THE ROLE OF INTERVENTIONAL ENDOSCOPY IN TREATMENT OF PATIENTS WITH VARICEAL BLEEDING Shestak I.S., Korotkevich A.G., Leontyev A.S., Marinich Ya.Ya., May S.A.
Novokuznetsk City Clinical Hospital No.29,
Novokuznetsk Institute of Postgraduate Medical Education,
Novokuznetsk City Clinical Hospital No.22, Novokuznetsk, Russia
THE ROLE OF INTERVENTIONAL ENDOSCOPY IN TREATMENT OF PATIENTS WITH VARICEAL BLEEDING
Varicose veins (VV) of the esophagus and the stomach appear in 50 % of patients with hepatic cirrhosis. 30 % of cases are complicated by bleeding, which presents the most dangerous complication and the main cause of death in such patients, despite of the use of prevention and treatment techniques: medicated, endoscopic and surgical ones [1, 2]. Moreover, the rate of VV is 9-12 % and takes the third place among the causes of gastrointestinal bleeding in VV of the esophagus and the stomach [3, 4]. According to WHO estimations, a significant increase in the incidence of hepatic cirrhosis and, as result, its complications, is anticipated in the near term [5].
Currently, some algorithms for treatment of patients with varicose bleedings have been developed in Russia and in the world. In the foreign countries, these algorithms have decreased the mortality, which is now varies within 15-20 % [2, 6]. At the same time, the recommended primary medicated hemostasis with use of vasoactive agents is not efficient in 20 % of cases [7]. In 10-15 % of cases, the bleeding control is not achieved even with the gold standard (endoscopic ligation of esophageal VV) [8, 9]. Moreover, the role of primary endoscopic hemostasis in these algorithms has not determined, and interventional endoscopy is considered as a secondary part of complex treatment. In Russia, the mortality from variceal bleedings achieves 80 %. Moreover, strict adherence to the recommendations for treating such patients is difficult: the use of vasoactive agents and endoscopic ligation of the esophageal VV are still unavailable in emergency medical care, and the main technique of hemostasis is the obturator probe [10, 11].
Therefore, the actuality of the study is determined by the persistent incidence of bleedings from esophageal and gastric VV, high mortality, the increasing incidence of hepatic cirrhosis and absence of the uniform opinion on interventional endoscopy as the technique for primary endoscopic hemostasis.
Objective – to evaluate the role of interventional endoscopy in the treatment of patients with variceal bleeding.
MATERIALS AND METHODS
The analysis included the medical records of 75 patients with bleedings from the varicose veins of the esophagus and the stomach. The patients were treated in City Clinical Hospital No.29, City Clinical Hospital No.1, City Clinical Hospital No.22, Novokuznetsk, in 2011-2017. All patients were admitted in urgent order. There were 46 (61 %) men and 29 (39 %) women. The age was 51 ± 12.5. 70 (93 %) patients received esophagogastroduodenoscopy with Olympus, Karl Storz and Fujinon endoscopes (2.8 mm instrumental canal) 1.2 ± 0.3 hours after admission. The presence of esophageal and gastric varicose veins, the degree of venous extension, degree of bleeding, possible presence of stigmas and other sources were evaluated. The obturator probe was installed for 25 (33.3 %) patients. The endoscopic hemostatic techniques were used for 50 (66.7 %) patients, including submucosal paravasal infiltration of 5 % aminocaproic acid and 1 % hydrogen peroxide for 34 (45.3 %) patients, and intravasal sclerotherapy with microfoam and 3 % aethoxysklerol for 12 (21.4 %) patients (the patent No.267108, April 21, 2017). All patients have signed the informed consent. The study was approved by the ethical committee of Novokuznetsk State Institute of Postgraduate Medical Education (the abstract from the protocol No.85, October 16, 2017).
Depending on the hemorrhage activity and a hemostasis type, the patients were distributed into 6 groups (the table), which were comparable in age, gender and severity of hepatic insufficiency (Child-Pugh). All groups were compared according to efficiency of the hemostatic techniques, the recurrence and mortality. Hemostasis was efficient, if active bleeding was arrested or (in case of bleeding) when no backsets happened.
Table. Groups of patients in dependance on bleeding intensity and hemostasis type
|
Hemostasis type |
Bleeding intensity |
Total |
|
|
Active |
Accomplished |
||
|
Obturator tube |
1 st group 17 (34 %) |
4th group 12 (48 %) |
29 (38.7 %) |
|
Infiltration hemostasis |
2nd group (50 %) |
5th group 9 (36 %) |
34 (45.3 %) |
|
Sclerotherapy with 3 % aethoxysklerol microfoam |
3rd group 8 (16 %) |
6th group 4 (16 %) |
12 (16 %) |
|
Total |
50 (66.7 %) |
25 (33.3 %) |
75 (100 %) |
The statistical analysis was performed with IBM SPSS Statistics Version 19 and χ2 test. P value of 0.05 was the critical level of significance for testing the statistical hypotheses.
RESULTS
The figure 1 shows the comparison of efficiency of different types of hemostasis for active hemorrhage. The highest efficiency in arresting the active hemorrhage during endoscopy was noted in the group of the patients who received hemostasis with intravasal sclerotherapy with microfoam of 3 % aethoxysklerol. The statistically significant differences in efficiency of the obturator probe and infiltration hemostasis (χ2 = 9.227, df = 1, р = 0.026), the obturator probe and intravasal sclerotherapy with microfoam of 3 % aethoxysklerol (χ2 = 9.865, df = 1, p = 0.0017) were received. The figure 2 shows the comparison of efficiency of different types of hemostasis in accomplished bleeding. The highest efficiency in bleeding control was noted in the patients who received intravasal sclerotherapy with microfoam of 3 % aethoxysklerol, but there were not any statistically significant differences in efficiency of the obturator probe and the techniques of endoscopic hemostasis.
Figure 1. Efficiency of endoscopic hemostatic methods and the obturator tube for active bleeding
Figure 2. Efficiency of endoscopic hemostatic methods and the obturator tube for accomplished bleeding
The figure 3 shows the comparison of the mortality after the use of the endoscopic techniques of hemostasis and the obturator probe in the patients with active hemorrhage. The highest mortality was found in the group of the patients with the obturator probe. The statistically significant differences in the groups of the obturator probe and infiltration hemostasis (χ2 = 3.712, df = 1, p = 0.054), the obturator probe and intravasal sclerotherapy with microfoam of 3 % aethoxysklerol (χ2 = 4.052, df = 1, p = 0.041) were found. The figure 4 shows the comparison of the mortality for the endoscopic techniques of hemostasis and the obturator probe in the patients with bleeding. The highest mortality was identified in the group of the patients after placement of the obturator probe. The statistically significant differences in the groups with the obturator probe and infiltration hemostasis (χ2 = 5.546, df = 1, p = 0.0185) were found. There were not any statistically significant differences in the patients with the obturator probe and intravasal sclerotherapy with 3 % aethoxysklerol; it was possibly associated with the small number of the patients.
Figure 3. Mortality after endoscopic hemostatic methods and the obturator tube in patients with active bleeding
Figure 4. Mortality after endoscopic hemostatic methods and the obturator tube in patients with accomplished bleeding
DISCUSSION
The dissatisfaction with the results of the generally accepted techniques for treating the gastric and esophageal VV bleedings shows the unsettled problem. About 20 % of variceal bleedings are uncontrolled according to the foreign data [7]. In Russia, the national guidelines correspond to the international ones; they include the administration of vasoactive agents and endoscopic eradication of esophageal VV. However the use of the obturator probe is also acceptable for primary hemostasis, despite of its unreliability (the efficiency varies within 50-90 %), discomfort for patients and possible complications such as bedsores and ruptures of the esophagus, mediastinitis and aspiration pneumonia [9]. The use of the obturator probe is traditionally considered as efficient and is one of the most popular techniques for arresting variceal bleeding. However before placement of the probe, esophagogastroduodenoscopy is often neglected in patients with esophageal-gastric bleeding and the proven portal hypertension with varicose veins of the esophagus. From other side, endoscopy is the generally accepted gold standard for diagnosis of varicose veins. Moreover, it should last for 12 hours from admission of a patient with suspected variceal bleeding [2]. Moreover, esophagogastroduodenoscopy identifies the source and excludes non-variceal changes in 27 % of patients with VV [12]. The endoscopic study gives a possibility for hemostasis and estimation of its efficiency. According to our data, regardless of a technique of endoscopic hemostasis (paravasal submucosal infiltration of solution or intravasal introduction of sclerosant microfoam), the good results are achieved even in invariant volume of circulating blood at the level of bleeding (Fig. 1). The endoscopic techniques are more efficient in comparison with the obturator probe (χ2 = 9.22, df = 1, p = 0.026; χ2 = 9.865, df = 1, p = 0.002). Also there is an inverse relationship between the mortality rates in use of the endoscopic hemostasis techniques and the obturator probe, and their efficiency in patients with active hemorrhage (Fig. 3). Also the mortality is higher in the patients with the obturator probe as compared to the used techniques of endoscopic hemostasis (76.5 %, χ2 = 3.712, df = 1, p = 0.054; χ2 = 4.052, df = 1, p = 0.041).
There is an unsolved problem of interventional endoscopy for VV bleedings. According to the international and national guidelines, after admission of a patient with esophageal or gastric VV bleedings, the primary procedure is arresting the bleeding with medicated hemostasis or the obturator probe, followed by endoscopic eradication of veins [2, 11]. More than 50 % of bleedings disappear without any interventions [12]. Therefore, after identification of the signs of variceal bleeding during esophagogastroduodenoscopy it is appropriate to conduct the secondary prevention of recurrence. However endoscopic ligation is not available everywhere. Therefore, for such cases, only diagnostic endoscopy is often used. Subsequently, the high risk of recurrent bleeding and death exists in realization of medical procedures and replacement of circulating blood volume in 60 % of such patients [7]. It is confirmed by the results of our study. The highest mortality was identified in the patients with variceal bleeding who did not receive the endoscopic hemostasis in primary esophagogastroduodenoscopy and who subsequently had the recurrent bleeding with need for the obturator probe (83.3 %, χ2 = 5.546, df = 1, p = 0,019; Fig. 4). At the same time, the endoscopic hemostatic techniques have shown the higher efficiency than the obturator probe (Fig. 2), although there were not any statistically significant differences.
Therefore, our study shows that interventional endoscopy with realization of primary infiltration hemostasis or intravasal sclerotherapy with mircofoam of 3 % aethoxysklerol for active variceal bleeding can be considered as the alternative for medicated hemostasis or the obturator probe. For established esophageal or gastric VV bleeding, the use of interventional endoscopy in primary esophagogastroduodenoscopy allows controlling hemostasis even in impossibility of ligation of esophageal VV.
CONCLUSION
1. Esophagogastroduodenoscopy for bleedings from the esophageal and gastric varicose veins should always be accompanied by primary endoscopic hemostasis regardless of active hemorrhage.
2. The endoscopic techniques of primary hemostasis are more efficient as compared to the obturator probe for active hemorrhage from the esophageal and gastric veins.
3. For use of the obturator probe, the mortality is reliably higher (76.5 %) as compared to the endoscopic hemostasis techniques in patients with active hemorrhage from the esophageal and gastric varicose veins.
4. There are not any statistically significant differences in comparison with the efficiency of the obturator probe and the endoscopic hemostatic techniques in efficiency of control of variceal bleeding.
5. The mortality is reliably higher (83.3 %) for the obturator probe with refusal from primary hemostasis as compared to primary infiltration hemostasis.