Refractory Esophageal Variceal Bleeding Research Articles

Esophageal Stent in Acute Refractory Variceal Bleeding: A Systematic Review and a Meta-Analysis.

Background: Acute esophageal variceal bleeding accounts for up to 70% of upper-gastrointestinal bleeding in cirrhotic patients. About 10-20% of patients with acute variceal bleeding have refractory bleeding that is not controlled by medical or endoscopic therapy, and this condition can be life-threatening. Balloon tamponade is a long-standing therapy which is only effective temporarily and has several complications, while transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation may not be readily available at some centers. The use of self-expandable metal stents (SEMSs) in refractory esophageal variceal bleeding has been studied for effectiveness and adverse events and has been recommended for use as a bridge to a more definitive treatment. Aim: To investigate the effectiveness and safety of SEMSs in managing refractory variceal bleeding. Methods: A systematic search of the MEDLINE, EMBASE, and Cochrane library databases was performed from inception to October 2022 using the following terms: "esophageal stent", "self-expandable metal stents", "endoscopic hemostasis", "refractory esophageal varices", and "esophageal variceal bleeding". Studies were included in the meta-analysis if they met the following criteria: (1) patients' age older than 18 and (2) a study (or case series) that has at least 10 patients in the study. Exclusion criteria included (1) non-English publications, (2) in case of overlapping cohorts, data from the most recent and/or most appropriate comprehensive report were collected. DerSimonian-Laird random-effects meta-analysis was performed using the meta package in R statistical software(version 4.2.2). Results: Twelve studies involving 225 patients with 228 stents were included in the analyses. The mean age and/or median age ranged from 49.4 to 69 years, with a male-to-female ratio of 4.4 to 1. The median follow-up period was 42 days. The mean SEMS dwell time was 9.4 days. The most common cause of acute refractory variceal bleeding in chronic liver disease patients included alcohol use followed by viral hepatitis. The pooled rate of immediate bleeding control was 91% (95% CI 82-95%, I2 = 0). The pooled rate of rebleeding was 17% (95% CI 8-32%, I2 = 69). The pooled rate of stent ulceration was 7% (95% CI 3-13%, I2 = 0), and the pooled rate of stent migration was 18% (95% CI 9-32%, I2 = 38). The pooled rate of all-cause mortality was 38% (95% CI 30-47%, I2 = 34). Conclusions: SEMSs should be primarily considered as salvage therapy when endoscopic band ligation and sclerotherapy fail and can be used as a bridge to emergent TIPS or definitive therapy, such as liver transplantation.

Esophageal stent placement for endoscopic treatment failure.

Up until approximately 10 years ago, the treatment for acute refractory esophageal variceal bleeding was balloon tamponading. Esophageal fully covered self-expanding stents are considered as effective as balloons and also much safer. They are kept in situ for longer periods, what eases the access to more definitive treatments with a low complication rate. We present 6 cases of patients with cirrhosis and massive bleeding due to esophageal varices refractory to conventional treatment, successfully treated with an esophageal fully covered self-expanding stent. There were no major complications, achieving an effective bleeding control in all cases.

S2107 Successful Management of Refractory Esophageal Variceal Bleeding Secondary to Chronic Portal Vein Thrombosis by Transsplenic Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt

INTRODUCTION: Trans-jugular intrahepatic portosystemic shunt (TIPS) becomes challenging in the presence of portal vein thrombus (PVT). We describe a case of successful management of refractory esophageal variceal bleeding secondary to chronic PVT and splenic vein thrombosis (SVT) by portal vein recanalization – TIPS through transsplenic and transhepatic approach. CASE DESCRIPTION/METHODS: A 29-year-old male with a history of homozygous methylenetetrahydrofolate reductase mutation with normal homocysteine levels on warfarin presented with acute hematemesis. He underwent emergent endoscopic band ligation of esophageal and GOV1 gastric varices. He had a history of chronic PVT with prior mechanical thrombectomy and thrombolysis two years ago, and received band ligation for bleeding esophageal varices in the last year, but did not follow up for surveillance. MRI of abdomen and pelvis revealed chronic PVT with cavernous transformation (Fig A) and chronic SVT. No further bleeding was reported after endoscopy. Liver biopsy one year ago showed benign liver tissue with focal mild congestion and sinusoidal dilation. There was a normal hepatic venous pressure gradient. Given concerns about his compliance and risk of re-bleeding, multidisciplinary team discussion led to consideration of a high-risk TIPS with splenic vein recanalization and stenting. Under ultrasound and fluoroscopic guidance, TIPS was placed using two snare targets. One snare was placed in the occluded portal vein via splenic vein access, and another was placed in the middle hepatic vein via internal jugular vein access. Using the gun-sight technique, a 21-gauge Chiba needle was advanced transhepatically through both the loop snares and then a guidewire was advanced until it could be captured by both the above snares (Fig B). With this newly obtained access, TIPS and splenic stents were successfully deployed (Fig C). Pressure gradient across TIPS was lowered to 6 mm Hg from 16 mm Hg. As varices did not fill on post TIPS portogram, embolization was not performed. He was started on aspirin in addition to his warfarin. Repeat CTA at 3 months demonstrated patent TIPS and splenic stent, and no further episodes of hematemesis were reported. DISCUSSION: In our patient, the gunsight TIPS approach helped decompress portal hypertension and prevent recurrent variceal bleeding when other alternatives including Sugiura surgery carried high morbidity and were not amenable. Post TIPS re-stenosis is a known complication, and may be prevented by aspirin and warfarin use.Figure 1.: Magnetic resonance imaging (MRI) of the abdomen and pelvis showing chronic portal vein thrombosis with cavernous transformation.Figure 2.: Fluoroscopic image showing gun-sight technique: Guide-wire is captured by the first snare in the presumed right portal vein and second snare in the middle hepatic vein.Figure 3.: Fluoroscopic image showing successful deployment of TIPS.

Esophageal Stenting for Refractory Esophageal Variceal Bleeding

Esophageal variceal bleeding is a lethal complication in patients with cirrhosis. Occasionally, esophageal variceal bleeding is refractory to standard endoscopic and pharmacologic therapies. We discuss a case of bleeding esophageal varices that was treated with esophageal stenting as a bridge to emergent transjugular intrahepatic portosystemic shunt (TIPS). A 55-year-old female with a past medical history of alcoholic and hepatitis C virus (HCV) cirrhosis presented with large volume hematemesis. One week previously, she was admitted with hematemesis and during upper endoscopy, five bands were placed treating large distal esophageal varices. During the current admission, labs were remarkable for a hemoglobin of 8.8, down from 9.6 two days earlier, INR of 1.7, platelets of 146, and MELD-Na of 22. The patient was transfused one unit of packed red blood cells (PRBC) and maintained on intravenous octreotide and pantoprazole. During endoscopy, multiple large varices were found in the middle and distal third of the esophagus. Two bands were placed on the esophageal varices in the distal esophagus. One band detached immediately and large volume bleeding ensued. Placement of additional bands at the bleeding site was not possible due to scarring. A temporizing covered esophageal stent was deployed across the gastroesophageal junction to achieve hemostasis by tamponade while emergent TIPS was arranged. Meanwhile, her vitals remained stable and there were no further episodes of hematemesis. She underwent emergent TIPS with retrograde embolization of the esophageal collaterals, which she tolerated well. The plan was to remove the esophageal stent in two weeks. Unfortunately, the patient continued to decompensate and passed away during liver transplantation surgery. Current standard management of acute variceal bleeding includes adequate resuscitation, vasoactive medications, acid suppression, antibiotic prophylaxis, and endoscopic banding. Previously balloon tamponade was used and had complications including migration, aspiration, and tissue ischemia with mortality rates around 20%. Placement of self-expanding metal stents (SEMS) is an effective option for refractory variceal bleeding due to its high initial bleeding control rate, low rebleeding rate, and lower rate of adverse events compared to balloon tamponade. Our case revealed that SEMS is an effective temporizing measure for refractory esophageal variceal bleeding until TIPS can be performed.1981_A Figure 1. Large esophageal varices with presence of postbanding ulcer1981_B Figure 2. Wallflex stent deployed

Self-Expandable Metal Stent Application as Bridging Therapy in Refractory Esophageal Variceal Bleeding

Self-Expandable Metal Stent Application as Bridging Therapy in Refractory Esophageal Variceal Bleeding

Protocolo de indicaciones y contraindicaciones de la derivación portosistémica percutánea intrahepática

IntroductionTIPS has become an important tool in the management of portal hypertension complications and has replaced surgery in its indications. IndicationsFirst used in refractory esophageal variceal bleeding, nowadays is a rescue option when conventional treatment fails in some other indications: refractory ascitis, secondary prophylaxis of esophageal or gastric variceal bleeding, refractory hepatic hydrothorax, hepatorenal syndrome and Budd Chiari syndrome. ContraindicationsMost of its contraindications are anatomic, due to its difficult placement. However we have to take in account, while selecting patients, the risk of cardiac and hepatic failure and encephalopathy.

Self-expanding metal stents for acute refractory esophageal variceal bleeding: A systematic review and meta-analysis.

Esophageal variceal bleeding is a severe complication of portal hypertension with significant morbidity and mortality. A substantial portion of cirrhotics fail to respond to conventional medical therapy and band ligation, necessitating alternative treatments including self-expanding metal stent (SEMS) placement for acute refractory esophageal variceal bleeding. In the present study, we carried out a systematic review and structured meta-analysis of all eligible studies to evaluate the technical feasibility, safety, clinical efficacy, and survival advantage of SEMS placement for the treatment of of acute esophageal variceal bleeding. Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were carried out through December 2015. Individual study proportions were transformed into a quantity using the Freeman-Tukey variant of the arcsine square root transformed proportion. Combined weighted proportions, and meta-regression were then determined. The search yielded 12 studies involving n=155 patients included in our meta-analysis. Pooled clinical success rate in achieving hemostasis within 24h was 96% (95% CI, 0.90-1.00). Technical success for SEMS deployment endoscopically was achieved in 97% of patients (95% CI, 0.91-1.00). Total adverse events (including rebleeding after 48h, ulceration, and stent migration) were shown in 36% of patients after SEMS placement (95% CI, 0.23-0.50). Pooled 30-day and 60-day survival rates were 68% (95% CI, 0.56-0.80) and 64% (95% CI, 0.48-0.78), respectively. This study demonstrated that esophageal SEMS placement is a technically feasible modality and highly efficacious in achieving hemostasis in acute esophageal variceal hemorrhage.

SAT-004 - Self-Expanding Metal Stents in Patients with Cirrhosis and Severe or Refractory Esophagealvariceal Bleeding: A Systematic Review and Meta-Analysis

SAT-004 - Self-Expanding Metal Stents in Patients with Cirrhosis and Severe or Refractory Esophagealvariceal Bleeding: A Systematic Review and Meta-Analysis

Self-Expandable Metal Stents for Persisting Esophageal Variceal Bleeding after Band Ligation or Injection-Therapy: A Retrospective Study

Background and Study AimsDespite a pronounced reduction of lethality rates due to upper gastrointestinal bleeding, esophageal variceal bleeding remains a challenge for the endoscopist and still accounts for a mortality rate of up to 40% within the first 6 weeks. A relevant proportion of patients with esophageal variceal bleeding remains refractory to standard therapy, thus making a call for additional tools to achieve hemostasis. Self-expandable metal stents (SEMS) incorporate such a tool.MethodsWe evaluated a total number of 582 patients admitted to our endoscopy unit with the diagnosis “gastrointestinal bleeding” according to our documentation software between 2011 and 2014. 82 patients suffered from esophageal variceal bleeding, out of which 11 cases were refractory to standard therapy leading to SEMS application. Patients with esophageal malignancy, fistula, or stricture and a non-esophageal variceal bleeding source were excluded from the analysis. A retrospective analysis reporting a series of clinically relevant parameters in combination with bleeding control rates and adverse events was performed.ResultsThe initial bleeding control rate after SEMS application was 100%. Despite this success, we observed a 27% mortality rate within the first 42 days. All of these patients died due to non-directly hemorrhage-associated reasons. The majority of patients exhibited an extensive demand of medical care with prolonged hospital stay. Common complications were hepatic decompensation, pulmonary infection and decline of renal function. Interestingly, we found in 7 out of 11 patients (63.6%) stent dislocation at time of control endoscopy 24 h after hemostasis or at time of stent removal. The presence of hiatal hernia did not affect obviously stent dislocation rates. Refractory patients had significantly longer hospitalization times compared to non-refractory patients.ConclusionsSelf-expandable metal stents for esophageal variceal bleeding seem to be safe and efficient after failed standard therapy. Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients. SEMS should be considered a reasonable treatment option for refractory esophageal variceal bleeding after treatment failure of ligature and sclerotherapy and non-availability of or contraindication for other measures (e.g. TIPS).

Is there a role for stenting in case of acute esophageal variceal bleeding?

Is there a role for stenting in case of acute esophageal variceal bleeding?

Esophageal Stents in Malignant and Benign Disorders

Endoscopic stent placement is an effective palliative treatment for malignant dysphagia and fistula, leading to rapid symptom relief. However, recurrent dysphagia and other stent-related complications are common, for which reason continuously new design modifications are implemented. Although some of these changes facilitate stent placement, complications remain and occur at similar rates. Recently, stents have also been used in benign esophageal disorders. Covered stents have the ability to effectively seal esophageal perforations and leaks, reducing the need for invasive surgery. This benefit does not pertain to patients with refractory benign esophageal strictures, in whom stents have limited long-term effect and are associated with a high complication rate. The initial results of fully covered metal stents in refractory esophageal variceal bleeding are encouraging, but their definite role remains to be further elucidated. This review provides an overview of indications, techniques, and management of complications of stents in malignant and benign esophageal disease.