自膨式金属支架治疗复杂性静脉曲张出血

liver411

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

背景：难治性静脉曲张破裂出血与高死亡率联系在一起。目前的抢救技术如经颈静脉肝内门体分流术（TIPS）和气球填充（BT）有着重大的缺陷，未必适合所有患者。
目的：评估一种新的可移动的自膨式金属支架治疗难治性食管静脉曲张出血的安全性和有效性。
设计：病例系列。
设置：三级肝脏转诊中心。
患者：10静脉曲张出血并伴有经颈静脉肝内门体分流术（TIPS）置入和气球填充（BT）禁忌的病人。
干预措施：置入一个自膨式金属支架(SX-Ella DANIS stent)
主要观察指标：存活率，出血无法控制和并发症。
结果：10例病人9例支架置入成功。3例出血无法控制（2例伴有胃静脉曲张），其余的均控制止血。42天总体存活率为50％。 6例患者急性出血存活，并在置入支架后9天（中位数）内镜下取出支架。有1例因支架置入引起了食管小溃疡。
结论：SX-Ella DANIS支架置入治疗难治性静脉曲张破裂出血或早期并发症可有效的控制出血。大多数患者可以在无透视的情况下完成支架置入，没有严重并发症。在选定的病人，SX-Ella DANIS支架置入提供了一种替代BT和TIPS的其他抢救方法，可以在前瞻性试验后，成为BT的替代品。

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].



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