| Background and Aims Gastroesophageal variceal bleeding(GEVB)is one of the serious complications of cirrhotic portal hypertension.Although it accounts for only 10-20%of all variceal hemorrhage,once it ruptures,the mortality rate is often higher and the prognosis is worse than esophageal varices(EV),which is a hard problem for treating portal hypertension.The treatment for gastric varices(GVs),especially gastric fundal varices(the GOV-2 and IGV-1 in the Sarin classification),have not been unified in the recommendations.Therefore,the treatment of GVs is far from being "individualized".In patients with gastric fundal varices,there usually exists a special and extensive type of collateral circulation between the portal system and the vena cava,including gastrorenal shunt(GRS),gastric diaphragmic shunt,and gastric pericardial shunt.GRS is the most common shunt present in approximately 70%-84%of the patients with gastric fundal varices.It directly connects the GVs and vena cava system,providing a possibility for interventional treatment of GVs through the vena cava system.However,during endoscopic embolization,tissue adhesives may migrate through larger GRS,thus increasing the potential risk of fatal embolism such as pulmonary embolism.Therefore,treating gastric fundal varices with large GRS is still challenging. Hemodynamics is an important factor in determining the treatment of GVs.How to treat GVs with different hemodynamic characteristics individually is of vital importance.Therefore,it is necessary to investigate the hemodynamics of GVs deeply and explore the optimized treatment strategy based on the research.Current issues to be studied include:the lack of hemodynamic characteristics between different types of GVs in previous studies;although there are many treatment methods at present,how to choose the optimized treatment plan based on hemodynamic characteristics and find suitable treatment options for different types of GVs need to be clarified;the interventional treatment for special type of GVs(segmental portal hypertension)is not clear.This paper discussed the above issues in three parts.In the first part,we reviewed the data of direct portal venography in patients with gastric fundal varices(GOV-2 and IGV-1)and analyzed their hemodynamic characteristics.The second part,the hemodynamic characteristics were used to choose different interventional treatments for GVs.In the third part,the treatment experience of treating special types of GVs(segmental portal hypertension)was preliminarily summarized.Part 1 Hemodynamic Characteristics of Gastric Fundal Varices Based on ImagingAims:The hemodynamic characteristics of different types of GVs were analyzed to provide an objective basis for clinical selection of treatment options.Methods:The imaging and direct portal venography were retrospectively analyzed in 70 patients with gastric fundal varices(GOV-2 and IGV-1).The imaging characteristics(including the width of portal vein,the width of splenic vein,the incidence of portal vein thrombosis,diameter of varices,etc.)and hemodynamic characteristics(including the detection rate of supplying vessels,main supplying sources,number of supplying vessels.detection rate of drainage blood vessels,main drainage vessels,type of drainage vessels,incidence of GRS、portal vein pressure,etc.)were compared.Results:1.The average width of the portal vein was 15.71±5.31 mm for patients with GOV-2 and 13.00±2.60 mm for patients with IGV-1(P=0.013).The incidence of portal vein thrombosis was 34.30%in patients with gastric fundal varices,46.30%in the GOV-2 group and 17.20%in the IGV-1 patients,respectively(P=0.012).2.Characteristics of supplying vessels:the left gastric vein(coronary vein),the posterior gastric vein and the short gastric vein are main supplying vessels for GVs.The detection rates of left gastric vein,posterior gastric vein and short gastric vein in GOV-2 and IGV-1 were 90.24%,31.71%,31.71%and 65.51%,48.28%,and 44.83%.respectively.The proportions of single supplying vessel in GOV-2 and IGV-1 patients were 56.10%and 44.83%,respectively.3.Characteristics of drainage vessels:gastrorenal shunt and azygous drainage system are the most common drainage methods,the rest of which includes left axillary vein,pericardial iliac vein and right infraorbital vein,etc.The detection rates of them in GOV-2 and IGV-1 were 58.54%,80.49%,4.88%,2.44%,2.44%,and 96.55%,3.45%,3.45%,3.45%,and 0%.The incidences of single-drainage of GRS were 2.44%and 82.76%,respectively.3.The portal pressure and HVPG were 27.45±7.62 mmHg,18.71±6.54 mmHg,16.35±5.91 mmHg,and 12.00±3.58 mmHg,respectively(P=0.002 and 0.038,respectively).Conclusion:The hemodynamics of the GVs are complicated.The supplying vessels,drainage vessels,and portal pressure between GOV-2 and IGV-1 are different.Therefore,the hemodynamic characteristics should be fully considered before choosing individualized treatment options.Part 2 Individualized Interventional Treatment of Gastric Varices Based on Different Hemodynamic CharacteristicsPart 2.1 Balloon-Assisted Percutaneous Transhepatic AntegradeEmbolization with 2-octyl Cyanoacrylate(BA-PTAE)for Treatment of Isolated Gastric Fundal Varices(IGV-1)Aims:To evaluate the safety and effectiveness of BA-PTAE for the treatment of isolated gastric fundal varices(IGV-1).Methods:1.Thirty patients with IGV-1 associated with large GRSs who had undergone PTAE assisted with a balloon to block the opening of the GRS in the left renal vein were retrospectively evaluated and followed up.2.Clinical and laboratory data were collected to evaluate the technical success of the procedure,complications,changes in liver function using Child-Pugh scores,worsening of the esophageal varices,the rebleeding rate,and survival.Laboratory data obtained before and after BA-PTAE were compared using the paired student’s t test.Results:1.BA-PTAE was technically successful in all 30 patients.No serious complications were observed except for one non-symptomatic pulmonary embolism.2.During a mean follow-up of 30 months,rebleeding was observed in 4/30(13.33%)patients,worsening of esophageal varices was observed in 4/30(13.33%)patients,and newly developed or aggravated ascites were observed on CT in 3/30(10.00%)patients.3.Significant improvement was observed in Child-Pugh scores(P=0.009)and the international normalized ratio(INR)(P=0.004)at 3 months after BA-PTAE.4.The cumulative survival rates at 1,2,3,and 5 years were 96.30%,96.30%,79.90%,and 79.90%,respectively.Conclusion:BA-PTAE is technically feasible,safe,and effective for the treatment of isolated gastric fundal varices(IGV-1).Part 2.2 Clinical Application of TIPS in the Treatment of GOV-2 Type Gastric Fundal VaricesAims:To evaluate the effect of TIPS in the treatment of GOV-2 type gastric fundal varices.Methods:A total of 28 liver cirrhotic patients with GOV-2 type of gastric variceal bleeding who underwent TIPS treatment between June 2010 and August 2015 were retrospectively recruited.Clinical and laboratory data were collected to summarize the technical success rate,clinical success rate and complications.In addition,patients were followed up to evaluate rebleeding rate and survival rate.Results:1.TIPS treatment failed in 2 patients,and the technical success rate was 92.86%.One patient developed stent occlusion and rebleeding after 3 days,the other patient developed hepatic artery hemorrhage after TIPS and died from liver failure although treated with hemostasis therapy.2.The portal vein pressure(PVP)was significantly reduced after TIPS.3.Twenty-six patients were followed up for 6 weeks,and one of them developed early rebleeding(3.57%)due to the stent occlusion several days after TIPS and received endoscopic treatment.4.The mean follow-up period for this study was 24.13±15.38 months.A total of 2 patients were lost to follow-up,and 7(25.00%)patients had rebleeding.The cumulative non-bleeding rates at 1 year,2 years,and 3 years after TIPS were 83.81%、73.78%and 73.78%,respectively.Causes of rebleeding after TIPS include TIPS stent stenosis(2 cases),gastric ulcer(1 case),and unknown reason(1 case).5.Three patients died during follow-up and the mortality rate was 10.71%.The cumulative survival rates at 1 year,2 years,and 3 years after TIPS were 92.3 1%、92.31%and 92.31%,respectively.6.The main complications of patients after TIPS include hepatic encephalopathy(HE)(53.57%),infection(7.14%),and hepatic myelopathy(3.57%).Conclusion:TIPS is safe and effective in the treatment of GOV-2 type of gastric varices,but the occurrence of post-TIPS HE should be given more attention to.Part 2.3 Clinical Application of BRTO in the Treatment of Gastric Varices with Large Gastrorenal Shunts-A preliminary experience reportAims:To summarize our preliminary experience of BRTO in the treatment of GVs with large GRSMethods:1.We retrospectively included 12 patients who underwent BRTO or modified BRTO in the Department of Gastroenterology in our hospital from May 2017 to August 2019 due to GVs and/or recurrent hepatic encephalopathy(HE)with larger gastrorenal shunts2.The technical success rate,clinical success rate,and complications were summarized.The patients were followed up to observe the weighting rate of esophageal varices,rebleeding rate and survival rateResults:1.Twelve patients were successfully performed with BRTO(8 traditional BRTO and 4 modified BRTO).The success rate of BRTO alone was 75.00%(9/12).The technical success rate was 100%after combined with other techniques(3 cases of PTVE and 1 case of EVO)2.GRS injury occurred in one case(8.33%)during operation,and improved after the combination with PTVE;post-operative ascites occurred in 2 cases(16.67%),1 case was improved after conservative treatment,and the other one died from spontaneous bacterial peritonitis(the mortality rate during the operation period was 8.33%)3.The average follow-up period was 9.09±7.15 months,during which one case(8.33%)of gastric fundal variceal rebleeding was observed;one case(8.33%)of esophageal variceal deterioration was observed and improved after twice sequential ligation;one case of death(8.33%)was observed during the perioperative period;no HE was observed,and 1 patient with preoperative recurrent HE improvedConclusion:BRTO or modified BRTO is a promising treatment option for GVs with GRS,and patients should be followed up regularly after surgery.Part 3 Endoscopic Variceal Ligation Combined with Partial Splenic Embolization for Segmental Portal Hypertension-A retrospective studyAims:Endoscopic variceal ligation(EVL)combined with partial splenic embolization(PSE)for the treatment of segmental portal hypertension(SPH)with gastric varices bleeding(GVB).Methods:We retrospectively included 10 cases of EVL combined with PSE for the treatment of patients with SPH with GVs.Summarize the hemostasis rate,adverse complications and rebleeding rate.Results:1.The bleeding was controlled successfully in all of the 10 patients and the technical success rate was 100%.2.Adverse complications included:2 cases(20%)of post-embolization syndrome(fever and abdominal pain),and 1 case(10%)of elevated platelets(due to myeloproliferative neoplasms with JAK-2 gene mutation),all of whom improved after conservative treatment.3.During the follow-up period(35.90±26.05 months),the ligated varices showed a"starfish-like" scar under endoscopy,whereas the tissue gel injected varices showed a"glue ulcer".One patient was lost to follow-up(6 months after treatment),and rebleeding was observed in 1 case(10%,53 months after surgery,the cause of pancreatic cystadenoma).Conclusion:Endoscopic treatment combined with PSE is a safe and effective treatment for patients with segmental portal hypertension and gastrointestinal bleeding,especially for patients who are unable to tolerate surgery or the primary lesion cannot be removed by surgery. |
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