How To Repair A Large Esophageal Varices

Acute esophageal variceal haemorrhage in patients with portal hypertension remains a complexity with a high mortality today. In cases refractory to standard therapy including endoscopic band ligation and pharmacological therapy, traditionally balloon tamponade has been used as salvage therapy. However, these techniques bear witness several important limitations. Cocky-expanding metal stents (SEMS) have been proposed as an alternative rescue treatment. The employ of variceal stenting in 7 patients with a total of ix haemorrhage episodes in 3 dissimilar Swiss hospitals is demonstrated. While firsthand bleeding control is achieved in a high percentage of cases, the v-day and half dozen-week mortality rate remain high. Bloodshed is strongly influenced past the severity of the underlying liver disease. Accordingly, our information correspond a high-risk patient commonage. Thanks to their safety and easy treatment, SEMS are an interesting alternative to balloon tamponade equally a bridging intervention to definitive therapy including the pre-hospital setting.

© 2022 S. Karger AG, Basel

Introduction

Today's standard therapy for astute esophageal variceal hemorrhage includes the combination of vasoactive drugs, endoscopic band ligation [1] and brusque-term administration of antibiotics. Furthermore, Garcia-Pagán et al. [2] have shown in 2022 that early on transjugular intrahepatic portosystemic shunt (TIPS) placement within 72 h in patients at high risk of treatment failure significantly reduces mortality. Despite the various handling approaches, the 6-week bloodshed rate linked to variceal bleeding still ranges from 15 to 20% depending on underlying severity of the liver disease [3,four,5]. Every bit a late example, the bloodshed within 6 weeks of follow-up among 162 patients in Spain who received emergency band ligation during an observation flow of 9 years was sixteen%. It is of import to point out that thereby mortality depends strongly on the adventure subgroups of the patients [6].

First approaches of using directly compression to treat haemorrhage esophageal varices were described by Westphal in 1930. In 1950, the Sengstaken-Blakemore tube was developed. Equally reported by Panés et al. [vii], balloon tamponade remained the first-line therapy in acute variceal hemorrhage in the 1980s. While the Sengstaken-Blakemore tube was being used in the outweighing cases of esophageal varices, the Linton-Nachlass tube has been preferred for the compression of gastric varices.

The success rates of balloon tamponade apropos short-term haemorrhage control vary from fifty upwards to 91.v% [7,eight,nine]. The main complications associated with balloon tamponade include aspiration pneumonia in unventilated patients, big esophageal ulcers, esophageal tears and airway obstruction [9]. Rebleeding was observed in almost one-half of the patients when the airship was deflated [seven]. In a prospective multicenter study conducted past Sorbi et al. in 2003 [10], airship tamponade was used in v.5% of patients with a beginning bleeding episode and in 17.four% of patients with a recurrent bleeding within 2 weeks. Latest consensus guidelines advise that balloon tamponade does all the same play a office today, but should only be used in massive uncontrolled bleeding and only equally a bridging mensurate for a maximum of 24 h until definitive therapy tin can exist initiated [eleven].

Since 2003, a new rescue treatment modality has been introduced. While traditionally self-expanding metallic stents (SEMS) accept been used in oncology with adept success in stenosing esophageal cancer [12], Hubmann et al. [thirteen] have developed a fully covered SEMS to be used as an alternative to airship tamponade in astute refractory variceal hemorrhage. Four different studies so far, the largest serial including 34 patients, accept shown encouraging results in terms of immediate bleeding control rates and low proportion of complications [xiii,14,15,16]. These data suggest that covered SEMS may be an option in refractory esophageal bleeding [11] and may replace balloon tamponade as a save technique in the future. In the instance of bleeding gastric varices, Linton tubes volition still be needed. Generally, experience and show regarding this method are not yet profound. Hither we have collected a total of 9 cases of stent employment in seven patients in three dissimilar Swiss hospitals in an emergency setting in acute variceal bleeding.

Case Reports

Our commonage covers a full of 9 variceal bleeding events in 7 cirrhotic patients equally summarized in table 1. The cases are derived from three unlike Swiss infirmary facilities (one principal, one secondary and one tertiary referral middle) in the time period from October 2022 to October 2022. In the bulk of cases, failure of standard approaches including band ligation, sclerotherapy and fifty-fifty emergency TIPS to stop hemorrhage led to the insertion of an SX-ELLA Stent Danis (ELLA-CS, Hradec-Kralove, Czech Republic). The stent and its delivery organisation are depicted in figure 1 and the insertion procedure is explained in figure 2. In 3/9 cases, insertion of the stent was performed every bit start-line emergency treatment besides standard pharmacological therapy. Stenting led to firsthand bleeding command (at time of endoscopy) in 89% (8/nine cases). The only instance with missing hemorrhage control was due to unsuccessful stent deployment. One patient received an additional Linton tube to shrink gastric fundus varices (instance 5 in tabular array i). Duodenal varices in case 1 in table ane were treated by histoacryl injection simultaneously to stenting of esophageal varices. In 44% (4/9) of the cases, the patient survived the astute haemorrhage episode for 5 days equally defined by the Baveno Five consensus guidelines [11]. After vi weeks, only 22% (2/9) of the patients were notwithstanding live. Cases 1a+b and 2 have been chosen exemplarily to exist described in detail below. One additionally inserted SX-ELLA Stent Danis used in prophylactic intention later on endoscopic mucosectomy in the distal esophagus with large varices was not included in this cohort. Anyway, this instance was uneventful considering insertion, removal and long-term follow-up.

Table one

Baseline patient characteristics and handling parameters

Fig. 1

a Schematic view of the delivery system of the SX-ELLA Stent Danis preloaded with the compressed stent. b Photograph of the deployed stent with a bore of 25 mm and a length of 135 mm. The stent is fabricated of nitinol and fully covered past a plastic membrane. Courtesy of ELLA-CS, Hradec-Kralove, Czechia.

Fig. 2

a If stent placement is assisted endoscopically, the guide wire is inserted through the working channel of the endoscope. Otherwise, the delivery arrangement can be inserted directly into the esophagus. b For fixation of the delivery system to the stomach, the balloon is inflated and pulled back against the cardia. c Stent deployment is achieved by removing the lock and pulling back the sheath handle. d The delivery system is removed, leaving behind the deployed stent in the distal esophagus. The stent can be left in the esophagus for up to 7 days. Courtesy of ELLA-CS, Hradec-Kralove, Czech republic.

Instance 1a+b

The 56-yr-old patient with known ethyl-toxic liver cirrhosis was admitted to the emergency room later 1 day of ongoing hematochezia. She presented with an initial hemoglobin level of 25 g/fifty. At emergency endoscopy, an overt haemorrhage from duodenal varices was treated using sclerotherapy and clipping. Pharmacological therapy with vitamin K, loftier-dose proton pump inhibitor, octreotide and ceftriaxone was initiated. Despite mass transfusion and intubation, the patient could not exist stabilized adequately and was transferred to the 3rd referral center the aforementioned day. At arrival, hemoglobin was at 8.iv g/dl, blood pressure 96/61 mm Hg and the Model for Terminate-Stage Liver Disease (MELD) score 21. The actively bleeding esophageal varices were immediately treated past band ligation. However, haemorrhage command was non sufficient and the patient underwent implantation of an emergency TIPS the following day. Additionally, considering of continued haemorrhage, the duodenal varices were treated by histoacryl injection and the esophageal varices were compressed by implantation of a SX-ELLA Stent Danis. At this point, hemostasis was finally achieved and the stent could be removed without difficulty after a 5-twenty-four hours haemorrhage-gratuitous interval.

However, the course had been complicated by ongoing liver failure with hepatic encephalopathy, acute respiratory distress syndrome and acute anuric renal failure. Xi days after the initial haemorrhage episode, recurrence of diffuse bleeding in the alimentary canal was observed. The MELD score had increased to 29 at that fourth dimension. Once again, an esophagus stent was placed with successful local hemostasis equally seen endoscopically. Owing to massive coagulopathy, however, there was an ongoing diffuse bleeding and the patient died one day later of multi-organ failure.

Example 2

Acute and unexpected onset of nausea and hematemesis in a 68-year-old patient led to admission to the emergency room of a peripheral hospital. At presentation, the patient was responsive, with pale complexion, blood pressure being 100/fourscore mm Hg, heart charge per unit 100/min and hemoglobin level 10.2 g/l. He had a known history of alcohol corruption, liver cirrhosis (actual MELD score 11), past hepatitis B infection and has been treated with ibuprofen the terminal 2 days due to painful knees. Upon emergency endoscopy, an active esophageal variceal bleeding was revealed (fig. 3a). Attempts to control haemorrhage with rubber band ligation were not successful. The usual pharmacotherapy including vitamin 1000, high-dose proton pump inhibitor, octreotide and ceftriaxone were immediately administered. While the patient's hemoglobin level dropped to 4.4 1000/l, mass transfusion was initiated and as a rescue therapy, a SX-ELLA Stent Danis was deployed in the esophagus under endoscopic control, which led the hemorrhage to terminate (fig. 3b). Under stable cardiocirculatory conditions and spontaneous respiration, the patient was then transferred to the secondary referral center. After, the stent was removed endoscopically and the patient underwent definitive therapy in terms of half dozen-fold variceal band ligation on the mean solar day of transfer. Apart from an episode of tachycardic atrial fibrillation, which was electrically converted back to sinus rhythm, the course of recovery was uneventful and the patient was dismissed from the hospital later on 8 days. Today, 2 years subsequently, the patient is in good wellness.

Fig. 3

a Endoscopic epitome of active hemorrhage of esophageal varices in Kid B liver cirrhosis. b Retrograde image of the inflated airship of the stent delivery system at the cardia. c The covered stent in the distal esophagus with compression of the varices leading to hemostasis.

Discussion

The use of SEMS in acute esophageal hemorrhage is a new treatment modality to command initial bleeding. In 10-xx% of patients, standard therapy combining pharmacological with endoscopic measures fails to stop initial hemorrhage [iii], which points out the demand for further treatment approaches. Studies up to now have reported success rates from 77 to 100% in initial control of hemorrhage using SEMS [13,xiv,15,16]. In the present case serial, insertion of the stent led to firsthand bleeding control in 89% (8/9) of patients. In all of these 8 cases no re-haemorrhage was observed afterward while the stent remained in situ. Therefore, in general the efficacy of this method seems non to be inferior to traditional balloon tamponade, with success rates for brusk-term hemostasis from 50 to ninety% [vii,8,9]. We did not find whatever stent-related complications in our patients.

According to the Baveno V consensus guidelines [xi], treatment success of an acute bleeding episode is measured within a time frame of five days. Thereby, a hepatic venous force per unit area gradient >20 mm Hg, Kid-Pugh C and agile bleeding at endoscopy qualify as predictors for 5-day treatment failure. All of the 9 cases presenting with active bleeding and seven/9 cases being classified as Child-Pugh C indicated a high-adventure patient collective in the nowadays study. v-twenty-four hours treatment failure in 56% (five/ix) cases is therefore not surprising; 3 out of these 5 cases died before reaching eligibility for definitive therapy such as TIPS placement. In the other 2 of these 5 cases, the patients had already been treated with relieve TIPS at their starting time bleeding episode but did then not survive the 2d bleeding episode (cases 1b and 3b). In plough, case iv was treated by constituent TIPS after hemorrhage had been controlled by the SEMS and survived the 42-day period. Case ii received band ligation as a definitive therapy after stent removal and is still alive today.

6-week bloodshed - as any death within half dozen weeks must exist considered a bleeding-related [11] - sums up to 77% (vii/nine patients). Other studies on the use of SEMS have reported 6-calendar week mortality rates from thirty to 50% [14,15,xvi]. These figures are significantly higher than a full general half-dozen-week bloodshed charge per unit of 15-20% using standard techniques [3,4,v]. This impressive difference implies a option bias of these collectives with nearly severe underlying liver diseases. Therefore it is of import to go on in mind that in all studies and then far, SEMS take virtually just been used in treatment-refractory variceal hemorrhage pregnant higher up-average risk for treatment failure. Case 1a+b described above is exemplary for such a high-hazard setting. The patient had terminate-stage liver affliction with poor prognosis already at hospital access. She was treated at the tertiary referral heart with all therapeutic options available. The SEMS was used as ultima ratio and indeed helped the patient to survive another 10 days, non preventing ongoing liver disease and finally decease due to multi-organ failure. On the other hand, instance 2 points out the power of the stent to serve every bit an elegant bridging measure to definitive therapy. Hither we take a patient with moderately advanced liver disease, life-threatened past an unexpected bleeding episode. Upon presentation at a peripheral hospital, he was successfully treated with a SEMS then transferred to a secondary referral center for stabilization and definitive therapy. 1 might further consider the usage of the SX-ELLA Stent Danis in the setting of any ambulance. The SEMS device is fabricated to be inserted without endoscopy, which in fact has been described in 1 instance by Wright et al. [15]. This approach may save lives in the pre-hospital phase. Anyhow, at the hospital gastroscopy is inevitable in any case because gastric varices are non fairly treated by SEMS. In these situations a combination with a Linton tube may be a viable and reasonable option, as we did one time (example v in tabular array 1).

In conclusion, the use of SEMS is an effective and prophylactic fashion of decision-making initial hemorrhage from esophageal varices and might supplant airship tamponade in the future as a bridging measure to definitive therapy, especially every bit the stent may remain in the esophagus for up to vii days. Bloodshed, however, remains loftier mainly due to underlying advanced liver disease in the patient collective treated.

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