自膨式金属支架治疗复杂性静脉曲张出血：一项单中心试验
A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center.
出处：Gastrointest Endosc 2010 Jan 71(1) :71-8
作者：Wright G;Lewis H;Hogan B;Burroughs Aatch D;O'Beirne J
PMID：19879564
BACKGROUND: Refractory variceal bleeding is associated with a high mortality. Existing salvage techniques such as transjugular intrahepatic portosystemic shunt (TIPS) and balloon tamponade (BT) have important limitations and may not be appropriate for all patients. OBJECTIVE: To evaluate the safety and efficacy of a novel removable self-expanding metal stent in the management of refractory variceal bleeding. DESIGN: Case series. SETTING: Tertiary referral liver center. PATIENTS: Ten patients with variceal hemorrhage with contraindications to TIPS insertion or BT. INTERVENTIONS: Insertion of a self-expanding metal stent (SX-Ella DANIS stent). MAIN OUTCOME MEASURES: Survival, failure to control bleeding, and complications. RESULTS: Stent insertion was successful in 9 of 10 patients. Failure to control bleeding was observed in 3 patients (2 with gastric varices), with control of bleeding in the remainder. Overall survival at 42 days was 50%. Six patients survived the acute bleeding episode and had stents removed endoscopically at a median of 9 days after insertion. One patient had a minor ulceration of the esophagus caused by stent insertion. CONCLUSIONS: Insertion of the SX-Ella DANIS stent in patients with refractory variceal bleeding or complications of previous therapy is effective for the control of bleeding. Stent insertion can be achieved in the majority of patients without fluoroscopic control and without major complications. In selected patients, SX-Ella DANIS stent insertion offers an alternative to other methods of salvage such as BT and TIPS and could be considered a substitute for BT after a prospective trial.
专家评价：
Asma Fikree and
Sean Preston
Barts and the London NHS Trust, United Kingdom
Gastroenterology & Hepatology
This study shows that the SX-Ella DANIS stent is a safe and well-tolerated device that can be used where there is failure of previous endoscopic attempts at haemostasis, balloon tamponade (BT) cannot be used and where transjugular intrahepatic portosystemic shunt (TIPS) is contraindicated.
Refractory variceal bleeding is a leading cause of death in patients with cirrhosis. The SX-Ella DANIS is a removable, self expanding, covered oesophageal metal stent which can be used where methods of haemostasis have failed and TIPS is contraindicated. Insertion is possible without endoscopic assistance and does not require the patient to be intubated. It can remain in place for over two weeks and unlike BT the patient is able to eat and drink. This case series looked at 10 cirrhotic patients who had a stent inserted for refractory variceal haemorrhage after failure of other haemostatic measures and where TIPS was contraindicated. Stent insertion was successful in 9 out of 10 cases. Failure was due to device malfunction. In 6 out of the 9 cases, the stent controlled the acute bleeding episode. One patient did not survive the acute bleeding episode and died in hospital. The 42-day survival rate was 50%. This informative preliminary study of one tertiary referral centre’s initial experience with the DANIS stent shows that it can be used safely in refractory cases of oesophageal variceal bleeding. There were no complications related to stent removal. Although BT is cheaper, it is not without complications and in this study 2 out of 10 patients had balloon related perforations which were treated successfully with the DANIS stent. Two limitations of the DANIS stent are that it does not treat gastric varices and stent migration has been a problem in the past. Although the numbers in this study are low, the experience of this single-centre is positive and highlights the potential benefits where TIPS cannot be accessed or is not accessible. A larger randomized controlled study directly comparing the efficacy and safety of BT with the DANIS stent after endoscopic therapy is needed. In situations of oesophageal variceal bleeding where TIPS is contraindicated and there is failure of haemostasis at initial endoscopy, the SX-Ella DANIS should be considered.
References: {1} Zehetner et al. Surg Endosc 2008, 22:2149-52 [PMID:18622540].
atch D;O'Beirne J