Minimal and Maximal Extent of Band Ligation for Acute Variceal Bleeding during the First Endoscopic Session
1
조회
0
다운로드
0
인용
0
참고문헌
키워드
초록
Background/Aims: The appropriate number of band ligations during the first endoscopic session for acute variceal bleeding is debatable. We aimed to compare the technical aspects of endoscopic variceal ligation (EVL) in patients with variceal bleeding according to the number of bands placed per session. Methods: We retrospectively reviewed multicenter data from patients who underwent EVL for acute variceal bleeding. Patients were classified into minimal EVL (targeting only the foci with active bleeding or stigmata of recent bleeding) and maximal EVL (targeting potential bleeding sources in addition to the aforementioned targets) groups. The primary endpoint was 5-day treatment failure. The secondary endpoints were 30-day rebleeding, 30-day mortality, and intraprocedural adverse events. Results: Minimal EVL was associated with lower rates of hypoxia and shock during EVL than maximal EVL (hypoxia, 0.9% vs 2.9%; shock, 1.3% vs 3.4%). However, treatment failure was higher in the minimal EVL group than in the maximal EVL group (odds ratio, 1.60; 95% confidence interval, 1.06 to 2.41). Age ≥60 years, Model for End-Stage Liver Disease score ≥15, Child-Turcotte-Pugh classification C, presence of hepatocellular carcinoma, and systolic blood pressure <90 mm Hg at initial presentation were also associated with treatment failure. In contrast, 30-day rebleeding and 30-day mortality did not differ between the minimal and maximal EVL groups. Conclusions: Given that minimal EVL was associated with a high risk of treatment failure, maximal EVL may be a better option for variceal bleeding. However, the minimal EVL strategy should be considered in select patients because it does not affect 30-day rebleeding and mortality.
Abstract
Background/Aims: The appropriate number of band ligations during the first endoscopic session for acute variceal bleeding is debatable. We aimed to compare the technical aspects of endoscopic variceal ligation (EVL) in patients with variceal bleeding according to the number of bands placed per session. Methods: We retrospectively reviewed multicenter data from patients who underwent EVL for acute variceal bleeding. Patients were classified into minimal EVL (targeting only the foci with active bleeding or stigmata of recent bleeding) and maximal EVL (targeting potential bleeding sources in addition to the aforementioned targets) groups. The primary endpoint was 5-day treatment failure. The secondary endpoints were 30-day rebleeding, 30-day mortality, and intraprocedural adverse events. Results: Minimal EVL was associated with lower rates of hypoxia and shock during EVL than maximal EVL (hypoxia, 0.9% vs 2.9%; shock, 1.3% vs 3.4%). However, treatment failure was higher in the minimal EVL group than in the maximal EVL group (odds ratio, 1.60; 95% confidence interval, 1.06 to 2.41). Age ≥60 years, Model for End-Stage Liver Disease score ≥15, Child-Turcotte-Pugh classification C, presence of hepatocellular carcinoma, and systolic blood pressure <90 mm Hg at initial presentation were also associated with treatment failure. In contrast, 30-day rebleeding and 30-day mortality did not differ between the minimal and maximal EVL groups. Conclusions: Given that minimal EVL was associated with a high risk of treatment failure, maximal EVL may be a better option for variceal bleeding. However, the minimal EVL strategy should be considered in select patients because it does not affect 30-day rebleeding and mortality.
참고문헌 (25)
- Lay CS, "Endoscopic variceal ligation in prophylaxis of first variceal bleeding in cirrhotic patients with high-risk esophageal varices", Hepatology, 25, pp.1346~1350 (1997)
- Lo GH, "Prophylactic banding ligation of high-risk esophageal varices in patients with cirrhosis : a prospective, randomized trial", J Hepatol, 31, pp.451~456 (1999)
- Djurdjevic D, "Combined ligation and sclerotherapy versus ligation alone for eradication of bleeding esophageal varices : a randomized and prospective trial", Endoscopy, 31, pp.286~290 (1999)
- Pomier-Layrargues G, "Transjugular intrahepatic portosystemic shunt(TIPS)versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis : a randomised trial", Gut, 48, pp.390~396 (2001)
- Singh P, "Combined ligation and sclerotherapy versus ligation alone for secondary prophylaxis of esophageal variceal bleeding : a meta-analysis", Am J Gastroenterol, 97, pp.623~629 (2002)
- Garcia-Tsao G, "Portal hypertensive bleeding in cirrhosis : risk stratification, diagnosis, and management. 2016 Practice guidance by the American Association for the Study of Liver Diseases", Hepatology, 65, pp.310~335 (2017)
- Saeed ZA, "Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices : a multicenter prospective randomized trial", Hepatology, 25, pp.71~74 (1997)
- Garcia-Tsao G, "Practice Guidelines Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis", Hepatology, 46, pp.922~938 (2007)
- Yeon Seok Seo, "Prevention and management of gastroesophageal varices", Clinical and Molecular Hepatology, 24(1), pp.20~42 (2018), 대한간학회
- Mao W, "The safety of combined sedation with propofol plus fentanyl for endoscopy screening and endoscopic variceal ligation in cirrhotic patients", J Dig Dis, 15, pp.124~130 (2014)
- Johanson JF, "Optimal nonsurgical treatment of hemorrhoids : a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy", Am J Gastroenterol, 87, pp.1600~1606 (1992)
- Ramirez FC, "The effects of the number of rubber bands placed at each endoscopic session upon variceal outcomes : a prospective, randomized study", Am J Gastroenterol, 102, pp.1372~1376 (2007)
- Al Traif I, "Randomized trial of ligation versus combined ligation and sclerotherapy for bleeding esophageal varices", Gastrointest Endosc, 50, pp.1~6 (1999)
- 김수진, "Emergency endoscopic variceal ligation in cirrhotic patients with blood clots in the stomach but no active bleeding or stigmata increases the risk of rebleeding", Clinical and Molecular Hepatology, 22(4), pp.466~476 (2016), 대한간학회[DOI]
- Petrasch F, "Differences in bleeding behavior after endoscopic band ligation : a retrospective analysis", BMC Gastroenterol, 10, pp.5~ (2010)
- Albillos A, "Stratifying risk in the prevention of recurrent variceal hemorrhage : results of an individual patient meta-analysis", Hepatology, 66, pp.1219~1231 (2017)
- de Franchis R, "Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension", J Hepatol, 53, pp.762~768 (2010)
- Fine JP, "A proportional hazards model for the subdistribution of a competing risk", J Am Stat Assoc, 94, pp.496~509 (1999)
- Ibrahim M, "Early application of haemostatic powder added to standard management for oesophagogastric variceal bleeding : a randomised trial", Gut, 68, pp.844~853 (2019)
- de la Peña J, "Variceal ligation compared with endoscopic sclerotherapy for variceal hemorrhage : prospective randomized trial", Gastrointest Endosc, 49(4 Pt 1), pp.417~423 (1999)
- Sarin SK, "Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices : influence on gastropathy, gastric varices and variceal recurrence", J Hepatol, 26, pp.826~832 (1997)
- Harewood GC, "Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleeding", J Gastroenterol Hepatol, 21(1 Pt 2), pp.237~241 (2006)
- Wang AJ, "Second-look endoscopyguided therapy under sedation prevents early rebleeding after variceal ligation for acute variceal bleeding", J Dig Dis, 21, pp.170~178 (2020)
- Garcia-Tsao G, "Management of varices and variceal hemorrhage in cirrhosis", N Engl J Med, 362, pp.823~832 (2010)
- Corley DA, "Octreotide for acute esophageal variceal bleeding : a metaanalysis", Gastroenterology, 120, pp.946~954 (2001)