Self‐expanding metal stents for acute refractory esophageal variceal bleeding: A systematic review and meta‐analysis

Abstract

Objectives Esophageal variceal bleeding is a severe complication of portal hypertension with significant morbidity and mortality. A substantial portion of cirrhotics fail to respond to conventional medical therapy and band ligation, necessitating alternative treatments including SEMS placement for acute refractory esophageal variceal bleeding. To perform a systematic review and structured meta-analysis of all eligible studies to evaluate the technically feasibility, safety, clinical efficacy, and survival advantage of SEMS for the treatment of acute esophageal variceal bleeding. Methods Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were performed through December 2015. Individual study proportions were transformed into a quantity using the Freeman – Tukey variant of the arcsine square root transformed proportion. Combined weighted proportions, and meta-regression were then determined. Results The search yielded 12 studies involving n=155 patients, included in our meta-analysis. The pooled clinical success rate in achieving hemostasis within 24 hours was 96% (95% CI, 0.90–1.00). Technical success for SEMS deployment endoscopically was achieved in 97% of patients (95% CI, 0.91–1.00). Total adverse events (including rebleeding after 48 hours, ulceration, and stent migration) were shown in 36% of patients after SEMS placement (95% CI, 0.23–0.50). The pooled 30 day and 60 day survival rate was 68% (95% CI, 0.56–0.80) and 64% (95% CI, 0.48–0.78), respectively. Conclusion This study demonstrated that esophageal SEMS placement is a technically feasible modality and highly efficacious in achieving hemostasis in acute esophageal variceal hemorrhage.

Outcomes after placement of a SX‐ELLA oesophageal stent for refractory variceal bleeding—A national multicentre study

“…A recent metaanalyses of 12 studies comprising a total of 155 patients reported a promising clinical success rate of 96% within 24 hours using SEMS for refractory variceal bleeding. 29 However, in three of the included studies, haemostasis within 24 hours was only achieved with lower rate ranging from 78% to 89%. 23,30,31 Another metaanalyses comprising n = 134 showed failure-to-control bleeding rate of 14.2%.…”

“…We found a high percentage of successful bleeding control within five days (82.4%) and one‐third had successful bleeding control without bleeding events during follow‐up. A recent meta‐analyses of 12 studies comprising a total of 155 patients reported a promising clinical success rate of 96% within 24 hours using SEMS for refractory variceal bleeding . However, in three of the included studies, haemostasis within 24 hours was only achieved with lower rate ranging from 78% to 89% .…”

Early feeding after esophageal variceal band ligation in cirrhotics is safe: Randomized controlled trial

“…Failure to control acute bleeding and very early rebleeding were assessed by two experienced clinicians. Patients with failure of initial hemostasis or very early rebleeding were treated with a vasoconstrictor along with balloon tamponade, SX‐ELLA‐Danis stent or transjugular intrahepatic portosystemic shunt (TIPSS) as clinically indicated. Delayed rebleeding was defined as when the criteria for failure to control acute variceal bleeding occurred between 5 and 30 days after enrolment in patients achieving control of acute bleeding.…”

Prevention and treatment of variceal haemorrhage in 2017

“…Balloon tamponade with a Sengstaken-Blakemore or a Linton-Nachlas tube may still be used in the very rare case of massive exsanguinating bleeding or recurrent bleeding as a "bridge" to TIPS or another definitive treatment. However, oesophageal self-expandable metallic stents have been shown to be very effective 49 and a recent RCT showed that oesophageal stents are as effective but safer than balloon tamponade. 50 This is part of current recommendations.…”