Treatment of patients with gastric variceal hemorrhage: Endoscopic N‐butyl‐2‐cyanoacrylate injection versus balloon‐occluded retrograde transvenous obliteration

Hong, Cheul Ho; Kim, Hong Joo; Park, Jung Ho; Park, Dong Il; Cho, Yong Kyun; Sohn, Chong Il; Jeon, Woo Kyu; Kim, Byung Ik; Hong, Hyun Pyo; Shin, Jun Ho

doi:10.1111/j.1440-1746.2008.05651.x

Cited by 107 publications

(124 citation statements)

References 29 publications

(83 reference statements)

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“…[8][9][10][11] Its use is gradually increasing in other countries such as the United States, [12][13][14] where transjugular intrahepatic portosystemic shunt (TIPS) placement is currently the standard treatment for GVs. 15 The reported rate of GV rebleeding is significantly lower after B-RTO than after TIPS placement 16 or endoscopic intervention, 17 but B-RTO results in increased portal venous pressure (PVP), which may cause enlargement of EVs. 18,19 We previously reported on the efficacy and safety of simultaneous combined B-RTO and partial splenic embolization (PSE) for GVs 20 based on the hypothesis that concomitant PSE can diminish the increase in PVP after B-RTO.…”

Section: Introductionmentioning

confidence: 99%

Simultaneous combined balloon‐occluded retrograde transvenous obliteration and partial splenic embolization for gastric fundal varices

et al. 2016

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Background: We previously reported the techniques and usefulness of simultaneous combined balloon-occluded retrograde transvenous obliteration (B-RTO) and partial splenic embolization (PSE), based on the hypothesis that concomitant PSE can diminish the increase in portal venous pressure after B-RTO. Objective: After experiencing more cases and performing longer-term follow-up, we re-evaluated the efficacy of simultaneous combined B-RTO and PSE for gastric fundal varices (GVs). Methods: We performed B-RTO in 36 consecutive patients treated for GVs from 2005 to 2013. Twenty-three patients underwent simultaneous combined B-RTO and PSE (Group 1) and 13 underwent B-RTO monotherapy (Group 2). The outcomes were retrospectively evaluated. Results: There were no significant differences in baseline characteristics between the two groups except that the splenic volumes were larger in Group 1 than 2. B-RTO was technically successful in 21 of 23 patients (91.3%) in Group 1 and in 12 of 13 patients (92.3%) in Group 2. In all patients with ruptured GVs (six in Group 1 and five in Group 2), complete hemostasis was obtained by B-RTO. Exacerbation of esophageal varices was significantly less frequent in Group 1 than 2 (p ¼ 0.0017). Conclusion: Concomitant PSE with B-RTO may contribute to prevention of the exacerbation of esophageal varices after B-RTO.

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Section: Introductionmentioning

confidence: 99%

Simultaneous combined balloon‐occluded retrograde transvenous obliteration and partial splenic embolization for gastric fundal varices

et al. 2016

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“…They concluded that B-RTO was a safe and effective procedure for the treatment of fundal GV, as eradication of the varices was confirmed in 31 of 32 patients without serious side effects [136]. Hong et al [137] reported that EIS with cyanoacrylate was associated with a higher rebleeding rate than B-RTO, although the immediate efficacies of these two treatments for bleeding GV and high-risk GV were similar. Akahoshi et al [138] reported that B-RTO was superior to EIS with cyanoacrylate and ethanolamine oleate in preventing rebleeding from isolated fundal GV with a major shunt.…”

Section: Antifibrotic Therapymentioning

confidence: 99%

Evidence-based clinical practice guidelines for liver cirrhosis 2015

et al. 2016

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The Japanese Society of Gastroenterology revised the evidence-based clinical practice guidelines for liver cirrhosis in 2015. Eighty-three clinical questions were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases for the period between 1983 and June 2012. Manual searching of the latest important literature was added until August 2015. The guidelines were developed with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. This digest version in English introduces selected clinical questions and statements related to the management of liver cirrhosis and its complications. Branched-chain amino acids relieve hypoalbuminemia and hepatic encephalopathy and improve quality of life. Nucleoside analogues and peginterferon plus ribavirin combination therapy improve the prognosis of patients with hepatitis B virus related liver cirrhosis and hepatitis C related compensated liver cirrhosis, respectively, although the latter therapy may be replaced by direct-acting antivirals. For liver cirrhosis caused by primary biliary cirrhosis and active autoimmune hepatitis, urosodeoxycholic acid and steroid are recommended, respectively. The most adequate modalities for the management of variceal bleeding are the endoscopic injection sclerotherapy for esophageal varices and the balloon-occluded retrograde transvenous obliteration following endoscopic obturation with cyanoacrylate for gastric varices. Beta-blockers are useful for primary prophylaxis of esophageal variceal bleeding. The V 2 receptor antagonist tolvaptan is a useful add-on therapy in careful diuretic therapy for ascites. Albumin infusion is useful for the prevention of paracentesis-induced circulatory disturbance and renal failure. In addition to disaccharides, the nonabsorbable antibiotic rifaximin is useful for the management of encephalopathy. Anticoagulation therapy is proposed for patients with acute-onset or progressive portal vein thrombosis.

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“…Another prospective multicenter randomized controlled clinical trial enrolled 140 patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding and randomized them to undergo DSRS (73) or TIPS (67) [78]. After a mean follow-up of 46 months there was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P=0.29) or first encephalopathy event (DSRS, 50%; TIPS, 50%).…”

Section: Surgical Portosystemic Shunts Versus Tipsmentioning

confidence: 99%

“…TIPS has been found to be quite effective in the prevention of GV rebleeding, not only by reducing the portal pressure but also by allowing the possibility of transhepatic obliteration of gastric variceal channels [72]. A number of radiologic or combination endoscopic-radiologic techniques such as BORTO (balloon-occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration) and balloon-occluded endoscopic injection sclerotherapy have been pioneered in Japan, but need further evaluation [73].…”

Section: Management Of Gastric Variceal Bleedingmentioning

confidence: 99%

Current Role of Surgery in Portal Hypertension

Pal

2011

Indian J Surg

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Treatment for portal hypertension (PHT) has evolved from surgery being the only option during the 1970s to the wide range of options currently available. Surgery has not vanished from the therapeutic armamentarium, but its role has changed and is constantly evolving. The present review primarily focuses on the role of surgery in tackling patients with PHT and varices with regard to the Indian scenario and also looks at its relevance, given the availability of a host of other therapeutic options.Keywords Portal hypertension . Portosystemic shunt . Surgery . Variceal haemorrhage Pathophysiology of PHTFor understanding how surgery can help modify the natural course in patients with PHT, it is necessary to understand its pathophysiology and the natural history of varices in such patients. PHT is usually the consequence of increased resistance to portal blood flow coupled with increased blood flow through the splanchnic circulation because of a hyperdynamic circulatory state that exists both in cirrhotics and to some extent in noncirrhotic etiologies (large congested splenomegaly) as well. Traditionally, at the ultrastructural level, PHT has been classified into presinusoidal, sinusoidal, and postsinusoidal. It is for the sinusoidal and postsinusoidal blocks that there is an accurate but invasive way of monitoring the portal pressure by using the method to estimate the hepatic venous pressure gradient (HVPG) in the vascular/hemodynamic lab [1][2][3]. In cirrhotic patients, as about a third to half of them will actually have PHT; HVPG >5 mmHg indicates PHT. PHT becomes clinically significant when the HVPG is ≥10 mmHg [1][2][3]. This is the pressure threshold when PHT leads to the formation of esophagogastric varices, retroperitoneal and periportal collaterals, hypersplenism, low serum albuminascitic albumin gradient ascites, spontaneous bacterial peritonitis, etc. Varices rupture and bleed only when the HVPG >12 mmHg [1][2][3]. Natural History of PHTIt has been estimated that varices are present in about 30-40% of compensated cirrhotics and nearly two-thirds of the decompensated patients. In cirrhotic patients without varices on the first endoscopy, the annual incidence of new varices is between 5% and 10% [1,4]. Once developed, the progression of varices from small to large depends on the deterioration of liver function and continued hepatic insult (virus-, alcohol-, metabolic-, drug-induced, etc.). The overall annual incidence of bleeding is about 4% and this increases to 15% per year in those with large varices, red signs, and poor Child's status [1,[4][5][6]. About a third of the cirrhotic patients with varices will bleed and the mortality following each episode of bleeding is about 20% (maybe higher) in experienced tertiary health centers. Early mortality (within 6 weeks) following an acute episode of variceal bleeding depends on the etiology of PHT, the severity of underlying liver disease (Child's C, model for end-stage liver disease [MELD] >18), actively bleeding varices, bleeding gastric varices (GV...

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Treatment of patients with gastric variceal hemorrhage: Endoscopic N‐butyl‐2‐cyanoacrylate injection versus balloon‐occluded retrograde transvenous obliteration

Abstract: The therapeutic efficacies of EBC and BRTO for the treatment of active GVH and/or high-risk GV appeared to be similar. However, EBC might be associated with a higher rebleeding rate than BRTO. BRTO could be an effective rescue treatment for patients with GVH after initial treatment of EBC.

Cited by 107 publications

References 29 publications

Simultaneous combined balloon‐occluded retrograde transvenous obliteration and partial splenic embolization for gastric fundal varices

Simultaneous combined balloon‐occluded retrograde transvenous obliteration and partial splenic embolization for gastric fundal varices

Evidence-based clinical practice guidelines for liver cirrhosis 2015

Current Role of Surgery in Portal Hypertension

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