Minimally invasive ways to treat and prevent gastroesophageal portal bleeding
https://doi.org/10.16931/1995-5464.2022-2-48-57
Abstract
Aim. To analyze the results of minimally invasive techniques to prevent and treat gastroesophageal bleeding in patients with cirrhosis.
Materials and methods. The study included 997 patients with liver cirrhosis: Child-Pugh class A – 21.7%; class B – 48.8%; class C – 29.5%. Esophageal varices of Grades III–IV were diagnosed in 95.5% of the patients, while gastric varices were observed in 17.4% of the patients. The following methods were used: endoscopic ligation, endoscopic sclerotherapy, TIPS, laparoscopic azygoportal disconnection, and distal splenorenal anastomosis.
Results. Following endoscopic procedures aimed at preventing the onset of gastroesophageal bleeding, variceal recurrence and bleeding were observed in 35.9% and 18.6% of cases, respectively. The efficacy of endoscopic ligation in case of bleeding amounted to 91.2%. Multiple endoscopic procedures provided means to treat esophageal and gastric varices in 56.2% of the patients. Rebleeding was observed in 9.3% of the patients, while esophageal and gastric varices persisted in 34.3% of the patients. TIPS was found to significantly reduce portal pressure and the grade of varices, with encephalopathy developing in 41.4% of the patients. In the long-term period, stent dysfunction was diagnosed in 22.5% of cases, while bleeding recurred in 10%. Laparoscopic azygoportal disconnection contributed to the regression of esophageal and gastric varices. In the long-term period, bleeding recurred in 42.3% of cases. Laparoscopic distal splenorenal anastomosis reliably prevented the recurrence of bleeding. No shunt thrombosis or lethal outcomes were observed, while the incidence of encephalopathy amounted to 14.7%.
Conclusion. A sufficient number of minimally invasive methods are currently available in the treatment and prevention of gastroesophageal portal bleeding. A case-specific approach to the choice of measures aimed at treating and preventing gastroesophageal bleeding in patients with cirrhosis is required, taking into account the degree of decompensation of portal hypertension and the severity of liver dysfunction.
About the Authors
B. N. KotivBogdan N. Kotiv – Doct. of Sci. (Med.), Professor, Deputy Head of the Academy for Clinical Work, Honored Doctor of the Russian Federation
6, Lebedeva str., Saint-Petersburg, 194044
I. I. Dzidzava
Russian Federation
Ilya I. Dzidzava – Doct. of Sci. (Med.), Associated Professor, Head of Department of Advanced Surgery, Honored Doctor of the Russian Federation
6, Lebedeva str., Saint-Petersburg, 194044
S. A. Bugaev
Sergey A. Bugaev – Cand. of Sci. (Med.), Advisor to the Director
27, Bol'shaya Serpukhovskaia str., Moscow, 117997
I. E. Onnitsev
Igor E. Onnitsev – Doct. of Sci. (Med.), Chief Surgeon
3, Gospitalnaya pl., Moscow, 105229
S. A. Soldatov
Sergey A. Soldatov – Head of Department for Coordinating Organ Donation and Transplantation
6, Lebedeva str., Saint-Petersburg, 194044
S. A. Alent’ev
Sergey A. Alent’ev – Doct. of Sci. (Med.), Associated Professor, Department of General Surgery
6, Lebedeva str., Saint-Petersburg, 194044
A. V. Smorodsky
Alexander V. Smorodsky – Cand. of Sci. (Med.), Lecturer, Department of Advanced Surgery
6, Lebedeva str., Saint-Petersburg, 194044
S. V. Shevtsov
Semyon V. Shevtsov – Graduate Student, Department of Advanced Surgery
6, Lebedeva str., Saint-Petersburg, 194044
A. A. Dzhafarov
Arif A. Dzhafarov – Adj. Prof., Department of Advanced Surgery
6, Lebedeva str., Saint-Petersburg, 194044
References
1. Seo Y.S. Prevention and management of varices. Clin. Mol. Hepatol. 2018; 24 (1): 20–42. https://doi.org/10.3350/cmh.2017.0064
2. Pfisterer N., Unger L.W., Reiberger T. Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis. World J. Hepatol. 2021; 13 (7): 731–746. https://doi.org/10.4254/wjh.v13.i7.731
3. Garbuzenko D.V. The principles of primary prevention of bleeding from esophageal varices in patients with liver cirrhosis. Clinical Medicine (Russian Journal). 2016; 94 (6): 503–509. https://doi.org/10.18821/0023-2149-2016-94-7-503-509 (In Russian)
4. Shertsinger A.G., Zhao A.V., Ivashkin V.T., Maevskaya M.V., Pavlov Ch.S., Vertkin A.L., Ogurtsov P.P., Lopatkina T.N., Kotiv B.N., Dzidzava I.I., Anisimov A.Yu., Prudkov M.I., Khoronko Yu.V., Nazyrov F.G., Devyatov A.V., Kitsenko E.A. Treatment of bleedings from varicose veins of the esophagus and stomach. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2013; 18 (3): 111–129. (In Russian)
5. Sarin S.K., Lahoti D., Saxena S.P., Murthy N.S., Makwana U.K. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992; 16 (6): 1343–1349. https://doi.org/10.1002/hep.1840160607
6. Kim T., Shijo H., Kokawa H., Tokumitsu H., Kubara K., Ota K., Akiyoshi N., Iida T., Yokoyama M., Okumura M. Risk factors for hemorrhage from gastric fundal varices. Hepatology. 1997; 25 (2): 307–312. https://doi.org/10.1053/jhep.1997.v25.pm0009021939
7. Trudeau W., Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest. Endosc. 1986; 32 (4): 264–268. https://doi.org/10.1016/s0016-5107(86)71843-9
8. Triantos C., Kalafateli M. Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis. World J. Hepatol. 2014; 6 (6): 363–369. https://doi.org/10.4254/wjh.v6.i6.363
9. Reiberger T., Püspök A., Schoder M., Baumann-Durchschein F., Bucsics T., Datz C., Dolak W., Ferlitsch A., Finkenstedt A., Graziadei I., Hametner S., Karnel F., Krones E., Maieron A., Mandorfer M., Peck-Radosavljevic M., Rainer F., Schwabl P., Stadlbauer V., Stauber R., Tilg H., Trauner M., Zoller H., Schöfl R., Fickert P. Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien. Klin. Wochenschr. 2017; 129 (Suppl. 3): S135–S158. https://doi.org/10.1007/s00508-017-1262-3
10. de Franchis R. Expanding consensus in portal hypertension. Report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J. Hepatology. 2015; 63 (3): 743–752. https://doi.org/10.1016/j.jhep.2015.07.001
11. Zheng X., Dou C., Yao Y., Liu Q. A meta-analysis study of laparoscopic versus open splenectomy with or without esophagogastric devascularization in the management of liver cirrhosis and portal hypertension. J. Laparoendosc. Adv. Surg. Tech. A. 2015; 25 (2): 103–111. https://doi.org/10.1089/lap.2014.0506
12. Pugh R.N.H., Murray-Lyon I.M., Dawson J.L. Transsection of the oesophagus for bleeding oesophageal variceas. Brit. J. Surg. 1973; 60 (8): 648–652. https://doi.org/10.1002/bjs.1800600817
13. Paquet K.J. Sclerotherapy for the prevention of bleeding esophageal varices. Internist (Berl.). 1983; 24 (2): 81–84. PMID: 6341290
14. Binmoeller P., Date S., Soehendra N. Treatment of esophagogastric varices: endoscopic, radiological, and pharmacological options. Endoscopy. 1998; 30 (2): 105–113. https://doi.org/10.1055/s-2007-1001236
15. Aggeletopoulou I., Konstantakis C., Manolakopoulos S., Triantos C. Role of band ligation for secondary prophylaxis of variceal bleeding. World J. Gastroenterol. 2018; 24 (26): 2902–2914. https://doi.org/10.3748/wjg.v24.i26.2902
16. Seo Y.S., Kim M.Y., Yim H.J., Kim H.S., Kim S.G., Park S.Y. Multicenter prospective randomized controlled trial comparing propranolol, endoscopic band ligation, and combination therapy for the primary prophylaxis variceal bleeding in patients with liver cirrhosis. J. Hepatol. 2017; 66 (1): S35. https://doi.org/10.1016/S0168-8278(17)30330-6
17. Chandra S., Holm A., El Abiad R.G., Gerke H. Endoscopic cyanoacrylate glue injection in management of gastric variceal bleeding: US tertiary care center experience. J. Clin. Exp. Hepatol. 2018; 8 (2): 181–187. https://doi.org/10.1016/j.jceh.2017.11.002
18. Goral V., Yilmaz N. Current approaches to the treatment of gastric varices: glue, coil application, TIPS, and BRTO. Medicina. 2019; 55 (7): 335. https://doi.org/10.3390/medicina55070335
19. Saeed Z.A., Stiegmann G.V., Ramirez F.C., Reveille R.M., Goff J.S., Hepps K.S., Cole R.A. Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: a multicenter prospective randomized trial. Hepatology. 1997; 25 (1): 71–74. https://doi.org/10.1002/hep.510250113
20. García-Pagán J.C., Caca K., Bureau C., Laleman W., Appenrodt B., Luca A., Abraldes J.G., Nevens F., Vinel J.P., Mössner J., Bosch J. Early use of TIPS in patients with cirrhosis and variceal bleeding. N. Engl. J. Med. 2010; 362 (25): 2370–2379. https://doi.org/10.1056/NEJMoa0910102
21. Strunk H., Marinova M. Transjugular intrahepatic portosystemic shunt (TIPS): pathophysiologic basics, actual indications and results with review of the literature. Fortschr. Röntgenstr. 2018; 190 (8): 701–711. https://doi.org/10.1055/a-0628-7347
22. Chen Y., Qiu H., Zhang X. Transjugular intrahepatic portal shunt in the treatment of portal hypertension due to cirrhosis: single center experience. BMC Surg. 2019; 19 (1): 191. https://doi.org/10.1186/s12893-019-0659-5
23. Hong D., Cheng J., Wang Z., Shen G., Xie Z., Wu W., Zhang Y., Zhang Y., Liu X. Comparison of two laparoscopic splenectomy plus pericardial devascularization techniques for management of portal hypertension and hypersplenism. Surg. Endosc. 2015; 29 (12): 3819–3826. https://doi.org/10.1007/s00464-015-4147-4
24. Tanaka M., Ikeda Y., Matsui S., Kato A., Nitori N., Kadomura T., Hatori T., Kitajima M. Right lateral decubitus approach to a laparoscopic modified Hassab's operation. Asian J. Endosc. Surg. 2016; 9 (1): 97–100. https://doi.org/10.1111/ases.12252
25. Boggi U., Belluomini M.A., Barbarello L., Caniglia F., Brunetto M., Amorese G. Laparoscopic robot-assisted distal splenorenal shunt. Surgery. 2015; 157 (2): 405. https://doi.org/10.1016/j.surg.2014.07.012
Supplementary files
Review
For citations:
Kotiv B.N., Dzidzava I.I., Bugaev S.A., Onnitsev I.E., Soldatov S.A., Alent’ev S.A., Smorodsky A.V., Shevtsov S.V., Dzhafarov A.A. Minimally invasive ways to treat and prevent gastroesophageal portal bleeding. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2022;27(2):48--57. (In Russ.) https://doi.org/10.16931/1995-5464.2022-2-48-57