Treatment Strategies in Emergency Endoscopy for Acute Esophageal Variceal Bleeding (CHESS1905): A Nationwide Cohort Study

Yifei Huang, Wenhui Zhang, Huiling Xiang, Yanna Liu, Lili Yuan, Liyao Zhang, Shengjuan Hu, Dongli Xia, Jia Li, Min Gao, Xing Wang, Xingsi Qi, Lijun Peng, Ying Song, Xiqiao Zhou, Jing Zeng, Xiaoyan Tan, Mingming Deng, Haiming Fang, Shenglin Qi, Song He, Yongfeng He, Bin Ye, Wei Wu, Tong Dang, Jiangbo Shao, Wei Wei, Jianping Hu, Xin Yong, Chaohui He, Jinlun Bao, Yuening Zhang, Guo Zhang, Rui Ji, Yang Bo, Wei Yan, Hongjiang Li, Yanling Wang, Mengmeng Li, Fengmei Wang, Jia Lian, Chang'en Liu, Ping Cao, Zhenbei Liu, Aimin Liu, Lili Zhao, Shuang Li, Yunhai Wu, Ye Gu, Yan Wang, Yanfei Fang, Pan Jiang, Bin Wu, Chuan Liu, Xiaolong Qi, Yifei Huang, Wenhui Zhang, Huiling Xiang, Yanna Liu, Lili Yuan, Liyao Zhang, Shengjuan Hu, Dongli Xia, Jia Li, Min Gao, Xing Wang, Xingsi Qi, Lijun Peng, Ying Song, Xiqiao Zhou, Jing Zeng, Xiaoyan Tan, Mingming Deng, Haiming Fang, Shenglin Qi, Song He, Yongfeng He, Bin Ye, Wei Wu, Tong Dang, Jiangbo Shao, Wei Wei, Jianping Hu, Xin Yong, Chaohui He, Jinlun Bao, Yuening Zhang, Guo Zhang, Rui Ji, Yang Bo, Wei Yan, Hongjiang Li, Yanling Wang, Mengmeng Li, Fengmei Wang, Jia Lian, Chang'en Liu, Ping Cao, Zhenbei Liu, Aimin Liu, Lili Zhao, Shuang Li, Yunhai Wu, Ye Gu, Yan Wang, Yanfei Fang, Pan Jiang, Bin Wu, Chuan Liu, Xiaolong Qi

Abstract

Background and aims: Emergency endoscopy is recommended for patients with acute esophageal variceal bleeding (EVB) and their prognosis has improved markedly over past decades due to the increased specialization of endoscopic practice. The study aimed to compare outcomes following emergency endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) in cirrhotic patients with acute EVB.

Methods: Cirrhotic patients with acute EVB who underwent emergency endoscopy were retrospectively enrolled from 2013 to 2020 across 34 university hospitals from 30 cities. The primary outcome was the incidence of 5-day rebleeding after emergency endoscopy. Subgroup analysis was stratified by Child-Pugh class and bleeding history. A 1:1 propensity score matching (PSM) analysis was performed.

Results: A total of 1,017 and 382 patients were included in EIS group and EVL group, respectively. The 5-day rebleeding incidence was similar between EIS group and EVL group (4% vs. 5%, P = 0.45). The result remained the same after PSM (P = 1.00). Among Child-Pugh class A, B and C patients, there were no differences in the 5-day rebleeding incidence between the two groups after PSM (P = 0.25, 0.82, and 0.21, respectively). As for the patients with or without bleeding history, the differences between EIS group and EVL group were not significant after PSM (P = 1.00 and 0.26, respectively).

Conclusion: The nationwide cohort study indicates that EIS and EVL are both efficient emergency endoscopic treatment strategies for acute EVB. EIS should not be dismissed as an economical and effective emergency endoscopic treatment strategy of acute EVB. ClincialTrials.gov number NCT04307264.

Keywords: emergency endoscopy; endoscopic injection sclerotherapy; endoscopic variceal ligation; liver cirrhosis; portal hypertension.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Huang, Zhang, Xiang, Liu, Yuan, Zhang, Hu, Xia, Li, Gao, Wang, Qi, Peng, Song, Zhou, Zeng, Tan, Deng, Fang, Qi, He, He, Ye, Wu, Dang, Shao, Wei, Hu, Yong, He, Bao, Zhang, Zhang, Ji, Bo, Yan, Li, Wang, Li, Wang, Lian, Liu, Cao, Liu, Liu, Zhao, Li, Wu, Gu, Wang, Fang, Jiang, Wu, Liu and Qi.

Figures

FIGURE 1
FIGURE 1
Study flow chart. EV, esophageal varices; EVB, esophageal variceal bleeding; EIS, endoscopic injection sclerotherapy; EVL, endoscopic variceal ligation.
FIGURE 2
FIGURE 2
Cumulative probability of 5-day rebleeding in all patients with cirrhosis. (A) Before PSM; (B) after PSM. EIS, endoscopic injection sclerotherapy; EVL, endoscopic variceal ligation; PSM, propensity score matching.

References

    1. Qi X, Huang Y, Pavlides M, Rockey DC. A community of portal hypertension. Hepatol Int. (2021) 15:575–8.
    1. Rigo GP, Merighi A, Chahin NJ, Mastronardi M, Codeluppi PL, Ferrari A, et al. A prospective study of the ability of three endoscopic classifications to predict hemorrhage from esophageal varices. Gastrointest Endosc. (1992) 38:425–9. 10.1016/s0016-5107(92)70470-2
    1. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. (2017) 65:310–35. 10.1002/hep.28906
    1. Ibrahim M, Mostafa I, Devière J. New developments in managing variceal bleeding. Gastroenterology. (2018) 154:1964–9. 10.1053/j.gastro.2018.02.023
    1. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. (2012) 107:345–60. 10.1038/ajg.2011.480
    1. Barkun AN, Almadi M, Kuipers EJ, Laine L, Sung J, Tse F, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the international consensus group. Ann Intern Med. (2019) 171:805–22. 10.7326/M19-1795
    1. Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med. (2010) 362:823–32. 10.1056/nejmra0901512
    1. Bosch J, Garcia-Pagan JC. Prevention of variceal rebleeding. Lancet. (2003) 361:952–4.
    1. European Association for the Study of the Liver [EASL]. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. (2018) 69:406–60. 10.1016/j.jhep.2018.03.024
    1. Singh P, Pooran N, Indaram A, Bank S. Combined ligation and sclerotherapy versus ligation alone for secondary prophylaxis of esophageal variceal bleeding: a meta-analysis. Am J Gastroenterol. (2002) 97:623–9. 10.1111/j.1572-0241.2002.05540.x
    1. Roberts D, Best LM, Freeman SC, Sutton AJ, Cooper NJ, Arunan S, et al. Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev. (2021) 4:CD013155. 10.1002/14651858.CD013155.pub2
    1. Stiegmann GV, Goff JS, Michaletz-Onody PA, Korula J, Lieberman D, Saeed ZA, et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med. (1992) 326:1527–32.
    1. Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med. (1995) 123:280–7. 10.7326/0003-4819-123-4-199508150-00007
    1. Lo GH, Lai KH, Cheng JS, Lin CK, Huang JS, Hsu PI, et al. Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices. Hepatology. (1997) 25:1101–4. 10.1002/hep.510250509
    1. Villanueva C, Piqueras M, Aracil C, Gómez C, López-Balaguer JM, Gonzalez B, et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. (2006) 45:560–7. 10.1016/j.jhep.2006.05.016
    1. Jensen DM, Kovacs TOG, Randall G. Emergency sclerotherapy vs. rubber band ligation for actively bleeding esophageal varices in a randomized prospective study [Abstract]. Gastrointest Endosc. (1994) 40:241.
    1. Luz GO, Maluf-Filho F, Matuguma SE, Hondo FY, Ide E, Melo JM, et al. Comparison between endoscopic sclerotherapy and band ligation for hemostasis of acute variceal bleeding. World J Gastrointest Endosc. (2011) 3:95–100. 10.4253/wjge.v3.i5.95
    1. R Core Team. (2020). R: A Language and Environment for Statistical Computing. Vienna: R Foundation for Statistical Computing.
    1. Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jiménez E, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology. (2004) 40:793–801. 10.1002/hep.20386
    1. Hsu YC, Chung CS, Tseng CH, Lin TL, Liou JM, Wu MS, et al. Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage. J Gastroenterol Hepatol. (2009) 24:1294–9. 10.1111/j.1440-1746.2009.05903.x
    1. Huh CW, Kim JS, Jung DH, Yang JD, Nam SW, Kwon JH, et al. Optimal endoscopy timing according to the severity of underlying liver disease in patients with acute variceal bleeding. Dig Liver Dis (2019) 51:993–8. 10.1016/j.dld.2019.01.013
    1. Ibrahim M. Management of acute gastric variceal hemorrhage. Endoscopy (2020) 52:528–30. 10.1055/a-1185-1110
    1. Wang S, Huang Y, Hu W, Mao H, McAlindon ME, Liu Y, et al. Detachable string magnetically controlled capsule endoscopy for detecting high-risk varices in compensated advanced chronic liver disease (CHESS1801): a prospective multicenter study. Lancet Reg Health West Pac. (2020) 6:100072. 10.1016/j.lanwpc.2020.100072
    1. Huang Y, Huang F, Yang L, Hu W, Liu Y, Lin Z, et al. Development and validation of a radiomics signature as a non-invasive complementary predictor of gastroesophageal varices and high-risk varices in compensated advanced chronic liver disease: a multicenter study. J Gastroenterol Hepatol. (2021) 36:1562–70. 10.1111/jgh.15306
    1. Li X, Kang N, Qi X, Huang Y. Artificial intelligence in the diagnosis of cirrhosis and portal hypertension. J Med Ultrason. (2021): [Epub ahead of print], 10.1007/s10396-021-01153-8
    1. Zhu Y, Cheng H, Chen J, Huang Y, Liu H, Qi X. Small varices in chronic liver diseases. Curr Opin Gastroenterol. (2022): [Epub ahead of print], 10.1097/MOG.0000000000000835
    1. Van Stiegmann G, Cambre T, Sun JH. A new endoscopic elastic band ligating device. Gastrointest Endosc. (1986) 32:230–3. 10.1016/s0016-5107(86)71815-4
    1. de Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. (2015) 63:743–52. 10.1016/j.jhep.2015.05.022
    1. Craaford C, Frenckner P. New surgical treatment of varices veins of the esophagus. Acta Otolaryngol. (1939) 27:422–9.
    1. Triantos CK, Goulis J, Patch D, Papatheodoridis GV, Leandro G, Samonakis D. An evaluationof emergency sclerotherapy of varices in randomizedtrials: looking the needle in the eye. Endoscopy. (2006) 38:797–807.
    1. de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C. Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol. (2021) 76:959–74.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj