Gut and Liver

The Korean Association for the Study of the Liver (대한간학회)
권호 표지
DOI QR코드

DOI QR Code

Balloon-Occluded Retrograde Transvenous Obliteration versus Transjugular Intrahepatic Portosystemic Shunt for the Management of Gastric Variceal Bleeding

  • Gimm, Geunwu (Seoul National University College of Medicine) ;
  • Chang, Young (Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine) ;
  • Kim, Hyo-Cheol (Department of Radiology, Seoul National University College of Medicine) ;
  • Shin, Aesun (Department of Preventive Medicine, Seoul National University College of Medicine) ;
  • Cho, Eun Ju (Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine) ;
  • Lee, Jeong-Hoon (Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine) ;
  • Yu, Su Jong (Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine) ;
  • Yoon, Jung-Hwan (Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine) ;
  • Kim, Yoon Jun (Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine)
  • Received : 2017.11.16
  • Accepted : 2018.04.06
  • Published : 2018.11.15
⟨ Previous Next ⟩

Abstract

Background/Aims: Gastric varices (GVs) are a major cause of upper gastrointestinal bleeding in patients with liver cirrhosis. The current treatments of choice are balloon-occluded retrograde transvenous obliteration (BRTO) and the placement of a transjugular intrahepatic portosystemic shunt (TIPS). We aimed to compare the efficacy and outcomes of these two methods for the management of GV bleeding. Methods: This retrospective study included consecutive patients who received BRTO (n=157) or TIPS (n=19) to control GV bleeding from January 2005 to December 2014 at a single tertiary hospital in Korea. The overall survival (OS), immediate bleeding control rate, rebleeding rate and complication rate were compared between patients in the BRTO and TIPS groups. Results: Patients in the BRTO group showed higher immediate bleeding control rates (p=0.059, odds ratio [OR]=4.72) and lower cumulative rebleeding rates (logrank p=0.060) than those in the TIPS group, although the difference failed to reach statistical significance. There were no significant differences in the rates of complications, including pleural effusion, aggravation of esophageal varices, portal hypertensive gastropathy, and portosystemic encephalopathy, although the rate of the progression of ascites was significantly higher in the BRTO group (p=0.02, OR=7.93). After adjusting for several confounding factors using a multivariate Cox analysis, the BRTO group had a significantly longer OS (adjusted hazard ratio [aHR]=0.44, p=0.01) and a longer rebleeding-free survival (aHR=0.34, p=0.001) than the TIPS group. Conclusions: BRTO provides better bleeding control, rebleeding-free survival, and OS than TIPS for patients with GV bleeding.

Keywords

References

  1. Nakano R, Iwao T, Oho K, Toyonaga A, Tanikawa K. Splanchnic hemodynamic pattern and liver function in patients with cirrhosis and esophageal or gastric varices. Am J Gastroenterol 1997;92:2085-2089.
  2. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a longterm follow-up study in 568 portal hypertension patients. Hepatology 1992;16:1343-1349. https://doi.org/10.1002/hep.1840160607
  3. de Franchis R, Primignani M. Natural history of portal hypertension in patients with cirrhosis. Clin Liver Dis 2001;5:645-663. https://doi.org/10.1016/S1089-3261(05)70186-0
  4. Triantafyllou M, Stanley AJ. Update on gastric varices. World J Gastrointest Endosc 2014;6:168-175. https://doi.org/10.4253/wjge.v6.i5.168
  5. Wani ZA, Bhat RA, Bhadoria AS, Maiwall R, Choudhury A. Gastric varices: classification, endoscopic and ultrasonographic management. J Res Med Sci 2015;20:1200-1207. https://doi.org/10.4103/1735-1995.172990
  6. Girotra M, Raghavapuram S, Abraham RR, Pahwa M, Pahwa AR, Rego RF. Management of gastric variceal bleeding: role of endoscopy and endoscopic ultrasound. World J Hepatol 2014;6:130-136. https://doi.org/10.4254/wjh.v6.i3.130
  7. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hyper tensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017;65:310-335. https://doi.org/10.1002/hep.28906
  8. Kim T, Shijo H, Kokawa H, et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology 1997;25:307-312. https://doi.org/10.1002/hep.510250209
  9. Kahloon A, Chalasani N, DeWitt J, et al. Endoscopic therapy with 2-octyl-cyanoacrylate for the treatment of gastric varices. Dig Dis Sci 2014;59:2178-2183. https://doi.org/10.1007/s10620-014-3148-9
  10. ASGE Technology Committee, Bhat YM, Banerjee S, et al. Tissue adhesives: cyanoacrylate glue and fibrin sealant. Gastrointest Endosc 2013;78:209-215. https://doi.org/10.1016/j.gie.2013.04.166
  11. Berry PA, Cross TJ, Orr DW. Clinical challenges and images in GI: pulmonary embolization of histoacryl "glue" causing hypoxia and cardiovascular instability. Gastroenterology 2007;133:1413-1748. https://doi.org/10.1053/j.gastro.2007.09.051
  12. Saracco G, Giordanino C, Roberto N, et al. Fatal multiple systemic embolisms after injection of cyanoacrylate in bleeding gastric varices of a patient who was noncirrhotic but with idiopathic portal hypertension. Gastrointest Endosc 2007;65:345-347. https://doi.org/10.1016/j.gie.2006.07.009
  13. Turler A, Wolff M, Dorlars D, Hirner A. Embolic and septic complications after sclerotherapy of fundic varices with cyanoacrylate. Gastrointest Endosc 2001;53:228-230. https://doi.org/10.1067/mge.2001.111561
  14. Chang CJ, Hou MC, Liao WC, et al. Management of acute gastric varices bleeding. J Chin Med Assoc 2013;76:539-546. https://doi.org/10.1016/j.jcma.2013.06.011
  15. Olson JC, Saeian K. Gastrointestinal issues in liver disease. Crit Care Clin 2016;32:371-384. https://doi.org/10.1016/j.ccc.2016.03.007
  16. Fukui H, Saito H, Ueno Y, et al. Evidence-based clinical practice guidelines for liver cirrhosis 2015. J Gastroenterol 2016;51:629-650. https://doi.org/10.1007/s00535-016-1216-y
  17. Saad WE, Darcy MD. Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices. Semin Intervent Radiol 2011;28:339-349. https://doi.org/10.1055/s-0031-1284461
  18. Kim MY, Um SH, Baik SK, et al. Clinical features and outcomes of gastric variceal bleeding: retrospective Korean multicenter data. Clin Mol Hepatol 2013;19:36-44. https://doi.org/10.3350/cmh.2013.19.1.36
  19. Wang YB, Zhang JY, Gong JP, Zhang F, Zhao Y. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: a meta-analysis. J Gastroenterol Hepatol 2016;31:727-733. https://doi.org/10.1111/jgh.13248
  20. Park JK, Saab S, Kee ST, et al. Balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices: review and meta-analysis. Dig Dis Sci 2015;60:1543-1553. https://doi.org/10.1007/s10620-014-3485-8
  21. Jang SY, Kim GH, Park SY, et al. Clinical outcomes of balloonoccluded retrograde transvenous obliteration for the treatment of gastric variceal hemorrhage in Korean patients with liver cirrhosis: a retrospective multicenter study. Clin Mol Hepatol 2012;18:368-374. https://doi.org/10.3350/cmh.2012.18.4.368
  22. Choi YH, Yoon CJ, Park JH, Chung JW, Kwon JW, Choi GM. Balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding: its feasibility compared with transjugular intrahepatic portosystemic shunt. Korean J Radiol 2003;4:109-116. https://doi.org/10.3348/kjr.2003.4.2.109
  23. Ninoi T, Nakamura K, Kaminou T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol 2004;183:369-376. https://doi.org/10.2214/ajr.183.2.1830369
  24. Lee SJ, Kim SU, Kim MD, et al. Comparison of treatment outcomes between balloon-occluded retrograde transvenous obliteration and transjugular intrahepatic portosystemic shunt for gastric variceal bleeding hemostasis. J Gastroenterol Hepatol 2017;32:1487-1494. https://doi.org/10.1111/jgh.13729
  25. Saad WE. Balloon-occluded retrograde transvenous obliteration of gastric varices: concept, basic techniques, and outcomes. Semin Intervent Radiol 2012;29:118-128. https://doi.org/10.1055/s-0032-1312573
  26. Kato T, Uematsu T, Nishigaki Y, Sugihara J, Tomita E, Moriwaki H. Therapeutic effect of balloon-occluded retrograde transvenous obliteration on portal-systemic encephalopathy in patients with liver cirrhosis. Intern Med 2001;40:688-691. https://doi.org/10.2169/internalmedicine.40.688
  27. Kumamoto M, Toyonaga A, Inoue H, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol 2010;25:1129-1135. https://doi.org/10.1111/j.1440-1746.2010.06262.x

Cited by

  1. The Choice of Interventional Treatment of Gastric Variceal Hemorrhage: What Is Better? vol.12, pp.6, 2018, https://doi.org/10.5009/gnl18464
  2. Comparison of the Effects of TIPS versus BRTO on Bleeding Gastric Varices: A Meta-Analysis vol.2020, pp.None, 2018, https://doi.org/10.1155/2020/5143013
  3. Ectopic Ascending Colonic Variceal Bleeding Treated with Balloon-Occluded Retrograde Transvenous Obliteration in a Decompensated Liver Cirrhosis Patient-A Hepatology Perspective vol.9, pp.7, 2020, https://doi.org/10.4236/crcm.2020.97027
  4. Feasibility and Effectiveness of Hepatic Artery Guiding Technique in Transjugular Intrahepatic Portosystemic Shunt Procedure vol.17, pp.3, 2020, https://doi.org/10.5812/iranjradiol.99198
  5. Balloon-occluded retrograde transvenous obliteration of colonic varices: a case report vol.3, pp.1, 2020, https://doi.org/10.1186/s42155-020-00108-3
  6. Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis-Current Understanding and Future Prospects vol.2021, pp.None, 2021, https://doi.org/10.1155/2021/8795115
  7. Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis vol.10, pp.11, 2018, https://doi.org/10.3390/jcm10112298
  8. Balloon-occluded retrograde transvenous obliteration for treatment of gastric varices vol.13, pp.6, 2021, https://doi.org/10.4254/wjh.v13.i6.650
  9. Diagnosis and Management of Esophageal and Gastric Variceal Bleeding: Focused on 2019 KASL Clinical Practice Guidelines for Liver Cirrhosis vol.78, pp.3, 2018, https://doi.org/10.4166/kjg.2021.113