Effect of balloon-occluded retrograde transvenous obliteration on the natural history of coexisting esophageal varices

Background and Aims: Balloon-occluded retrograde transvenous obliteration (BRTO) provides an effective mean of controlling gastric variceal (GV) bleeding; however, increased portal pressure after the obliteration of gastrorenal shunts may lead to a worsening and subsequent rupture of esophageal varices (EV). The aim of this study was to determine whether the natural history of coexisting EV is affected by BRTO. Methods: Two hundred thirty-seven patients with gastric varices and no history of EV or GV bleeding at the time of diagnosis were included. Clinical, laboratory, and endoscopic features were compared between 25 patients who underwent BRTO due to GV bleeding (BRTO group) and 198 patients who never experience GV bleeding (control group) during follow-up. The incidences of EV bleeding were evaluated and compared between these 2 groups. Results: The BRTO and control groups were not significantly different with respect to baseline characteristics including age, sex, etiologies of cirrhosis, hepatic function, and the classification or extent of EV and GV. During follow-up (median 48 mo), the overall incidence of first EV bleeding in the patients with fundal varices was significantly higher in the BRTO group (P=0.04). The incidences of EV bleeding were not different at 1 or 3 years (10.1% vs. 12.9%, P=0.32 and 39.3% vs. 38.4%, P=0.57), but became significantly higher in the BRTO group at 5 (72.2% vs. 48.5%, P=0.02) and 7 years (90.7% vs. 50.6%, P<0.01). Conclusions: BRTO increased the bleeding rate of coexisting EV in the long term. Close monitoring and prophylaxis of EV bleeding may be warranted after BRTO.