A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma

Marshall J. Orloff, Jon I. Isenberg, Henry O. Wheeler, Kevin S. Haynes, Horacio Jinich-Brook, Roderick Rapier, Florin Vaida, Robert J. Hye, Susan Orloff

Research output: Contribution to journalArticle

5 Citations (Scopus)

Abstract

Background: Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied. Methods: Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had >10 years of follow-up. HCC screening involved serum α-fetoprotein (AFP) every 3 months, ultrasonography every 6 months, and selective computed tomography (CT). Results: HCC occurred in 15 patients, all incurable, a mean of 2.94 years after entry. They died a mean 1.33 years after discovery. Serial AFP and ultrasound examinations were unrevealing over a mean of 2.3 years. The mean model of end-stage liver disease score was 12.7 at entry and 17.4 at HCC diagnosis. Conclusions: Long-term screening by AFP and ultrasound plus selective CT failed to detect HCC at a curable stage. The detection of HCC in cirrhotic patients with BEV remains a serious, unsolved problem. The use of CT for routine screening warrants consideration despite increased costs.

Original languageEnglish (US)
Pages (from-to)182-190
Number of pages9
JournalAmerican Journal of Surgery
Volume203
Issue number2
DOIs
StatePublished - Feb 2012

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Emergency Treatment
Esophageal and Gastric Varices
Hepatocellular Carcinoma
Fibrosis
Randomized Controlled Trials
Hemorrhage
Tomography
Fetal Proteins
Surgical Portacaval Shunt
End Stage Liver Disease
Sclerotherapy
Ultrasonography
Emergencies
Costs and Cost Analysis
Serum

Keywords

  • Bleeding esophageal varices
  • Cirrhosis
  • Emergency portacaval shunt
  • Endoscopic sclerotherapy
  • Hepatocellular carcinoma (HCC)
  • Screening for HCC

ASJC Scopus subject areas

  • Surgery

Cite this

A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma. / Orloff, Marshall J.; Isenberg, Jon I.; Wheeler, Henry O.; Haynes, Kevin S.; Jinich-Brook, Horacio; Rapier, Roderick; Vaida, Florin; Hye, Robert J.; Orloff, Susan.

In: American Journal of Surgery, Vol. 203, No. 2, 02.2012, p. 182-190.

Research output: Contribution to journalArticle

Orloff, Marshall J. ; Isenberg, Jon I. ; Wheeler, Henry O. ; Haynes, Kevin S. ; Jinich-Brook, Horacio ; Rapier, Roderick ; Vaida, Florin ; Hye, Robert J. ; Orloff, Susan. / A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma. In: American Journal of Surgery. 2012 ; Vol. 203, No. 2. pp. 182-190.
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AB - Background: Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied. Methods: Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had >10 years of follow-up. HCC screening involved serum α-fetoprotein (AFP) every 3 months, ultrasonography every 6 months, and selective computed tomography (CT). Results: HCC occurred in 15 patients, all incurable, a mean of 2.94 years after entry. They died a mean 1.33 years after discovery. Serial AFP and ultrasound examinations were unrevealing over a mean of 2.3 years. The mean model of end-stage liver disease score was 12.7 at entry and 17.4 at HCC diagnosis. Conclusions: Long-term screening by AFP and ultrasound plus selective CT failed to detect HCC at a curable stage. The detection of HCC in cirrhotic patients with BEV remains a serious, unsolved problem. The use of CT for routine screening warrants consideration despite increased costs.

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