Endoscopy 2020; 52(04): 247-248
DOI: 10.1055/a-1112-0962
Editorial

Endoscopic treatments for patients with cirrhosis: to do or not to do

Referring to Miaglia C et al. p. 276–284
Daisuke Kikuchi
Department of Gastroenterology, Toranomon Hospital
› Author Affiliations

Endoscopic resection is a widespread minimally invasive treatment for superficial gastrointestinal tumors. In recent years, endoscopic resection has been performed not only in the stomach, esophagus, and colon but also in more difficult locations such as the pharynx and duodenum [1]. Conventional endoscopic mucosal resection (EMR) involves piecemeal resection depending on factors such as tumor size and location, and presence of scars. Endoscopic submucosal dissection (ESD) makes en bloc resection possible regardless of the limitations of EMR. However, ESD is technically more difficult than EMR, and presents problems such as high incidence of adverse events, long procedure time, and high costs. The decision to use EMR or ESD should be comprehensively determined based on the size, depth, and location of the tumor, the endoscopist’s skill, and the patient’s condition.

Surgery for patients with liver cirrhosis poses high risks [2]. In open surgery in particular, there is a high risk of adverse events such as decompensated liver cirrhosis and bleeding, and risk of death.

In this issue of Endoscopy, Miaglia et al. retrospectively analyzed the short and long term results of 164 endoscopic resection procedures in 126 patients with liver cirrhosis [3]. The majority of the patients (117 cases) had non-severe liver cirrhosis (Child – Pugh class A or B), and more than half had alcohol-related liver cirrhosis. Endoscopic resection was performed in the esophagus in 34 procedures (25 cases), the stomach in 20 procedures (15 cases), the duodenum in 11 procedures (9 cases), and the colorectum in 99 procedures (77 cases). About 60 % of procedures in the esophagus and stomach were ESD, whereas most of the treatments in the duodenum and colon were EMR. The R0 resection rate for neoplastic lesions was 88.2 % (127/144), and the curative resection rate was 84.0 % (121/144), which was good. The overall incidence of adverse events was 6.1 % (10/164), with bleeding in eight cases. In multivariate analysis, the site of treatment in the duodenum and low glomerular filtration rate were selected as risk factors for the incidence of adverse events.

“Endoscopic resection for patients with non-severe liver cirrhosis is highly effective and can be safely performed, with an adverse event rate of 6.1 %.”

However, the study has some limitations. First, it was a retrospective study conducted at a single institution. For this reason, the entry period of the study was quite long. Recent advances in endoscopic treatment have been remarkable, and there were likely substantial changes to endoscopic resection methods and devices during this period. In fact, as noted above, over 60 % of the procedures in the esophagus and stomach were ESD. However, EMR and ESD cannot be regarded in the same manner as endoscopic resection. Second, as the authors note in their Discussion, their study focused on liver cirrhosis patients alone. The lack of comparison with patients without liver cirrhosis is considered a major limitation. Thus, a comparative study comprising large cohorts with the same background and treatment method is needed.

Two important points should be considered when selecting endoscopic resection for patients with liver cirrhosis. The first is to accurately diagnose gastrointestinal lesions. It is important to confirm whether the lesion is a neoplastic lesion or not; image-enhanced endoscopy and magnifying endoscopy are useful for differential diagnosis. For neoplastic lesions, it is necessary to precisely diagnose the extent and depth of the lesion. Endoscopic ultrasonography should also be used to diagnose invasion depth. It can also identify submucosal blood vessels and stratify the risk of intraoperative and postoperative bleeding [4]. The second important consideration it to accurately determine the prognosis of liver cirrhosis. This study included only seven cases of severe liver cirrhosis (Child – Pugh class C). The 3-year survival rate was greater than 80 %, but the 5-year survival rate was less than 60 %. Cirrhosis-related causes of death exceeded 60 %, including sepsis and bleeding, and liver cirrhosis was considered to be the primary factor determining the long term prognosis of patients with liver cirrhosis. The prognosis of liver cirrhosis can vary depending on the cause and treatment method, so it should be thoroughly evaluated by a hepatology specialist. In other words, both accurate diagnosis of the lesion itself and correct evaluation of the general condition of the patient’s liver and renal function are needed.

When deciding what treatment will be given, treatment with low risk of adverse events is advised. Prevention of bleeding is of utmost importance. Methods for preventing bleeding in the duodenum, which had a significantly high incidence of adverse events in the Miaglia et al. study, include suturing with an endoclip [5], shielding using a polyglycolic acid sheet with fibrin glue [6] [7], and suturing with an over-the-scope clip [8]. Maximal precautions should be taken in cases with multiple risk factors for complications. In addition, new methods such as full-layer stitching by hand suturing have been reported [9]; further development of these methods is needed.

Endoscopic resection for patients with non-severe liver cirrhosis can be safely performed, with an adverse event rate of 6.1 %. Its efficacy is also high, so it should be considered as first-line treatment for superficial gastrointestinal tumors in patients with liver cirrhosis. However, it is essential to carefully consider the merits and demerits, and to obtain informed consent from patients. Treatment decisions should be made with the greatest emphasis on the benefit to the patient, and treatment in the interest of the endoscopist should not be allowed under any circumstance. When treatment is selected, all necessary precautions and measures should be taken against adverse events.



Publication History

Article published online:
25 March 2020

© Georg Thieme Verlag KG
Stuttgart · New York

 
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