Is stenting a treatment option for oesophageal varices?

Stenting for Esophageal Varices: Treatment Options and Recommendations

Self-expandable metal stents (SEMS) can be used as a rescue therapy for refractory esophageal variceal bleeding, but they are not recommended as a primary treatment option for esophageal varices. The primary treatments remain endoscopic variceal ligation (EVL) and transjugular intrahepatic portosystemic shunt (TIPS).

Primary Management of Esophageal Varices

First-Line Therapy

• Endoscopic Variceal Ligation (EVL): Recommended as the primary endoscopic treatment for acute esophageal variceal bleeding 1
• Pharmacological Therapy: Vasoactive agents (terlipressin, somatostatin, or octreotide) should be initiated as soon as possible after admission 1
• Combined Approach: Combination of endoscopic and pharmacological therapy is superior to either treatment alone, with 5-day hemostasis rates of 77% vs. 58% for endoscopy alone 1

For Refractory Bleeding

When first-line therapy fails to control bleeding, the following options should be considered:

1. TIPS (Transjugular Intrahepatic Portosystemic Shunt):

   • Recommended as the best rescue treatment for patients with inadequate bleeding control despite combined pharmacological and endoscopic therapy 1
   • Achieves control of bleeding in approximately 90% of patients 1
   • Early TIPS (within 72 hours, ideally <24 hours) should be considered in high-risk patients (Child-Pugh class B with active bleeding or Child-Pugh class C with MELD <14) 1
   • Covered stents are now standard practice due to significantly improved patency rates 1

2. Self-Expandable Metal Stents (SEMS):

   • Can be used as a bridge therapy when standard treatments fail 2, 3
   • Initial bleeding control rate after SEMS application is approximately 100% 2
   • Provides a safer alternative to balloon tamponade with better control of bleeding (85% vs. 47%) and fewer serious adverse events (15% vs. 47%) 4
   • Can remain in place for up to 2 weeks 1
   • May be considered for definitive treatment in patients with limited life expectancy or those unsuitable for TIPS 5

3. Balloon Tamponade:

   • Traditional bridge therapy that provides hemostasis in 80-90% of patients 1
   • High rebleeding rate (approximately 50%) after deflation 1
   • Associated with serious complications (esophageal ulceration, rupture, aspiration pneumonia) 1
   • Should not exceed 24 hours of use 1

Limitations and Complications

TIPS Complications

• Hepatic encephalopathy (15-25% of patients) 1
• Risk of hepatic decompensation due to diversion of portal flow 1
• Not recommended where the Child-Pugh score is >13 1

SEMS Complications

• Stent migration/dislocation (reported in up to 63.6% of cases) 2
• May require multiple procedures for placement and removal

Decision Algorithm

1. Initial Management:

   • Start vasoactive drugs immediately upon suspicion of variceal bleeding
   • Perform endoscopic therapy (preferably EVL) once patient is stable
   • Add antibiotic prophylaxis

2. If Bleeding Persists or Recurs Within 5 Days:

   • For hemodynamically stable patients with Child's C disease (C10-13) or MELD ≥19: Consider early TIPS within 72 hours
   • For other patients with refractory bleeding: Consider rescue TIPS

3. If TIPS is Contraindicated or Not Immediately Available:

   • Consider SEMS as a bridge therapy (can remain in place for up to 2 weeks)
   • SEMS is preferable to balloon tamponade due to better efficacy and safety profile

4. For Long-Term Management:

   • TIPS with covered stents for patients who have failed endoscopic and pharmacological therapy
   • SEMS may be considered as definitive treatment only in patients with limited life expectancy or those unsuitable for TIPS

Important Considerations

• Stent migration is common with SEMS (63.6%) but doesn't necessarily lead to rebleeding 2
• TIPS should be performed with covered stents due to superior patency rates 1
• The goal portal pressure gradient after TIPS should be <12 mmHg 6
• Concurrent obliteration of varices is recommended during TIPS creation 6

In conclusion, while stenting with SEMS can be an effective rescue therapy for refractory esophageal variceal bleeding, it is primarily used as a bridge to more definitive treatment (usually TIPS) rather than as a primary treatment option for esophageal varices.