HVPG-guided Laparoscopic Versus Endoscopic Therapy for Variceal Rebleeding in Portal Hypertension: A Multicenter Randomized Controlled Trial (CHESS1803)
- Conditions
- Portal HypertensionVariceal Rebleeding
- Interventions
- Procedure: Laparoscopic splenectomy and pericardial devascularizationProcedure: Endoscopic therapy
- Registration Number
- NCT03783065
- Lead Sponsor
- Nanfang Hospital, Southern Medical University
- Brief Summary
The development of portal hypertension is a vital event in the natural progression of cirrhosis and is associated with severe complications including gastroesophageal varices bleeding. Cirrhotic patients with hemorrhagic shock and/or liver failure caused by variceal bleeding face a mortality of 5-20%.
Hepatic venous pressure gradient (HVPG) is the recommended golden standard for portal pressure assessment globally with favorable consistency and repeatability. Reducing the HVPG to levels of 12mmHg or below is associated with protection of variceal hemorrhage. An HVPG\> 16mmHg indicates a higher risk of death and HVPG ≥ 20mmHg predicts failure to control bleeding, early rebleeding, and death during acute variceal hemorrhage.
The management of portal hypertension has showed a trend of diversification with the development of medication, endoscopy, radiological intervention and liver transplantation. Although medication and endoscopic therapy have achieved preferable effects and are recommended as standard of care for the prevention of variceal rebleeding, patients with HVPG≥ 16mmHg still have a high risk of treatment failure and a high rate of rebleeding. Recent years, early TIPS is recommended as the first-line therapy for the prevention of rebleeding in cirrhotic patients with HVPG≥ 20mmHg. However, for those with HVPG values between 16 to 20mmHg, there is still lack of strong evidence to demonstrate the best practice for the management.
With the rapid advancement of laparoscopic device and technique, the utility of laparoscopic splenectomy and pericardial devascularization showed less surgical trauma, bleeding and complications while retaining dependable effects compared to traditional open surgery, especially for portal hypertension with hypersplenism. In the study, the investigators aim to conduct a multicenter randomized controlled trial to compare the safety and effectiveness of HVPG-guided (16 to 20mmHg) laparoscopic versus endoscopic therapy for variceal rebleeding in patients with portal hypertension.
- Detailed Description
The development of portal hypertension is a vital event in the natural progression of cirrhosis and is associated with severe complications including gastroesophageal varices bleeding. Cirrhotic patients with hemorrhagic shock and/or liver failure caused by variceal bleeding face a mortality of 5-20%.
Hepatic venous pressure gradient (HVPG) is the recommended golden standard for portal pressure assessment globally with favorable consistency and repeatability. Reducing the HVPG to levels of 12mmHg or below is associated with protection of variceal hemorrhage. An HVPG\> 16mmHg indicates a higher risk of death and HVPG ≥ 20mmHg predicts failure to control bleeding, early rebleeding, and death during acute variceal hemorrhage.
The management of portal hypertension has showed a trend of diversification with the development of medication, endoscopy, radiological intervention and liver transplantation. Although medication and endoscopic therapy have achieved preferable effects and are recommended as standard of care for the prevention of variceal rebleeding, patients with HVPG≥ 16mmHg still have a high risk of treatment failure and a high rate of rebleeding. Recent years, early TIPS is recommended as the first-line therapy for the prevention of rebleeding in cirrhotic patients with HVPG≥ 20mmHg. However, for those with HVPG values between 16 to 20mmHg, there is still lack of strong evidence to demonstrate the best practice for the management.
With the rapid advancement of laparoscopic device and technique, the utility of laparoscopic splenectomy and pericardial devascularization showed less surgical trauma, bleeding and complications while retaining dependable effects compared to traditional open surgery, especially for portal hypertension with hypersplenism. In the study, the investigators aim to conduct a multicenter (Shunde Hospital of Southern Medical University, Xingtai People's Hospital, The Fifth Medical Center of Chinese PLA General Hospital, The First Hospital of Lanzhou University) randomized controlled trial to compare the safety and effectiveness of HVPG-guided (16 to 20mmHg) laparoscopic versus endoscopic therapy for variceal rebleeding in patients with portal hypertension.
Recruitment & Eligibility
- Status
- UNKNOWN
- Sex
- All
- Target Recruitment
- 40
- Clinically and/or pathologically diagnosed cirrhosis with portal hypertension
- History of varicial bleeding without receiving endoscopic treatment
- HVPG values between 16-20 mmHg
- ECOG score ≤ 2 or KPS score ≥ 60 during screening
- Voluntarily participated in the study and able to provide written informed consent, understand and willing to comply with the requirements of the study
- Child-Pugh class A or B
- Pregnant or breastfeeding women
- Prior known or suspected malignancy (hepatocellular carcinoma, cholangiocarcinoma etc.)
- Limited coagulation situation (Quick< 50%, PTT> 50 sec, thrombocyte count <50000 / μl or disturbed thrombocyte function)
- Massive ascites
- Child-Pugh class C
- Refuse or inadequate for HVPG measurement
- Other situations whose existence judged inadequate for participation by the investigators
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Experimental group Propranolol Procedure: Laparoscopic splenectomy and pericardial devascularization Drug: Propranolol Experimental group Laparoscopic splenectomy and pericardial devascularization Procedure: Laparoscopic splenectomy and pericardial devascularization Drug: Propranolol Control group Propranolol Procedure: Endoscopic therapy Drug: Propranolol Control group Endoscopic therapy Procedure: Endoscopic therapy Drug: Propranolol
- Primary Outcome Measures
Name Time Method Variceal rebleeding 1 year The occurrence rate of gastroesophageal varices rebleeding within 1-year follow-up
- Secondary Outcome Measures
Name Time Method Overall survival 1 year The number of participants still alive 1 year after the therapy
Hepatocellular carcinoma occurrence 1 year The occurrence rate of hepatocellular carcinoma 1 year after the therapy
Karnofsky score 1 year The Karnofsky score categorized into low (score 10-40), intermediate (50-70), and high (80-100) upon each follow-up.
Venous thrombosis 1 year The occurrence rate of venous thrombosis upon each follow-up
Quality of life score 1 year The quality of life score measured using the 36-item Short Form Health Survey (SF-36) questionnaire upon each follow-up.
Trial Locations
- Locations (4)
Xingtai People's Hospital
🇨🇳Xingtai, Hebei, China
The First Hospital of Lanzhou University
🇨🇳Lanzhou, Gansu, China
The Fifth Medical Center of Chinese PLA General Hospital
🇨🇳Beijing, Beijing, China
Shunde Hospital, Southern Medical University
🇨🇳Shunde, Guangdong, China