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Self-Expandable Metal Stents for Persisting Esophageal Variceal Bleeding after Band Ligation or Injection-Therapy: A Retrospective Study.

Müller M, Seufferlein T, Perkhofer L, Wagner M, Kleger A - PLoS ONE (2015)

Bottom Line: The presence of hiatal hernia did not affect obviously stent dislocation rates.Refractory patients had significantly longer hospitalization times compared to non-refractory patients.Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine I, Ulm University, Ulm, Germany.

ABSTRACT

Background and study aims: Despite a pronounced reduction of lethality rates due to upper gastrointestinal bleeding, esophageal variceal bleeding remains a challenge for the endoscopist and still accounts for a mortality rate of up to 40% within the first 6 weeks. A relevant proportion of patients with esophageal variceal bleeding remains refractory to standard therapy, thus making a call for additional tools to achieve hemostasis. Self-expandable metal stents (SEMS) incorporate such a tool.

Methods: We evaluated a total number of 582 patients admitted to our endoscopy unit with the diagnosis "gastrointestinal bleeding" according to our documentation software between 2011 and 2014. 82 patients suffered from esophageal variceal bleeding, out of which 11 cases were refractory to standard therapy leading to SEMS application. Patients with esophageal malignancy, fistula, or stricture and a non-esophageal variceal bleeding source were excluded from the analysis. A retrospective analysis reporting a series of clinically relevant parameters in combination with bleeding control rates and adverse events was performed.

Results: The initial bleeding control rate after SEMS application was 100%. Despite this success, we observed a 27% mortality rate within the first 42 days. All of these patients died due to non-directly hemorrhage-associated reasons. The majority of patients exhibited an extensive demand of medical care with prolonged hospital stay. Common complications were hepatic decompensation, pulmonary infection and decline of renal function. Interestingly, we found in 7 out of 11 patients (63.6%) stent dislocation at time of control endoscopy 24 h after hemostasis or at time of stent removal. The presence of hiatal hernia did not affect obviously stent dislocation rates. Refractory patients had significantly longer hospitalization times compared to non-refractory patients.

Conclusions: Self-expandable metal stents for esophageal variceal bleeding seem to be safe and efficient after failed standard therapy. Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients. SEMS should be considered a reasonable treatment option for refractory esophageal variceal bleeding after treatment failure of ligature and sclerotherapy and non-availability of or contraindication for other measures (e.g. TIPS).

No MeSH data available.


Related in: MedlinePlus

Differences in patients with variceal bleeding treated either with SEMS (Self Expandable Metal Stent) or without SEMS.(A): Occurrence of different Child-Pugh classes within the SEMS–group and the conventionally treated group. (B): Mean duration of hospital stay within the SEMS-group and the conventionally treated group, p-value was generated with an unpaired t-test. (C): Prevalence of previous bleeding episodes (%) in both groups.
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pone.0126525.g002: Differences in patients with variceal bleeding treated either with SEMS (Self Expandable Metal Stent) or without SEMS.(A): Occurrence of different Child-Pugh classes within the SEMS–group and the conventionally treated group. (B): Mean duration of hospital stay within the SEMS-group and the conventionally treated group, p-value was generated with an unpaired t-test. (C): Prevalence of previous bleeding episodes (%) in both groups.

Mentions: 11 cases (3 female, 8 male) were refractory to standard therapy leading to SEMS application (Fig 1). Average age of the patients was 64 years (range 43–72 years). 10 out of 11 patients suffered from advanced liver cirrhosis (Child-Pugh score B or C) from different origins (Table 1, Table 3, Fig 2A), (multiple reasons possible: alcoholic liver disease n = 9; hepatitis B n = 1, cryptogenic cirrhosis n = 1, portal vein thrombosis associated with a Jak2 mutation n = 1). Interestingly, patients with bleeding control upon conventional therapy had less advanced liver cirrhosis and fewer previous bleeding episodes (Fig 2A and C). Variceal localization was esophageal (OV) in 8 patients and gastroesophageal (GOV Type I/II) in 3 patients. Mostly, we found grade III varices (Table 1; Paquet classification: Grade I n = 1, Grade III n = 6, Grade II n = 2, Grade VI n = 2). In 4 individuals, portal vein thrombosis was an additional cause for the development of portal hypertension. Three patients in our study were suffering from hepatocellular carcinoma in addition to liver cirrhosis. We noticed ascites in the vast majority of the investigated patients (81.8%, n = 9). Compared to those patients receiving bleeding control with conventional treatment, amount of previous bleeding episodes was higher in the stent group (Table 1, Table 4, Fig 2C). In the SEMS cohort hemostasis was further compromised by coagulation disorder (n = 4) and/or low platelets (n = 8) (Table 3).


Self-Expandable Metal Stents for Persisting Esophageal Variceal Bleeding after Band Ligation or Injection-Therapy: A Retrospective Study.

Müller M, Seufferlein T, Perkhofer L, Wagner M, Kleger A - PLoS ONE (2015)

Differences in patients with variceal bleeding treated either with SEMS (Self Expandable Metal Stent) or without SEMS.(A): Occurrence of different Child-Pugh classes within the SEMS–group and the conventionally treated group. (B): Mean duration of hospital stay within the SEMS-group and the conventionally treated group, p-value was generated with an unpaired t-test. (C): Prevalence of previous bleeding episodes (%) in both groups.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4476696&req=5

pone.0126525.g002: Differences in patients with variceal bleeding treated either with SEMS (Self Expandable Metal Stent) or without SEMS.(A): Occurrence of different Child-Pugh classes within the SEMS–group and the conventionally treated group. (B): Mean duration of hospital stay within the SEMS-group and the conventionally treated group, p-value was generated with an unpaired t-test. (C): Prevalence of previous bleeding episodes (%) in both groups.
Mentions: 11 cases (3 female, 8 male) were refractory to standard therapy leading to SEMS application (Fig 1). Average age of the patients was 64 years (range 43–72 years). 10 out of 11 patients suffered from advanced liver cirrhosis (Child-Pugh score B or C) from different origins (Table 1, Table 3, Fig 2A), (multiple reasons possible: alcoholic liver disease n = 9; hepatitis B n = 1, cryptogenic cirrhosis n = 1, portal vein thrombosis associated with a Jak2 mutation n = 1). Interestingly, patients with bleeding control upon conventional therapy had less advanced liver cirrhosis and fewer previous bleeding episodes (Fig 2A and C). Variceal localization was esophageal (OV) in 8 patients and gastroesophageal (GOV Type I/II) in 3 patients. Mostly, we found grade III varices (Table 1; Paquet classification: Grade I n = 1, Grade III n = 6, Grade II n = 2, Grade VI n = 2). In 4 individuals, portal vein thrombosis was an additional cause for the development of portal hypertension. Three patients in our study were suffering from hepatocellular carcinoma in addition to liver cirrhosis. We noticed ascites in the vast majority of the investigated patients (81.8%, n = 9). Compared to those patients receiving bleeding control with conventional treatment, amount of previous bleeding episodes was higher in the stent group (Table 1, Table 4, Fig 2C). In the SEMS cohort hemostasis was further compromised by coagulation disorder (n = 4) and/or low platelets (n = 8) (Table 3).

Bottom Line: The presence of hiatal hernia did not affect obviously stent dislocation rates.Refractory patients had significantly longer hospitalization times compared to non-refractory patients.Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine I, Ulm University, Ulm, Germany.

ABSTRACT

Background and study aims: Despite a pronounced reduction of lethality rates due to upper gastrointestinal bleeding, esophageal variceal bleeding remains a challenge for the endoscopist and still accounts for a mortality rate of up to 40% within the first 6 weeks. A relevant proportion of patients with esophageal variceal bleeding remains refractory to standard therapy, thus making a call for additional tools to achieve hemostasis. Self-expandable metal stents (SEMS) incorporate such a tool.

Methods: We evaluated a total number of 582 patients admitted to our endoscopy unit with the diagnosis "gastrointestinal bleeding" according to our documentation software between 2011 and 2014. 82 patients suffered from esophageal variceal bleeding, out of which 11 cases were refractory to standard therapy leading to SEMS application. Patients with esophageal malignancy, fistula, or stricture and a non-esophageal variceal bleeding source were excluded from the analysis. A retrospective analysis reporting a series of clinically relevant parameters in combination with bleeding control rates and adverse events was performed.

Results: The initial bleeding control rate after SEMS application was 100%. Despite this success, we observed a 27% mortality rate within the first 42 days. All of these patients died due to non-directly hemorrhage-associated reasons. The majority of patients exhibited an extensive demand of medical care with prolonged hospital stay. Common complications were hepatic decompensation, pulmonary infection and decline of renal function. Interestingly, we found in 7 out of 11 patients (63.6%) stent dislocation at time of control endoscopy 24 h after hemostasis or at time of stent removal. The presence of hiatal hernia did not affect obviously stent dislocation rates. Refractory patients had significantly longer hospitalization times compared to non-refractory patients.

Conclusions: Self-expandable metal stents for esophageal variceal bleeding seem to be safe and efficient after failed standard therapy. Stent migration appeared to be a common incident that did not lead to reactivation of bleeding in any of our patients. SEMS should be considered a reasonable treatment option for refractory esophageal variceal bleeding after treatment failure of ligature and sclerotherapy and non-availability of or contraindication for other measures (e.g. TIPS).

No MeSH data available.


Related in: MedlinePlus