Cost saving by reloading the multiband ligator in endoscopic esophageal variceal ligation: A proposal for developing countries

AIM:To assess the cost savings of reloading the multiband ligator in endoscopic esophageal variceal ligation (EVL) used on the same patient for subsequent sessions. METHODS:This single centre retrospective descriptive study analysed patients undergoing variceal ligation at a tertiary care centre between 1st January, 2003 and 30th June, 2006. The multiband ligator was reloaded with six hemorrhoidal bands using hemorrhoidal ligator for the second and subsequent sessions. Analysis of cost saving was done for the number of follow-up sessions for the variceal eradication. RESULTS:A total of 261 patients underwent at least one session of endoscopic esophageal variceal ligation between January 2003 and June 2006. Out of 261, 108 patients (males 67) agreed to follow the eradication program and underwent repeated sessions. A total of 304 sessions was performed with 2.81 sessions per patient on average. Thirty-two patients could not complete the programm. In 76 patients (70%), variceal obliteration was achieved. The ratio of the costs for the session with reloaded ligator versus a session with a new ligator was 1:2.37. Among the patients who completed esophageal varices eradication, cost saving with reloaded ligator was 58%. CONCLUSION:EVL using reloaded multiband ligators for the follow-up sessions on patients undergoing variceal eradication is a cost saving procedure. Reloading the ligator thus is recommended especially for developing countries where most of the patients are not health insured.

Evaluation of the efficacy and safety of endoscopic band ligation in the treatment of bleeding from mild to moderate gastric varices type 1

BACKGROUND According to practice guidelines,endoscopic band ligation(EBL)and endoscopic tissue adhesive injection(TAI)are recommended for treating bleeding from esophagogastric varices.However,EBL and TAI are known to cause serious complications,such as hemorrhage from dislodged ligature rings caused by EBL and hemorrhage from operation-related ulcers resulting from TAI.However,the optimal therapy for mild to moderate type 1 gastric variceal hemorrhage(GOV1)has not been determined.Therefore,the aim of this study was to discover an individualized treatment for mild to moderate GOV1.AIM To compare the efficacy,safety and costs of EBL and TAI for the treatment of mild and moderate GOV1.METHODS A clinical analysis of the data retrieved from patients with mild or moderate GOV1 gastric varices who were treated under endoscopy was also conducted.Patients were allocated to an EBL group or an endoscopic TAI group.The differences in the incidence of varicose relief,operative time,operation success rate,mortality rate within 6 wk,rebleeding rate,6-wk operation-related ulcer healing rate,complication rate and average operation cost were compared between the two groups of patients.RESULTS The total effective rate of the two treatments was similar,but the efficacy of EBL(66.7%)was markedly better than that of TAI(39.2%)(P<0.05).The operation success rate in both groups was 100%,and the 6-wk mortality rate in both groups was 0%.The average operative time(26 min)in the EBL group was significantly shorter than that in the TAI group(46 min)(P<0.01).The rate of delayed postoperative rebleeding in the EBL group was significantly lower than that in the TAI group(11.8%vs 45.1%)(P<0.01).At 6 wk after the operation,the healing rate of operation-related ulcers in the EBL group was 80.4%,which was significantly greater than that in the TAI group(35.3%)(P<0.01).The incidence of postoperative complications in the two groups was similar.The average cost and other related economic factors were greater for the EBL than for the TAI(P<0.01).CONCLUSION For mild to moderate GOV1,patients with EBL had a greater one-time varix eradication rate,a greater 6-wk operation-related ulcer healing rate,a lower delayed rebleeding rate and a lower cost than patients with TAI.

Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices:Which is better?

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies.Moreover,the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

Self-expanding metal stent for relieving the stricture after endoscopic injection for esophageal varices

BACKGROUND Esophageal stricture is one of the complications after esophageal varices sclero-therapy injection(ESI),and the incidence rate is between 2%-10%.AIM To explore the efficacy of self-expanding metal stent(SEMS)for the stricture after endoscopic injection with cyanoacrylate(CYA)and sclerotherapy for esophageal varices.METHODS We retrospectively analyzed the efficacy of SEMS to improve the stricture after endoscopic injection with CYA and sclerotherapy for esophageal varices in 4 patients from February 2023 to June 2023.RESULTS The strictures were improved in four patients after stenting.The stent was removed after two weeks because of chest pain with embedding into esophageal mucosa in one patient.The stent was removed after one month,however,the stent was reinserted because of the strictures happening again in two patients.The stent was removed after three months,however,the stent was reinserted because of the strictures happening again in one patient.The stent embedded into esophageal mucosa in three patients.There were 3 patients suffered reflux esophagitis,and the acid reflux was relieved by taking hydrotalcite.There was no other complication of esophageal perforation,bleeding from varices or infection.CONCLUSION SEMS may relieve the stricture which happened after endoscopic injection with CYA and sclerotherapy for esophageal varices.However,when we should remove the stent still needs to be explored.

Transparent cap adjusted the stent placed for stenosis after endoscopic injection of esophageal varices:A case report

BACKGROUND The stent embedded in the esophageal mucosa is one of the complications after stenting for esophageal stricture.We present a case of stent adjustment with the aid of a transparent cap after endoscopic injection of an esophageal varices stent.CASE SUMMARY A 61-year-old male patient came to the hospital with discomfort of the chest after the stent implanted for the stenosis because of endoscopic injection of esophageal varices.The gastroscopy was performed,and the stent embedded into the esophageal mucosa.At first,we pulled the recycling line for shrinking the stent,however,the mucosa could not be removed from the stent.Then a forceps was performed to remove the mucosa in the stent,nevertheless,the bleeding form the mucosa was obvious.And then,we used a transparent cap to scrape the mucosa along the stent,and the mucosa were removed successfully without bleeding.CONCLUSION A transparent cap helps gastroscopy to remove the mucosa embedded in the stent after endoscopic injection of the esophageal varices stent.

Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage:A meta-analysis

AIM:To compare the effect of endoscopic variceal ligation(EVL)with that of endoscopic injection sclerotherapy(EIS)in the treatment of patients withesophageal variceal bleeding.METHODS:We performed a systematic literature search of multiple online electronic databases.Metaanalysis was conducted to evaluate risk ratio(RR)and95%confidence interval(CI)of combined studies for the treatment of patients with esophageal variceal bleeding between EVL and EIS.RESULTS:Fourteen studies comprising 1236 patients were included in the meta-analysis.The rebleeding rate in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group(RR=0.68,95%CI:0.57-0.81).The variceal eradication rate in actively bleeding varices patients in the EVL group was significantly higher than that in the EIS group(RR=1.06,95%CI:1.01-1.12).There was no significant difference about mortality rate between the EVL group and EIS group(RR=0.95,95%CI:0.77-1.17).The rate of complications in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group(RR=0.28,95%CI:0.13-0.58).CONCLUSION:Our meta-analysis has found that EVL is better than EIS in terms of the lower rates of rebleeding,complications,and the higher rate of variceal eradication.Therefore,EVL is the first choice for esophageal variceal bleeding.

Efficacy of β-adrenergic blocker plus 5-isosorbide mononitrate and endoscopic band ligation for prophylaxis of esophageal variceal rebleeding:A meta-analysis

AIM: To systematically assess the efficacy and safety of β-adrenergic blocker plus 5-isosorbide mononitrate (BB + ISMN) and endoscopic band ligation (EBL) on prophylaxis of esophageal variceal rebleeding. METHODS: Randomized controlled trials (RCTs) comparing the efficacy and safety of BB + ISMN and EBL on prophylaxis of esophageal variceal rebleeding were gathered from Medline, Embase, Cochrane Controlled Trial Registry and China Biological Medicine database between January 1980 and August 2007. Data from five trials were extracted and pooled. The analyses of the available data using the Revman 4.2 software were based on the intention-to-treat principle. RESULTS: Four RCTs met the inclusion criteria. In comparison with BB + ISMN with EBL in prophylaxis of esophageal variceal rebleeding, there was no significant difference in the rate of rebleeding [relative risk (RR), 0.79; 95% CI: 0.62-1.00; P = 0.05], bleeding-related mortality (RR, 0.76; 95% CI: 0.31-1.42; P = 0.40), overall mortality (RR, 0.81; 95% CI: 0.61-1.08; P = 0.15) and complications (RR, 1.26; 95% CI: 0.93-1.70; P = 0.13). CONCLUSION:In the prevention of esophageal variceal rebleeding, BB + ISMN are as effective as EBL. There are few complications with the two treatment modalities. Both BB + ISMN and EBL would be considered as the first-line therapy in the prevention of esophageal variceal rebleeding.

Evaluation of the effects of combined endoscopic variceal ligation and splenectomy with pericardial devascularization on esophageal varices

AIM: To detect the hemodynamic alterations in collateral circulation before and after combined endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization by ultrasonography, and to evaluate their effect using hemodynamic parameters. METHODS: Forty-three patients with esophageal varices received combined EVL and splenectomy with pericardial devascularization for variceal eradication. The esophageal vein structures and azygos blood flow (AZBF) were detected by endoscopic ultrasonography and color Doppler ultrasound. The recurrence and rebleeding of esophageal varices were followed up. RESULTS: Patients with moderate or severe varices in the esophageal wall and those with severe peri- esophageal collateral vein varices had improvements after treatment, while the percentage of patients with severe para-esophageal collateral vein varices decreased from 54.49% to 2.33%, and the percentage of patients with detectable perforating veins decreased from 79.07% to 4.65% (P < 0.01). Color Doppler flowmetry showed a significant decrease both in AZBF (43.00%, P < 0.05) and in diameter of the azygos vein (28.85%, P < 0.05), while the blood flow rate was unchanged. The recurrence rate of esophageal varices was 2.5% (1/40, mild), while no re-bleeding cases were recorded. CONCLUSION: EVL in combination with splenectomy with pericardial devascularization can block the collateral veins both inside and outside of the esophageal wall, and is more advantagious over splenectomy in combination with pericardial devascularization or EVL in preventing recurrence and re-bleeding of varices.

Management of acute esophageal variceal bleeding by endoscopic sclerotherapy in technically difficult endoscopic band ligation cases—A population based cohort study

Endoscopic band ligation is regarded as the main therapeutic option for acute esophageal variceal bleeding, while sclerotherapy may be used in the acute setting if ligation is technically difficult. The incidence of difficult-to-perform band ligation in acute esophageal variceal bleeding, as well as the outcome of patients subjected to injection sclerotherapy as an alternative treatment, has not been clearly investigated. Our aim is to study the outcome of patients subjected to injection sclerotherapy in the acute setting of esophageal variceal bleeding when endoscopic band ligation is technically difficult to perform. We included 151 patients with acute esophageal variceal bleeding originnating from medium or large sized varices. All patients were planned for EBL as the 1st treatment option (EBL group 61.6%), meanwhile, EIS using 5% ethanolamine oleate was reserved as the 2nd treatment option when EBL was technically difficult (EIS group 38.4%). The mean time to restore hemodynamic stability was significantly prolonged in the EIS group (11.5 ± 6.5 hrs versus 9.5 ± 5.0 hrs, p 0.05). Initial control of bleeding was significantly higher in the EBL group versus the EIS group (96.7% vs 84.5%, p 0.021). Re-bleeding was more among the EIS group (42.9% vs 24.2%, p 0.04). There were no significant differences as regarding mortality and duration of hospital stay. So, a considerable proportion of cases presenting with acute variceal bleeding will have difficulty in performing EBL. In these patients, sclerotherapy is not a waning procedure with an accepted success rate, without much additional complications and without deranging mortality.

Risk factors for predicting early variceal rebleeding after endoscopic variceal ligation

AIM: To analyze the clinical risk factors for early variceal rebleeding after endoscopic variceal ligation (EVL).METHODS: 342 cirrhotic patients with esophageal varices who received elective EVL to prevent bleeding or rebleeding at our endoscopy center between January 2005 and July 2010.were included in this study.The early rebleeding cases after EVL were confirmed by clinical signs or endoscopy.A case-control study was performed comparing the patients presenting with early rebleeding with those without this complication.RESULTS: The incidence of early rebleeding after EVL was 7.60%,and the morbidity of rebleeding was 26.9%.Stepwise multivariate logistic regression analysis showed that four variables were independent risk factors for early rebleeding: moderate to excessive ascites [odds ratio (OR) 62.83,95% CI: 9.39-420.56,P < 0.001],the number of bands placed (OR 17.36,95% CI: 4.00-75.34,P < 0.001),the extent of varices (OR 15.41,95% CI: 2.84-83.52,P = 0.002) and prothrombin time (PT) > 18 s (OR 11.35,95% CI: 1.93-66.70,P = 0.007).CONCLUSION: The early rebleeding rate after EVL is mainly affected by the volume of ascites,number of rubber bands used to ligate,severity of varices and prolonged PT.Effective measures for prevention and treatment should be adopted before and after EVL.

Comparison between endoscopic sclerotherapy and band ligation for hemostasis of acute variceal bleeding

AIM:To compare band ligation(BL) with endoscopic sclerotherapy(SCL) in patients admitted to an emergency unit for esophageal variceal rupture. METHODS:A prospective,randomized,single-center study without crossover was conducted.After endoscopic diagnosis of esophageal variceal rupture,patients were randomized into groups for SCL or BL treatment.Sclerotherapy was performed by ethanolamine oleate intravascular injection both above and below the rupture point,with a maximum volume of 20 mL.For BL patients,banding at the rupture point was attempted,followed by ligation of all variceal tissue of the distal esophagus.Primary outcomes for both groups were initial failure of bleeding control(5 d) ,early re-bleeding(5 d to 6 wk),and complications,including mortality.From May 2005 to May 2007,100 patients with variceal bleeding were enrolled in thestudy:50 SCL and 50 BL patients.No differences between groups were observed across gender,age,ChildPugh status,presence of shock at admission,mean hemoglobin levels,and variceal size. RESULTS:No differences were found between groups for bleeding control,early re-bleeding rates,complications,or mortality.After 6 wk,36(80%) SCL and 33(77 %) EBL patients were alive and free of bleeding.A statistically significant association between Child-Pugh status and mortality was found,with 16%mortality in Child A and B patients and 84%mortality in Child C patients(P<0.001) . CONCLUSION:Despite the limited number of patients included,our results suggest that SCL and BL are equally efficient for the control of acute variceal bleeding.

Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication

BACKGROUND Bleeding esophageal varices(BEV)is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25%within six weeks of the index variceal bleed.After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selectiveβ-blockers to prevent further bleeding and eradicate EV.AIM To assess the efficacy of endoscopic variceal ligation(EVL)in controlling acute variceal bleeding,preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices(EV)in patients who present with BEV.METHODS A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018.Control of acute bleeding,variceal recurrence,rebleeding,eradication and survival were analyzed using Baveno assessment criteria.RESULTS One hundred and forty patients(100 men,40 women;mean age 50 years;range,21-84 years;Child-Pugh grade A=32;B=48;C=60)underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions.One hundred and fourteen(81%)of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV,while 26(19%)patients had complicated and refractory variceal bleeding.EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients(95.7%).Six patients required balloon tamponade for control and 4 other patients rebled in hospital.Overall 5-d endoscopic failure to control variceal bleeding was 7.1%(n=10)and four patients required a salvage transjugular intrahepatic portosystemic shunt.Index admission mortality was 14.2%(n=20).EV were completely eradicated in 50 of 111 patients(45%)who survived>3 mo of whom 31 recurred and 3 rebled.Sixteen(13.3%)of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital.Overall rebleeding from all sources after 2 years was 21.7%(n=26).Sixty-nine(49.3%)of the 140 patients died,mainly due to liver failure(n=46)during follow-up.Cumulative survival for the 140 patients was 71.4%at 1 year,65%at 3 years,60%at 5 years and 52.1%at 10 years.CONCLUSION EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%.Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV,of whom 62%recurred,there was a significant reduction in subsequent rebleeding.

Splenectomy with endoscopic variceal ligation is superior to splenectomy with pericardial devascularization in treatment of portal hypertension

AIM: To investigate the therapeutic efficacy and complications of splenectomy with endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization (i.e. Hassab’s operation) in patients with portal hypertension. METHODS: A total of 103 patients with liver cirrhosis and portal hypertension were randomly selected to receive either splenectomy with EVL (n = 53, group A) or Hassab’s operation (n = 50, group B). RESULTS: The portal blood flow volume, the presence of portal vein thrombosis, gastric emptying time and free portal venous pressure (FPP) before and after the operation were determined. Patients were followed up for up to 64 mo with an average of 45 mo, and the Dagradi classification of variceal veins and the grading of portal hypertension gastropathy (PHG) were evaluated. It was found that all esophageal varices were occluded or decreased to grade Ⅱ or less in both groups. There was little difference in the recurrence rate of esophageal varices (11.9% vs 13.2%) and the re-bleeding rate (7.1% vs 5.3%) between groups A and B. The incidence of complications and the percentage of patients with severe PHG after the operation were significantly higher in group B (60.0% and 52.0%) than in group A (32.1% and 20.8%, P < 0.05). No patients died of operation-related complications. There was no significant difference in gastric emptying time, FPP and portal blood flow volume between the two groups. CONCLUSION: The results suggest that splenectomy with EVL achieves similar therapeutic efficacy to that of Hassab’s operation in terms of the recurrence rate of esophageal varices and the re-bleeding rate, but theformer results in fewer and milder complications.

A new technique of combined endoscopic sclerotherapy and ligation for variceal bleeding

AIM: To develop a technique of combined endoscopic sclerotherapy and ligation (ESL) in which both techniques of endoscopic sclerotherapy (ES) and endoscopic variceal ligation (EVL) can be optimally used.METHODS: ESL was performed in 10 patients (age 46.4±7.9;9 males, 1 female) with cirrhosis of liver using sclerotherapy needle and Speedband, Superview multiple band ligater (Boston Scientific, Microvasive, Watertown, MA). A single band was placed 5-10 cm proximal to the gastro-esophageal junction over each varix from proximal to distal margin,followed by intravariceal injection of 1.5 % ethoxysclerol (4 ml each) 2 to 3 cm proximal to the gastroesophageal junction on the ligated varices distal to deployed band. EVL was then performed at the injection site. Similarly other varices were also injected and ligated from distal to proximally. In the subsequent sessions, ES alone was performed to sclerose small varices at the gastroesophageal junction.RESULTS: ESL was successfully performed in all patients.A median of 3 (ESL 1, ES 2) sessions (ranged 1-4) were required to eradicate the varices in 9 (90 %) of 10 patients.Recurrence of varices without bleed was seen in 1 patient during a mean follow-up of 10.3 months (ranged 6-15).Two patients died of liver failure. None died of variceal bleeding. None of the patients had procedure related complications.CONCLUSION: ESL may be useful in the fast eradication of esophageal varices. However, randomised controlled trials are required to find out its relative efficacy and impact on variceal recurrence in comparison to ES or EVL.

Comparative study for predictability of type 1 gastric variceal rebleeding after endoscopic variceal ligation:High-frequency intraluminal ultrasound study

BACKGROUND The efficacy of endoscopic ultrasonography for the follow-up of gastric varices treated with endoscopic variceal ligation(EVL)has not been established.AIM To evaluate the diagnostic correlation of esophagogastroduodenoscopy(EGD)and high-frequency intraluminal ultrasound(HFIUS)for type 1 gastric varices(GOV1)after EVL and to identify the predictability for rebleeding of EGD and HFIUS.METHODS In liver cirrhosis patients with GOV1,we performed endoscopic follow-up using EGD and HFIUS synchronously after EVL for hemorrhage from GOV1.Endoscopic grading and red color signs were analyzed using EGD,and the largest variceal cross-sectional areas were measured using HFIUS.In addition,1-year follow-up was performed.Variceal rebleeding was defined as the presence of hematemesis,hematochezia,or melena without other evidence of bleeding on endoscopic follow-up.RESULTS In 26 patients with GOV1,variceal cross-sectional areas on HFIUS of GOV1 was poorly correlated with EGD grading of GOV1(r=0.36).In 17 patients who completed the 1-year follow-up,variceal cross-sectional areas on HFIUS was a good predictor of subsequent rebleeding,whereas EGD grading was not a predictor of subsequent rebleeding.CONCLUSION HFIUS measurement is more predictive of GOV1 rebleeding than EGD grading,so HFIUS measurement may be necessary for endoscopic follow-up after EVL in patients with GOV1.

Lateral position intubation followed by endoscopic ultrasoundguided angiotherapy in acute esophageal variceal rupture: A case report

BACKGROUND Massive esophageal variceal bleeding can be catastrophic,leading to high morbidity and mortality.Patients experiencing massive esophageal variceal bleeding are at high risk of aspiration and hemorrhagic shock in acute episodes.Intubation and bleeding control are the two essential steps for resuscitation of these patients.CASE SUMMARY A 47-year-old male patient was admitted to our hospital with upper digestive tract bleeding.He was diagnosed with alcohol-induced liver cirrhosis and consequent esophagogastric varices.As he did not show a good response to somatostatin and Sengstaken-Blakemore tube placement,the patient was scheduled for endoscopic angiotherapy under anesthesia.Preoperative assessment showed an ASA physical status of III and Child-Pugh classification B.However,massive hemorrhage occurred just after induction of anesthesia.Intubation by video-guided laryngoscopy in the lateral decubitus position was attempted twice and was successful.After that,an experienced endoscopic ultrasound(EUS)specialist performed angiotherapy and occluded the culprit vessel.An ultra-thin gastroscope was then inserted into the endotracheal tube to extract the blood observed in the lobar bronchi.The patient suffered hemorrhagic shock with an estimated blood loss of 1500 mL in 20 min and remained in the intensive care unit for two days.The patient was discharged from our hospital eight days later without major complications.CONCLUSION Intubation in the lateral decubitus position and EUS-guided treatment can be lifesaving procedures in patients with massive upper gastrointestinal hemorrhage.

Suspected cerebrovascular air embolism during endoscopic esophageal varices ligation under sedation with fatal outcome: A case report

BACKGROUND Air embolism is a very rare,yet serious and potentially fatal complication of digestive endoscopic treatment.Air embolism is the result of air directly entering the arteries or veins.However,to recognize neurological dysfunction under sedation can be difficult.Therefore,it is extremely important to identify high-risk groups and take preventive measures.CASE SUMMARY Herein,we report a 74-year-old female patient with esophageal varices who suffered from consciousness disturbance after the third endoscopic ligation of esophageal varices under sedation.Combined with the patient’s imaging examination results and medical history,we highly suspected that the patient had developed paradoxical cerebral air embolism during endoscopic ligation.We learned that the patient died at a later follow-up.In order to be able to identify and prevent the occurrence of air embolism early,we summarize and analyze the risk factors,pathogenesis,clinical manifestations,prevention and treatment options of gastrointestinal endoscopy complicated by cerebral air embolism.CONCLUSION Electroencephalographic monitoring helps to recognize the occurrence of air embolism in time and increase the patient's chance of survival.

Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study

BACKGROUND Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis.The current standard treatment is endoscopic variceal ligation(EVL),and Western guidelines recom-mend antibiotic prophylaxis following hemostasis.However,given the impro-vements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria,there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis.AIM To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL.METHODS We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals.Patients were divided into the prophylaxis group(received antibiotics on admission or the next day)and the non-prophylaxis group(did not receive antibiotics within one day of admission).The primary outcome was composed of 6-wk mortality,4-wk rebleeding,and 4-wk spontaneous bacterial peritonitis(SBP).The secondary outcomes were each individual result and in-hospital mortality.A logistic regression with inverse probability of treatment weighting was used.A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures,while sensitivity analyses for antibiotic type and duration were also performed.RESULTS Among 980 patients,790 were included(prophylaxis:232,non-prophylaxis:558).Most patients were males under the age of 65 years with a median Child-Pugh score of 8.The composite primary outcomes occurred in 11.2%of patients in the prophylaxis group and 9.5%in the non-prophylaxis group.No significant differences in outcomes were observed between the groups(adjusted odds ratio,1.11;95%confidence interval,0.61-1.99;P=0.74).Individual outcomes such as 6-wk mortality,4-wk rebleeding,4-wk onset of SBP,and in-hospital mortality were not significantly different between the groups.The primary outcome did not differ between the Child-Pugh subgroups.Similar results were observed in the sensitivity analyses.CONCLUSION No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study.Global reassessment of routine antibiotic prophylaxis is imperative.

Comparison of hepatic venous pressure gradient and endoscopic grading of esophageal varices

AIM: To determine the correlation between the hepatic venous pressure gradient and the endoscopic grade of esophageal varices.METHODS: From September 2009 to March 2013, a total of 176 measurements of hepatic venous pressure gradient (HVPG) were done in 146 patients. Each transjugular HVPG was measured twice, first using an end whole catheter (EH-HVPG), and then using a balloon catheter (B-HVPG). The HVPG was compared with the endoscopic grade of esophageal varices (according to the general rules for recording endoscopic findings of esophagogastric varices), which was recorded within a month of the measurement of HVPG.RESULTS: The study included 110 men and 36 women, with a mean age of 56.1 years (range, 43-76 years). The technical success rate of the pressure measurements was 100% and there were no complication related to the procedures. Mean HVPG was 15.3 mmHg as measured using the end hole catheter method and 16.5 mmHg as measured using the balloon catheter method. Mean HVPG (both EH-HVPG and B-HVPG) was not significantly different among patients with different characteristics, including sex and comorbid factors, except for cases with hepatocellular carcinoma (B-HVPG, P = 0.01; EH-HVPG, P = 0.02). Portal hypertension (&#x0003e; 12 mmHg HVPG) occurred in 66% of patients according to EH-HVPG and 83% of patients according to B-HVGP, and significantly correlated with Child&#x02019;s status (B-HVPG, P &#x0003c; 0.000; EH-HVGP, P &#x0003c; 0.000) and esophageal varies observed upon endoscopy (EH-HVGP, P = 0.003; B-HVGP, P = 0.006). One hundred and thirty-five endoscopies were performed, of which 15 showed normal findings, 27 showed grade 1 endoscopic esophageal varices, 49 showed grade 2 varices, and 44 showed grade 3 varices. When comparing endoscopic esophageal variceal grades and HVPG using univariate analysis, the P value was 0.004 for EH-HVPG and 0.002 for B-HVPG.CONCLUSION: Both EH-HVPG and B-HVPG showed a positive correlation with the endoscopic grade of esophageal varices, with B-HVPG showing a stronger correlation than EH-HVPG.

Role of combined propofol and sufentanil anesthesia in endoscopic injection sclerotherapy for esophageal varices

AIM To investigate the efficacy and safety of a combination of sufentanil and propofol injection in patients undergoing endoscopic injection sclerotherapy(EIS) for esophageal varices(EVs). METHODS Patients with severe EVs who underwent EIS with sufentanil and propofol anesthesia between April 2016 and July 2016 at our hospital were reviewed. Although EIS and sequential therapy were performed under endotracheal intubation, we only evaluated the efficacy and safety of anesthesia for the first EIS procedure. Patients were intravenously treated with 0.5-1 μg/kg sufentanil. Anesthesia was induced with 1-2 mg/kg propofol and maintained using 2-5 mg/kg per hour of propofol. Information, regarding age, sex, weight, American Association of Anesthesiologists(ASA) physical status, Child-Turcotte-Pugh(CTP) classification, indications, preanesthetic problems, endoscopic procedure, successful completion of the procedure, anesthesia time, recovery time, and anesthetic agents, was recorded. Adverse events, including hypotension, hypertension, bradycardia, and hypoxia, were also noted.RESULTS Propofol and sufentanil anesthesia was provided in 182 procedures involving 140 men and 42 women aged 56.1± 11.7 years(range, 25-83 years). The patients weighed 71.4 ± 10.7 kg(range, 45-95 kg) and had ASA physical status classifications of Ⅱ(79 patients) or Ⅲ(103 patients). Ninety-five patients had a CTP classification of A and 87 had a CTP classification of B. Intravenous anesthesia was successful in all cases. The mean anesthesia time was 33.1 ± 5.8 min. The mean recovery time was 12.3 ± 3.7 min. Hypotension occurred in two patients(1.1%, 2/182). No patient showed hypertension during the endoscopic therapy procedure. Bradycardia occurred in one patient(0.5%, 1/182), and hypoxia occurred in one patient(0.5%, 1/182). All complications were easily treated with no adverse sequelae. All endoscopic procedures were completed successfully.CONCLUSION The combined use of propofol and sufentanil injection in endotracheal intubation-assisted EIS for EVs is effective and safe.