liver cirrhosis; Portal hypertension; Gastric varices; Gastrorenal shunt; Partial gastrectomy; Pericardial devascularization; Splenectomy; Laparoscopy

The Devascularisation Procedure for the Treatment of Fundic and Oesophageal Varices in Portal Hypertension - a Retrospective Analysis of 55 Cases

The most dangerous complication of portal hypertension is the formation of oesophageal varices, as the risk of bleeding is up to 80%. In order to reduce pressure reduction in the portosystemic circulation and as secondary prophylaxis, the TIPSS procedure has proven successful. In patients with portal vein thrombosis, portosystemic shunt surgery is possible to reduce the risk of variceal bleeding. However, if thrombosis of the mesentericoportal axis or hepatic encephalopathy is imminent, interventional or surgical creation of a portosystemic shunt is contraindicated. As a last resort to avoid recurrent bleeding or in case of inexorable bleeding, a devascularisation procedure may be indicated. The aim of this study was to investigate perioperative complications, morbidity and mortality, the incidence of postoperative recurrent bleeding, and patient survival after devascularisation surgery. We retrospectively analysed 55 patients with a history of variceal haemorrhage or acute bleeding without the possibility of an invasive or operative portosystemic shunt for complication rate, recurrent variceal recurrence, rebleeding and survival. While complications for elective surgery were 61%, they increased significantly in emergency surgeries (75%, p = 0.002), especially for severe complications (Dindo/Clavien grade III - V° [14 vs. 58%, p = 0.002]). Devascularisation significantly reduced varicosis occurrence. Furthermore, only 16% of patients suffered recurrent bleeding in a follow-up period of up to 24 years. Median survival (MS) after devascularisation surgery was 169 ± 23 months. After elective surgery, MS was 194 ± 25 months, but after emergency surgery only 49 ± 16 months. No patient showed any hepatic encephalopathy during their hospital stay. Devascularisation surgery is well suited for secondary prophylaxis in patients with fundic and oesophageal varices and portal hypertension with no possibility of portosystemic shunt or with impending hepatic encephalopathy. However, if the operation is performed in an emergency situation, significantly more major complications occur and the outcome is significantly worse. Therefore, especially in the absence of an opportunity of lowering pressure in the portal venous system and with progressive varices, elective devascularisation should be considered at an early stage.

A randomized controlled study of CT portograph combined with endoscopic ultrasonography for the precision treatment of esophagogastric varices in patients with cirrhosis

Objective To investigate the efficacy and safety of CT portograph combined with endoscopic ultrasonography for the pricision treatment of esophagogastric varices in patients with cirrhosis. Methods A total of 130 inpatients with cirrhosis complicated with esophagogastric variceal bleeding who received endoscopic treatment from January 2013 to January 2015 were selected. Using prospective randomized controlled design, the patients were divided into two groups, the experimental group and the control group, with 65 cases in each group. The number and degree of esophagogastric varices were assessed by CT portography in the experimental group. Then endoscopic ultrasonography was used to assess the paraesophageal vein and perforator vein before endoscopic treatment. The range and degree of esophagogastric varices were observed and the lesions were treated by endoscopy in the control group. Results A total of 62 patients completed the study in the experimental group, and 63 in the control group. The number of treatment was significantly lower in the experimental group than that in the control group(3.00±0.76 VS 5.63±0.92, P=0.000). The disappearance time of varices was significantly shorter in the experimental group than that in the control group(7.25±1.16 months VS 8.88±1.64 months, P=0.039). The variceal recurrence rate of the experimental group was significantly lower than that of the control group [1.6% (1/62) VS 12.7% (8/63), P=0.040]. The incidence of pleural effusion was significantly lower in the experimental group than that in the control group[0(0/62) VS 9.5% (6/63), P=0.040]. The total complication rate was significantly lower in the experimental group than that in the control group[27.4% (17/62) VS 58.7% (37/63), P=0.003]. Conclusion CT portography combined with endoscopic ultrasonography is safe and effective for esophageal gastric varices in patients with cirrhosis. Key words: Ultrasonography; Liver cirrhosis; Esophageal and gastric varices; CT portography; Endoscopic precise therapy

Transjugular intrahepatic portosystemic shunt for the prevention of recurrent esophageal variceal bleeding in patients with cavernous transformation of portal vein

Treatment options for patients with cavernous transformation of portal vein (CTPV) are limited. This study aimed to evaluate the feasibility, efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) to prevent recurrent esophageal variceal bleeding in patients with CTPV. We retrospectively analyzed 67 consecutive patients undergone TIPS from January 2011 to December 2016. All patients were diagnosed with CTPV. The indication for TIPS was a previous episode of variceal bleeding. The data on recurrent bleeding, stent patency, hepatic encephalopathy and survival were retrieved and analyzed. TIPS procedure was successfully performed in 56 out of 67 (83.6%) patients with CTPV. TIPS was performed via a transjugular approach alone (n = 15), a combined transjugular/transhepatic approach (n = 33) and a combined transjugular/transsplenic approach (n = 8). Mean portosystemic pressure gradient (PSG) decreased from 28.09 ± 7.28 mmHg to 17.53 ± 6.12 mmHg after TIPS (P < 0.01). The probability of the remaining free recurrent variceal bleeding was 87.0%. The probability of TIPS patency reached 81.5%. Hepatic encephalopathy occurrence was 27.8%, and survival rate was 88.9% until the end of follow-up. Four out of 11 patients who failed TIPS died, and 4 had recurrent bleeding. TIPS should be considered a safe and feasible alternative therapy to prevent recurrent esophageal variceal bleeding in patients with CTPV, and to achieve clinical improvement.

PS01.042: THE PRESENCE OF HCC AFFECT LONG-TERM PROGNOSIS AFTER ENDOSCOPIC TREATMENT FOR ESOPHAGEAL VARICES

Abstract Background Gastroesophageal varices are present in approximately 50% of patients with cirrhosis, and their rupture is a life-threatening complication. However, mortality rates have declined due to the progress in the management of these patients. Especially advances in endoscopic treatment have contributed to the improved survival rates. In this study, we investigated the prognostic factors associated with long-term survival after endoscopic treatment for esophageal varices. Methods The subjects were 256 patients who underwent initial endoscopic treatment for esophageal varices in our hospital between January 1997 and January 2017. Among them, 143 successfully followed up. The patients’ characteristics were: mean age, 63.8 years (29–85); 97 men and 46 women; and median survival period, 53 months. For analysis, subjects were divided into long-term survival and non-long-term survival groups (n = 59 for each) with a 53-month survival period as a cut-off value. Results The mean age in the long-term/non-long-term survival group was 62.4 ± 9.4 years/67.2 ± 10.5 years, indicating a significantly higher age in the non-long-term group (P &lt; 0.01). Preoperative Child-Pugh score was 6.3 ± 1.2/7.5 ± 2.2 (P &lt; 0.01) and hepatocellular carcinoma (HCC) presence rate was 25.7%/56.2% (P &lt; 0.01), significantly higher in the non-long-term group. Additionally, regarding the treatment method, endoscopic injection sclerotherapy (EIS): endoscopic variceal ligation (EVL) alone in the groups was 50:9/41:18, suggesting a significantly higher EVL rate in the non-long-term group (P &lt; 0.05). Recurrence of esophageal varices occurred in 33 and 22 patients in the long-term and non-long-term groups, respectively, with no significant difference between groups. Analysis of the factors affecting survival period using Cox proportional hazards model showed that Child-Pugh score B or C [hazard ratio(HR):2.0143, P &lt; 0.05], total bilirubin value≧ 2 [HR:2.5573, P &lt; 0.05], and presence of HCC [HR:2.2450, P &lt; 0.01] were noted as significant factors, but the recurrence of esophageal varices was not noted as significant. Only presence of HCC was found to be a significant factor affecting the long-term survival using multiple logistic regression analysis [odds ratio(OR) 0.3463, P &lt; 0.05]. Conclusion Our study revealed that liver function and the presence of HCC affect long-term prognosis after endoscopic treatment for esophageal varices. Disclosure All authors have declared no conflicts of interest.

PS01.039: RECURRENCE PREDICTION EQUATION OF ESOPHAGEAL VARICES

Abstract Background Endoscopic treatment is widely performed for esophageal varices, but prediction of post-treatment recurrence is difficult. Methods The subjects were 298 patients with cirrhosis who underwent initial endoscopic treatment for esophageal varices from January 1997 to December 2010 and were followed-up at our hospital. The average age was 64.5 years (29–84) and the male/female ratio was 119:89. The causes of cirrhosis were hepatitis C virus (HCV), hepatitis B virus (HBV), alcoholism, non-alcoholic steatohepatitis (NASH), and others in 66, 14, 13, 3 and 4% of the subjects, respectively. Hepatic reserve capacity before treatment was Child-Pugh score 6.9 ± 1.5 points, albumin 3.2 ± 0.6 g/dl, total bilirubin 1.4 ± 0.7 mg/dl, and PT% 71.0 ± 13.8%. Complication of hepatocellular cancer (HCC) was present in 63 subjects (30.4%). Treatment-indicated recurrence was defined as ³F2 and ³RC2. Recurrence occurred in 102 subjects, including 65 who redeveloped varicosity within 1 year. Data were compared between patients with (n = 65) and without (n = 43) early recurrence (within 1 year). Results The early recurrence group had a significantly higher Child-Pugh score (7.4 ± 1.8 vs. 6.7 ± 1.3, P &lt; 0.01), total bilirubin (1.6 ± 0.8 vs. 1.2 ± 0.6 mg/dl, P &lt; 0.01), and HCC complication rate (44.6% vs. 23.9%, P &lt; 0.01), and significantly lower albumin (3.0 ± 0.7 vs. 3.3 ± 0.6 g/dl, P &lt; 0.01) and administration rate of antihypertensive drugs (10.8% vs. 41.0%, P &lt; 0.01). In multivariate logistic regression analysis, use of antihypertensive drugs, total bilirubin, HCC, underlying disease (alcoholism), and treatment method (endoscopic injection sclerotherapy [EIS] or endoscopic variceal ligation [EVL]) emerged as factors that affected early recurrence. Based on these findings, we developed the following predictive equation: recurrence time (months) = - 12.5206 (HCC: confirmed = 1, not confirmed = 0) - 3.5029 (total bilirubin) + 6.2169 (antihypertensive drug: used = 1, not used = 0) - 7.2581 (alcoholism: yes = 1, no = 0) - 6.0764 (EVL = 1, EIS = 0) + 35.7165. Based on this formula, we examined the predicted and actual recurrence times in 68 subjects from January 2011 to December 2012 and found a significant positive correlation between these data (R = 0.583, P &lt; 0.01). Conclusion An equation was developed for prediction of recurrence of esophageal varices after treatment and was shown to have utility in actual cases. Disclosure All authors have declared no conflicts of interest.

Is the endovascular embolization of tributaries of the internal iliac veins essential in the treatment of isolated pelvic-perineal reflux?

Aim: The aim of study was to investigate the opportunities of local phlebectomy in the elimination of isolated pelvic-perineal reflux (PPR), as well as to determine the feasibility of endovascular embolization of the tributaries of internal iliac veins in PPR. Clinical trial no. NCT01598051.Materials and methods: The work is based on the results of examination and treatment of 43 female patients with varicose veins of the pelvis, perineum, and lower extremities. Patients had no signs of pelvic congestion syndrome (PCS). All patients underwent duplex ultrasound scanning (DUS) and ovariography with pelvic phlebography (OPP). For the elimination of PPR, local phlebectomy was performed in the major labia and perineal area, with maximal possible mobilization of the vessel within the operative wound (33 patients). In 10 patients with isolated varicose transformation of the superficial veins on the posterior thigh, mini-phlebectomy was performed using the Varady phlebectomy extractors.Results and discussion: The varicose syndrome of the external genitalia, perineum, and posterior thigh was successfully treated in 100% of patients. Findings suggest that thorough mobilization and excision of the veins of the pudendal labia, perineum, and subcutaneous veins of the thigh is a reliable method for eliminating the pathological reflux from the intrapelvic veins to the superficial veins of the perineum and lower extremities. No recurrences of vulvar, perineal varices or dilation of the veins of the lower extremities were observed in 100% of patients over the 3-year follow-up period.Conclusion: Local phlebectomy is an effective technique for eliminating the isolated PPR in patients with varicose transformation of intrapelvic, vulvar, or perineal veins. Endovascular embolization of the tributaries of the internal iliac veins is not an essential component in the treatment of PPR. The present study has a limitation due to the absence of patients with PCS. The effectiveness of phlebectomy in the treatment of isolated PPR was studied.

Comparison of Endoscopic Variceal Ligation with Endoscopic Sclerotherapy for Secondary Prophylaxis of Variceal Hemorrhage: A Randomized Trial.

BackgroundThough endoscopic variceal ligation (EVL) is commonly being used and has overcome the disadvantages of sclerotherapy (ST), still sclerotherapy is used as a therapeutic procedure for bleeding esophageal varices in the present institute. Hence, the study was done to see the advantages of EVL over ST.MethodsPatients with portal hypertension and bleeding esophageal varices underwent banding if found to have grade 3 or 4 varices. They were randomized to EVL group, where they were reviewed after two weeks for any residual varices for which repeat banding was done and endoscopic sclerotherapy (EST) group, where ST was done until the varices were obliterated or reduced to grade 1. The efficacy, complications, recurrent bleeding rate and recurrence of varices were compared.ResultsA total of 60 patients were included, 30 in each group. In EVL group, four sessions were needed to eradicate the varices in 73% of patients while it was five sessions in EST group (46% patients) (p-value = 0.0001). The mean number of sessions needed in EVL and EST group was 3.73 and 5.36, respectively. The average time taken for eradication of varices was 78.6 and 134.6 days in EVL and EST group, respectively (p-value = 0.004). Complications were higher in EST group (p-value < 0.05).ConclusionEVL alone was effective than ST in terms of the number of sessions needed for eradication of varices and total duration required to completely obliterate them. The complications were less in EVL group with no significant difference in recurrent bleeding rate and recurrence of varices between the groups.

SAT-309 - Predictive factors of esophageal varices recurrence after prophylactic endoscopic band ligation

SAT-309 - Predictive factors of esophageal varices recurrence after prophylactic endoscopic band ligation

Clinical Outcomes of Underdilated TIPS for Refractory Ascites and Variceal Hemorrhage

Transjugular intrahepatic portosystemic shunt (TIPS) placement is routinely used for the management of refractory ascites and recurrent variceal

Therapeutic effect of endoscopic variceal ligation plus sclerotherapy for esophageal varices with liver cirrhosis: a randomized controlled trial

Objective To investigate the safety and efficacy of endoscopic varices ligation (EVL) plus endoscopic varices sclerotherapy (EVS) for esophageal varices hemorrhage in patients with liver cirrhosis. Methods Fifty-two liver cirrhosis patients with esophageal varices bleeding were randomly divided into EVL group (n=24) and EVLS group (n=28) according to random numbers generated by computer after first EVL. The EVL group continued undergoing EVL, and the EVLS group was treated by EVS. The interval of treatment was 2 weeks till varices disappeared. All patients were followed up for 18 months with endoscopy and endoscopic ultrasonography (EUS). The efficacy, changes of esophageal varices and perforating veins, varices recurrence and rebleeding were observed. Results There was no significant difference of complete cure rate between EVLS group and EVL group[67.9% (19/28) VS 62.5% (15/24), P>0.05]. The mean session of treatment (2.68±1.0 VS 1.83±0.7, P 0.05], and the varices recurrence rate was higher in EVL group than that in EVLS group[77.3% (17/22) VS 44.0% (11/25), P<0.05]. Child-Pugh class B patients in EVL group had a higher varices recurrence rate compared to that in EVLS group[75.0% (9/12) VS 31.5% (5/16), P<0.05]. Endoscopic recurrences occurred in patients with non-occlusive perforating veins. Conclusion EVL plus EVS sequential procedure is safe and effective for treatment of esophageal varices hemorrhage, especially for Child-Pugh class B patients. Perforating veins may play a key role in the development of esophageal varices and recurrence after endoscopic therapy. EUS findings can direct the endoscopic therapy and predict the variceal recurrence. Key words: Esophageal varices; Endoscopic rubber banding for esophageal varices; Sclerotherapy for esophageal varices; Endoscopic ultrasonography

Recurrent varices after surgery: a clinical and color-Doppler ultrasound scan analysis.

To evaluate clinical pictures, symptoms and etiology of recurrent varices after surgery (REVAS) through a clinical and color-Doppler-ultrasound scan (CDUS) analysis. During a three-year period, data about 9043 consecutive outpatients were collected. Among these, 160 patients (1.8%) were affected by REVAS. Data about risk factors, types of primary vein surgery, symptoms, clinical and CDUS characteristics were analyzed using the Clinical, Etiology, Anatomy and Pathophysiology (CEAP), Stonebridge and Perrin classifications in order to evaluate clinical and anatomical varices patterns. Family history for chronic venous disease (90%), sedentary lifestyle (61.9%) and obesity (11.9%) were the most representative risk factors. REVAS symptoms were rather heterogeneous, although only 10% of cases was fully asymptomatic. CEAP classification showed a prevalence of C2 and C3 class (56.3% and 35% respectively). About half of inguinal REVAS was connected from a great saphenous vein residual stump (Stonebridge type 1). Lower limb perforating veins resulted associated to REVAS in 43.8% of cases. REVAS remain a major and still unsolved problem in patients following varicose veins surgery. Their clinical pictures and symptoms are heterogeneous and require a watchful analysis in order to identify both etiology and natural history.

ЭНДОСКОПИЧЕСКОЕ ЛИГИРОВАНИЕ КАК МЕТОД ПЕРВИЧНОЙ И ВТОРИЧНОЙ ПРОФИЛАКТИКИ ПИЩЕВОДНЫХ КРОВОТЕЧЕНИЙ ПРИ ВАРИКОЗНО - РАСШИРЕННЫХ ВЕНАХ ПИЩЕВОДА

This article is devoted to experience of endoscopic ligation of varices in N.A. Semashko Republic Clinical Hospital.&#x0D; We analyzed the results of ligation in 28 patients treated since February 2013 to March 2016. Selected patients had&#x0D; diagnoses of liver cirrhosis, syndrome of portal hypertension of different origin, 10 (35.5 %) had the history of one or&#x0D; more episodes of bleeding from varicose veins of the esophagus. Endoscopic ligation was performed for patients with&#x0D; varices of grade 3–4 according to J. Paquet classification, grade 3 according to N. Soehendra, K. Binmoeller classifica-&#x0D; tion improving primary and secondary prevention of bleeding. The effectiveness of endoscopic ligation as a method&#x0D; of primary and secondary prevention of bleeding from the varices, with subsequent transfer to oral administration of&#x0D; non-selective β-adrenoblockers was evaluated. In the result of the study throughout the entire period of observation&#x0D; we indicated no episodes of esophageal bleeding and established a low rate of recurrence of varices. Those patients&#x0D; who, after the first endoscopic ligation session, followed the recommendations for taking beta-blockers, have a better&#x0D; prognosis and the outcome in relation to patients who have neglected the recommendations. During the first year of&#x0D; follow-up there was one fatal outcome – a man with VHC died as a result of hepatocellular insufficiency.