Published online Aug 27, 2022. doi: 10.4254/wjh.v14.i8.1584
Peer-review started: March 30, 2022
First decision: June 8, 2022
Revised: June 22, 2022
Accepted: July 26, 2022
Article in press: July 26, 2022
Published online: August 27, 2022
Processing time: 148 Days and 21.9 Hours
Salvage treatment using balloon tamponade techniques such as Sengstaken-Blakemore tubes (SBT) represents the most severe end of the spectrum of acute variceal bleeding (AVB), where failure to achieve primary haemostasis inevitably results in death. However, few studies report on the clinical practice and outcomes of this procedure in the current era, and only include small study populations where balloon tamponade is often performed by non-specialists in the emergency department setting. This retrospective multi-centre cohort study is the largest study including 80 patients over a decade who have undergone SBT for salvage therapy performed by gastroenterologists during endoscopy in tertiary hospitals. This study provides detailed technical aspects of the SBT insertion procedure and provides insight into the success rate, clinical outcomes of patients who undergo SBT insertion for refractory AVB and predictors of mortality, re-bleeding and complications from SBT.
The main topics of this study include detailed descriptions regarding the real-world practice of SBT performed by gastroenterologists in tertiary hospitals, and the clinical outcomes and predictors of short- and long-term mortality after SBT for AVB, the success rate of balloon tamponade in achieving primary haemostasis and the rate of re-bleeding and complications arising from SBT insertion. Information regarding these topics are not currently available for the current era which significantly differs from historical cohorts from the 1970-1980s due to a very different patient population where balloon tamponade was often first-line therapy. Currently, there are clear expert opinion-based consensus guidelines using a range of medical and endoscopic therapies and definitive treatment with radiologic procedures or liver transplantation for AVB. Furthermore, performing salvage technique with SBT is highly resource-intense and thus appropriate risk stratification to optimise outcomes for patients is required.
To assess the primary outcome which was all-cause mortality of AVB requiring SBT in the short-term (6 wk) as well as long-term (52 wk) and the secondary outcomes of re-bleeding and complications after SBT insertion. The predictors of these outcomes were also analysed. These objectives were all achieved apart from the predictors of complications from SBT as serious complications were infrequent.
Due to the infrequent need to perform SBT for AVB, an appropriate method to undertake this study resulted in a multi-centre retrospective cohort study including 80 adult patients with SBT for refractory AVB from 2008 to 2019. The study population was identified using International Classification of Diseases-10 codes and clinical data was collected from medical records. Descriptive statistics, univariate and multivariate binomial regression and survival analyses were used to analyse the data collected.
SBT salvage for refractory AVB is a life-threatening condition with high mortality rates of 48.8% at 6 wk and 53.8% at 52 wk. The SBT procedure was highly successful in achieving primary haemostasis in 91.3% of patients but re-bleeding was common at 34.2% and associated with very high mortality of 76.0%. The predictors of mortality after SBT insertion included increased severity of liver disease, severe metabolic disturbance, presence of hepatocellular carcinoma (HCC) and re-bleeding. Serious complications from SBT insertion were uncommon at 6.3% and the main complications were superficial mucosal trauma without perforation which was managed conservatively. Despite this procedure being performed by specialist gastroenterologists in this study, there was still significant variation amongst technical aspects of the SBT procedure particularly amongst gastric and oesophageal balloon inflation volumes.
In the current era, SBT as a salvage therapy for refractory AVB continues to be associated with high short and long-term mortality rates. The utilisation of this temporising procedure remains relevant and is associated with high rates of primary haemostasis over 90%. As the mortality rate exceeds 75% after re-bleeding, this highlights the importance of prompt treatment with definitive therapies such as transjugular intrahepatic portosystemic shunts to optimise clinical outcomes. Furthermore, as SBT is associated with intense use of resources with even greater mortality in the presence of advanced HCC, this study suggests early palliation may be more appropriate in this futile setting.
Future directions of this research should focus on strategies to optimise the clinical outcomes for this cohort of severe refractory AVB including prevention, the use of covered self-expandable oesophageal stents and prompt transition to definitive treatments before re-bleeding occurs. Further studies into risk stratification for optimal outcomes is required as well to assist clinicians in decision making regarding whether or not salvage therapy should be performed at all.