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Sa1482 Clinical Outcomes in Hepatocellular Carcinoma Patients With Esophageal Variceal Bleeding Managed With Endoscopic Band Ligation or Cyanoacrylate Injection
Abstracts
timing of DBE in OV. Objective: to compare the diagnostic and therapeutic yields between urgent and non-urgent DBE in patients with OV. Methods: Between 1/2006 and 9/2013, 126 patients with OV who underwent DBE were retrospectively reviewed. An urgent DBE was defined as DBE performed within 72hrs from the last visible gastrointestinal bleeding (nZ78) whereas a non-urgent DBE was defined as DBE performed after 72hrs (nZ48). Diagnostic yields, therapeutic impact and clinical outcomes were evaluated. Results: Diagnostic yield in urgent DBE was significantly higher than that of non-urgent DBE (72% vs. 33%; p!0.001). Urgent DBE offered significantly more therapies including endoscopic therapy, angiographic embolization, and surgery than non-urgent DBE (54% vs. 19%; p!0.001). Endoscopic therapy was performed in 44% of urgent-DBE patients whereas only 14% of patients in the other group received endoscopic therapy (p!0.001). In patients with identified bleeding sources, rebleeding rate was lower in patients who underwent urgent DBE than those in non-urgent DBE (9% vs. 27%, NS) during 162.4 months follow-up period. (Table 1) Conclusions: Urgent DBE in OV provided significant higher diagnostic and therapeutic yields than non-urgent DBE. The recurrent bleeding rate in patients undergoing urgent DBE tended to be lower.
score (mean, EBL 14.7, CYA 19.9, pZ0.004,) was significantly higher in CYA group (see Table 1). There was no difference in the death-adjusted 30-day rebleeding rate between the two groups (EBL 31.3%, CYA 32.7%, pZ0.840). The 6-month bleedingrelated mortality after adjustment for competing risk from other causes of death were: EBL 18.8%, 95% CI (9.1-31.0), CYA 32.7% 95% CI (20.3-45.6), pZ0.098. The modified Cox proportional hazard model verified that BCLC stage C/D HCC was the only significant predictor of the 6-month bleeding-related mortality (adjusted hazard ratio, 5.86, pZ0.001) (see Table 2). The rate ratios of additional endoscopy per 100 patient-days at 3 months and 6 months were: EBL/CYA 1.05, 95% CI (0.71-1.56), pZ0.806 and EBL/CYA 0.78, 95% CI (0.54-1.13), pZ0.194, respectively. Conclusion: In advanced HCC patients with short life expectancy, CYA had similar efficacy in prevention of EV rebleeding when compared to EBL. Advanced or terminal HCC stage was significantly associated with increased bleeding-related mortality at 6 months.
The baseline characteristics of patients and the results of DBE between two groups
Age (years) Gender: Male (%) Cause of cirrhosis HBV (%) HCV (%) Others MELD score
57+/-12 41 (85.4)
57+/-11 48 (92.3)
36 (75.0) 5 (10.4) 7 (14.6) 14.7+/-5.0
43 (82.7) 5 (9.6) 4 (7.7) 19.9+/-9.1
HCC characteristics BCLC stage 0+A+B (%) C+D (%) Portal vein thrombosis (%)
27 (56.3) 21 (43.8) 25 (52.1)
20 (38.5) 32 (61.5) 33 (63.5)
10 (20.8) 28 (58.3) 2 (4.2) 3 (6.3) 0 (0)
17 16 11 1 1
Table 1. Baseline characteristics of patients Characteristics
Urgent DBE (n[78) Baseline characteristics Mean age (yr) Mean initial hemoglobin (g/dl) Median time from last visible bleeding to DBE*(hr, range) Endoscopic results Identified bleeding sources*
602.3 7.20.2 48 (0-72)
Non-urgent DBE p(n[48) value 552.9 7.80.3 168 (84-720)
56 (72%)
16 (33%)
Ulcer Inactive angiodysplasia Active angiodysplasia Small bowel varices Small bowel tumor Bleeding diverticulum Bleeding polyp Portal hypertensive enteropathy Meckel’s diverticulum Hemobilia Endoscopic therapies*
23 (29%) 9 (11%) 4 (5%) 6 (8%) 4 (5%) 3 (4%) 2 (3%) 2 (3%) 2 (3%) 1 (1%) 34 (44%)
8 (17%) 4 (8%) 0 (0%) 1 (2%) 2 (4%) 0 (0%) 1 (2%) 0 (0%) 0 (0%) 0 (0%) 7 (14%)
Argon plasma coagulation Clipping Glue injection Adrenaline injection Bipolar coaptation
18 5 5 4 2
6 (12%) 0 (0%) 0 (0%) 1 (2%) 0 (0%)
(24%) (6%) (6%) (5%) (3%)
NS NS ! 0.001 ! 0.001
! 0.001
Sa1482 Clinical Outcomes in Hepatocellular Carcinoma Patients With Esophageal Variceal Bleeding Managed With Endoscopic Band Ligation or Cyanoacrylate Injection Raymond S. Tang*1, Moe Htet Kyaw1, Yee Kit TSE1, Jessica Ching1, Vincent W. Wong1, Grace Wong1, Stephen L. Chan2, Charing Chong3, Henry L. Chan1, Francis K. L. Chan1 1 Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong; 2Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong, Hong Kong; 3Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong Background: Management of esophageal variceal (EV) bleeding in hepatocellular carcinoma (HCC) patients remains challenging. In advanced HCC patients, it is desirable to employ an endoscopic therapy that is both effective and would require less number of repeated endoscopies for control and prevention of EV bleeding, but limited data is available regarding the optimal endoscopic therapy. This study aims to assess the clinical outcomes in HCC patients with EV bleeding treated with endoscopic band ligation (EBL) or cyanoacrylate injection (CYA). Methods: Review of a prospective upper gastrointestinal bleeding registry at a tertiary hospital between January 2001 and December 2007 was performed. All HCC patients who underwent EBL or CYA for acute EV bleeding were identified. Outcome measures include death-adjusted 30-day rebleeding rate, 6-month bleeding-related mortality and associated risk factors, and number of additional endoscopies. Death occurring prior to recurrent bleeding was considered a competing risk event in analysis. Results: 100 HCC patients with acute EV bleeding were identified: 48 received EBL (mean age 57; 85.4% male), 52 received CYA (mean age 57; 92.3% male). The MELD
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EBL group (N [ 48) CYA group (N [ 52)
Overall cause of death Bleeding-related (%) Liver failure (%) Multi-organ failure (%) HCC rupture (%) Aspiration after endoscopy (%) Infection (%) Others (%)
p
0.004
0.075
3 (6.3) 2 (4.2)
0.25
(32.7) (30.8) (21.1) (1.9) (1.9)
2 (3.8) 4 (7.7)
EBL Z Endoscopic band ligation CYA Z Cyanoacrylate injection Expressed as the mean +/- standard deviation HBV Z Hepatitis B HCV Z Hepatitis C MELD Z Model for End-stage Liver Disease score; expressed as the mean +/- standard deviation HCC Z Hepatocellular carcinoma BCLC Z Barcelona Liver Clinic Cancer staging system
Table 2. Multivariate modified Cox proportional hazards model to predict bleeding-related mortality within 6 months after accounting for death from other causes as the competing risk event Predictive variables Endoscopic treatment (CYA / EBL) BCLC stage (C+D / 0+A+B)
Hazard Ratio
95% CI
p
1.55 5.86
0.68 - 3.51 2.05 - 16.76
0.293 0.001
CYA Z Cyanoacrylate injection, EBL Z Endoscopic band ligation BCLC Z Barcelona Liver Clinic Cancer staging system
Sa1483 Fibrin Glue Injection for the Patients With Upper Gastrointestinal Bleeding Soon Man Yoon*, Ki Bae Kim, Joo Young Lee, Joung-Ho Han, Hee Bok Chae, Seon Mee Park, Sei Jin Youn Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea Background and Aims: Upper gastrointestinal bleeding (UGIB) is a troublesome and life-threatening emergency. Recently, various endoscopic tools such as clip for hemostasis have been developed and clinically used. However, there are difficult cases of bleeding control due to inaccessible location or intractable lesion. The aim of this study was to determine the usefulness of fibrin glue for UGIB in patients who had difficulties in other hemostatic agents or techniques. Patients and Methods: We investigated 67 patients who underwent hemostasis with the injection of a fibrin glue to treat UGIB between October 2010 and September 2012 in a tertiary university hospital. Results: All of 67 patients were treated with endoscopic hemostasis using a local injection of the fibrin glue. The causes of UGIB were gastric ulcer (34
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB229
timing of DBE in OV. Objective: to compare the diagnostic and therapeutic yields between urgent and non-urgent DBE in patients with OV. Methods: Between 1/2006 and 9/2013, 126 patients with OV who underwent DBE were retrospectively reviewed. An urgent DBE was defined as DBE performed within 72hrs from the last visible gastrointestinal bleeding (nZ78) whereas a non-urgent DBE was defined as DBE performed after 72hrs (nZ48). Diagnostic yields, therapeutic impact and clinical outcomes were evaluated. Results: Diagnostic yield in urgent DBE was significantly higher than that of non-urgent DBE (72% vs. 33%; p!0.001). Urgent DBE offered significantly more therapies including endoscopic therapy, angiographic embolization, and surgery than non-urgent DBE (54% vs. 19%; p!0.001). Endoscopic therapy was performed in 44% of urgent-DBE patients whereas only 14% of patients in the other group received endoscopic therapy (p!0.001). In patients with identified bleeding sources, rebleeding rate was lower in patients who underwent urgent DBE than those in non-urgent DBE (9% vs. 27%, NS) during 162.4 months follow-up period. (Table 1) Conclusions: Urgent DBE in OV provided significant higher diagnostic and therapeutic yields than non-urgent DBE. The recurrent bleeding rate in patients undergoing urgent DBE tended to be lower.
score (mean, EBL 14.7, CYA 19.9, pZ0.004,) was significantly higher in CYA group (see Table 1). There was no difference in the death-adjusted 30-day rebleeding rate between the two groups (EBL 31.3%, CYA 32.7%, pZ0.840). The 6-month bleedingrelated mortality after adjustment for competing risk from other causes of death were: EBL 18.8%, 95% CI (9.1-31.0), CYA 32.7% 95% CI (20.3-45.6), pZ0.098. The modified Cox proportional hazard model verified that BCLC stage C/D HCC was the only significant predictor of the 6-month bleeding-related mortality (adjusted hazard ratio, 5.86, pZ0.001) (see Table 2). The rate ratios of additional endoscopy per 100 patient-days at 3 months and 6 months were: EBL/CYA 1.05, 95% CI (0.71-1.56), pZ0.806 and EBL/CYA 0.78, 95% CI (0.54-1.13), pZ0.194, respectively. Conclusion: In advanced HCC patients with short life expectancy, CYA had similar efficacy in prevention of EV rebleeding when compared to EBL. Advanced or terminal HCC stage was significantly associated with increased bleeding-related mortality at 6 months.
The baseline characteristics of patients and the results of DBE between two groups
Age (years) Gender: Male (%) Cause of cirrhosis HBV (%) HCV (%) Others MELD score
57+/-12 41 (85.4)
57+/-11 48 (92.3)
36 (75.0) 5 (10.4) 7 (14.6) 14.7+/-5.0
43 (82.7) 5 (9.6) 4 (7.7) 19.9+/-9.1
HCC characteristics BCLC stage 0+A+B (%) C+D (%) Portal vein thrombosis (%)
27 (56.3) 21 (43.8) 25 (52.1)
20 (38.5) 32 (61.5) 33 (63.5)
10 (20.8) 28 (58.3) 2 (4.2) 3 (6.3) 0 (0)
17 16 11 1 1
Table 1. Baseline characteristics of patients Characteristics
Urgent DBE (n[78) Baseline characteristics Mean age (yr) Mean initial hemoglobin (g/dl) Median time from last visible bleeding to DBE*(hr, range) Endoscopic results Identified bleeding sources*
602.3 7.20.2 48 (0-72)
Non-urgent DBE p(n[48) value 552.9 7.80.3 168 (84-720)
56 (72%)
16 (33%)
Ulcer Inactive angiodysplasia Active angiodysplasia Small bowel varices Small bowel tumor Bleeding diverticulum Bleeding polyp Portal hypertensive enteropathy Meckel’s diverticulum Hemobilia Endoscopic therapies*
23 (29%) 9 (11%) 4 (5%) 6 (8%) 4 (5%) 3 (4%) 2 (3%) 2 (3%) 2 (3%) 1 (1%) 34 (44%)
8 (17%) 4 (8%) 0 (0%) 1 (2%) 2 (4%) 0 (0%) 1 (2%) 0 (0%) 0 (0%) 0 (0%) 7 (14%)
Argon plasma coagulation Clipping Glue injection Adrenaline injection Bipolar coaptation
18 5 5 4 2
6 (12%) 0 (0%) 0 (0%) 1 (2%) 0 (0%)
(24%) (6%) (6%) (5%) (3%)
NS NS ! 0.001 ! 0.001
! 0.001
Sa1482 Clinical Outcomes in Hepatocellular Carcinoma Patients With Esophageal Variceal Bleeding Managed With Endoscopic Band Ligation or Cyanoacrylate Injection Raymond S. Tang*1, Moe Htet Kyaw1, Yee Kit TSE1, Jessica Ching1, Vincent W. Wong1, Grace Wong1, Stephen L. Chan2, Charing Chong3, Henry L. Chan1, Francis K. L. Chan1 1 Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, Hong Kong; 2Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong, Hong Kong; 3Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong Background: Management of esophageal variceal (EV) bleeding in hepatocellular carcinoma (HCC) patients remains challenging. In advanced HCC patients, it is desirable to employ an endoscopic therapy that is both effective and would require less number of repeated endoscopies for control and prevention of EV bleeding, but limited data is available regarding the optimal endoscopic therapy. This study aims to assess the clinical outcomes in HCC patients with EV bleeding treated with endoscopic band ligation (EBL) or cyanoacrylate injection (CYA). Methods: Review of a prospective upper gastrointestinal bleeding registry at a tertiary hospital between January 2001 and December 2007 was performed. All HCC patients who underwent EBL or CYA for acute EV bleeding were identified. Outcome measures include death-adjusted 30-day rebleeding rate, 6-month bleeding-related mortality and associated risk factors, and number of additional endoscopies. Death occurring prior to recurrent bleeding was considered a competing risk event in analysis. Results: 100 HCC patients with acute EV bleeding were identified: 48 received EBL (mean age 57; 85.4% male), 52 received CYA (mean age 57; 92.3% male). The MELD
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EBL group (N [ 48) CYA group (N [ 52)
Overall cause of death Bleeding-related (%) Liver failure (%) Multi-organ failure (%) HCC rupture (%) Aspiration after endoscopy (%) Infection (%) Others (%)
p
0.004
0.075
3 (6.3) 2 (4.2)
0.25
(32.7) (30.8) (21.1) (1.9) (1.9)
2 (3.8) 4 (7.7)
EBL Z Endoscopic band ligation CYA Z Cyanoacrylate injection Expressed as the mean +/- standard deviation HBV Z Hepatitis B HCV Z Hepatitis C MELD Z Model for End-stage Liver Disease score; expressed as the mean +/- standard deviation HCC Z Hepatocellular carcinoma BCLC Z Barcelona Liver Clinic Cancer staging system
Table 2. Multivariate modified Cox proportional hazards model to predict bleeding-related mortality within 6 months after accounting for death from other causes as the competing risk event Predictive variables Endoscopic treatment (CYA / EBL) BCLC stage (C+D / 0+A+B)
Hazard Ratio
95% CI
p
1.55 5.86
0.68 - 3.51 2.05 - 16.76
0.293 0.001
CYA Z Cyanoacrylate injection, EBL Z Endoscopic band ligation BCLC Z Barcelona Liver Clinic Cancer staging system
Sa1483 Fibrin Glue Injection for the Patients With Upper Gastrointestinal Bleeding Soon Man Yoon*, Ki Bae Kim, Joo Young Lee, Joung-Ho Han, Hee Bok Chae, Seon Mee Park, Sei Jin Youn Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea Background and Aims: Upper gastrointestinal bleeding (UGIB) is a troublesome and life-threatening emergency. Recently, various endoscopic tools such as clip for hemostasis have been developed and clinically used. However, there are difficult cases of bleeding control due to inaccessible location or intractable lesion. The aim of this study was to determine the usefulness of fibrin glue for UGIB in patients who had difficulties in other hemostatic agents or techniques. Patients and Methods: We investigated 67 patients who underwent hemostasis with the injection of a fibrin glue to treat UGIB between October 2010 and September 2012 in a tertiary university hospital. Results: All of 67 patients were treated with endoscopic hemostasis using a local injection of the fibrin glue. The causes of UGIB were gastric ulcer (34
Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB229