Portal de Periódicos da CAPES

Endoscopic treatment of esophagogastric varices

2021; Wiley; Volume: 34; Issue: S2 Linguagem: Inglês

10.1111/den.14166

1443-1661

Katsutoshi Obara,

Gastroesophageal reflux and treatments

Necessary keys to success for the safe and effective treatment of esophagogastric varices include deep understanding of the mechanism of treatment drugs, selection of the optimal treatment method considering patient condition and portal hemodynamics, practice of treatment procedures, prevention of complications, careful monitoring and periodic follow-up of a patient, and building a good medical team. The following describes an historical overview of endoscopic treatment for esophagogastric varices in Japan. Endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) are popular endoscopic treatment procedures for esophageal varices (EV). EIS by intravariceal injection of 5% monoethanolamine oleate (EO) was developed in the UK by Hunt and Johnstone and introduced in Japan in 1978 by Takase et al.1 They employed the embolization method or the EO method in which EO mixed with a contrast agent was injected to embolize feeding veins as well as EV under fluoroscopy, and it became a cornerstone of EIS in Japan. On the other hand, extravariceal injection of 1% polidocanol (Aethoxysklerol [AS]; Ferndale Phamaceuticals Ltd., Wetherby, UK) introduced by Raschke and Kapp in West Germany was developed by Paquet (1978), and employed in Japan by Suzuki and Nagao in 1981 to become very popular as intra/extravariceal injection of AS (AS method).2 Furthermore, Futagawa et al.3 reported extravariceal injection of sodium morrhuate followed by that of Phenol (Paoscle; Torii Phamaceutical Co. Ltd., Tokyo, Japan) by Kumagaya and Makuuchi in 1981.4 In 1987, Kitano and Sugimachi developed a new technique using a transparent over-tube (K-S tube, ST-E1; Olympus, Tokyo, Japan) to secure a field of vision for the precise injection of EO without X-ray fluoroscopy,5 and Obara et al.6 reported the EO-AS combination method,6 which is a procedure based on metachronous combination of the Takase method (EO method) and the Suzuki method (AS method). Obara et al.7 also introduced the AS consolidation method in 1989 followed by the laser consolidation method in 1994 for prevention of variceal recurrence.8 Now, argon plasma coagulation (APC) is widely used instead of laser owing to its ease of operation (Fig. 1). EIS rapidly became very popular in Japan owing to widespread dissemination of endoscope and development of treatment procedures. Endoscopic injection sclerotherapy was performed nationwide in the 1980s; however, the drugs used were not approved by the Ministry of Health and Welfare (MHW). Therefore, according to the discussion at the 1st Research Conference on Endoscopic Injection Sclerotherapy for Esophageal Varices, a subcommittee was established within the Japan Gastroenterological Endoscopy Society (JGES) in 1986 to promote MHW approval of sclerosing agents. Clinical studies on 5% EO and 1% AS were conducted from January to July in 1988 and they were approved in October in 1991. For about 20 years since the endoscopic treatment for EV was introduced in Japan in 1978, procedures were developed and revised aggressively to further seek safe and effective procedures. In the 2000s, EIS using the EO-AS combination method followed by APC consolidation method, and EVL were performed nationwide, and a number of excellent studies were reported on long-term outcome and prognosis after EIS or EVL in Digestive Endoscopy and Gastroenterological Endoscopy, the official journals of the JGES. Endoscopic variceal ligation reported by Stiegmann in 19869 was introduced in Japan by Yamamoto et al. in 1990.10 As EVL is easy to perform without the complications of sclerosing agents, a good indication for EVL is a case where EIS is contraindicated. EVL can be combined with EIS (AS method) in order to reduce the high rate of variceal recurrence after EVL. Moreover, as feeding veins still remain after this EVL-AS combination method, APC consolidation can be additionally performed to further reduce recurrence rates which are still higher than those of the cases treated using the EO-AS combination method (Fig. 1). EVL spread rapidly and is selected as the first-line treatment for EV in many institutions; however, indications for EVL in elective/prophylactic cases should be discussed again taking into consideration long-term prognosis and patient quality of life (QOL). Treatment options for isolated gastric varices (GV) include endoscopic treatment, interventional radiology such as balloon-occluded retrograde transvenous obliteration, and Hassab's operation, among which endoscopic treatment made a rapid progress by adoption of cyanoacrylate adhesives (CA). Suzuki et al. in 198811 introduced N-butyl-2-cyanoacrylate (Histoacryl; B. Braun Surgical SA, Rubi, Spain) and Obara et al.12 in 1989 introduced α-cyanoacrylate monomer (Aronα-A; Toagosei Co., Ltd., Toyama, Japan) which made possible safe and effective GV treatment. The general consensus is that intravariceal injection of CA (CA method) should be the first choice in GV bleeding cases, while in elective/prophylactic cases, each institution adopts its own treatment approach. In addition, endoscopic treatment using the CA-EO combination method is widely performed, which consists of obliteration of GV using the CA method and occlusion of the blood supply routes using the EO method (Fig. 2). The Guidelines for Gastrointestinal Endoscopy (1st edition) were published by the JGES in 1999, and revised as the 2nd edition in 2002 and the 3rd edition in 2006, where "Guidelines for treatment of esophagogastric varices" showed updated treatment strategies.13 In 2010, Evidence-based Guidelines for Liver Cirrhosis 2010 were published by the Japanese Society of Gastroenterology, and revised in 2015 and 2020.14 At the beginning of the 2000s, one of the big challenges was how to standardize EV treatment strategy, and it was discussed in the JGES-attached study groups, the Study Group for Portal Hemodynamics from 2003 to 2005 and the Varix Standardization Study Group from 2006 to 2008. It was strongly desirable to conduct multidisciplinary treatment by selecting or combining therapeutic procedures that were safe and free from rebleeding, and that take the patient's QOL into consideration. Therefore, the Study Group for Multidisciplinary Varix Treatment was set up, where multicenter research was conducted to establish current treatment strategies. Treatment strategies based on the patient conditions are as follows (Fig. 3). In bleeding cases, check the whole-body condition of the patient and perform emergency endoscopy to confirm the bleeding source. With or without hepatocellular carcinoma (HCC) or severe hepatic disorder (Child-Pugh C, TBIL ≥4 mg/dL), temporary hemostasis should be achieved using EVL for EV bleeding and the CA method for GV bleeding. If the whole-body condition is too poor to withstand endoscopy or if no endoscopist is available for an emergency patient, perform astriction by means of balloon tamponade and conduct elective treatment within 12 h or transfer the patient to the facilities where endoscopic treatment can be performed. In cases with severe hepatic disorder, avoid EIS whenever possible because it aggravates bilirubin value leading to hepatic failure, and select EVL for EV and the CA method for GV. In cases without severe hepatic disorder, select EIS for EV and the CA-EO combination method or B-RTO for GV. HCC complicated cases should be treated according to the degree of portal vascular invasion (Vp).15 In cases without Vp (Vp0) and those with Vp into the third-order branch (Vp1) or the second-order branch (Vp2), the treatment policy can be identical to that for the hepatic cirrhosis cases not complicated by HCC, which is based on severity of hepatic disorder. In cases with Vp into the first-order branch (Vp3) or the main trunk/contralateral branch (Vp4), patients should be followed closely without endoscopic treatment taking into consideration the life prognosis of patients. However, EVL is indicated for EV and the CA method is for GV when bleeding occurred during follow-up in prophylactic cases and when the risk of bleeding is high in elective cases. Treatment strategies based on portal hemodynamics are as follows. Endoscopic ultrasonography (EUS) and three-dimensional computed tomography (3D-CT) are indispensable in the evaluation of portal hemodynamics before and after treatment (Fig. 4). EUS is a useful means of performing non-invasive identification of blood routes inside and outside the esophagogastric walls. With observation using a 20 MHz ultrasonic miniprobe (UMP), EV are imaged as a non- or low-echoic lumen in the submucosa. EV often communicate with the peri-esophageal veins (Peri-v) and para-esophageal veins (Para-v) through a perforating vein (Pv). Peri-v are the small vessels located adjacent to the esophageal adventitia and partially in the muscle layer. Para-v are the large vessels located at a distance from the esophageal adventitia. Irisawa et al. reported that the recurrence frequency is high when the remaining Peri-v or large Pv is observed during UMP examination after treatment.16 Therefore, it is important to obliterate Peri-v and a Pv during the initial EIS. If Peri-v and/or a Pv remain after treatment, the APC consolidation method should be additionally employed to prevent recurrence. Furthermore, in cases with a large Pv which acts as a shunt to the outside of the EV during EIS, appropriate measures need to be taken to prevent the sclerosant from leaking into the general circulation. 3D-CT is useful for evaluating the portal venous system such as the development of blood supply/drainage routs and the presence of a gastrorenal shunt leading to greater circulatory system. This examination method can replace and is less invasive than abdominal angiography or percutaneous transhepatic angiography. For these 41 years since endoscopic treatment of esophagogastric varices was first employed, a number of studies have demonstrated the safest and the most effective treatment procedures in Japan. As a result, it is now possible to provide the optimal treatment that best matches the pathologic condition and portal hemodynamics of each patient. Taking into consideration patient QOL, endoscopic treatment is the first choice. In order to achieve the utmost safety and effectiveness, it is essential that endoscopists should acquire the technique of endoscopic treatment perfectly at a professional institution. Author declares no conflict of interest for this article. None.