Dataset Information

A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma.

ABSTRACT:

Background

Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied.

Methods

Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had >10 years of follow-up. HCC screening involved serum α-fetoprotein (AFP) every 3 months, ultrasonography every 6 months, and selective computed tomography (CT).

Results

HCC occurred in 15 patients, all incurable, a mean of 2.94 years after entry. They died a mean 1.33 years after discovery. Serial AFP and ultrasound examinations were unrevealing over a mean of 2.3 years. The mean model of end-stage liver disease score was 12.7 at entry and 17.4 at HCC diagnosis.

Conclusions

Long-term screening by AFP and ultrasound plus selective CT failed to detect HCC at a curable stage. The detection of HCC in cirrhotic patients with BEV remains a serious, unsolved problem. The use of CT for routine screening warrants consideration despite increased costs.

SUBMITTER: Orloff MJ

PROVIDER: S-EPMC6369695 | biostudies-literature | 2012 Feb

REPOSITORIES: biostudies-literature

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Publications

A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma.

Orloff Marshall J MJ Isenberg Jon I JI Wheeler Henry O HO Haynes Kevin S KS Jinich-Brook Horacio H Rapier Roderick R Vaida Florin F Hye Robert J RJ Orloff Susan L SL

American journal of surgery 20110616 2

<h4>Background</h4>Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied.<h4>Methods</h4>Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had ...[more]

PMID: 21679921

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Project description:BackgroundEmergency treatment of bleeding esophageal varices (BEV) in cirrhotic patients is of prime importance because of the high mortality rate surrounding the episode of acute bleeding. Nevertheless, there is a paucity of randomized controlled trials of emergency surgical therapy and no reports of the costs of any of the widely used forms of emergency treatment. The important issue of direct costs of care was examined in a randomized controlled trial that compared endoscopic sclerotherapy (EST) to emergency portacaval shunt (EPCS).MethodsTwo hundred eleven unselected consecutive patients with ultimately biopsy-proven cirrhosis and endoscopically proven acute BEV were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic workup was completed, and EST or EPCS was initiated within 8 h. Criteria for failure of EST or EPCS were clearly defined, and crossover rescue treatment was applied, when primary therapy failed. Ninety-six percent of patients underwent more than 10 years follow-up, or until death. Complete charges for all aspects of care were obtained continuously for more than 10 years.ResultsDirect charges for all aspects of care were significantly lower in patients treated by EPCS than in patients treated by emergency EST followed by long-term repetitive sclerotherapy. Charges per patient, per year of treatment, and per year in each child's risk class were significantly lower in patients randomized to EPCS. Charges in patients who failed endoscopic sclerotherapy and underwent a rescue portacaval shunt were significantly higher than the charges in both the unshunted sclerotherapy patients and the patients randomized to EPCS. This result was particularly noteworthy given the widespread practice of using surgical portacaval shunt as rescue treatment only when all other forms of therapy have failed.ConclusionsIn this randomized controlled trial of emergency treatment of acute BEV, EPCS was significantly superior to EST with regard to direct costs of care as reflected in charges for care as well as in survival rate, control of bleeding, and incidence of portal-systemic encephalopathy. These results provide support for the use of EPCS as a first line of emergency treatment of BEV in cirrhosis.

Project description:ImportanceBleeding esophageal varices has been studied extensively, but bleeding gastric varices (BGV) has received much less investigation. However, BGV has been reported in ≤ 30% of patients with acute variceal bleeding. In our studies of 1,836 bleeding cirrhotics, 12.7% were bleeding from gastric varices. BGV mortality rate of 45-55% has been reported. The BGV literature has mainly involved retrospective case reports, often with short-term follow-up.ObjectiveWe sought to describe the results of a prospective, randomized, controlled trial (RCT) in unselected, consecutive patients with BGV comparing endoscopic therapy (ET) with portacaval shunt (PCS; n = 518), and later comparing emergency transjugular intrahepatic portosystemic shunt (TIPS) with emergency portacaval shunt (EPCS; n = 70).Design, setting, and participantsInitially, our RCT involved 518 patients with BGV comparing ET with direct PCS regarding control of bleeding, mortality rate, and disability. When entry of patients ended, the RCT was expanded to compare emergency TIPS with EPCS (n = 70). This RCT of BGV was separate from our other RCTs of bleeding esophageal varices.InterventionsInitially, ET was compared with PCS. In the second part of our RCT, emergency TIPS was compared with emergency PCS (EPCS).Main outcome measuresOutcomes were survival, control of bleeding, portal-systemic encephalopathy (PSE), quality of life, and direct costs of care. In the RCT of ET versus PCS, 28 and 30%, respectively, were in Child class C. In the expanded RCT of TIPS versus EPCS, 40 and 41%, respectively, were in Child class C. Permanent control of BGV was achieved in 97-100% of patients treated by emergency or elective PCS, compared with 27-29% by ET. TIPS was even less effective, achieving long-term control of BGV in only 6%. Survival rates after PCS were greater at all time intervals and in all Child classes (P < .001). Repeated episodes of PSE occurred in 50% of TIPS patients, 16-17% treated by ET, and 8-11% treated by PCS. Shunt stenosis or occlusion occurred in 67% of TIPS patients, in contrast with 0-2% of PCS patients.ConclusionThese results support the conclusion that PCS is uniformly effective, whereas ET and TIPS are not very effective.

Project description:BackgroundThere is limited reporting of treatment options for early esophageal squamous cell carcinoma in esophageal-gastric fundal varices patients. Historically, surgery is the preferred treatment for squamous cell carcinoma; however, esophagectomy is associated with higher complications and death rates. The difficulty of such an operation was the varicose veins around the mucosa of the lesion. Possibility of concomitant intraoperative fatal bleeding. Previous studies have proved the effectiveness of endoscopic mucosal resection (EMR) paired with endoscopic injection sclerotherapy (EIS) for treating early esophageal cancers on esophageal varices.Case descriptionWe reported an effective endoscopic treatment of such conditions in a 62-year-old man with liver cirrhosis. After seeking informed consent, we performed endoscopic submucosal dissection (ESD) of early esophageal squamous cell carcinoma after the eradication of esophageal-gastric fundal varices using EIS. The resection margins indicated negative for carcinoma and dysplasia, suggesting that no recurrence and complication occurred. The patient was discharged 5 days after ESD without any complications including perforation or bleeding. No complaint from the patient was received during the 1-week follow-up, and the patient was tolerating solid food. The pathological result of the two lesions both showed moderately differentiated squamous cell carcinoma of the esophagus, T1bN0M0. The resection margins suggested negative for both carcinoma and dysplasia according to pathological examination. There was no recurrence or adverse event during follow-up.ConclusionsOur case presented the successful treatment of esophageal squamous cell carcinoma on esophageal-gastric fundal varices. This indicated that patients with cirrhosis and portal hypertension could also be treated with ESD, which could reduce trauma and discomfort and improve their quality of life. We recommend future studies to further investigate the indications of using endoscopic treatment for patients with cirrhosis.

Dataset Information

A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma.

Background

Methods

Results

Conclusions

Publications

A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma.

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