Delayed Argon Plasma Coagulation After Endoscopic Injection Sclerotherapy for Esophageal Varices Reduces Recurrence Risk.
Delaying argon plasma coagulation after endoscopic injection sclerotherapy for esophageal varices may reduce recurrence without increasing adverse events.
Where it sits
this study against the rest of the hmg (human menopausal gonadotropin) corpusSummary and findings
This study evaluated the timing of argon plasma coagulation (APC) after endoscopic injection sclerotherapy (EIS) for esophageal varices in 112 patients. Patients were divided into inpatient and outpatient groups based on the EIS-APC interval. A longer interval was associated with reduced variceal recurrence and fewer residual ulcers.
Abstract
<h4>Objectives</h4>Argon plasma coagulation (APC) is commonly used as consolidation therapy after endoscopic injection sclerotherapy (EIS) for esophageal varices (EVs); however, the optimal timing of APC remains unclear. This study evaluated the association between the EIS-APC interval and clinical outcomes.<h4>Methods</h4>This single-center retrospective cohort study included consecutive patients receiving EIS followed by APC for EVs. Patients were categorized according to APC setting as inpatient or outpatient, which reflected differences in the EIS-APC interval. The primary outcome was cumulative variceal recurrence as analyzed using the Fine-Gray competing risk model. Secondary outcomes included ulcer persistence at the time of APC and procedure-related adverse events.<h4>Results</h4>Among 112 patients, 82 underwent inpatient APC and 30 underwent outpatient APC. The median EIS-APC interval was 7 days and 28 days, respectively (<i>p</i> < 0.001). The cumulative 3-year incidence of variceal recurrence was lower in the outpatient group (13.9% vs. 28.0%; Gray's test, <i>p</i> = 0.039). In the multivariable Fine-Gray model, a longer EIS-APC interval was independently associated with a lower cumulative incidence of recurrence (subdistribution hazard ratio 0.92, 95% CI 0.86-0.99; <i>p</i> = 0.026). Residual post-EIS ulcers at the time of APC were also less frequent in the outpatient group (33.3% vs. 81.7%, <i>p</i> < 0.001), while adverse events were comparable (20.7% vs. 10.0%, <i>p</i> = 0.268).<h4>Conclusions</h4>A longer EIS-APC interval was associated with a lower recurrence rate without an increase in adverse events. Delaying APC until after mucosal healing may optimize EIS treatment outcomes.<h4>Trial registration</h4>N/A (Only approval of the research protocol by an Institutional Review Board of Fukushima Medical University).
Background
The study investigates the optimal timing of argon plasma coagulation (APC) following endoscopic injection sclerotherapy (EIS) for esophageal varices. Previous research has established APC as a consolidation therapy, but the timing of its application remains uncertain. This study aims to clarify the impact of the EIS-APC interval on clinical outcomes, which is significant for optimizing treatment strategies.
Methods
This was a single-center retrospective cohort study involving 112 patients who received EIS followed by APC for esophageal varices. Patients were categorized into inpatient and outpatient groups based on the EIS-APC interval. The primary outcome was the cumulative incidence of variceal recurrence, analyzed using the Fine-Gray competing risk model. Secondary outcomes included ulcer persistence at the time of APC and procedure-related adverse events.
Results
The study found that the median EIS-APC interval was 7 days for the inpatient group and 28 days for the outpatient group, with a significant difference (p<0.001). The cumulative 3-year incidence of variceal recurrence was significantly lower in the outpatient group at 13.9% compared to 28.0% in the inpatient group (p=0.039). A longer EIS-APC interval was independently associated with a lower recurrence rate (subdistribution hazard ratio 0.92, 95% CI 0.86-0.99, p=0.026). Residual ulcers were less frequent in the outpatient group (33.3% vs 81.7%, p<0.001), while adverse events were similar between groups (20.7% vs 10.0%, p=0.268).
Interpretation
The findings suggest that delaying APC after EIS until after mucosal healing may reduce variceal recurrence without increasing adverse events. The effect size, while statistically significant, may be clinically meaningful given the reduction in recurrence rates. However, the study's retrospective nature and single-center design limit the generalizability of the results. The findings align with the hypothesis that a longer EIS-APC interval is beneficial, but further prospective studies are needed to confirm these results.
Key findings
- 82 inpatient APC vs 30 outpatient APC, n=112
- Median EIS-APC interval: 7 days vs 28 days, p<0.001
- 3-year variceal recurrence: 13.9% outpatient vs 28.0% inpatient, p=0.039
- Subdistribution hazard ratio for recurrence: 0.92, 95% CI 0.86-0.99, p=0.026
- Residual ulcers: 33.3% outpatient vs 81.7% inpatient, p<0.001
- Adverse events: 20.7% inpatient vs 10.0% outpatient, p=0.268
Limitations
- Single-center study
- Retrospective design
- Small sample size, n=112
- Short follow-up period for adverse events
- Potential selection bias due to non-randomized design