Comparison of outcomes in patients at high risk for recurrent gastroesophageal variceal bleeding treated by EUS-guided cyanoacrylate injection for secondary prophylaxis or conventional endoscopic cyanoacrylate injection for index bleeding alone
Refereed conference paper presented and published in conference proceedings


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AbstractBackground: Patients with hepatocellular carcinoma (HCC) or other malignancies + portal vein thrombosis (PVT) are at high risk for recurrent variceal bleeding. Rebleeding rate remains high (28 - 42%) in patients with HCC and esophageal variceal (EV) bleeding treated by endoscopic cyanoacrylate (CYA) injection or band ligation. Recent evidence suggested secondary prophylaxis (SP) for variceal bleeding may improve outcomes in patients with HCC, but the optimal approach is not well defined. This study aims to compare outcomes in patients at high risk for recurrent gastroesophageal variceal bleeding treated by EUS-guided CYA injection for SP and conventional CYA injection for index bleeding alone.

Methods: From 2014-2016, consecutive patients with HCC +/-PVT, or non-HCC malignancy +PVT presenting with gastroesophageal variceal bleeding within 12 weeks were recruited for EUS-CYA for SP. EV and GV were assessed on EUS for size and vascular flow. Varices ≥ 3mm were treated by EUS-CYA via a 19G needle with linear echoendoscope. Doppler was used for real-time confirmation of variceal obliteration. Patients were followed for 6 months after EUS or till death, with follow-up EUS at day 90 and 180. A historical control group of HCC patients who underwent conventional EGD-CYA for index GV or EV bleeding alone was identified in a prospective GI bleed database from 2009-2013 for comparison. Outcome measures are death-adjusted cumulative incidence of rebleeding at 30-day and 90-day, and procedure related complications.

Results: 23 patients (mean age 64+/-9; 87.0% male) underwent EUS-CYA for SP during the study period, while 33 HCC patients (mean age 59+/-10, 90.9% male) who underwent EGD-CYA for index GV or EV bleeding alone were identified as historical controls. In the EUS-CYA for SP group, 20 patients had HCC +cirrhosis (85.0% also with PVT), while the other 3 patients had non-HCC malignancy +PVT. Majority of the HCC patients in the EUS-CYA for SP group and the EGD-CYA control group had Barcelona Clinic Liver Cancer (BCLC) stage C disease (85.0% vs 75.8%, p=0.421) and Child-Pugh class B cirrhosis (55.0% vs 71.4%, p=0.241). 13 OV, 6 GV, and 4 OV+GV were treated by EUS-CYA for SP. 52.2% of patients in the EUS-CYA for SP group had varices ≥ 5mm on EUS. Both the 30-day and 90-day death adjusted cumulative incidence of rebleeding were significantly lower in the EUS-CYA for SP group when compared to EGD-CYA control group (13% vs 42% at 30-day, p=0.023 and 22% vs 61% at 90-day, p=0.005, respectively). No pulmonary CYA embolism (as indicated by lipiodol on chest x-ray) was found in either group.

Conclusion: In this study, EUS-CYA for SP was found to significantly reduce both the 30-day and 90-day death adjusted cumulative incidence of rebleeding in patients at high risk for recurrent gastroesophageal variceal bleeding when compared to EGD-CYA for index bleeding alone.
All Author(s) ListTang RS, Wong JC, Kyaw MH, Teoh AY, Tse YK, Lam TY, Wu JC, Lau JY
Name of ConferenceDigestive Disease Week Conference
Start Date of Conference06/05/2017
End Date of Conference09/05/2017
Place of ConferenceChicago
Country/Region of ConferenceUnited States of America
Proceedings TitleGastrointestinal Endoscopy
Year2017
Month5
Volume Number85
Issue Number5S
PagesAB475 - AB476
ISSN0016-5107
eISSN1097-6779
LanguagesEnglish-United States
KeywordsEUS, varices, glue injection

Last updated on 2021-15-04 at 00:08