Songtanin Busara, Kahathuduwa Chanaka, Nugent Kenneth
Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA.
J Clin Med. 2024 Jan 9;13(2):357. doi: 10.3390/jcm13020357.
Acute esophageal variceal bleeding accounts for up to 70% of upper-gastrointestinal bleeding in cirrhotic patients. About 10-20% of patients with acute variceal bleeding have refractory bleeding that is not controlled by medical or endoscopic therapy, and this condition can be life-threatening. Balloon tamponade is a long-standing therapy which is only effective temporarily and has several complications, while transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation may not be readily available at some centers. The use of self-expandable metal stents (SEMSs) in refractory esophageal variceal bleeding has been studied for effectiveness and adverse events and has been recommended for use as a bridge to a more definitive treatment. To investigate the effectiveness and safety of SEMSs in managing refractory variceal bleeding. A systematic search of the MEDLINE, EMBASE, and Cochrane library databases was performed from inception to October 2022 using the following terms: "esophageal stent", "self-expandable metal stents", "endoscopic hemostasis", "refractory esophageal varices", and "esophageal variceal bleeding". Studies were included in the meta-analysis if they met the following criteria: (1) patients' age older than 18 and (2) a study (or case series) that has at least 10 patients in the study. Exclusion criteria included (1) non-English publications, (2) in case of overlapping cohorts, data from the most recent and/or most appropriate comprehensive report were collected. DerSimonian-Laird random-effects meta-analysis was performed using the meta package in R statistical software(version 4.2.2). Twelve studies involving 225 patients with 228 stents were included in the analyses. The mean age and/or median age ranged from 49.4 to 69 years, with a male-to-female ratio of 4.4 to 1. The median follow-up period was 42 days. The mean SEMS dwell time was 9.4 days. The most common cause of acute refractory variceal bleeding in chronic liver disease patients included alcohol use followed by viral hepatitis. The pooled rate of immediate bleeding control was 91% (95% CI 82-95%, = 0). The pooled rate of rebleeding was 17% (95% CI 8-32%, = 69). The pooled rate of stent ulceration was 7% (95% CI 3-13%, = 0), and the pooled rate of stent migration was 18% (95% CI 9-32%, = 38). The pooled rate of all-cause mortality was 38% (95% CI 30-47%, = 34). SEMSs should be primarily considered as salvage therapy when endoscopic band ligation and sclerotherapy fail and can be used as a bridge to emergent TIPS or definitive therapy, such as liver transplantation.
急性食管静脉曲张出血占肝硬化患者上消化道出血的比例高达70%。约10%-20%的急性静脉曲张出血患者存在难治性出血，药物或内镜治疗无法控制，这种情况可能危及生命。气囊压迫是一种长期使用的治疗方法，仅能暂时有效且有多种并发症，而经颈静脉肝内门体分流术（TIPS）和肝移植在一些中心可能无法随时开展。自膨式金属支架（SEMS）用于难治性食管静脉曲张出血的有效性和不良事件已得到研究，并被推荐用作更确定性治疗的桥梁。为研究SEMS治疗难治性静脉曲张出血的有效性和安全性。从数据库建立至2022年10月，使用以下检索词对MEDLINE、EMBASE和Cochrane图书馆数据库进行了系统检索：“食管支架”“自膨式金属支架”“内镜止血”“难治性食管静脉曲张”和“食管静脉曲张出血”。符合以下标准的研究纳入荟萃分析：（1）患者年龄大于18岁；（2）一项研究（或病例系列）中至少有10例患者。排除标准包括：（1）非英文出版物；（2）若队列重叠，收集最新和/或最合适的综合报告中的数据。使用R统计软件（版本4.2.2）中的meta包进行DerSimonian-Laird随机效应荟萃分析。分析纳入了12项研究，涉及225例患者和228个支架。平均年龄和/或中位数年龄在49.4至69岁之间，男女比例为4.4比1。中位随访期为42天。SEMS平均留置时间为9.4天。慢性肝病患者急性难治性静脉曲张出血的最常见原因包括饮酒，其次是病毒性肝炎。即时出血控制的合并率为91%（95%CI 82%-95%，I² = 0）。再出血的合并率为17%（95%CI 8%-32%，I² = 69）。支架溃疡的合并率为7%（95%CI 3%-13%，I² = 0），支架移位的合并率为18%（95%CI 9%-32%，I² = 38）。全因死亡率的合并率为38%（95%CI 30%-47%，I² = 34）。当内镜下套扎和硬化治疗失败时，应首先考虑将SEMS作为挽救治疗方法，并可作为紧急TIPS或确定性治疗（如肝移植）的桥梁。
