title: Acute management of refractory variceal bleeding in liver cirrhosis by self-expanding metal stents.
abstract: OBJECTIVE
  Current treatment strategies of variceal bleeding (VB) include banding and sclerotherapy. However, up to 10% of bleeding events remain refractory to standard therapy with high mortality. With this study, we aimed to evaluate the implantation of self-expanding metal stents (SEMS) for the management of therapy-refractory variceal bleeding.
  
  
  METHODS
  Eight cirrhotic patients who presented to our unit with a total of 9 refractory bleeding events were treated by SEMS placement.
  
  
  RESULTS
  Stenting resulted in immediate hemostasis in all cases without recurrent bleeding with SEMS in situ. After stabilization, 1 patient was treated by transjugular intrahepatic portosystemic shunt (TIPS) and after the second bleeding episode by TIPS dilation. One patient underwent orthotopic liver transplantation (OLT). The remaining patients were treated with standard drug regimens to reduce portal pressure. The SEMS were removed after a median of 11 days. No acute hemorrhage was noted on stent retrieval. While no early rebleeding occurred in the patients after TIPS implant, TIPS dilation or OLT, 3 out of 5 patients on conservative treatment experienced recurrence of VB within 9 days after SEMS removal.
  
  
  CONCLUSIONS
  SEMS placement sufficiently stops hemorrhage in refractory VB. Due to the high rebleeding rate after conservative treatment alone following SEMS removal, this procedure may be utilized as a mere bridging method. Additional interventional and/or surgical methods to effectively reduce portal pressure (i.e. TIPS, OLT) should be considered. Further studies to evaluate the optimum treatment algorithm of refractory esophageal VB are warranted.
authors.affiliation: Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany.
authors.forename: A
authors.initials: A
authors.lastname: Dechêne
authors.forename: A H
authors.initials: AH
authors.lastname: El Fouly
authors.forename: L P
authors.initials: LP
authors.lastname: Bechmann
authors.forename: C
authors.initials: C
authors.lastname: Jochum
authors.forename: F H
authors.initials: FH
authors.lastname: Saner
authors.forename: G
authors.initials: G
authors.lastname: Gerken
authors.forename: A
authors.initials: A
authors.lastname: Canbay
mesh_terms: D000328:Adult; D000368:Aged; D016099:Endoscopy, Gastrointestinal; D004932:Esophageal and Gastric Varices / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D015607:Stents; D016896:Treatment Outcome