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HBV carrier, child’s B cirrhosis Admitted x Upper GI Bleeding OGD: bleeding esophageal varices, banding performed Rebleeding few hours later failed to stop bleeding with
endoscopic method (banding and sclerotherapy) Put in Sengstaken tube complicated with esophageal tear
We put in a metal stent for rupture esophagus– Patient has no more bleeding
? Metal stent can stop variceal bleeding?
[4]
Haemetemesis/Melena
Resuscitation
Endoscopy (OGD)
Variceal ligation (Banding) / Sclerotherapy
Confirm esophageal variceal bleeding
Prevent rebleeding:-Vasoconstrictor
Balloon Temponade:- Sengstaken-Blakemore tube
Success Failure
Haemetemesis/Melena
Resuscitation
Endoscopy (OGD)
Variceal ligation (Banding) / Sclerotherapy
Confirm esophageal variceal bleeding
Prevent rebleeding:-Vasoconstrictor
Balloon Temponade:- Sengstaken-Blakemore tube
Success Failure
SEMS
• SX-Ella DANIS stent [10]
– Removable, covered, self-expanding
– Control variceal bleeding by tamponade effect
– Placed at most 2 weeks
– Gold markers: loops at both end (for repositioning and stent removal)
– Radiopaque markers: at both ends and midpoint
• Stent insertion
– Mean duration of procedure: 10 (+/- 6 minutes) [7]
[14]
GuidewireGastric balloon
Stent
Balloon port
Wire port
Blue lockWhite lock
[14]
Stent Removal
[5]
– Can be left in situ as long as 2 weeks
– Cannot be removed by an agitated patient
– Allow detailed and repeated endoscopic examination
– Less risk of pulmonary aspiration
Limitation– Gastric varices cannot be controlled [9]
– Do not exert a lasting effect
Complication– Stent migration into stomach– Esophageal ulcer– Esophageal tear
SEMS
Control of acute bleeding (Time frame: 120 hours (5 days)), failed if [12]
– Death– Fresh hematemesis / >=100ml fresh blood aspirated – Hypovolaemic shock– Hb drop >3g/dL within any 24 hour
Success of stent placement Duration of placement Stent migration Complication Mortality
Definition according to Baveno criteria
No. of patient
Success in stent placement
Control of bleeding
duration
Stent migration
Local complication
mortality
Hubmann et al. 2006 [3]
15 100% 100% 5 days (1-14)
25% 6.7% esophageal tear
20% (60 days)
Zehetner et al. 2008 [4]
34 100% 97% 5 days (1-14)
18% 2.9% esophageal tear
29% (60 days)
Wright et al. 2010 [5]
10 90% 70% 9 days (6-14)
N/A 10% esophageal ulcer
50% (42 days)
Dechene et al. 2012 [6]
8 100% 88% 11 days (7-14)
0% 12.5%compression of left main bronchus
75% (60 Days)
Zakaria et al 2013 [7]
16 93.75% 87.5% 2-4 days 37.5% 6.25% esophageal ulcer
25% (42 days)
Febienne et al 2013 [8]
9 89% 89% 1-5 days 22% 0% 77% (42 days)
No. of patient
Success in stent placement
Control of bleeding
duration
Stent migration
Local complication
mortality
Hubmann et al. 2006 [3]
15 100% 100% 5 days (1-14)
25% 1 esophageal tear
20% (60 days)
Zehetner et al. 2008 [4]
34 100% 97% 5 days (1-14)
18% 1 esophageal tear
29% (60 days)
Wright et al. 2010 [5]
10 90% 70% 9 days (6-14)
N/A 1 esophageal ulcer
50% (42 days)
Dechene et al. 2012 [6]
8 100% 88% 11 days (7-14)
0% 1compression of left main bronchus
75% (60 Days)
Zakaria et al 2013 [7]
16 93.75% 87.5% 2-4 days 37.5% 1 esophageal ulcer
25% (42 days)
Febienne et al 2013 [8]
9 89% 89% 1-5 days 22% 0% 77% (42 days)
– Case series, not controlled trial– Small sample size
No. of patient
Success in stent placement
Control of bleeding
duration
Stent migration
Local complication
mortality
Hubmann et al. 2006 [3]
15 100% 100% 5 days (1-14)
25% 1 esophageal tear
20% (60 days)
Zehetner et al. 2008 [4]
34 100% 97% 5 days (1-14)
18% 1 esophageal tear
29% (60 days)
Wright et al. 2010 [5]
10 90% 70% 9 days (6-14)
N/A 1 esophageal ulcer
50% (42 days)
Dechene et al. 2012 [6]
8 100% 88% 11 days (7-14)
0% 1compression of left main bronchus
75% (60 Days)
Zakaria et al 2013 [7]
16 93.75% 87.5% 2-4 days 37.5% 1 esophageal ulcer
25% (42 days)
Febienne et al 2013 [8]
9 89% 89% 1-5 days 22% 0% 77% (42 days)
– Failure (delivery system error) gastric balloon rupture failed inflation
No. of patient
Success in stent placement
Control of bleeding
duration
Stent migration
Local complication
mortality
Hubmann et al. 2006 [3]
15 100% 100% 5 days (1-14)
25% 1 esophageal tear
20% (60 days)
Zehetner et al. 2008 [4]
34 100% 97% 5 days (1-14)
18% 1 esophageal tear
29% (60 days)
Wright et al. 2010 [5]
10 90% 70% 9 days (6-14)
N/A 1 esophageal ulcer
50% (42 days)
Dechene et al. 2012 [6]
8 100% 88% 11 days (7-14)
0% 1compression of left main bronchus
75% (60 Days)
Zakaria et al 2013 [7]
16 93.75% 87.5% 2-4 days 37.5% 1 esophageal ulcer
25% (42 days)
Febienne et al 2013 [8]
9 89% 89% 1-5 days 22% 0% 77% (42 days)
c.f. Balloon tamponade: 80%
– Failure: GV bleeding failed stent deployment
No. of patient
Success in stent placement
Control of bleeding
duration
Stent migration
Local complication
mortality
Hubmann et al. 2006 [3]
15 100% 100% 5 days (1-14)
25% 1 esophageal tear
20% (60 days)
Zehetner et al. 2008 [4]
34 100% 97% 5 days (1-14)
18% 1 esophageal tear
29% (60 days)
Wright et al. 2010 [5]
10 90% 70% 9 days (6-14)
N/A 1 esophageal ulcer
50% (42 days)
Dechene et al. 2012 [6]
8 100% 88% 11 days (7-14)
0% 1compression of left main bronchus
75% (60 Days)
Zakaria et al 2013 [7]
16 93.75% 87.5% 2-4 days 37.5% 1 esophageal ulcer
25% (42 days)
Febienne et al 2013 [8]
9 89% 89% 1-5 days 22% 0% 77% (42 days)
How to decide??
No. of patient
Success in stent placement
Control of bleeding
duration
Stent migration
Local complication
mortality
Hubmann et al. 2006 [3]
15 100% 100% 5 days (1-14)
25% 1 esophageal tear
20% (60 days)
Zehetner et al. 2008 [4]
34 100% 97% 5 days (1-14)
18% 1 esophageal tear
29% (60 days)
Wright et al. 2010 [5]
10 90% 70% 9 days (6-14)
N/A 1 esophageal ulcer
50% (42 days)
Dechene et al. 2012 [6]
8 100% 88% 11 days (7-14)
0% 1compression of left main bronchus
75% (60 Days)
Zakaria et al 2013 [7]
16 93.75% 87.5% 2-4 days 37.5% 1 esophageal ulcer
25% (42 days)
Febienne et al 2013 [8]
9 89% 89% 1-5 days 22% 0% 77% (42 days)
Immediate repositioning
No. of patient
Success in stent placement
Control of bleeding
duration
Stent migration
Local complication
mortality
Hubmann et al. 2006 [3]
15 100% 100% 5 days (1-14)
25% 6.7% esophageal tear
20% (60 days)
Zehetner et al. 2008 [4]
34 100% 97% 5 days (1-14)
18% 2.9% esophageal tear
29% (60 days)
Wright et al. 2010 [5]
10 90% 70% 9 days (6-14)
N/A 10% esophageal ulcer
50% (42 days)
Dechene et al. 2012 [6]
8 100% 88% 11 days (7-14)
0% 12.5%compression of left main bronchus
75% (60 Days)
Zakaria et al 2013 [7]
16 93.75% 87.5% 2-4 days 37.5% 6.25% esophageal ulcer
25% (42 days)
Febienne et al 2013 [8]
9 89% 89% 1-5 days 22% 0% 77% (42 days)
Esophageal tear
Esophageal ulcer
No. of patient
Success in stent placement
Control of bleeding
duration
Stent migration
Local complication
mortality
Hubmann et al. 2006 [3]
15 100% 100% 5 days (1-14)
25% 1 esophageal tear
20% (60 days)
Zehetner et al. 2008 [4]
34 100% 97% 5 days (1-14)
18% 1 esophageal tear
29% (60 days)
Wright et al. 2010 [5]
10 90% 70% 9 days (6-14)
N/A 1 esophageal ulcer
50% (42 days)
Dechene et al. 2012 [6]
8 100% 88% 11 days (7-14)
0% 1compression of left main bronchus
75% (60 Days)
Zakaria et al 2013 [7]
16 93.75% 87.5% 2-4 days 37.5% 1 esophageal ulcer
25% (42 days)
Febienne et al 2013 [8]
9 89% 89% 1-5 days 22% 0% 77% (42 days)
c.f. Usual 6 week mortality rate: 15-20%
– Reason of death liver failure, multi-organ failure, uncontrolled bleeding
– High mortality rate Selection bias (more severe underlying liver disease)
– Further study to rule out ? Related to stent Delayed / Unrecognized complication
How to monitor any re-bleeding/complication after stent insertion – ? Daily OGD/CXR
? One single size of stent fit for every patient
Need expertise for stent placement
Limitation of study– Limited number of study available– Not a controlled study– Small sample size– Only short term follow up (up to 60 days)
Future study– Need randomized trial– Larger sample size– Long term follow up
SEMS is a recent advance in management of refractory esophageal variceal bleeding
– Considered as a alternative to balloon temponade
– safe and effective treatment in limited data low complication rateSatisfactory rate of bleeding control & stent deployment
– need further study
– Practical aspect: duration, monitoring, expertise
1. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46: 922-38.
2. Gin-Ho Lo. Management of acute esophageal variceal hemorrhage. Kaohsiung J Med Sci 2010; 26: 55-67.
3. Hubmann R, Bodlaj G, Czompo M, et al. The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 2006; 38: 896–901.
4. Zehetner J, Shamiyeh A, Wayand W, et al. Results of a new method to stop acute bleeding from esophageal varices: implantation of a self-expanding stent. Surg Endosc 2008; 22:2149–2152.
5. Wright G, Lewis H, Hogan B, et al. Self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 2010;71:71–78.
6. Dechene A, El Fouly AH, Bechmann LP, et al. Acute management of refractory variceal bleeding in liver cirrhosis by self-expanding metal stents. Digestion 2012;85:185–191.
7. Zakaria MS, Hamza IM, Mohey MA, et al. The fist Egyptian experience using new self-expandable metal stents in acute esophageal variceal bleeding: Pilot study. Saudi J Gastroenterol 2013; 45: 485-8.
8. Fabienne C. Fierz, Walter Kistler, Volker Stenz, et al. Treatment of esophageal variceal hemorrhage with self-expanding metal stents as a rescue maneuver in a swiss multicentric cohort. Case Rep Gastroenterol 2013; 7: 97-105.
9. Fuad Maufa and Firas H. Al-Kawas. Role of Self-Expandable Metal Stents in Acute Variceal Bleeding. Internalional Journal of Hepatology 2012; 418369.
10. Angels Escorsell and Jaime Bosch. Self-Expandable Metal Stents in the Treatment of Acute Esophageal Variceal Bleeding. Gastroenterology Research and Practice 2011; 910986.
11. Vivek Kumbhari, Payal Saxena, Mouen A, et al. Self-Expandable Metallic Stents for Bleeding Esophageal Varices. The Saudi J of Gastroenterology 2013; 1434
12. Roberto de Franchis, on behalf of the Baveno V Faculty, Revising consensus in portal hypertension: Report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension, Journal of Hepatology 2010; 53: 762-768
13. National Institute for Health and Clinical Excellence. Stent insertion for bleeding oesophageal varices. 2011; AprilLászló Benk M.D. New minimal invasive therapeutic options in the management of acute and recurrent esophageal bleeding, 2007
[13]
Weak evidence
SEMS
Failure
SEMS
1st stage 2nd stage
The Danis stent is larger in diameter and the expansion force has been adjusted to work efficiently against bleeding varices, but not to harm the esophageal tissue.
The larger diameter is sufficient to fit every patient.
The pressure exerted by the stent has been evaluated in animal model and later with clinical experience to be sufficient and safe
[9]
Pre-primary prophylaxis (Prevention of formation of varices)– Non-selective beta-blockers: no evidence to prevent formation
of varices– OGD: Should be screened for varices at diagnosis
Primary prophylaxis (prevention of first variceal hemorrhage)– Non-selective beta blocker: Recommended – OGD: Esophageal variceal ligation (EVL) recommended
Repeated every 1-2 weeks till complete obliteration
Secondary prophylaxis (prevention of rebleeding)– Combination of nonselective beta blockers + EVL– TIPS: recurrent variceal haemorrhage– Transplant
When remove stent– Bind time to let pharmcological therapy to work– When elective procedure a/v or expertise a/v– Convert emergency procedure to elective
Contraindication of stent– Stricture– Esophageal tumor– Previous radiation– Body weight <40kg
Risk of stent complication like esophageal rupture– Protective pressure valve does not allow gastric balloon to
inflate against resistance– if gastric balloon inflate wrongly in esophagus safety balloon
at tip of delivery system is inflated
Migration– Covered stent
Wait for 3 minutes for full expansion Optimal integration with esophageal wall
– Uncovered stent Metal wire to dense: impringe on varices with pin point pressure Metal wire not close: varices may squeeze out between wire and can’t
exert temponade effect
Pressure it exert– Not specific mentioned– Radial pressure– Evaluate in animal model and clinical experience to be sufficient
and safe
Monitoring– CXR daily– OGD alt day
Treat the symptom, not underlying cause (liver failure)– Treat esophageal varices
Physical: banding, sengstaken, SEMS Chemical: sclerosant, superglue (cyanoarcylate monomer)
– Treat underlying disease Best medical treatment
Further treatment– Late stage– Further treatment has its own risk and complication, e.g. TIPS (seldom
do)– Best medical treatment
Nutrition, lactulose, antibiotic, avoid hepatotoxic drug, medication, etc
– In our study: EVL, TIPS, shunt surgery, transplant
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