Safe and effective digestive endoscopic resection in patients with cirrhosis: a single-center experience

Abstract

Background Endoscopic resection has developed over the years. The main complications are perforation and bleeding. This study aimed to evaluate safety and effectiveness of digestive endoscopic resection in patients with cirrhosis.

Methods This retrospective, open-label, single-center study included all consecutive patients with cirrhosis who were admitted for endoscopic resection between 2009 and 2016. Safety, efficacy, and risk factors for delayed bleeding were analyzed.

Results 126 patients undergoing 164 procedures were included: 65 endoscopic resections (49 patients) in the upper gastrointestinal tract (esophagus 34, stomach 20, duodenum 11) and 99 in the lower gastrointestinal tract (77 patients). Mean Model for End-Stage Liver Disease score was 9.9 (standard deviation 4.5). Esophageal varices were present in 50 patients, and 21 patients had decompensated cirrhosis. The overall curative rate of endoscopic resection was 84.0 %. No patients died during 30-day follow-up. Immediate overall morbidity was 6.1 %, with two postoperative fevers and eight bleeds. Risk factors for delayed bleeding were duodenal location (P < 0.01), antiplatelet medication (P = 0.02), and lower glomerular filtration rate (GFR) (P = 0.01) in univariate analysis. Duodenal location and lower GFR remained statistically significant in multivariate analysis, with respective odds ratios for bleeding of 52.12 and 1.04. No liver decompensation occurred after endoscopic resection.

Conclusions Endoscopic resection was safe and effective in patients with mild (Child – Pugh class A/B) cirrhosis, and should be proposed as a first option for treatment of superficial neoplasia. Additional data in patients with severe cirrhosis are needed to confirm the safety in this population.

Publication History

Received: 23 May 2019

Accepted: 17 December 2019

Article published online:
20 January 2020

• References

• 1 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2015; 47: 829-854
• 2 Dinis-Ribeiro M, Areia M, de Vries AC. European Society of Gastrointestinal Endoscopy, European Helicobacter Study Group, European Society of Pathology, Sociedade Portuguesa de Endoscopia Digestiva. et al. Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Endoscopy 2012; 44: 74-94
• 3 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2017; 49: 270-297
• 4 Zeng Y, Liang W, Liu J. et al. Endoscopic treatment versus esophagectomy for early-stage esophageal cancer: a population-based study using propensity score matching. J Gastrointest Surg 2017; 21: 1977-1983
• 5 Jin X-F, Gai W, Chai T-H. et al. Comparison of endoscopic resection and minimally invasive esophagectomy in patients with early esophageal cancer. J Clin Gastroenterol 2017; 51: 223-227
• 6 Cummings LC, Kou TD, Schluchter MD. et al. Outcomes after endoscopic versus surgical therapy for early esophageal cancers in an older population. Gastrointest Endosc 2016; 84: 232-240.e1
• 7 Fujita H, Sueyoshi S, Yamana H. et al. Optimum treatment strategy for superficial esophageal cancer: endoscopic mucosal resection versus radical esophagectomy. World J Surg 2001; 25: 424-431
• 8 Le Roy F, Manfredi S, Hamonic S. et al. Frequency of and risk factors for the surgical resection of nonmalignant colorectal polyps: a population-based study. Endoscopy 2016; 48: 263-270
• 9 Douard R, Lentschener C, Ozier Y. et al. Operative risks of digestive surgery in cirrhotic patients. Gastroenterol Clin Biol 2009; 33: 555-564
• 10 de Goede B, Klitsie PJ, Lange JF. et al. Morbidity and mortality related to non-hepatic surgery in patients with liver cirrhosis: a systematic review. Best Pract Res Clin Gastroenterol 2012; 26: 47-59
• 11 Simmelink AL, Dong R, Nayi V. et al. Perioperative risk assessment and management of cirrhotic patients. J Hepatol Gastrointest Dis 2015; DOI: 10.4172/2475-3181.1000101.
• 12 Zarski JP, Bichard P, Bourbon P. et al. Extrahepatic digestive surgery in cirrhotic patients: mortality, morbidity and preoperative prognostic factors. Gastroenterol Clin Biol 1988; 12: 43-47
• 13 Causey MW, Nelson D, Johnson EK. et al. The impact of Model for End-Stage Liver Disease-Na in predicting morbidity and mortality following elective colon cancer surgery irrespective of underlying liver disease. Am J Surg 2014; 207: 520-526
• 14 Chang CC, Chen SH, Pan S. et al. Endoscopic mucosal resection with a cap-fitted endoscope for early gastric carcinoma with focal submucosal invasion in a patient with decompensated liver cirrhosis. J Formos Med Assoc 2001; 100: 841-843
• 15 Ganne-Carrié N, Ziol M, de Ledinghen V. et al. Accuracy of liver stiffness measurement for the diagnosis of cirrhosis in patients with chronic liver diseases. Hepatology 2006; 44: 1511-1517
• 16 Paquet KJ, Kuhn R. Prophylactic endoscopic sclerotherapy in patients with liver cirrhosis, portal hypertension, and esophageal varices. Hepatogastroenterology 1997; 44: 625-636
• 17 Veitch AM, Vanbiervliet G, Gershlick AH. et al. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Endoscopy 2016; 48: c1 DOI: 10.1055/s-0042-122686.
• 18 Laurence JM, Tran PD, Richardson AJ. et al. Laparoscopic or open cholecystectomy in cirrhosis: a systematic review of outcomes and meta-analysis of randomized trials. HPB (Oxford) 2012; 14: 153-161
• 19 Cobb WS, Heniford BT, Burns JM. et al. Cirrhosis is not a contraindication to laparoscopic surgery. Surg Endosc 2005; 19: 418-423
• 20 Park CH, Jung YS, Nam E. et al. Comparison of efficacy of prophylactic endoscopic therapies for postpolypectomy bleeding in the colorectum: a systematic review and network meta-analysis. Am J Gastroenterol 2016; 111: 1230-1243
• 21 Matsumoto M, Kato M, Oba K. et al. Multicenter randomized controlled study to assess the effect of prophylactic clipping on post-polypectomy delayed bleeding. Dig Endosc 2016; 28: 570-576
• 22 Pioche M, Camus M, Rivory J. et al. A self-assembling matrix-forming gel can be easily and safely applied to prevent delayed bleeding after endoscopic resections. Endosc Int Open 2016; 4: E415-419
• 23 Cao Y, Liao C, Tan A. et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009; 41: 751-757
• 24 Saito Y, Fukuzawa M, Matsuda T. et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc 2010; 24: 343-352
• 25 Neuhaus H, Terheggen G, Rutz EM. et al. Endoscopic submucosal dissection plus radiofrequency ablation of neoplastic Barrett’s esophagus. Endoscopy 2012; 44: 1105-1113
• 26 Nonaka S, Oda I, Tada K. et al. Clinical outcome of endoscopic resection for nonampullary duodenal tumors. Endoscopy 2015; 47: 129-135
• 27 Navaneethan U, Hasan MK, Lourdusamy V. et al. Efficacy and safety of endoscopic mucosal resection of non-ampullary duodenal polyps: a systematic review. Endosc Int Open 2016; 4: E699-708
• 28 Tsou Y-K, Liu C-Y, Fu K-I. et al. Endoscopic submucosal dissection of superficial esophageal neoplasms is feasible and not riskier for patients with liver cirrhosis. Dig Dis Sci 2016; 61: 3565-3571
• 29 Xu Z-G, Zhao Y-B, Yu J. et al. Novel endoscopic treatment strategy for early esophageal cancer in cirrhotic patients with esophageal varices. Oncol Lett 2019; 18: 2560-2567
• 30 Choe WH, Kim JH, Park JH. et al. Endoscopic submucosal dissection of early gastric cancer in patients with liver cirrhosis. Dig Dis Sci 2018; 63: 466-473
• 31 Ogura K, Okamoto M, Sugimoto T. et al. Efficacy and safety of endoscopic submucosal dissection for gastric cancer in patients with liver cirrhosis. Endoscopy 2008; 40: 443-445
• 32 Al-Mammari S, Owen R, Findlay J. et al. Endoscopic mucosal resection of early oesophageal neoplasia in patients requiring anticoagulation: is it safe?. Surg Endosc 2016; 30: 2390-2395
• 33 Park S-E, Kim DH, Jung H-Y. et al. Risk factors and correlations of immediate, early delayed, and late delayed bleeding associated with endoscopic resection for gastric neoplasms. Surg Endosc 2016; 30: 625-632
• 34 Repici A, Pagano N, Hassan C. et al. Endoscopic submucosal dissection of gastric neoplastic lesions in patients with liver cirrhosis: a systematic review. J Gastrointest Liver Dis 2012; 21: 303-307
• 35 Navaneethan U, Lourdusamy D, Mehta D. et al. Endoscopic resection of large sporadic non-ampullary duodenal polyps: efficacy and long-term recurrence. Surg Endosc 2014; 28: 2616-2622
• 36 Lépilliez V, Chemaly M, Ponchon T. et al. Endoscopic resection of sporadic duodenal adenomas: an efficient technique with a substantial risk of delayed bleeding. Endoscopy 2008; 40: 806-810
• 37 Kataoka Y, Tsuji Y, Sakaguchi Y. et al. Bleeding after endoscopic submucosal dissection: risk factors and preventive methods. World J Gastroenterol 2016; 22: 5927-5935
• 38 Libânio D, Costa MN, Pimentel-Nunes P. et al. Risk factors for bleeding after gastric endoscopic submucosal dissection: a systematic review and meta-analysis. Gastrointest Endosc 2016; 84: 572-586