Liver transplantation in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis.

Item request has been placed! ×
Item request cannot be made. ×
loading   Processing Request
Read More Add to Saved list
  • Additional Information
    • Source:
      Publisher: Elsevier Science Inc Country of Publication: United States NLM ID: 0243532 Publication Model: Print Cited Medium: Internet ISSN: 1873-2623 (Electronic) Linking ISSN: 00411345 NLM ISO Abbreviation: Transplant Proc Subsets: MEDLINE
    • Publication Information:
      Publication: New York, N.Y. : Elsevier Science Inc.
      Original Publication: New York Stratton.
    • Subject Terms:
      Emergency Treatment* ; Liver Transplantation*; Esophageal and Gastric Varices/*surgery ; Liver Cirrhosis/*surgery; Acute Disease ; Humans ; Survival Rate ; Treatment Outcome
    • Abstract:
      Background: Bleeding esophageal varices (BEV) in cirrhosis has been considered an indication for liver transplantation (LT). This issue was examined in a randomized controlled trial (RCT) of unselected, consecutive patients with advanced cirrhosis and BEV that compared endoscopic sclerotherapy (EST; n = 106) to emergency direct portacaval shunt (EPCS; n = 105).
      Methods: Diagnostic work-up and treatment were initiated within 8 hours. Patients were evaluated for LT on admission and repeatedly thereafter; 96% underwent over 10 years of regular follow-up. The analysis was supplemented by 1300 unrandomized cirrhotic patients who previously underwent portacaval shunt (PCS) with 100% follow-up.
      Results: In the RCT long-term bleeding control was 100% following EPCS, only 20% following EST. Also, 3-, 5-, 10-, and 15-year survival rates were 75%, 73%, 46%, and 46%, respectively, following EPCS compared with 44%, 21%, 9%, and 9% following EST, respectively (P < .001). Only 13 RCT patients (6%) were ultimately referred for LT mainly because of progressive liver failure; only 7 (3%) were approved for LT and only 4 (2%) underwent LT. The 1- and 5-year LT survival rates were 0.68% and 0, respectively, compared with 81% and 73%, respectively, after EPCS. In the 1300 unrandomized PCS patients, 50 (3.8%) were referred and 19 (1.5%) underwent LT. The 5-year survival rate was 53% compared with 72% for all 1300 patients.
      Conclusions: If bleeding is permanently controlled, as occurred invariably following EPCS, cirrhotic patients with BEV seldom require LT. PCS is effective first-line and long-term treatment. Should LT be required in patients with PCS, although technically more demanding, numerous studies have shown that PCS does not increase mortality or complications. EST is not effective emergency or long-term therapy.
      (Copyright © 2010 Elsevier Inc. All rights reserved.)
    • References:
      Br J Surg. 1987 Sep;74(9):787-90. (PMID: 3499203)
      Transplant Proc. 2005 Apr;37(3):1491-2. (PMID: 15866651)
      Cochrane Database Syst Rev. 2006 Oct 18;(4):CD000553. (PMID: 17054131)
      Ann Surg. 2009 Oct;250(4):598-610. (PMID: 19730244)
      World J Surg. 2005 Aug;29(8):966-73. (PMID: 15981047)
      Transplant Proc. 1991 Feb;23(1 Pt 2):1570-1. (PMID: 1989295)
      Lancet. 1994 Apr 30;343(8905):1079-84. (PMID: 7909104)
      Am J Surg. 1973 Dec;126(6):748-51. (PMID: 4543312)
      J Hepatol. 1995 Aug;23(2):123-8. (PMID: 7499782)
      Surg Gynecol Obstet. 1991 Mar;172(3):215-9. (PMID: 1994497)
      JAMA. 2001 Apr 18;285(15):1987-91. (PMID: 11308435)
      Hepatology. 1999 Jan;29(1):44-50. (PMID: 9862848)
      Surgery. 1988 Oct;104(4):697-705. (PMID: 3051474)
      Am J Surg. 1993 May;165(5):566-71. (PMID: 8488938)
      J Am Coll Surg. 2009 Jul;209(1):25-40. (PMID: 19651060)
      Ann Surg. 1989 Jan;209(1):51-6. (PMID: 2642690)
      Clin Liver Dis. 2006 Aug;10(3):583-98, ix. (PMID: 17162229)
      Langenbecks Arch Surg. 2003 Jul;388(3):150-4. (PMID: 12756568)
      Hepatology. 1993 Jul;18(1):66-72. (PMID: 8325623)
      N Engl J Med. 1994 Jan 20;330(3):165-71. (PMID: 8264738)
      Adv Surg. 1992;25:189-208. (PMID: 1536096)
      N Engl J Med. 1989 May 25;320(21):1393-8. (PMID: 2654633)
      Hepatology. 1994 Jul;20(1 Pt 1):46-55. (PMID: 8020904)
      Arch Surg. 1974 Mar;108(3):302-5. (PMID: 4544310)
      Arch Surg. 1999 Apr;134(4):416-20. (PMID: 10199316)
      Endoscopy. 2006 Aug;38(8):797-807. (PMID: 17001564)
      Major Probl Clin Surg. 1964;1:1-85. (PMID: 4950264)
      Surgery. 2005 Jun;137(6):620-5. (PMID: 15933628)
      Ann Intern Med. 2001 Apr 17;134(8):663-94. (PMID: 11304107)
      Am J Surg. 1977 Jul;134(1):146-52. (PMID: 879407)
      Am J Gastroenterol. 1992 Jun;87(6):714-8. (PMID: 1590306)
      Am J Gastroenterol. 2003 Nov;98(11):2424-34. (PMID: 14638344)
      Gastroenterology. 1982 May;82(5 Pt 1):968-73. (PMID: 7037525)
      Hepatology. 2005 Feb;41(2):386-400. (PMID: 15660434)
      Hepatology. 1988 Nov-Dec;8(6):1475-81. (PMID: 3056820)
      Am J Surg. 1990 Jul;160(1):105-10. (PMID: 2368870)
      Hepatology. 1989 Jun;9(6):801-7. (PMID: 2785478)
      Br J Surg. 1981 Jul;68(7):485-7. (PMID: 6972793)
      Alcohol Res Health. 2003;27(3):257-68. (PMID: 15535454)
      Am J Surg. 1990 Jul;160(1):111-6. (PMID: 2368871)
      Gastroenterology. 1981 Apr;80(4):800-9. (PMID: 6970703)
      J Am Coll Surg. 1995 Mar;180(3):257-72. (PMID: 7874335)
      Hepatology. 1995 Jul;22(1):332-54. (PMID: 7601427)
      Ann Surg. 1980 Jul;192(1):9-17. (PMID: 6447485)
    • Grant Information:
      R01 DK041920 United States DK NIDDK NIH HHS; R01 DK041920-07 United States DK NIDDK NIH HHS; 234-2005-370011C United States PHS HHS
    • Publication Date:
      Date Created: 20101221 Date Completed: 20110425 Latest Revision: 20240320
    • Publication Date:
      20240320
    • Accession Number:
      PMC3032417
    • Accession Number:
      10.1016/j.transproceed.2010.09.035
    • Accession Number:
      21168637