Endoscopic treatment of gastroesophageal variceal bleeding after oxaliplatin-based chemotherapy in patients with colorectal cancer

Abstract

Background Oxaliplatin, used as first-choice treatment for colorectal cancer (CRC), induces sinusoidal endothelial injury and portal hypertension. This study investigated the characteristics of oxaliplatin-induced portal hypertension and evaluated the efficacy of endoscopic management of gastroesophageal variceal bleeding. Methods We performed a retrospective, multicenter, case-control study between January 2010 and December 2018. Patients who received oxaliplatin-based chemotherapy after CRC surgery and presented with portal hypertension and gastroesophageal varices were compared with consecutive patients with hepatitis B-related cirrhotic portal hypertension receiving endoscopic treatment for variceal bleeding. Results 39 patients with oxaliplatin-induced portal hypertension were identified, 35 of whom had a history of variceal bleeding. The median period between start of oxaliplatin-based chemotherapy and the occurrence of varices was 50.4 months (n = 39). A total of 26 patients with oxaliplatin-related portal hypertension and 230 patients with hepatitis B-related portal hypertension underwent endoscopic treatment. Kaplan-Meier analysis revealed that the 1-year rebleeding rate was significantly higher in the oxaliplatin group than in the hepatitis B group (43.3 % vs. 19.0 %, P = 0.001). Multivariable Cox regression analysis showed that oxaliplatin-based chemotherapy was an independent factor for 3-year rebleeding (hazard ratio [HR] 2.46, 95 % confidence interval [CI] 1.24–4.87; P = 0.01) and 3-year overall mortality (HR 9.43, 95 %CI 2.32–38.31; P = 0.002). Conclusions Oxaliplatin-related portal hypertension was characterized by massive ascites, splenomegaly, gastric varices, concomitant arterioportal fistula, and relatively normal liver function. Endoscopic treatment to prevent variceal rebleeding in these patients was unsatisfactory compared with endoscopic treatment for hepatitis B-related portal hypertension.

Prediction of Esophagogastric Varices Associated with Oxaliplatin Administration

“…In the EGV group, there were no obvious changes in biochemical signs of liver damage, such as AST, ALT and total bilirubin. Huang and colleagues suggested that oxaliplatin-related portal hypertension is characterized by massive ascites, splenomegaly, gastric varices, concomitant arterioportal stula, and relatively normal liver function [11]. This report supported our data, together indicating that the absence of signs of liver damage could delay the detection of EGV.…”

“…Recently, it has also become widely known that oxaliplatin may lead to the development of portal hypertension and esophagogastric varices (EGV). Some case reports, including from our group, have shown that EGV formation or rupture during or after oxaliplatin-containing chemotherapy can make it di cult to continue the treatment and may worsen the prognosis [8][9][10][11][12]. However the prevalence of and risk for developing EGV after oxaliplatin treatment is unclear.…”

Prediction of esophagogastric varices associated with oxaliplatin administration

“…Huang and colleagues suggested that oxaliplatin-related portal hypertension is characterized by massive ascites, splenomegaly, gastric varices, concomitant arterio-portal fistula, and relatively normal liver function. 11 This report supported our data, indicating that the absence of signs of liver damage could delay the detection of EGVs. Therefore, it is important to assess changes in platelet counts and spleen size on CT scan in patients treated with oxaliplatin-based chemotherapy.…”

“…Some case reports, including from our group, have shown that EGV formation or rupture during or after oxaliplatincontaining chemotherapy can make it difficult to continue the treatment and may worsen the prognosis. [8][9][10][11][12] However, the prevalence of and risk for developing EGVs after oxaliplatin treatment are unclear. We therefore evaluated clinical features predictive of the development of EGVs in colorectal cancer patients treated with oxaliplatin-based chemotherapy.…”

Isolated gastric variceal bleeding related to non-cirrhotic portal hypertension following oxaliplatin-based chemotherapy: A case report

“…Ligation and cyanoacrylate glue injection under gastroscopy are the first-line treatment options for esophageal and gastric variceal bleeding in liver cirrhosis[ 17 ], but whether they are appropriate for esophageal and gastric variceal bleeding related to NCPH remains controversial. A previous study reported that the effect of endoscopic therapy in preventing variceal rebleeding in patients with NCPH is not ideal, compared to its effect in preventing hepatitis B cirrhosis-related portal hypertension[ 18 ]. Due to good functional liver reserve in patients with NCPH, transjugular intrahepatic portosystemic shunt (TIPS) treatment has a lower rebleeding rate, and the incidence and mortality of postoperative hepatic encephalopathy are lower[ 19 ].…”