A retrospective study conducted on 28 patients with refractory bleeding post-band ulcers admitted to a specialized tertiary center (Hepatology and Gastroenterology Department), National Liver Institute, Menuofia University, Egypt, who received fully covered self-expandable metallic stents (FCSEMS) (NITI-S Mega stents-Tae Wong-S Korea) as a management of their refractory bleeding from post-variceal band ligation ulcer between January 2017 and December 2018.
During these 2 years, 1324 cases of hematemesis were admitted to our hospital, and 1096 cases had portal hypertensive cause of bleeding, and 612 had esophageal varices bleeding.
Prior endoscopic band ligation (EBL) treatments in the emergency setting, laboratory parameters, size of varices, and the bleeding episodes were recorded. The Child-Pugh score, MELD, MELD-Na, and ALBI were calculated. Rebleeding rates and mortality after SEMS placement were defined as primary efficacy endpoints within 6 weeks. Moreover, adverse events and the patients’ clinical course were recorded. We recorded rates of successful bleeding control (≤ 5 days), early rebleeding (≤ 6 weeks), bleeding-related mortality (≤ 6 weeks), and overall mortality. Successful SEMS removal was defined as no rebleeding or death within 1 day after stent removal. Refractory acute variceal bleeding (failure-to-control bleeding) with vasoactive drugs and endoscopy was defined according to the Baveno IV and V guidelines [17, 18]: fresh hematemesis or aspiration of more than100 mL of new blood via the nasogastric tube beyond 2 h after the endoscopy and a 3 g/dL drop in hemoglobin without blood transfusion. According to the Baveno V guidelines, rebleeding was defined as evidence of rebleeding from portal hypertensive sources (hematemesis, melaena, aspiration of more than 100 mL of fresh blood in patients with a nasogastric tube or drop in hemoglobin of 3 g/dL without blood transfusion) [17, 18].
We classified post-banding ulcer endoscopically into (A) ulcer covered with clot; (B) ulcer oozing with blood; and (C) ulcer actively spurting.
We excluded patients with age < 18 years, intermediate and advanced HCC, the simultaneous presence of fundal varices, and previous attempts for balloon tamponade (B.T.) by sungestaken tube insertion management for refractory bleeding.
The technique of stent deployment
After sedation and adequate airway protection, the patient was placed in the left lateral position, the endoscope was passed into the esophagus, and a guidewire (0.035-in.) was established. The SEMS was loaded onto the guidewire and passed under fluoroscopic guidance. The radiopaque markers were helpful in the accurate positioning of the stent. Oral feeds with a liquid diet were started 12–24 h after the procedure, and patients were positioned at 45° in a supine position for 1 day.
No informed consent has been obtained in this retrospective study.
This study was conducted under the Declaration of Helsinki and approved by the ethics committees of our IRB.
Calculations
From online calculators
Child-Pugh
https://www.mdcalc.com/child-pugh-score-cirrhosis-mortality
ALBI
https://www.mdcalc.com/albi-albumin-bilirubin-grade-hepatocellular-carcinoma-hcc
MELD
https://www.mdcalc.com/meld-score-original-pre-2016-model-end-stage-liver-disease
MELD-Na
https://www.mdcalc.com/meldna-meld-na-score-liver-cirrhosis
Statistical analysis
Results were statistically analyzed using IBM SPSS version 21 for Windows. Variables were summarized as mean ± S.D., range, median, or frequency (%), as appropriate. Student’s t test was used to compare the results of all examined subjects in all groups under study. Odds ratio (OR) and 95% confidence interval (CI), and the chi-square test were used. Results were considered significant when P ≤ 0.05.