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M/58

Recent advance in management of esophageal variceal bleeding Joint Hospital Surgical Grand Round 25 January, 2014 Tse Pui Ying Nicole (TMH). M/58. HBV carrier, child’s B cirrhosis Admitted x Upper GI Bleeding OGD: bleeding esophageal varices, banding performed

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M/58

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  1. Recent advance in management of esophageal variceal bleedingJoint Hospital Surgical Grand Round25 January, 2014TsePui Ying Nicole (TMH)

  2. M/58 • HBV carrier, child’s B cirrhosis • Admitted x Upper GI Bleeding • OGD: bleeding esophageal varices, banding performed • Rebleeding few hours later failed to stop bleeding with endoscopic method (banding and sclerotherapy) • Put in Sengstaken tube  complicated with esophageal tear • We put in a metal stent for rupture esophagus • Patient has no more bleeding ? Metal stent can stop variceal bleeding?

  3. Recent advance in management of esophageal variceal bleedingSelf-Expanding Metal Stents (SEMS) [4]

  4. Current management Haemetemesis/Melena Resuscitation Endoscopy (OGD) Confirm esophageal variceal bleeding Variceal ligation (Banding) / Sclerotherapy Failure Success Balloon Temponade: - Sengstaken-Blakemore tube • Prevent rebleeding: • Vasoconstrictor

  5. Current management Haemetemesis/Melena Resuscitation Endoscopy (OGD) Confirm esophageal variceal bleeding Variceal ligation (Banding) / Sclerotherapy Failure Success Balloon Temponade: - Sengstaken-Blakemore tube • Prevent rebleeding: • Vasoconstrictor SEMS

  6. SEMS • SX-Ella DANIS stent [10] • Removable, covered, self-expanding • Control variceal bleeding by tamponade effect • Placed at most 2 weeks • Gold markers: loops at both end (for repositioning and stent removal) • Radiopaque markers: at both ends and midpoint

  7. SEMS • Stent insertion • Mean duration of procedure: 10 (+/- 6 minutes) [7] Balloon port Gastric balloon Guidewire White lock Blue lock Stent Wire port [14]

  8. [14]

  9. Stent Removal [5]

  10. SEMS VS Sengstaken tube - Advantages • Can be left in situ as long as 2 weeks • Cannot be removed by an agitated patient • Allow detailed and repeated endoscopic examination • Less risk of pulmonary aspiration

  11. SEMS • Limitation • Gastric varices cannot be controlled [9] • Do not exert a lasting effect • Complication • Stent migration into stomach • Esophageal ulcer • Esophageal tear SEMS

  12. Recent studies on SEMS • Control of acute bleeding (Time frame: 120 hours (5 days)), failed if[12] • Death • Fresh hematemesis / >=100ml fresh blood aspirated • Hypovolaemic shock • Hb drop >3g/dL within any 24 hour • Success of stent placement • Duration of placement • Stent migration • Complication • Mortality Definition according to Baveno criteria

  13. Case series, not controlled trial • Small sample size

  14. Failure (delivery system error) • gastric balloon rupture • failed inflation

  15. c.f. Balloon tamponade: 80% • Failure: • GV bleeding • failed stent deployment

  16. How to decide??

  17. Immediate repositioning

  18. Esophageal tear • Esophageal ulcer

  19. c.f. Usual 6 week mortality rate: 15-20% • Reason of death • liver failure, multi-organ failure, uncontrolled bleeding • High mortality rate • Selection bias (more severe underlying liver disease) • Further study to rule out • ? Related to stent • Delayed / Unrecognized complication

  20. Discussion – practical aspect • How to monitor any re-bleeding/complication after stent insertion • ? Daily OGD/CXR • ? One single size of stent fit for every patient • Need expertise for stent placement

  21. SEMS • Limitation of study • Limited number of study available • Not a controlled study • Small sample size • Only short term follow up (up to 60 days) • Future study • Need randomized trial • Larger sample size • Long term follow up

  22. Conclusion • SEMS is a recent advance in management ofrefractory esophageal variceal bleeding • Considered as a alternative to balloon temponade • safe and effective treatment in limited data • low complication rate • Satisfactory rate of bleeding control & stent deployment • need further study • Practical aspect: duration, monitoring, expertise

  23. Reference • Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46: 922-38. • Gin-Ho Lo. Management of acute esophageal variceal hemorrhage. Kaohsiung J Med Sci 2010; 26: 55-67. • Hubmann R, Bodlaj G, Czompo M, et al. The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 2006; 38: 896–901. • Zehetner J, Shamiyeh A, Wayand W, et al. Results of a new method to stop acute bleeding from esophageal varices: implantation of a self-expanding stent. Surg Endosc 2008; 22:2149–2152. • Wright G, Lewis H, Hogan B, et al. Self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 2010;71:71–78. • Dechene A, El Fouly AH, Bechmann LP, et al. Acute management of refractory variceal bleeding in liver cirrhosis by self-expanding metal stents. Digestion 2012;85:185–191. • Zakaria MS, Hamza IM, Mohey MA, et al. The fist Egyptian experience using new self-expandable metal stents in acute esophageal variceal bleeding: Pilot study. Saudi J Gastroenterol 2013; 45: 485-8. • Fabienne C. Fierz, Walter Kistler, Volker Stenz, et al. Treatment of esophageal variceal hemorrhage with self-expanding metal stents as a rescue maneuver in a swiss multicentric cohort. Case Rep Gastroenterol 2013; 7: 97-105. • Fuad Maufa and Firas H. Al-Kawas. Role of Self-Expandable Metal Stents in Acute Variceal Bleeding. Internalional Journal of Hepatology 2012; 418369. • Angels Escorsell and Jaime Bosch. Self-Expandable Metal Stents in the Treatment of Acute Esophageal Variceal Bleeding. Gastroenterology Research and Practice 2011; 910986. • Vivek Kumbhari, Payal Saxena, Mouen A, et al. Self-Expandable Metallic Stents for Bleeding Esophageal Varices. The Saudi J of Gastroenterology 2013; 1434 • Roberto de Franchis, on behalf of the Baveno V Faculty, Revising consensus in portal hypertension: Report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension, Journal of Hepatology 2010; 53: 762-768 • National Institute for Health and Clinical Excellence. Stent insertion for bleeding oesophageal varices. 2011; AprilLászló Benk M.D. New minimal invasive therapeutic options in the management of acute and recurrent esophageal bleeding, 2007

  24. Thank You

  25. [13]

  26. Should we use it? • Weak evidence 1st stage 2nd stage SEMS Failure SEMS

  27. The Danis stent is larger in diameter and the expansion force has been adjusted to work efficiently against bleeding varices, but not to harm the esophageal tissue. The larger diameter is sufficientto fit every patient. The pressure exerted by the stent has been evaluated in animal model and later with clinical experience to be sufficient and safe

  28. [9]

  29. Management • Pre-primary prophylaxis (Prevention of formation of varices) • Non-selective beta-blockers: no evidence to prevent formation of varices • OGD: Should be screened for varices at diagnosis • Primary prophylaxis (prevention of first variceal hemorrhage) • Non-selective beta blocker: Recommended • OGD: Esophageal variceal ligation (EVL) recommended • Repeated every 1-2 weeks till complete obliteration • Secondary prophylaxis (prevention of rebleeding) • Combination of nonselective beta blockers + EVL • TIPS: recurrent variceal haemorrhage • Transplant

  30. When remove stent • Bind time to let pharmcological therapy to work • When elective procedure a/v or expertise a/v • Convert emergency procedure to elective • Contraindication of stent • Stricture • Esophageal tumor • Previous radiation • Body weight <40kg • Risk of stent complication like esophageal rupture • Protective pressure valve  does not allow gastric balloon to inflate against resistance • if gastric balloon inflate wrongly in esophagus  safety balloon at tip of delivery system is inflated

  31. Migration • Covered stent • Wait for 3 minutes for full expansion • Optimal integration with esophageal wall • Uncovered stent • Metal wire to dense: impringe on varices with pin point pressure • Metal wire not close: varices may squeeze out between wire and can’t exert temponade effect • Pressure it exert • Not specific mentioned • Radial pressure • Evaluate in animal model and clinical experience to be sufficient and safe • Monitoring • CXR daily • OGD alt day

  32. Treat the symptom, not underlying cause (liver failure) • Treat esophageal varices • Physical: banding, sengstaken, SEMS • Chemical: sclerosant, superglue (cyanoarcylate monomer) • Treat underlying disease • Best medical treatment • Further treatment • Late stage • Further treatment has its own risk and complication, e.g. TIPS (seldom do) • Best medical treatment • Nutrition, lactulose, antibiotic, avoid hepatotoxic drug, medication, etc • In our study: EVL, TIPS, shunt surgery, transplant

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