Endoscopic band ligation of oesophageal varices

BACKGROUND: For 25 years the optimal management of bleeding oesophageal varices has included endoscopic injection sclerotherapy (EIS) both to arrest bleeding and to prevent rebleeding. However, the recent innovation of endoscopic variceal ligation (EVL) may be a more effective treatment; this paper reviews its efficacy. METHODS: All Medline (National Library of Medicine, Washington DC, USA) articles containing the text words 'oesophageal varices', 'sclerotherapy' or 'band ligation' were reviewed. Prospective randomized studies comparing sclerotherapy with band ligation, or combinations thereof, were included. RESULTS: After an acute variceal bleed EVL is as effective as EIS for control and eradication of oesophageal varices. Initial control of bleeding is similar, but eradication is achieved in fewer sessions with EVL. EVL is associated with lower rebleeding rates and fewer procedure-related complications; it is also more effective for control of active bleeding at initial endoscopy. Combination therapy (EIS plus EVL) confers no advantage over EVL alone. CONCLUSION: EVL is similar to EIS for control of bleeding varices, but the former has less associated morbidity, lower rebleeding rates and achieves more rapid variceal eradication. EVL should be considered the endoscopic treatment of choice in the management of variceal haemorrhage.     

Rupture of rectal varices treated with endoscopic variceal ligation

We report here 3 cases of rectal varices treated with endoscopic variceal ligation and discuss the pathogenesis, treatment, and prognosis of rectal varices with referring to previous reports. Of the 3 patients, 2 had been diagnosed as liver cirrhosis and 1 as extrahepatic portal hypertension. All of the 3 patients had previously undergone treatment of esophagogastric varices. The rupture of rectal varices appeared to have some relationship with the treatment of esophageal varices. In previous reports, 73% of patients with ruptured rectal varices treated with endoscopic injection sclerotherapy or endoscopic variceal ligation had undergone treatments of esophageal varices. The endoscopic treatments resulted in a favorable prognosis in 2 patients. Although no fatality from endoscopic injection sclerotherapy or endoscopic variceal ligation has been reported, 1 of the present 3 cases died of liver failure.     

Portal hypertension: a surgical hepatologist's view of current management

Current strategies for management of acute esophageal variceal bleeding and for long-term treatment after an episode of variceal bleeding are outlined. Acute variceal bleeding is best managed by means of endoscopic therapy (sclerotherapy, band ligation, or “superglue”), whereas the role of pharmacologic agents remains controversial. In cases of failure of endoscopic therapy, a transjugular intrahepatic portosystemic shunt (TIPS) procedure, an emergency shunt, or a transection operation should be performed. Patients who experience an acute variceal bleeding episode require long-term management to prevent recurrent bleeding. Endoscopic treatment is preferred using either sclerotherapy or banding. The principal alternative is long-term pharmacologic therapy with beta-adrenergic receptor blocking agents. Major surgical procedures should be reserved for failures of endoscopic or pharmacologic therapy. The distal splenorenal shunt or the new narrow-diameter polytetrafluoroethylene portacaval shunt is preferred. All patients who are first seen with acute variceal bleeding should be considered for a liver transplant, although few will ultimately become transplant candidates. Patients with end-stage liver disease who are not transplant candidates should be identified and major high-cost therapy discontinued. Prophylactic therapy prior to variceal bleeding should be considered in selected patients. At present, only pharmacologic therapy is justified. The major problem remains identification of those patients at high risk for a first episode of variceal bleeding.     

Endoscopic sclerotherapy

Various sclerotherapy techniques have proved successful in the management of acute variceal bleeding and in long-term control of patients after a variceal bleed. We prefer either an intravariceal or a combined intravariceal and paravariceal technique using ethanolamine oleate, but we advocate that individual units utilize the technique with which they have the most experience. The use of an unmodified flexible endoscope has been almost universally accepted. Once active variceal bleeding is diagnosed on emergency endoscopy, immediate emergency sclerotherapy should be performed. When this is not possible, bleeding should be controlled by balloon-tube tamponade with subsequent delayed emergency sclerotherapy after resuscitation. Patients with variceal bleeding that has stopped at the time of the diagnostic endoscopy can either be treated by immediate sclerotherapy or be observed initially and subsequently treated using the long-term management policy of the unit concerned. Over 90% of actively bleeding patients should be controlled using emergency sclerotherapy. Failures are defined as patients who have more than two acute variceal bleeds during a single hospital admission. Such patients should be identified early and treated either by simple staple-gun transection or by an emergency portosystemic shunt. Repeated injection sclerotherapy using a flexible endoscope and the technique with which the group concerned has the most experience is recommended as the primary form of treatment for the majority of patients after a proven esophageal variceal bleed. Repeat injection treatments should probably be performed at weekly intervals until the esophageal varices are eradicated, with follow-up at 6-month or yearly intervals thereafter. Recurrent varices should be treated similarly. Failures of sclerotherapy are defined as patients who have either recurrent bleeds or in whom varices are difficult to eradicate. They require either a portosystemic shunt or a devascularization and transection operation. All patients presenting with cirrhosis and variceal bleeding should be evaluated for liver transplantation; unfortunately, however, few variceal bleeders are candidates for transplantation. Prophylactic sclerotherapy in patients with esophageal varices that have not bled remains unjustified outside of controlled trials. Available trials have produced conflicting data.     

Endoscopic sclerotherapy in the management of esophageal varices in 61 children with biliary atresia

Sixty-one children who have survived 2.5 years or more after corrective surgery for biliary atresia were prospectively followed by endoscopy. Esophageal varices were detected in 41 patients (67%), 17 of whom (28%) had experienced episodes of variceal hemorrhage. Control of variceal bleeding was achieved by endoscopic injection sclerotherapy in all but one child who died from hemorrhage before the completion of treatment. Complications of the technique comprised episodes of bleeding before variceal obliteration (7), esophageal ulceration (5), and stricture (3). These resolved with conservative management and without long-term sequelae. During a mean follow-up period of 2.8 years after variceal obliteration, rebleeding from recurrent esophageal varices developed in only one child and responded to further sclerotherapy. These results are better than those following surgical procedures for portal hypertension in biliary atresia, and therefore endoscopic sclerotherapy is recommended as the treatment of choice.     

A prospective evaluation of injection sclerotherapy in the treatment of acute bleeding from esophageal varices.

In a 25 month study of massive upper-gastrointestinal hemorrhage, 64 patients were shown to have esophageal varices on emergency endoscopy. Twenty-four patients were actively bleeding from varices and were treated with a Sengstaken tube, and in 22 this was followed by emergency injection sclerotherapy using a rigid esophagoscope and general anesthesia. These 22 patients were followed prospectively and had 51 episodes of endoscopically proven active bleeding from esophageal varices which required Sengstaken tube control of hemorrhage during 36 separate admissions. This group included our total experience of injection sclerotherapy in acute variceal bleeding. The majority (14 of 22 patients) had alcoholic cirrhosis. Definitive control of variceal bleeding during the period of hospitalization was achieved in 33 hospital admissions (92%), usually with a single injection (27 hospital admissions: 75%). The results were satisfactory in 26 hospital admissions (72%). There were nine deaths (41% overall patient mortality rate), but no patient died primarily of variceal bleeding, and exsanguinating variceal bleeding was no longer a problem. The mortality rate per injection was 18%, and the mortality rate per hospital admission was 25%. Injection sclerotherapy is proposed as the emergency treatment of choice for patients with proven bleeding esophageal varices who do not stop bleeding on initial conservative treatment.     

The current role of devascularization and transection procedures in portal hypertension]

It is not clear which theory should be used in patients with bleeding esophageal varices that are not controlled by emergency endoscopic sclerotherapy. Definitive hemostasis is the key to successful therapy of variceal bleeding. Recurrence of haemorrhage in patients with portal hypertension is the most feared life threatening complication. Based on our management of 658 patients with esophageal varices and the availability of treatment options at our institution, the strategy of management of uncontrollable variceal haemorrhage by endoscopic sclerotherapy has evolved. Bleeding was controlled in 64 liver cirrhosis (100%) by devascularization and transection procedures and 50 patients (78%) survived to leave the hospital including 43 of 64 patients (67%) with Child grade C liver cirrhosis. Cumulative rebleeding rate at 10 years following emergency surgery was 3% (2/64). It is associated with a lower morbidity and mortality as well as a lower incidence of subsequent encephalopathy. We suggest that emergency transection and devascularization is an effective salvage treatment for the endoscopic sclerotherapy failed group.     

Has sclerotherapy altered the management of patients with variceal bleeding?

Sclerotherapy is currently the primary treatment of choice for the majority of patients who present with esophageal variceal bleeding. Although it has altered the management of these patients, unanswered questions and controversies remain. Patients with acute variceal bleeding should preferably be treated in a specialized center. The primary treatment should be immediate sclerotherapy, when possible. Portosystemic shunts and esophageal transection should be reserved for the 5% to 10% of patients in whom sclerotherapy fails to control acute bleeding. There are several treatment options for long-term management after a variceal bleeding episode. Sclerotherapy is one option and has become the primary treatment in most major centers. All patients with end-stage liver disease must be considered for liver transplantation, and sclerotherapy should be the primary method of treatment in those who are selected. Pharmacologic therapy remains controversial. I propose that portosystemic shunts and devascularization and transection operations be reserved for those few patients in whom sclerotherapy fails to eradicate the varices and to prevent recurrent variceal bleeding. Patients in whom sclerotherapy is unsuccessful should be identified and treated early.     

Portal hypertension management

Summary Injection sclerotherapy is the mainstay of treatment for acute variceal bleeding and for long-term management after a variceal bleed. In those few patients in whom sclerotherapy fails to control acute bleeding, either a surgical shunt or a simple esophageal transection is recommended. A surgical shunt or a more extensive esophagogastric evascularization and transection operation is advocated for the failures of long-term sclerotherapy management. The role of pharmacological agents in acute variceal bleed management remains in question, and the use of propranolol in long-term management, either as an alternative to sclerotherapy or in combination with sclerotherapy, is controversial. The definitive roles of the newly described variceal banding and transjugular intrahepatic portosystemic shunts (TIPS) procedures have yet to be established. All patients presenting with end-stage liver disease and esophageal variceal bleeding should be evaluated for a liver transplant, although few will qualify. A possible future transplant should be kept in mind when emergency treatment is planned. Any form of prophylactic therapy for patients with esophageal varices that have not yet bled will remain unjustified until those patients at high risk of a first variceal bleed can be identified. The gastric mucosal lesion, portal hypertensive gastropathy, has been underdiagnosed in the past. Although bleeding does occur, it is seldom a major clinical problem. When necessary, bleeding can be controlled by propranolol or a surgical shunt.     

Acute bleeding varices: a five-year prospective evaluation of tamponade and sclerotherapy.

In a five-year study of massive upper gastrointestinal hemorrhage, 143 patients had esophageal varices diagnosed on emergency endoscopic examination. Seventy-one patients had active bleeding from varices and required Sengstaken tube tamponade during at least one hospital admission. The remaining patients included 33 with variceal bleeding which had stopped and 39 who were bleeding from another source. Sixty-six of the former group of 71 patients were referred for emergency injection sclerotherapy. These 66 patients were followed prospectively to August 1980, and had 137 episodes of endoscopically proven variceal bleeding requiring Sengstaken tube control followed by injection sclerotherapy during 93 separate hospital admissions. Definitive control of hemorrhage was achieved in 95% the patients admitted to the hospital (single injection 70%; two or three injections 22%). The death rate per hospital admission was 28%. No patient died of continued variceal bleeding, and exsanguinating variceal hemorrhage no longer poses a major problem at our hospital. The combined use of initial Sengstaken tube tamponade followed by injection sclerotherapy has simplified emergency treatment in the group of patients who continue to bleed actively from esophageal varices, despite initial conservative treatment.     

Esophageal sclerotherapy: an effective modality in children

During the past five years, sclerotherapy has been used at our institution in 13 children for the management of recurrent major variceal bleeding. The varices were secondary to extrahepatic portal hypertension in seven patients and to intrahepatic portal hypertension in the remaining six. Sclerotherapy was performed under direct vision using either rigid or flexible endoscopic equipment, and the sclerosing agents were injected directly into the varices. The average age at initiation of sclerotherapy was 9 years (range: 1 to 19 years). The follow-up has ranged from 2 to 4 1/2 years with a mean of 3 1/2 years. Complete obliteration of all varices was obtained in eight of these patients. Two children have minimal residual varices, in one of whom 17 sclerotherapy procedures have been performed to date. One additional patient had a severe episode of bleeding during esophagoscopy, and transesophageal ligation of varices was required for control. Two patients have died following initiation of sclerotherapy. In neither case was the death the result of bleeding esophageal varices or a complication of endosclerosis. Bleeding from varices was the major clinical problem in all of these children, and this problem has been largely corrected by the sclerotherapy program. With one exception, there have been no episodes of variceal bleeding requiring transfusion in these patients following initiation of this therapy. One child developed an esophageal ulcer postinjection, but none have developed esophageal strictures. One patient developed an allergic reaction to the sclerosant that was treated during subsequent injections with prior administration of an antihistamine (diaphenhydramine chloride) and steroids.(ABSTRACT TRUNCATED AT 250 WORDS)     

内镜治疗食管胃静脉曲张的效果分析

目的探讨内镜下套扎、硬化剂、组织粘合剂治疗食管胃静脉曲张的临床疗效。方法选择有食管、胃静脉曲张破裂出血史的患者107例,进行胃镜检查,依据LDRf分型结果选择内镜下套扎、硬化剂或者组织粘合剂治疗食管胃静脉曲张并随访。结果进行内镜下套扎治疗52例,硬化剂治疗18例,组织粘合剂治疗8例,硬化剂加组织粘合剂治疗15例,未进行内镜下治疗14例。结论内镜下治疗食管胃底静脉曲张破裂出血操作简单、疗效可靠、止血率高、静脉曲张消失快、并发症少,是治疗食管胃底静脉曲张破裂出血的有效方法。LDRf内镜下分型简单明了、规范、统一,对于食管胃静脉曲张的内镜下治疗有指导意义。     

Management of Variceal Hemorrhage in Children with Extrahepatic Portal Venous Obstruction-Shunt Surgery Versus Endoscopic Sclerotherapy

Extrahepatic portal venous obstruction (EHPVO) is a common cause of portal hypertention in children. Esophageal variceal hemorrhage is a major cause of morbidity and mortality in these patients. For many decades, portal systemic shunts were considered as the most effective treatment of variceal hemorrhage. Endoscopic injection sclerotherapy (EIS) was first introduced for emergency management of bleeding varices and subsequently as definitive treatment to prevent recurrent hemorrhage. The purpose of the study was to compare the safety and efficacy of shunt surgery and endoscopic sclerotherapy for patients with proven esophageal variceal bleeding due to EHPVO. The study was a prospective randomized study of 61 children with bleeding esophageal varices due to EHPVO carried out jointly by the department of General Surgery and Gastroenterology at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, between March 2001 and September 2003. Thirty patients received surgery and other 31 patients received EIS. Overall incidence of rebleeding was 22.6% in sclerotherapy group and 3.3% in shunt surgery group. Treatment failure occurred in 19.4% patients in sclerotherapy group and 6.7% in shunt surgery group. The rebleeding rate of sclerotherapy is significantly higher than that of shunt surgery. However, the therapy failure rate of sclerotherapy is not significantly different from that of shunt surgery.     

Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices

OBJECTIVE: This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis. SUMMARY BACKGROUND DATA: Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy. METHODS: Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24-87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565 upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded. RESULTS: Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1-174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3-198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death. CONCLUSION: Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients.     

内镜下硬化与套扎治疗食管静脉曲张破裂出血疗效比较

目的：对比内镜下硬化治疗（EIS）、套扎治疗（EVL）及套扎联合硬化治疗（ESL）3种方法对食管静脉曲张破裂出血的临床疗效。方法：回顾分析中日友好医院消化内科2001—2005年内镜下治疗肝硬化单纯食管静脉曲张破裂出血149例,其中EIS46例、EVL32例、ESL71例,对3种方法的止血率、静脉曲张消失率及再出血率进行比较。结果：3种治疗方法止血率均在90%以上;静脉曲张消失率分别为EIS80.4%、EVL68.8%、ESL87.3%;2年内再出血率分别为EIS52.2%、EVL59.3%、ESL43.6%,差异无统计学意义（P〉0.05）。结论：内镜下EIS、EVL及ESL治疗肝硬化食管曲张静脉出血均可达到较好效果,临床实践中可结合患者实际情况综合考虑后选择。     

The surgeon''s role in the management of portal hypertension.

Patients with portal hypertension are referred to surgeons for several reasons. These include the management of continued active variceal bleeding; therapy after a variceal bleed to prevent further recurrent bleeds; consideration for prophylactic surgical therapy to prevent the first variceal bleed; or, rarely, an unusual cause of portal hypertension which may require some specific surgical therapy. Injection sclerotherapy is the most widely used treatment for both acute variceal bleeding and long-term management after a variceal bleed. Unfortunately it has probably been overused in the past. The need to identify the failures of sclerotherapy early and to treat them by other forms of major surgery is emphasized. The selective distal splenorenal shunt is the most widely used portosystemic shunt today, particularly in nonalcoholic cirrhotic patients. The standard portacaval shunt is still used for the management of acute variceal bleeding as well as for long-term management, particularly in alcoholic cirrhotic patients. For acute variceal bleeding the surgical alternative to sclerotherapy or shunting is simple staple-gun esophageal transection, whereas in long-term management the main alternative is an extensive devascularization and transection operation. Liver transplantation is the only therapy that cures both the portal hypertension and the underlying liver disease. All patients with cirrhosis and portal hypertension should be assessed as potential liver transplant recipients. If they are candidates for transplantation, sclerotherapy should be used to treat bleeding varices whenever possible, as this will interfere least with a subsequent liver transplant.     

Portal hypertension and bleeding esophageal varices

Summary Bleeding from esophageal varices exacts a high mortality and extraordinary societal costs. Prophylaxis—medication, sclerotherapy, or shunt surgery to prevent an initial bleeding episode—is ineffective. In patients who have bled from varices, endoscopic injection sclerotherapy can control acute bleeding in more than 90% of patients. Because recurrent bleeding frequently occurs and survival without definitive therapy is dismal, selection of a permanently effective treatment is mandatory once variceal bleeding has been controlled.Long-term injection sclerotherapy can be performed in compliant patients; it is relatively safe but is associated with a 30–50% rebleeding rate. Betablockers significantly reduce portal pressure and recurrent bleeding but have not been shown to diminish mortality from BEV. Portal decompressive surgery permanently halts bleeding in more than 90% of patients; the risk of operative mortality is high in decompensated cirrhotics, and long-term complications of encephalopathy and accelerated liver failure may limit indications for shunt surgery to good-risk cirrhotics who are not liver transplant candidates. Devascularization procedures have a low operative mortality and encephalopathy rate but unacceptably high rates of recurrent bleeding.Liver transplantation is curative therapy for bleeding esophageal varices and the associated underlying hepatic dysfunction; cost and availability of donor organs generally limit its use in this setting to variceal bleeders with end-stagè liver disease not associated with active alcoholism.     

The use of sclerotherapy for the management of oesophageal varices in portal hypertension

Summary Although sclerotherapy is currently the most widely used treatment for the management of both acute variceal bleeding and the long-term management of patients with varices, its definitive role in the treatment of these patients has yet to be finally proven. Sclerotherapy appears to be the most effective treatment for the majority of patients with acute variceal bleeding. Failures require either a shunt or a transection and/or devascularisation procedure. Current evidence favours simple staple gun transection or a shunt (either a portacaval shunt or a side-to-side narrow diameter polytetrafluoroethylene graft between the portal vein and vena cava). In long-term management of patients after a variceal bleed the currently favoured treatment is repeated sclerotherapy. However, failures should be identified early. We define failures as patients who present with varices that are either difficult to eradicate by sclerotherapy or who have repeated life-threatening variceal bleeds during the course of repeated injection sclerotherapy. Such patients should have either a portal-to-systemic shunt or a transection and devascularisation operation. Further controlled trials are required to define the specific indications for the individual forms of therapy. Prophylactic treatment for varices that have not yet bled is unjustified at present. Based on a presentation to the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

Attempt of photodynamic therapy on esophageal varices

Small vessels gradually reappear within the esophageal wall after endoscopic injection sclerotherapy or endoscopic variceal ligation, which causes late recurrent bleeding. Additional ligation or a small amount of sclerotherapy of these thin and serpentine vessels is sometimes difficult to perform, and stenosis of the esophagus sometimes occurs after a small amount of sclerotherapy. In this study we attempted endoscopic photodynamic therapy on newly visible vessels and evaluated its ability to prevent recurrent bleeding. Fourteen patients with newly visible vessels within the esophageal wall were enrolled. All patients had esophageal varices secondary to hepatitis B and had their varices eliminated through endoscopic sclerotherapy before neovascularization. Seven patients received photodynamic therapy, and seven patients served as the control group. In the photodynamic therapy group, intravenous injection of 5 mg/kg of hematoporphyrin monomethyl ether was given and immediately followed by endoscopic irradiation of the newly visible vessels by copper vapor laser for 40 min with a power density of 150 mW/cm². Endoscopic examination was performed 3 months later to evaluate the therapeutic effect. The duration of non-bleeding was compared between the two groups. The number of newly visible vessels was found to have decreased after photodynamic therapy when compared with the control group (P < 0.001). Kaplan–Meier analyses demonstrated a longer period of non-bleeding in the photodynamic therapy group. The recurrent bleeding rate in the photodynamic therapy (PDT) group was lower than that in the control group (P = 0.027). One patient in the photodynamic therapy group suffered from facial dermatitis from shining direct light. Endoscopic photodynamic therapy seemed to be effective in the elimination of esophageal newly visible vessels and the prevention of recurrent bleeding.     

Long Term Variceal Sclerotherapy: Is Endoscopic Sclerosis a Unique Therapeutic Approach and a True Alternative to Surgery?

Endoscopic sclerotherapy has been used to control acute variceal haemorrhage which persists despite conservative therapy, prevent recurrent variceal haemorrhage in patients with a history of oesophageal haemorrhage, and to prevent a haemorrhage in patients with oesophageal varices who never bled. In this short paper I will cover our personal experience with more than 2000 patients receiving particularly paravariceal endoscopic sclerotherapy of bleeding esophageal varices, and especially present the results of our prospective and controlled randomized trials (Table 1) and underline the thesis that endoscopic sclerotherapy and surgical procedures for patients with portal hypertension are complementary supporting measures or options.