Dr. Rainer Hubmann Endo Linz 20./ R.Hubmann Endo 2012 Linz

Transcription

1 Dr. Rainer Hubmann Endo Linz 20./

2 Warum Wie Warum nicht Wo stehen wir Neue Ideen

3 Ösophagusvarizen entstehen durch eine Dilatation des Venenplexus in der Lamina propria des distalen Ösophagus Diese werden versorgt durch die linke gastrische Vene und drainieren in das Azygossystem über perforierende Venen durch die Muskulatur

4 The ideal treatment of active variceal hemorrhage would be universally effective, completely safe, easy to administer, and inexpensive. Medications (vasopressin and somatostatin and their analogs), endoscopy, surgery, and transjugular intrahepatic portosystemic shunting. None of the existing modalities comes close to being ideal. Only LTX can cure Cirrh. Complications

5 It is recommended as soon as possible in any patient who presents with documented upper GI bleeding and in whom esophageal varices are the cause of bleeding (within 12h) Ligation (EVL) is the recommended form of endoscopic therapy for acute esophageal variceal bleeding, although sclerotherapymay be used in the acute setting if ligation is technically difficult De FranchisR. Revising consensus in portal hypertension: Report of the BavenoV consensus BAVENO V, 2010 workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol(2010)

6 Acute Stopping Recurrent Bleeding

7 Balloon tamponade should only be used in massive bleeding as a temporary bridge until definitive treatment can be instituted (for a maximum of 24 h, preferably in an intensive care facility) De FranchisR. Revising consensus in portal hypertension: Report of the BavenoV consensus BAVENO V, 2010 workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol(2010)

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9 The correct positioning is allowed by a balloon at the end of the set.

10 Set Einführen, Ballon ausfahren und aufblasen, Retraktion an die Kardia, Stent freigeben, Ballon dessufflieren, Set entfernen, Lagekontrolle nach einigen Minuten

11 SX-ELLA Danis Stent Self-expandable. Nitinol stent. Covered by polyurethane foil. Jan Danis

12 Bleeding Stent implanted after implantation Extraction

13 R.Hubmann et al., Endoscopy 2006; 38: Duration of stenting days Previous bleeding episodes Previus treatment for bleeding Underlying type of Final therapy Mortality Mortality Init. Age Disease Child stent after stenting 30 days 60 days IR 27 7 viral (post LTXC 2 2xBL a conservative alive died NW 36 5 alcoholic B 3 1xST, 2xBL b non compliant alive alive HF 56 6 cryptogenic C 5 5xBL, 3xBT b acygoportal disconnection and transplantation alive alive PM 49 5 immunologic C 1 1xBL b TIPS and transplantation alive alive AK 56 5 alcoholic B 2 xbl, 1xST, 1xB c Band Ligation alive alive SA 36 5 alcoholic B 2 2xBL a Band Ligation alive alive KW 44 5 cryptogenic B 2 2xBL, 1xBT c acygoportal disconnection alive alive TD 32 3 cryptogenic B 1 1xBL c TIPS alive alive WG 45 1 ulcer + alcohoc 1 1xST c TIPS alive alive SR 57 7 alcoholic C 3 xst, 2xBL, 1xB c acygoportal disconnection alive alive AH 57 5 alcoholic C 3 1xST, 2xBL c acygoportal disconnection alive alive GJ 69 6 alcoholic B 3 3xBL c Band Ligation alive died KH alcoholic C 2 2xBL c Band Ligation alive alive ZD 48 3 viral C 4 xst, 2xBL, 2xB c letal (hepatic failure) died died SE 52 9 alcoholic C 1 1xBL c Interventional radiologic guided coiling alive alive BD alcoholic C 3 3xBL, 1xBT c acygoportal disconnection alive alive HH 63 5 cryptogenic C 2 2xBL c TIPS alive alive SA 87 5 alcoholic C 1 1xBL c letal (hepatic failure) died died NL 38 7 alcoholic B 1 1xBL c TIPS alive alive HK 52 2 viral B 1 1xBL c Band Ligation and transplantation alive alive 2 of 20 4 of 20 BL Band ligation a ST Sclerotherapy b BT Balloon tampona c CHOOSTENT TM NES M.I.Tech Co., Ltd; guidewire BOUBELA-DANIS Esophageal Stent with Introducing Set; guidewire DANIS Stent Set with Introducer System, Danis ELLA-CS; without guidewire

14 Entfernung mittels Fremdkörperzange Zugriff am proximalen Loop (oder auch distal zur Reposition) Sichere Entfernung auch nach längerer Liegedauer mittels einem für diesen Zweck entwickelten Extraktor

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16 40 patients (20 each) Acute variceal bleeding Severe active visual bleeding, spurters, Stent Active bleeding but visual BL

17 Austria Egypt

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19 Child score at admission: - Child A: - Child B: - Child C: Stent group 15% 51 % 34% Band Ligation 45% 40% 15% Bleeding stopped Complications,. Outcome within 3 months: Alive: Died: Stent group 70% 30% Band Ligation 80% 20%

20 Hubmann R. The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy Sep;38(9): J.Zehetner et al. Results of a new method to stop acute bleeding from esophageal varices: implantation of a self-expanding stent. Surg Endosc Oct; 22(10): ) Aabakken L. Best Practice & Research Clinical Gastroenterology. Chapter 7- Endoscopic haemostasis. Vol. 22, No. 5, pp , 2008 W. R. Matull, T. J. S. Cross, D. Yu, M. C. Winslet, and J. O'Beirne, A removable covered self-expanding metal stent for the management of Sengstaken-Blakemore tube-induced esophageal tear and variceal hemorrhage, Gastrointestinal Endoscopy, vol. 68, no. 4, pp , Wright G. et al. A self-expanding metal stent for complicated variceal hemorrhage:experience at a single center. Gastrointest Endosc 2010;71:71-8 Renteln D., Endoscopic management of acute esophageal dissection by using a covered, self-expanding metal stent. Gastrointest Endosc 2009; 69: Brandt L J. A removable covered self-expanding metal stent for the management of Sengstaken-Blakemore tube induced esophageal tear and variceal hemorrhage. Gastrointest. Endosc. 2008; 68:

21 I. Mishin, G. Ghidirim, A. Dolghii, G. Bunic, andg. Zastavnitsky, Implantation of self-expanding metal stent in the treatment of severe bleeding from esophageal ulcer after endoscopic band ligation, Diseases of the Esophagus, vol. 23, no. 7, pp. E35 E38, De Franchis R; Baveno V Faculty.Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol Oct;53(4): Epub 2010 Jun 27 ÀngelsEscorsellandJaime Bosch, Self-Expandable Metal Stents in the Treatment of Acute Esophageal Variceal Bleeding, GastroenterologyResearch andpractice, vol. 2011, ArticleID , 6 pages, von Renteln D, Vassiliou MC, Caca K, Schmidt A, Rothstein RI. Feasibility and safety of endoscopic transesophageal access and closure using a Maryland dissector and a self-expanding metal stent. SurgEndosc Jul;25(7): Epub 2010 Dec 7 NICE Interventional Procedures, Stent insertion for bleeding oesophageal varices, 2010 Study: Self-expandable Esophageal Stent Versus Balloon Tamponadein Refractory Esophageal Variceal Bleeding Hospital Clinic of Barcelona. Recruiting The Stent OesophagealBleeding SOB Study-THE ROYAL FREE SHEILA SHERLOCK LIVER CENTRE. Effective haemostasisusing self-expandable covered mesh-metal oesophagealstents versus standard endoscopic therapy in the emergency treatment of oesophagealvaricealhaemorrhage: A multicentre, open, prospective, randomised, controlled study.

22 The need for correction of coagulation disorders. Influence of coagulopathy and thrombocytopenia on outcome. Improve prognostic models: Better stratification of risk to determine timing of the initial endoscopy, duration of drug therapy and type of treatment. Treatment and prevention of HE. Best antibiotic. Role of self-expandable esophageal stents. Treatment of gastric varices. Treatment of paediatric patients: no studies define the best approach. Treatment of bleeding ectopic varices like duodenal varices. Role of erythromycin before endoscopy. De FranchisR. Revising consensus in portal hypertension: Report of the BavenoV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol(2010)

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24 Surgical sutures: Dexon- Polyglycolide(PGA) suture Vicryl- PGA/Polylactide Polylactide(PLA) 90:10 suture PDS - Polydioxanone(PDS) Maxon- PGA/Tri-Methylene Carbonate (TMC)

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26 Hydrolytic degradation First the amorphousand and then the crystallinic structure is attacked Degradation products are involved Krebs cycle

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29 2 weeks after implantation 4 weeks after implantation

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31 Algorithm for treatment of acute variceal bleeding Bleeding Nonvariceal bleed. Endoscopy Initial assessment (history, physical exam, blood tests, cultures) Variceal bleeding Resuscitation (prevent aspiration, peripheral + central lines, blood gases, pulse oximetry, transfusion Ht 25-30%), start vasoactive drugs + antibiotic prophylaxis Perform band ligation or sclerotherapy and continue vasoactive drug for up to 5 days Treat as appropriate according to the bleeding source High risk patients: Early PTFE-TIPS Success? Failure Start prophylaxis of rebleeding Emergency surgical shunt Emergency TIPS /Stent?

32 DANKE