Correlation between diameter of esophageal varices and early rebleeding following endoscopic variceal ligation: a multicenter retrospective study based on artificial intelligence-based endoscopic virtual rule.

Background and objective: Bleeding following endoscopic variceal ligation (EVL) may occur as a result of numerous factors, including a diameter of esophageal varices (EV) that is too large to be completely ligated. The present study aimed to develop an artificial intelligence-based endoscopic virtual ruler (EVR) to measure the diameter of EV with a view to finding more suitable cases for EVL. Methods: The present study was a multicenter retrospective study that included a total of 1,062 EVLs in 727 patients with liver cirrhosis with EV, who underwent EVL from April 2016 to March 2023. Patients were divided into early rebleeding (n = 80) and non-rebleeding groups (n = 982) according to whether postoperative bleeding occurred at 6 weeks. The characteristics of patient baseline data, the status of rebleeding at 6 weeks after surgery and the survival status at 6 weeks after rebleeding were analyzed. Results: The early rebleeding rate following 1,062 EVL procedures was 7.5%, and the mortality rate at 6 weeks after bleeding was 16.5%. Results of the one-way binary logistic regression analysis demonstrated that the risk factors for early rebleeding following EVL included: high TB (P = 0.009), low Alb (P = 0.001), high PT (P = 0.004), PVT (P = 0.026), HCC (P = 0.018), high Child-Pugh score (P < 0.001), Child-Pugh grade C(P < 0.001), high MELD score(P = 0.004), Japanese variceal grade F3 (P < 0.001), diameter of EV (P < 0.001), and number of ligature rings (P = 0.029). Results of the multifactorial binary logistic regression analysis demonstrated that Child-Pugh grade C (P = 0.007), Japanese variceal grade F3 (P = 0.009), and diameter of EV (P < 0.001) may exhibit potential in predicting early rebleeding following EVL. ROC analysis demonstrated that the area under curve (AUC) for EV diameter was 0.848, and the AUC for Japanese variceal grade was 0.635, which was statistically significant (P < 0.001). Thus, results of the present study demonstrated that EV diameter was more optimal in predicting early rebleeding following EVL than Japanese variceal grade criteria. The cut-off value of EV diameter was calculated to be 1.35 cm (sensitivity, 70.0%; specificity, 89.2%). Conclusion: If the diameter of EV is ≥1.4 cm, there may be a high risk of early rebleeding following EVL surgery; thus, we recommend caution with EVL.

Application of Indian ink markers for locating gastric varices under endoscopic ultrasonography.

OBJECTIVE: The present study aimed to investigate the accuracy of endoscopic ultrasonography (EUS) combined with Indian ink in locating target vessels of gastric varices (GVs) compared with conventional endoscopic techniques. Additionally, the characteristics of GVs under conventional endoscopy were also explored. METHODS: All 50 cirrhotic patients with GVs between August 2021 and December 2022 were included in the study. Firstly, conventional endoscopy was employed to identify GVs and to record the expected injection sites. Subsequently, EUS was used to locate the perforated vessel and the injection site was them marked with India ink followed by injection with cyanoacrylate (CYA). Finally, conventional endoscopy was used to examine GVs, to identify the marker points of Indian ink and to compare whether the injection points under conventional endoscopy were consistent with those marked with Indian ink. Furthermore, patients with consistent and inconsistent distribution of endoscopic markers and injection sites were divided into two groups. RESULTS: EUS could detect the perforating vessels in real time and intuitively. The distribution of markers using EUS was significantly different compared with the injection points obtained by conventional endoscopy (P < 0.001). Therefore, 20 cases were allocated to the consistent group and 30 cases to the non-consistent group. 16 patients who showed red wale signs were obtained in the consistent group and 11 patients in the non-consistent group (P = 0.048). The diameter of the largest GVs was 13.5 (10-15) mm in the consistent group compared with 10 (7.5-10) mm in the non-consistent group (P = 0.006). CONCLUSION: EUS could provide the exact location of GVs, thus more accurately describing the endoscopic characteristics of the GVs. Furthermore, the red wale signs and diameter of the largest GVs obtained using conventional endoscopy were helpful in determining the location of target GVs.

Endoscopic ultrasonography-guided injection of cyanoacrylate in the treatment of gastroesophageal varices type 1: a single-center randomized study.

BACKGROUND AND AIM: First, it has been demonstrated that endoscopic ultrasonography (EUS)-guided cyanoacrylate (CYA) injection (EUS-CYA) has greater efficacy than direct endoscopic injection of cyanoacrylate (DEI-CYA) for treating type 1-isolated gastric varices. However, it is necessary to conduct further studies to determine whether EUS has any advantage over the current guidelines for treating gastroesophageal varices type 1 (GOV1). Second, liver function is an important prognostic factor in patients with liver cirrhosis. Therefore, we evaluated the liver function of patients treated with EUS-CYA. METHODS: In a single-center study, a prospective cohort from February 2021 to September 2022 involving 89 patients with cirrhosis with GOV1 were assigned to undergo EUS-CYA (n = 45) or DEI-CYA (n = 44). The success rate of CYA injection, the rate of overall rebleeding, the rate of reintervention, the complications during the follow-up period, and the liver function were compared. RESULTS: In both groups, 100% of the operations were successful. The follow-up time of the two groups was 290 (153-398) days and 267 (177-416) days, respectively. In the EUS group, the perforating veins had an average diameter of 7.0 ± 2.7 mm, and they had a 100% occlusion rate. A statistically significant difference was found between the two groups regarding the number of sessions needed to eradicate GV (p = 0.005, pairwise comparisons were conducted using the Bonferroni correction method.), the late rebleeding rate after EUS-CYA [n = 3 (6.7%) vs n = 10 (22.7%); p = 0.032], and the incidence of postinjection ulcers [n = 4 (8.9%) vs n = 12 (27.3); p = 0.023)]. Following EUS or DEI-CYA treatment, the patient's liver function did not show any significant deterioration or decline. CONCLUSION: EUS-CYA has a higher eradication success rate and fewer complications, recurrences, and rebleeding episodes than DEI-CYA used for GOV1 treatment. In addition, EUS-CYA did not impair liver function.

Balloon-occluded Esophageal Varices Obliteration Versus Ligation for the Management of F2 Esophageal Varices: A Randomized Controlled Trial.

AIM: To compare balloon-occluded esophageal varices obliteration (BEVO) with esophageal variceal ligation (EVL) in the management of cirrhotic patients with type F2 esophageal varices (F2-EVs). MATERIALS AND METHODS: A total of 157 patients with F2-EVs were randomly assigned to either BEVO (n=79) or EVL (n=78) group in the prospective study between July 2021 and December 2021. Primary outcomes included recurrence and eradication rates. Secondary outcomes included rebleeding rate, and procedural complications. RESULTS: The recurrence rate of EVs was notably lower in the BEVO group than in the EVL group (3.80% vs. 21.79%; P =0.001). The rate of complete eradication in the BEVO group was significantly higher than that of the EVL group (96.20% vs. 74.36%; P <0.001). The incidence of rebleeding in the BEVO group was markedly lower than that of the EVL group (7.59% vs. 20.51%; P =0.02). There was a higher incidence of transient dysphagia in the EVL group than in the BEVO group (10.26% vs. 1.27%; P =0.015). CONCLUSIONS: BEVO exerted an effective treatment option for F2-EVs.

Balloon-compression endoscopic injection sclerotherapy versus transjugular intrahepatic portosystemic shunt for esophageal variceal rebleeding.

BACKGROUND: In cirrhotic patients, recurrent bleeding after the first episode of esophageal variceal bleeding (EVB) is common and lethal. The present study was aimed to compare balloon-compression endoscopic injection sclerotherapy (bc-EIS) with transjugular intrahepatic portosystemic shunt (TIPS) for the prophylaxis of variceal rebleeding. METHODS: Between June 2020 and September 2022, 81 cirrhotic patients with EVB (42 in the bc-EIS group and 39 in the TIPS group) were evaluated retrospectively. The occurrence of rebleeding, hepatic encephalopathy (HE) or other complications, as well as liver functions and survival rate were compared between two groups. RESULTS: During the 12 months of follow-up, variceal eradication was achieved in 40 (95.24%) patients of the bc-EIS group after a mean of 1.80 ± 0.94 sessions. TIPS was successfully performed in 39 (100%) patients. No significant difference in the variceal rebleeding rate was observed between bc-EIS and TIPS groups (16.67 vs. 17.95%; p = 0.111). While the bc-EIS group showed significantly decreased incidence of HE (2.38 vs. 17.95%; p < 0.001) and lower level of total bilirubin (p < 0.05) in comparison with the TIPS group. The difference in mortality between the two groups failed to reach statistical significance (0.00 vs. 7.69%; p = 0.107). CONCLUSION: Bc-EIS is not inferior to TIPS in the survival and control of variceal rebleeding, but associated with decreased risk of HE and liver dysfunction.

Balloon-Occluded Esophageal Variceal Obliteration Procedure: A Novel Technique Report from Three Centers.

Introduction: Esophageal variceal bleeding (EVB) is a potentially fatal complication of cirrhosis. The purpose of the present study was to evaluate the safety and efficacy of a novel technique of balloon-occluded esophageal varices (EVs) obliteration (BEVO) for EVs classified as F2 (medium size, F2-EVs) and F3 (large size, F3-EVs). Materials and Methods: Between December 2020 and December 2021, a total of 73 consecutive patients with EVs were treated using BEVO. An injection of sclerosant was administered via direct puncture of the varices during balloon occlusion. Immediate postprocedural Doppler endoscopic ultrasonography (EUS) was conducted to evaluate the blood flow in the EVs. Several factors, including the technical success, controlling of acute bleeding, intraoperative bleeding at the injection site, variceal eradication, variceal recurrence, and BEVO-related complications, were assessed. Results: BEVO was successfully performed in all patients. Immediate hemostasis was achieved in 100% (25/25) of patients with active EVB. The incidence of injection site intraoperative bleeding presenting as oozing and spurting bleeding was 76.71% (56/73) and 8.22% (6/73), respectively. Based on Doppler EUS and endoscopic examination, EVs were completely eradicated in 71 out of 73 patients (97.26%) after three sessions. A total of 3 (4.11%) patients were diagnosed with EV recurrence during follow-up after complete EV eradication. Retrosternal chest discomfort (13.70%; 10/73) and abdominal bloating (2.74%; 2/73) were spontaneously relieved after a few days. No serious BEVO-related complications were observed. Discussion: BEVO is a convenient and effective treatment for obliterating F2 and F3 EVs. Clinical Trial Registration No. ChiCTR2000039974.

Automatic detection of early gastric cancer in endoscopy based on Mask region-based convolutional neural networks (Mask R-CNN)(with video).

The artificial intelligence (AI)-assisted endoscopic detection of early gastric cancer (EGC) has been preliminarily developed. The currently used algorithms still exhibit limitations of large calculation and low-precision expression. The present study aimed to develop an endoscopic automatic detection system in EGC based on a mask region-based convolutional neural network (Mask R-CNN) and to evaluate the performance in controlled trials. For this purpose, a total of 4,471 white light images (WLIs) and 2,662 narrow band images (NBIs) of EGC were obtained for training and testing. In total, 10 of the WLIs (videos) were obtained prospectively to examine the performance of the RCNN system. Furthermore, 400 WLIs were randomly selected for comparison between the Mask R-CNN system and doctors. The evaluation criteria included accuracy, sensitivity, specificity, positive predictive value and negative predictive value. The results revealed that there were no significant differences between the pathological diagnosis with the Mask R-CNN system in the WLI test (χ2 = 0.189, P=0.664; accuracy, 90.25%; sensitivity, 91.06%; specificity, 89.01%) and in the NBI test (χ2 = 0.063, P=0.802; accuracy, 95.12%; sensitivity, 97.59%). Among 10 WLI real-time videos, the speed of the test videos was up to 35 frames/sec, with an accuracy of 90.27%. In a controlled experiment of 400 WLIs, the sensitivity of the Mask R-CNN system was significantly higher than that of experts (χ2 = 7.059, P=0.000; 93.00% VS 80.20%), and the specificity was higher than that of the juniors (χ2 = 9.955, P=0.000, 82.67% VS 71.87%), and the overall accuracy rate was higher than that of the seniors (χ2 = 7.009, P=0.000, 85.25% VS 78.00%). On the whole, the present study demonstrates that the Mask R-CNN system exhibited an excellent performance status for the detection of EGC, particularly for the real-time analysis of WLIs. It may thus be effectively applied to clinical settings.

Efficient Initial Eradication of Large Esophageal Varices by Balloon-compression Endoscopic Injection Sclerotherapy.

BACKGROUND: The management of large esophageal varices (EVs) remains challenging because of the difficulty of endoscopic variceal ligation and fatal post-endoscopic variceal ligation bleeding ulcers. The current study evaluated the efficacy and safety of balloon-compression endoscopic injection sclerotherapy (bc-EIS) in the treatment of large EVs. MATERIALS AND METHODS: This retrospective study included 105 patients with cirrhosis exhibiting large EVs (64 in the bc-EIS group and 41 in the EIS group). Primary outcomes included the initial rate of variceal eradication and intraoperative bleeding signs. Secondary outcomes included incidences of rebleeding, mortality, complications, and optimal time of balloon-compression (bc). RESULTS: The initial rate of variceal eradication in the bc-EIS group was significantly higher than that in the EIS group (46.9 vs. 24.4%; P =0.021). The incidence of intraoperative bleeding, which was represented as oozing and spurting, in the bc-EIS group was markedly lower than that in the EIS group (43.8 vs. 61.0% and 9.4 vs. 39.0%, respectively; P =0.043). Patients in the bc-EIS group showed a significantly lower incidence of rebleeding (0.0 vs. 17.1%; P =0.001). However, no significant difference in mortality rate was observed between different groups. Chest pain or discomfort tended to be more common in the EIS group than in the bc-EIS group (58.5 vs. 17.2%; P =0.001). The cut-off value of 11.5-minutes appeared to have a maximum combined sensitivity and specificity of 80.0% and 58.8%, respectively. The area under the curve was 0.708 (95% confidence interval =0.576-0.839; P =0.004). CONCLUSION: bc-EIS could achieve a higher variceal eradication rate and milder intraoperative bleeding signs in large EVs. Furthermore, 11.5-minutes appeared to be the optimal compression time in bc-EIS.

Screening, clinical features and prognostic analysis of liver cirrhosis-related hepatocellular carcinoma.

OBJECTIVE: To explore the impact of the screening interval and methods on cirrhosis-related hepatocellular carcinoma (HCC) detection and to analyse the clinical features and prognosis of HCC. MATERIALS AND METHODS: We recruited 3000 patients diagnosed with liver cirrhosis, who had been treated at the First Affiliated Hospital of Anhui Medical University from January 2016 to January 2020. The time of admission was divided into 3- (group A, 539 cases), 6- (group B, 1012 cases), and 12-month screening groups (group C, 1449 cases). We compared the detection rate of small HCCs in each group and analysed the clinical characteristics and prognosis of the patients with HCC. RESULTS: We detected a total of 124 HCC cases, including 41 cases of small HCC: 21, 14, and 6 cases in groups A, B, and C, respectively. The detection rate was 3.9% (21/539) in group A, which was significantly higher than that in groups B and C (χ2 = 31.186, p < .001). Single small, right liver lobe, and alpha-fetoprotein-negative HCCs accounted for 90.2%, 73.2%, and 68.3%, respectively. We detected vascular invasion and lymph node metastasis in one and three cases, respectively. The average survival time of patients in the small HCC group was significantly higher than that in the non-small-HCC group (35.68 ± 12.95 vs. 22.87 ± 11.42 months) (t = 5.623, p < .001). CONCLUSIONS: Screening patients with a history of liver cirrhosis at intervals of 3 months can increase the detection rate of small HCCs. Early detection can provide more patients with an opportunity for radical treatment and prolong their survival.

Effects of diabetes on the rebleeding rate following endoscopic treatment in patients with liver cirrhosis.

In the present study, the effects of diabetes on rebleeding following endoscopic treatment were assessed in patients with liver cirrhosis. A retrospective analysis of patients who underwent endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS) at the First Affiliated Hospital of Anhui Medical University (Hefei, China) between June 2015 and March 2018 was performed. The patients were divided into the EVL and the EIS groups and each group was subdivided into diabetic and non-diabetic groups. The post-operative rebleeding rate was compared between the EVL and the EIS groups and between the diabetic and non-diabetic patients. The differences in the post-operative rebleeding rate of diabetic patients with hepatogenic and non-hepatogenic diabetes and in patients with different liver function grades were also determined. In the total patient cohort, the rebleeding rate in the EVL subgroup (11.3, 16.5 and 23.5%) was not significantly different compared with that in the EIS subgroup (9.8, 17.4 and 29.3%) at 1, 3 and 6 months following surgery, respectively (P=0.724, 0.868 and 0.339). In the total diabetic group, the rebleeding rate in the EVL subgroup (25.0, 36.1 and 44.4%) was not significantly different compared with that in the EIS subgroup (20.6, 32.4 and 47.1%) at 1, 3 and 6 months following surgery (P=0.660, 0.741 and 0.826, respectively). In the EVL group, the rebleeding rate in the diabetic subgroup (25.0, 36.1 and 44.4%) was higher than that in the non-diabetic subgroup (5.1, 7.6 and 13.9%) at 1, 3, and 6 months following surgery and the differences were significant (P=0.005, <0.001 and <0.001, respectively). In the EIS group, the rebleeding rate in the diabetic subgroup (20.6, 32.4 and 47.1%) was significantly higher than that in the non-diabetic subgroup (3.4, 8.6 and 19.0%) at 1, 3 and 6 months following surgery (P=0.021, 0.004 and 0.004, respectively). Adjustment for age and liver function grade in the EVL and EIS groups was performed using binary logistic regression and the parameter diabetes was indicated to be a risk factor for post-operative rebleeding (P<0.05). No significant difference was noted in the rate of rebleeding between patients with hepatogenic diabetes and non-hepatogenic diabetes at 1, 3 and 6 months following surgery (P=0.634, 0.726 and 0.446, respectively). In the total diabetic group, the rebleeding rate in the Child-Pugh grade A subgroup (14.3, 17.9 and 25.0%) was lower than that in the Child-Pugh grade B/C subgroup (28.6, 45.2 and 59.5%) at 1, 3 and 6 months following surgery, respectively. No significant difference was noted between the two groups at 1 month following surgery (P=0.163). However, the differences were significant at 3 and 6 months following surgery (P=0.018 and 0.005, respectively). The results suggested that diabetes is a risk factor for post-operative rebleeding in patients with cirrhosis. Diabetic patients with poor liver function were more likely to bleed following surgery and the post-operative bleeding rate was not significantly different between patients with hepatogenic and non-hepatogenic diabetes. The study was registered in the Chinese Clinical Trial Registry (no. ChiCTR1800017772).