Gluing gastric varices in 2012: lessons learnt over 25 years

Advances in the endoscopic management of gastric varices

This review provides an overview of the treatment options available for gastric varices (GV) with a focus on endoscopic methods. Various minimally invasive techniques, including endoscopic band ligation, endoscopic cyanoacrylate injection, and transjugular intrahepatic portosystemic shunt, can be applied to the treatment of GV. Endoscopic cyanoacrylate injection is now recognized as a first-line treatment for GV. Endoscopic ultrasound-guided cyanoacrylate injection combined with coils has shown good security and effectiveness. Thrombin injection therapy is a promising treatment, with a similar hemostasis rate to cyanoacrylate injection but with fewer serious complications. With the deepening understanding of the hemodynamics of the GV system, various treatment methods and their combination are gradually evaluated to provide patients with safer and more effective treatment options.

Role of endoscopy in hepatology

The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.

Comparison of endoscopic ultrasound-guided primary and secondary prophylaxis for gastric variceal bleeding

OBJECTIVES

Endoscopic ultrasound (EUS)-guided injection of cyanoacrylate (CYA) for primary prophylaxis (PP) of gastric varices (GV) is controversial. This study evaluates the safety and efficacy of this intervention.

METHODS

Patients treated for PP of GV bleeding by EUS injection of CYA with or without coils were identified. Endoscopic techniques, outcomes, and adverse events (AEs) were reviewed and compared with a group treated for secondary prophylaxis (SP). Patients were followed until: (i) loss to follow-up; (ii) GV bleeding; (iii) interventional radiology or surgery decompression; (iv) liver transplant; or (v) death or comfort care.

RESULTS

One hundred and nineteen patients (61 men; mean 59 ± 12 years) underwent EUS for PP (n = 24) or SP (n = 95). The PP group was treated with CYA alone (n = 18) or with coils (n = 4). Eight (33%) mild (n = 6) or moderate (n = 2) AEs and no index GV bleeding occurred during a mean of 6.1 ± 5.9 months follow-up. Repeat EUS in 22 (92%) PP patients showed 7 (32%) residual GVs, which were retreated with CYA alone (n = 6) or with coils (n = 1). Two (29%) mild (n = 1) or moderate (n = 1) AEs occurred after repeat EUS and 1/22 (5%) index GV bleed occurred during a mean 23 ± 25 months follow-up. Compared to the SP group, the PP group had lower Model for End-stage Liver Disease (MELD) score (P = 0.03), fewer GV stigmata (P < 0.001), required less CYA (P = 0.019) during index EUS, and had a longer time between index and surveillance EUS (P = 0.014). The incidence of AEs and GV bleeding between the two groups were similar.

CONCLUSION

Posttreatment GV bleeding and AEs are similar following EUS-guided primary and secondary GV prophylaxis.

Clinical Outcomes and Their Determinants in Patients With Gastric Variceal Bleed Undergoing Endoscopic Cyanoacrylate Injection: An Observational Study

Background and aims

Gastric variceal bleeding (GVB), compared to esophageal varices, is rare but often massive and associated with high mortality. Endoscopic cyanoacrylate glue injection (ECGI) is the first-line treatment for GVB. Hence, we conducted this study to assess the clinical outcomes and the determinants of ECGI for gastric variceal bleeding.

Methods

This was a prospective observational study of patients with ECGI for GVB between June 2019 and February 2023. The demographic characteristics, etiology and severity of cirrhosis, size, type of gastric varices, volume of cyanoacrylate used, number of sessions required, technical success, rebleeding rate, and survival at three months were studied.

Results

A total of 135 patients underwent ECGI for GVB. Their mean (SD) age was 44.9 (13.6) years, with a male preponderance (n = 23, 68.1 %). Eighty-two patients (60.7 %) had cirrhosis. Their mean model for end-stage liver disease (MELD) score was 14.3 (7.3). Gastric varices were gastroesophageal varices (GOV)1 in 42 (31.1 %), GOV2 in 73 (54.1 %), and isolated gastric varices (IGV)1 in 20 (14.8 %) patients. Varices were large in 35 (25.9 %) and had F1 morphology in 89 (65.9 %) patients. The success rate of initial hemostasis was 98.5 %. The median sessions required were 1 (1-2), and the median volume of cyanoacrylate per session was 2 (1-2) ml. The procedure was associated with minor complications like transient abdominal pain in 11 (8.1 %) and fever in 2 (2.7 %) patients. Rebleeding was observed in 23 (17 %) patients. GOV2, F1 morphology, and a high MELD score were significantly associated with rebleeding. Five (3.7 %) patients died during the study; 2 (1.5 %) were due to failure to control bleeding.

Conclusion

In conclusion, our study demonstrated ECGI to be very safe and effective for GVB. The technical success was high and could be achieved in fewer sessions with a smaller volume of cyanoacrylate during each session.

Technical tips for EUS-guided embolization of varices and pseudoaneurysms

Backgrounds and Aims

EUS-guided vascular intervention has expanded the horizons of diagnostic as well as therapeutic interventions for vascular pathology. EUS-guided embolization is a commonly performed technique for the treatment of gastric varices. However, there is a lack of data on the standardization of the technique. Here, we review the techniques and difficulties encountered during EUS-guided embolization of varices and pseudoaneurysms.

Methods

This article and accompanying video describe the EUS-guided embolization techniques for various vascular lesions. EUS-guided embolization was achieved by combination therapy using coils and cyanoacrylate. Complete obliteration of the lesions was documented on follow-up. The existing literature of EUS-guided embolization therapy is also reviewed.

Results

Patients with various vascular lesions, including gastric varices, ectopic duodenal varices, and splenic artery pseudoaneurysms, were successfully treated with EUS-guided coil plus cyanoacrylate injection. Patients with gastric varices underwent treatment with 2 EUS-guided techniques: (1) direct puncture of the varix and embolization and (2) feeder vessel embolization. Following embolization, the absence of Doppler flow within the varix and pseudoaneurysm was documented.

Conclusions

Techniques of EUS-guided embolization of varices and pseudoaneurysms are demonstrated. Understanding the techniques and the challenges encountered during therapy is crucial to optimize outcomes and reduce adverse events.

[Suspected pulmonary nodule in a male heavy smoker: Is biopsy really necessary?]

INTRODUCTION

Sclerotherapy is a widely used as a lifesaving therapeutic option in cases of upper gastrointestinal bleeding (UGB) due to ruptured gastro-esophageal varices (GOV) in cirrhotic patients, especially when there exists a portosystemic shunt. This endoscopic technique can entail many complications, including systemic and non-thrombotic pulmonary embolism (PE). While multiple pulmonary parenchymal manifestations have been described following sclerotherapy of GOV, to our knowledge no solitary suspicious pulmonary nodule has been described.

CASE PRESENTATION

We report the case of 55-year-old man with heavy smoking history who was referred to our pulmonary clinic for work-up of a solitary pulmonary nodule. He was known to have liver cirrhosis with history of massive UGB due to rupture of GOV two months before. He was treated with sclerotherapy by injecting a 3 cc of Histoacryl/lipiodole solution. The post- endoscopic phase was unremarkable. An enhanced CT scan of chest and abdomen performed two months later showed a right upper lobe nodule, even though at that point, the patient was completely asymptomatic. This was ascribed to non-thrombotic PE secondary to sclerotherapy due to complete resolution of the nodule on a CT scan carried out at 2-month follow-up. At that point, his condition did not require any further treatment.

CONCLUSION

Solitary pulmonary nodule is one of the radiologic manifestations of PE subsequent to sclerotherapy of GOV. Awareness and radiologic follow-up of this unusual radiologic presentation may prevent unnecessary biopsies.

Pulmonary Embolization After Gastric Varices Obliteration

N-butyl-2-cyanoacrylate (NB2CYA) is frequently used in the treatment of variceal hemorrhage with a success rate in hemostatic control of 87%-100%. Although rare, complications include esophageal perforation, infection, or arterial and venous embolization. We present the case of a 67-year-old male with chronic ethanolic liver disease hospitalized due to melena and hematemesis. He had anemia requiring transfusion support, octreotide, and pantoprazole infusion. Upper digestive endoscopy was performed showing gastric varices with a hemorrhagic rupture point treated with cyanoacrylate. The patient developed respiratory failure over the next 48 hours with chest computed tomography (CT) angiography showing several dense, scattered linear images, with arterial vascular trajectories suggestive of cyanoacrylate embolization. It was decided to provide ventilatory support with invasive mechanical ventilation, initiate systemic corticosteroid therapy, and transfer the patient to the intensive care unit (ICU). The patient was ventilated for 11 days with initial favorable evolution, but after two episodes of decompensation of his chronic liver disease (CLD) (hepatic encephalopathy and hepatorenal syndrome) and a new nosocomial pneumonia, he ended up dying. The present case illustrates a rare but potentially fatal complication associated with cyanoacrylate, highlighting the importance of a high suspicion index in cases of respiratory failure and dyspnea after this therapy.

Glue embolization to the lung vasculature following histoacryl injection sclerotherapy: A neglected etiology of pulmonary embolism

Pulmonary embolism is a significant complication of N-butyl-2-cyanoacrylate, commonly known as histoacryl, used to sclerose bleeding gastroesophageal varices. We present a 50-year-old female with seronegative chronic liver disease who was managed with endoscopic histoacryl injection sclerotherapy for bleeding gastric fundal varices. Following treatment, the patient developed sudden respiratory distress due to multiple pulmonary glue emboli, requiring inpatient supportive care along with close monitoring for a week. The patient slowly recovered with conservative management. On subsequent outpatient follow-up, the patient showed no signs of any long-term consequences. Our aim is to alert physicians regarding the uncommon occurrence of acute respiratory distress secondary to pulmonary embolism following histoacryl injection sclerotherapy, as well as to describe its clinical and radiological manifestations.

Pulmonary biological glue embolism after endoscopic repair of gastric varices - A case report

Cyanoacrylate injection is widely used to treat hemorrhagic gastric varices. A pulmonary glue embolism is an unusual but potentially fatal complication. We present a case of a 51-year-old man with a history of alcoholic hepatic cirrhosis Child-Pugh B, who had an acute pulmonary embolism with sudden cardiorespiratory collapse due to biological glue injection used for the emergent repair of bleeding gastric varices. After the restoration of respiratory and hemodynamic parameters, he was admitted to the intensive care unit and the pulmonary biological glue emboli were documented with computed tomography scan. A high index of suspicion for this entity is essential in patients submitted to endoscopic sclerotherapy. Some might be asymptomatic or mildly symptomatic, while others might present with cardiorespiratory collapse.

Endoscopic ultrasound-guided coiling and glue is safe and superior to endoscopic glue injection in gastric varices with severe liver disease: a retrospective case control study

BACKGROUND/AIMS

Gastric varices (GV) are present in 25% of cirrhotic patients with high rates of rebleeding and mortality. Data on endoscopic ultrasound (EUS)-guided treatment in severe liver disease (model for end stage liver disease sodium [MELD-Na] >18 and Child-Turcotte-Pugh [CTP] C with GV) are scarce. Thus, we performed a retrospective comparison of endoscopic glue injection with EUS-guided therapy in cirrhotic patients with large GV.

METHODS

A retrospective study was performed in the tertiary hospitals of India. A total of 80 patients were recruited. The inclusion criteria were gastroesophageal varices type 2, isolated gastric varices type 1, bleeding within 6 weeks, size of GV >10 mm, and a MELD-Na >18. Treatment outcomes and complications of endoscopic glue injection and EUS-guided GV therapy were compared.

RESULTS

In this study, the patients' age, sex, liver disease severity (CTP, MELD-Na) and clinical parameters were comparable. The median number of procedures, injected glue volume, complications, and GV obturation were better in the EUS group, respectively. On subgroup analysis of the EUS method (e.g., direct gastric fundus vs. paragastric collateral [PGC] coil placement), PGC coil placement showed decreased coil requirement, less injected glue volume, decreased luminal coil extrusion, and increased successful GV obturation.

CONCLUSION

EUS-guided treatment is more efficient and safer, and requires a smaller number of treatment sessions, as compared to endoscopic treatment in severe liver disease patients with large GV. Furthermore, PGC coil placement increases the complete obliteration of GV.

CYANOACRYLATE GLUE FOR GASTROESOPHAGEAL VARICES: A SINGLE CENTRE EXPERIENCE FROM NORTH INDIA

BACKGROUND

In natural history of cirrhosis, variceal bleeding is one of the earliest decompensations to happen, and, if adequately managed, survival is improved. Gastric varices have challenges in management due to their location, size and propensity to bleed. The N-butyl 2-cyanoacrylate (NBC) glue application has emerged as definitive therapy in bleeding gastric varices. Here we present our experience with use of NBC in management of gastric and difficult cases of esophageal varices.

METHODS

A total of 75 patients underwent NBC glue application for varices which included 69 patients with gastric varices and six patients with esophageal varices. All the procedures were done with flexible endoscope and sclerotherapy needle after due precautionary measures.

RESULTS

Hemostasis was varices in all patients after endotherapy. The average quantity of glue used was 2.75±0.95 mL. Complete obliteration with single session of NBC application was achieved in 55 patients. Re-bleeding occurred in five patients within 5 days of index event. 20 patients had in-hospital mortality but none was related to gastrointestinal bleeding. 6-week all-cause mortality was 26 (35%).

CONCLUSION

Glue therapy with NBC is a life saving therapy in patients with bleeding gastric varices and esophageal varices not amenable to endoscopic variceal ligation or sclerotherapy.

Overview of Complications in Cirrhosis

BACKGROUND

Cirrhosis is the outcome of chronic liver disease of any etiology due to progressive liver injury and fibrosis. Consequently, cirrhosis leads to portal hypertension and liver dysfunction, progressing to complications like ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, cirrhotic cardiomyopathy, sarcopenia, hepatocellular carcinoma, and coagulation disorders. End-stage liver disease leads to an impaired quality of life, loss of social and economic productivity, and reduced survival.

METHODS

This narrative review explains the pathophysiology of complications of cirrhosis, the diagnostic approach and innovative management, with focus on data from India. A comprehensive literature search of the published data was performed in regard with the spectrum, diagnosis, and management of cirrhosis and its complications.

RESULTS

There is a change in the epidemiology of metabolic syndrome, lifestyle diseases, alcohol consumption and the spectrum of etiological diagnosis in patients with cirrhosis. With the advent of universal vaccination and efficacious long-term viral suppression agents for chronic hepatitis B, availability of direct-acting antiviral agents for chronic hepatitis C, and a booming liver transplantation programme across the country, the management of complications is essential. There are several updates in the standard of care in the management of complications of cirrhosis, such as hepatorenal syndrome, hepatocellular carcinoma, and hepatic encephalopathy, and new therapies that address supportive and palliative care in advanced cirrhosis.

CONCLUSION

Prevention, early diagnosis, appropriate management of complications, timely transplantation are cornerstones in the management protocol of cirrhosis and portal hypertension. India needs improved access to care, outreach of public health programmes for viral hepatitis care, health infrastructure, and disease registries for improved healthcare outcomes. Low-cost initiatives like immunization, alcohol cessation, awareness about liver diseases, viral hepatitis elimination, and patient focused decision-making algorithms are essential to manage liver disease in India.

The role of endoscopic ultrasound for portal hypertension in liver cirrhosis

Chronic liver disease is still a major problem because disease progression will ultimately lead to liver cirrhosis. Portal hypertension is the hallmark in advanced liver disease management. By establishing portal vein access, endoscopic ultrasound (EUS) has been utilized in various clinical applications. In comparison to standard upper gastrointestinal endoscopy, EUS-Doppler has been shown to be a better modality for detecting esophageal and gastric varices along with peri-esophageal collateral veins, para-esophageal collateral veins, and perforating veins, and may be used to objectively predict the recurrence of bleeding. EUS-guided portal vein catheterization has also been proposed to overcome the limitations of trans-jugular approaches. The combination of EUS-elastography and azygos vein evaluation can also enhance the diagnostic accuracy of each modality. Another well-known implementation of EUS-guided procedures is in the management of ascites; particularly in paracentesis and ascitic fluid analysis. In addition, the most common clinical application of EUS in the treatment of portal hypertension is through vascular therapy or creation of intrahepatic portosystemic shunts. Major drawbacks of EUS mainly revolve around technical difficulties, the high cost of the procedure, as well as the requirement of more studies in humans to evaluate EUS-guided advanced therapeutic modalities in portal hypertension.

The Role of Interventional Endoscopic Ultrasound in Liver Diseases: What Have We Learnt?

Chronic liver disease (CLD) is still a major problem, where the disease progression will lead to liver cirrhosis (LC) or hepatocellular carcinoma (HCC). Portal hypertension (PH) management and loco-regional therapy for HCC have become the cornerstones in advanced liver disease management. Recently, there are studies looking at the potential role of interventional endoscopic ultrasound (EUS) in liver diseases. EUS may be useful in vascular changes of the digestive wall evaluation, performing dynamic assessment of hemodynamic changes, predicting variceal bleeding and rebleeding risk, and assessing the pharmacological effects. In PH management, EUS-guided vascular therapy-which revolves around glue injection, endovascular coil placement/embolization, and combination of both-has shown promising results. As a diagnostic modality for liver cancer, the implementation of EUS in liver diseases is currently not only limited to liver biopsy (EUS-LB) but also in shear-wave elastography (SWE) and portal pressure gradient measurement, as well as portal vein sampling. The application of EUS-guided radiofrequency ablation (EUS-RFA) and tumor injection can also overcome the limitations shown by both modalities without EUS. Nevertheless, establishing EUS as a firm diagnostic and therapeutic modality is still challenging since the performance of interventional EUS requires high expertise and adequate facilities.

Modified 'sandwich' injection with or without ligation for variceal bleeding in patients with both esophageal and gastric varices: a retrospective cohort study

OBJECTIVES

Esophagogastric variceal bleeding (EGVB) is a serious disease with high mortality. Endoscopic therapy has long been shown to be effective but the optimum technique is still unclear. We aimed to investigate the efficacy, safety and predictive factors of 1-year rebleeding of modified 'sandwich' injection combined with esophageal variceal ligation (EVL) for treating EGVB.

METHODS

A retrospective analysis was performed of 100 patients with EGVB who underwent modified 'sandwich' injection with or without EVL (EVL + and EVL - group). Patient follow-up was 1 year. Outcomes such as control of bleeding, rebleeding, complication rate and mortality were compared. Further, prognostic factors for rebleeding at one year were estimated.

RESULTS

No significant differences between two groups regarding initial bleeding control, complications, 6-week rebleeding or mortality in 1-year were observed. Rebleeding rate at 1-year of EVL - group was significantly higher than EVL + group (40 vs 20%, p = .029). Independent predictors of rebleeding at 1-year were gender, bilirubin and whether EVL was combined with injection.

CONCLUSIONS

Based on this single-center retrospective study, both of the two kinds therapies appeared to have relatively favorable outcomes. With respect to the rebleeding rate at 1-year, modified 'sandwich' injection combined with EVL may be superior to modified 'sandwich' injection alone.

Use of n-Butyl 2 Cyanoacrylate without Lipiodol, Using a Modified Protocol in Gastric Variceal Bleed Management: Retrospective Analysis of 2299 Patients

Aim To assess the feasibility and amount of cyanoacrylate glue that can be injected safely per session, complications, and long-term results in GOV1, GOV2 and IGV1 varices, using a modified method.

Method All patients from October 2008 to December 2019 presenting to us with variceal bleeding were included. We injected 0.5 mL of cyanoacrylate glue followed by 1.5 mL to 3 mL distilled water in all GOV 1, GOV 2 and IGV varices. Number of glues used were not restricted. Esophageal variceal ligation (EVL) was done for esophageal varices. Follow-up was done at 4 weeks and 3 to 6 months and analyzed.

Results 2299 patients received therapy. Male:female, 69%:31%. Causes of varices–cirrhosis (84.9%) and extrahepatic portal vein obstruction (EHPVO) (15.1%). Causes of cirrhosis–alcohol (38.4%), nonalcoholic fatty liver disease (NAFLD) (29%), hepatitis B (19.9%), hepatitis C (10.1%), Wilson’s disease (1.8%), and autoimmune diseases (0.9%). As much as 41.1% had blood in stomach and 10.2% had active spurt on index endoscopy. As much as 14.5% required endotracheal intubation (active bleed [53.1%], encephalopathy [40.5%], respiratory distress [6.6%]). As much as 30.9% had GOV1 + GOV2, 1.5% had GOV2 + IGV1, 21.3% had GOV1 + IGV1 and 16.4% had GOV1 + GOV2 + IGV1. Hemostasis could be achieved in 99.2% on index endoscopy. A total of 18 (0.8%) patients had uncontrolled bleed of whom 10 (55.6%) had hepatocellular carcinoma. Ongoing bleed was treated with transjugular intrahepatic portosystemic shunt (TIPSS) (61.1%) and endoscopic ultrasound (EUS)-guided coiling (38.8%). Amount of glue required for gastric variceal obturation was 3.6 on index endoscopy, 1.6 on follow-up at 4 to 6 weeks, and 1.2 at 3 months follow up. Glue extrusion with ulcers were seen in 6.4% at 4 to 6 weeks and 4.3% at 3 months. Rebleed occurred in 2.1% and 0.7% patients before 4 weeks and 3 months follow-up, respectively. As much as 1.3% and 1.2% patients were lost to follow-up before 4 weeks and 3 months follow-up sessions, respectively. Complications include pulmonary aspiration in 0.9% and bleeding from ulcers 2.8%. No evidence of pulmonary embolism was seen. In two endoscopic procedures, glue splashing into operator’s eyes occurred. Incidents of needle getting stuck in the varix occurred in three patients.

Conclusions Our modified protocol for glue in gastric varices is safe and feasible, as it has less rebleed, no pulmonary embolism and less ulcers with glue extrusion as compared with available literature.

Biomaterials in Gastroenterology: A Critical Overview

In spite of the large diversity of diagnostic and interventional devices associated with gastrointestinal endoscopic procedures, there is little information on the impact of the biomaterials (metals, polymers) contained in these devices upon body tissues and, indirectly, upon the treatment outcomes. Other biomaterials for gastroenterology, such as adhesives and certain hemostatic agents, have been investigated to a greater extent, but the information is fragmentary. Much of this situation is due to the paucity of details disclosed by the manufacturers of the devices. Moreover, for most of the applications in the gastrointestinal (GI) tract, there are no studies available on the biocompatibility of the device materials when in intimate contact with mucosae and other components of the GI tract. We have summarized the current situation with a focus on aspects of biomaterials and biocompatibility related to the device materials and other agents, with an emphasis on the GI endoscopic procedures. Procedures and devices used for the control of bleeding, for polypectomy, in bariatrics, and for stenting are discussed, particularly dwelling upon the biomaterial-related features of each application. There are indications that research is progressing steadily in this field, and the establishment of the subdiscipline of "gastroenterologic biomaterials" is not merely a remote projection. Upon the completion of this article, the gastroenterologist should be able to understand the nature of biomaterials and to achieve a suitable and beneficial perception of their significance in gastroenterology. Likewise, the biomaterialist should become aware of the specific tasks that the biomaterials must fulfil when placed within the GI tract, and regard such applications as both a challenge and an incentive for progressing the research in this field.

Endoscopic Cyanoacrylate Injection with Lauromacrogol for Gastric Varices: Long-Term Outcomes and Predictors in a Retrospective Cohort Study

Introduction: The first-line treatment for gastric variceal rebleeding in cirrhotic patients is endoscopic cyanoacrylate injection. We focused on the efficacy and prognosis of cyanoacrylate combined with Lauromacrogol^® for gastric varices (GV) in a retrospective study of long-term follow-up. Materials and Methods: One hundred thirty patients with cirrhosis and GV from March 2011 to February 2013 were included. Sixty-eight patients underwent endoscopic cyanoacrylate injection with Lauromacrogol and 62 patients without Lauromacrogol. The median follow-up was 40.1 and 38.8 months, respectively. Results: The volumes of cyanoacrylate used for the GV eradication in the Lauromacrogol group were significantly lower than those in the Ethiodol^® group (1.6 ± 0.8 versus 2.1 ± 1.2 mL, P = .029). No ectopic embolisms were observed during follow-up. The 1- and 3-year rebleeding-free rate did not differ between groups (83.7% and 59.2% versus 75.8% and 62.5%; P = .797). The same was observed for mortality (86.6% and 83.5% versus 85.5% and 83.7%; P = .955). New portal venous thrombosis (PVT) and progression of previous partial PVT were independently associated with rebleeding (hazard ratio [HR] 5.127, 95% confidence interval [CI], 2.430-10.817, P = .000) and death (HR 10.093, 95% CI, 3.988-25.548, P = .000). Conclusions: Endoscopic cyanoacrylate injection with Lauromacrogol might minimize the required dosage of cyanoacrylate, but it did not improve rebleeding rate or survival. Exacerbation of PVT was associated with rebleeding and death.

Sandwich method with or without lauromacrogol in the treatment of gastric variceal bleeding with liver cirrhosis: A meta-analysis

BACKGROUND

To compare the efficacy and safety of the modified sandwich method with lauromacrogol in the treatment of gastric variceal bleeding (GVB) caused by liver cirrhosis with the traditional sandwich method no accompanied by lauromacrogol via a meta-analysis.

METHODS

The Cochrane Library, Pubmed, the China National Knowledge Infrastructure (CNKI) database, the Chinese Wanfang database, and the Chongqing VIP database were searched to identify cohort studies comparing modified to traditional sandwich method in the treatment of GVB with liver cirrhosis. The relative risk for hemostasis rate, gastric varices (GV) remission rate, re-bleeding rate, the incidence of post-operative complications (pain, fever, ulcer or erosion, ectopic embolism), and all-cause mortality were calculated. The mean difference for average tissue adhesive dosage per case was calculated. Relevant data were analyzed with the Reviewer Manager 5.3.5.

RESULTS

Four cohort studies with a total of 587 patients were included in this meta-analysis. In the treatment of GVB with liver cirrhosis, compared with the traditional sandwich method, the modified sandwich method was associated with a higher GV remission rate (RR: 1.24, 95% CI: 1.09-1.42; P = .001) according to the pooled results. There were no statistically significant differences between the 2 methods in the rate of hemostasis, re-bleeding, pain, fever, ulcer or erosion, ectopic embolism, and all-cause mortality (P ≧ .05).

CONCLUSIONS

This meta-analysis indicated that the modified sandwich method with lauromacrogol is more effective than the traditional sandwich method without lauromacrogol. Due to the limited number of studies and samples, more RCT studies are needed to further validate the efficacy and safety of the modified sandwich method with lauromacrogol in the treatment of GVB with liver cirrhosis.

Acute pulmonary embolism following endoscopic sclerotherapy for gastroesophageal variceal hemorrhage: A case report and literature review

Gastroesophageal variceal hemorrhage is a substantial cause of death in patients with portal hypertension. Cyanoacrylate injection is a widely used endoscopic treatment for variceal hemorrhage. We report herein the case of a 49-year-old male with decompensated alcoholic cirrhosis, who received endoscopic sclerotherapy to stop gastroesophageal variceal hemorrhage during hospitalization. The following day, he developed acute progressive dyspnea, and computed tomogram of pulmonary artery revealed acute pulmonary embolism at the right lower pulmonary artery. A final diagnosis of sclerotherapy-associated pulmonary embolism was made, and he gradually improved conservatively without anticoagulant treatment 2 weeks after hospitalization.

SAFETY AND EFFICACY OF EUS-GUIDED COIL PLUS CYANOACRYLATE VERSUS CONVENTIONAL CYANOACRYLATE TECHNIQUE IN THE TREATMENT OF GASTRIC VARICES: A RANDOMIZED CONTROLLED TRIAL

BACKGROUND

One of the most feared complications with the use of cyanoacrylate for treatment of gastric varices is the occurrence of potentially life-threatening systemic embolism. Thus, endoscopists are turning towards new techniques, including endoscopic coiling, as a potentially safer and more effective treatment option. However, no studies have been performed comparing the two techniques.

OBJECTIVE

This study aims to compare the safety and efficacy of endoscopic ultrasound guided coil and cyanoacrylate injection versus the conventional technique of injection of cyanoacrylate alone.

DESIGN

A pilot randomized controlled trial.

METHODS

Patients randomized into group I were treated with coil and cyanoacrylate, and those in group II with cyanoacrylate alone. Flow within the varix was evaluated immediately after the treatment session and one month following initial treatment. If thrombosis was confirmed, additional follow-up was performed 4 and 10 months following initial treatment. All patients underwent a thoracic computerized tomography scan after the procedure.

RESULTS

A total of 32 patients, 16 in each group, were followed for an average of 9.9 months (range 1-26 months). Immediately after the procedure, 6 (37.5%) group-I patients and 8 (50%) group-II patients presented total flow reduction in the treated vessel (P=0.476). After 30 days, 11 (73.3%) group-I patients and 12 (75%) group-II patients were found to have varix thrombosis. In both groups, the majority of patients required only one single session for varix obliteration (73.3% in group I versus 80% in group II). Asymptomatic pulmonary embolism occurred in 4 (25%) group-I patients and 8 (50%) group-II patients (P=0.144). No significant difference between the groups was observed.

CONCLUSION

There is no statistical difference between endoscopic ultrasound guided coils plus cyanoacrylate versus conventional cyanoacrylate technique in relation to the incidence of embolism. However, a greater tendency towards embolism was observed in the group treated using the conventional technique. Both techniques have similar efficacy in the obliteration of varices. Given the small sample size of our pilot data, our results are insufficient to prove the clinical benefit of the combined technique, and do not yet justify its use, especially in light of higher cost. Further studies with larger sample size are warranted.

Pulmonary Glue Embolism: An unusual complication following endoscopic sclerotherapy for gastric varices

A pulmonary glue embolism is an unusual but potentially life-threatening complication following the treatment of variceal bleeding, especially in patients with large varices requiring large volumes of sclerosant. Other contributory factors include the rate of injection and ratio of the constituent components of the sclerosant (i.e. n-butyl-cyanoacrylate and lipiodol). This condition may be associated with a delayed onset of respiratory compromise. Therefore, a high degree of clinical suspicion is essential in patients with unexplained cardiorespiratory decline during or following endoscopic sclerotherapy. We report a 65-year-old man who was admitted to the Hull Royal Infirmary, Hull, UK, in 2017 with haematemesis and melaena. He subsequently developed acute respiratory distress syndrome secondary to a glue embolism following emergency sclerotherapy for bleeding gastric varices. The aetiology of the embolism was likely a combination of the large size of the gastric varices and the large volume of cyanoacrylate needed. After an endoscopy, the patient underwent transjugular intrahepatic portosystemic shunting twice to control the bleeding, after which he recovered satisfactorily.

Procedure-related complications in gastric variceal obturation with tissue glue

AIM

To focus on procedure-related complications, evaluate their incidence, analyze the reasons and discuss the solutions.

METHODS

Overall, 628 endoscopic gastric variceal obturation (EGVO) procedures (case-times) with NBC were performed in 519 patients in the Department of Endoscopy of the Third Affiliated Hospital of Sun Yat-Sen University from January 2011 to December 2016. The clinical data of patients and procedure-related complications of EGVO were retrospectively analyzed.

RESULTS

In the 628 EGVO procedures, sticking of the needle to the varix occurred in 9 cases (1.43%), including 1 case that used lipiodol-diluted NBC and 8 cases that used undiluted NBC (P = 0.000). The needle was successfully withdrawn in 8 cases. Large spurt bleeding occurred in one case, and hemostasis was achieved by two other injections of undiluted glue. The injection catheter became blocked in 17 cases (2.71%) just during the injection, and 4 cases were complicated with the needle sticking to the varix. Large glue adhesion to the endoscope resulted in difficulty withdrawing the endoscope in 1 case. Bleeding from multiple sites was observed in the esophagus and gastric cardia after the endoscope was withdrawn. Hemostasis was achieved by 1% aethoxysklerol injection and intravenous somatostatin. The ligation device stuck to the varices in two cases during the subsequent endoscopic variceal ligation. In one case, the ligation device was successfully separated from the esophageal varix after all bands were released. In another case, a laceration of the vein and massive bleeding were observed. The bleeding ceased after 1% aethoxysklerol injection.

CONCLUSION

Although EGVO with tissue glue is usually safe and effective, a series of complications can occur during the procedure that may puzzle endoscopists. There is no standard operating procedure for addressing these complications. The cases described in the current study can provide some reference for others.

Endoscopic cyanoacrylate injection with or without lauromacrogol for gastric varices: A randomized pilot study

BACKGROUND AND AIM

Current guidelines recommend injection of cyanoacrylate as first-line therapy to prevent gastric variceal rebleeding. The method still poses a risk of ectopic embolism, which possibly correlates with the volume of cyanoacrylate used. In this trial, we evaluated the short-term efficacy and safety of tissue adhesive injection combined with lauromacrogol for treating gastric varices.

METHODS

Patients admitted to our hospital for variceal hemorrhage were enrolled and blindly randomized into two treatment groups: lauromacrogol group (lauromacrogol-cyanoacrylate-lauromacrogol) and lipiodol group (lipiodol-cyanoacrylate-lipiodol). Patient follow-up was 6 months. Primary outcome was rebleeds, and secondary outcomes were mortality, gastric varices eradication, and treatment-related adverse events.

RESULTS

Between March 6, 2013 and October 16, 2013, 96 patients met the criteria. Two cases were lost to follow-up, and all treated cases were successful. No procedural-related adverse events were observed in either group. Cyanoacrylate volumes used in the lauromacrogol group were significantly less than those of the lipiodol group (0.9 ± 0.5 vs 2.0 ± 1.2 mL, P = 0.000). Eleven patients developed upper gastrointestinal rebleeding, which did not show significant difference between groups. On multivaritate analysis, portal venous thrombosis and fever were potential risk factors of rebleeding. Treatment failure, complications, gastric varices obturation, and survival did not differ between the two groups.

CONCLUSION

Tissue adhesives combined with lauromacrogol is a safe therapeutic option for gastric varices, with comparably less cyanoacrylate volume used. Because of the small number of study patients, it cannot be proven to have better efficacy than without lauromacrogol. Multicenter studies with larger patient groups are necessary.

Pitfalls in histoacryl glue injection therapy for oesophageal, gastric and ectopic varices: A review

Histoacryl glue is used increasingly for the treatment of gastric and ectopic varices, and there is experience in its use for oesophageal varices. It is an effective treatment, yet numerous reports of complications have accumulated. This review of the literature describes the technique, explores circulatory and vascular consideration unique to portal hypertension and categorises the complications into: “Embolisation”, “local venous thrombosis”, “fistulisation and extravascular injection”, “ulceration, erosion and extrusion”, and “nidus of infection”. A case is then made for standardisation of the technique and the consent process.

Complications of therapeutic gastroscopy/colonoscopy other than resection

Gastrointestinal (GI) endoscopy is profoundly utilized for diagnostic and therapeutic purposes. The therapeutic potential of GI endoscopy has amplified many folds with the evolution of novel techniques as well as equipments. However, with the augmentation of therapeutic endoscopy, the extent, likelihood and severity of adverse events have increased as well. The attendant risks and adverse events with therapeutic endoscopy are many folds that of diagnostic endoscopy. Besides endoscopic resection, therapeutic endoscopy is widely utilized for hemostasis in GI bleeds, dilatation of stenosis, enteral stenting, foreign body removal, ablation of Barrett's esophagus etc. Major adverse events associated with interventional endoscopic procedures include bleeding and perforation. Adverse events of endoscopic interventions are diverse and related to the underlying disease, therapeutic modality used and operator's experience. Many of these adverse events can be prevented. Early recognition of an unavoidable adverse event is important to minimize the associated morbidity and mortality.

Management of gastric varices: a French national survey

BACKGROUND AND AIMS

Bleeding from gastric varices is more severe than that from esophageal varices, but its management remains debated. We aimed to determine how French hepatogastroenterologists manage cirrhotic patients with gastric varices.

METHODS

Hepatogastroenterologists (n=1163) working in general or university hospitals received a self-administered questionnaire.

RESULTS

Overall, 155 hepatogastroenterologists (13.3%) from 112 centers (33.3%; 39/40 university hospitals, 73/296 general hospitals) answered. Primary prophylaxis was used by 98.1% of hepatogastroenterologists as follows: β-blockers 96.1% (93.8 vs. 97.0%; university vs. general hospitals respectively; P=0.57), glue obliteration 16.9% (17.2 vs. 16.3%; P=0.88), and transjugular intrahepatic portosystemic shunt (TIPS) 8.0% (12.7 vs. 4.6%; P=0.12). To manage bleeding, university hospitals had greater local access to glue obliteration (95.4 vs. 68.2%; P<0.001) and TIPS (78.5 vs. 3.5%; P<0.001). Early TIPS was proposed by 53.6% (72.1 vs. 39.2%; P<0.001). Glue obliteration was performed under general anesthesia (86.1%) using Glubran (43.1%) or Histoacryl (52.9%), and lipiodol (78.8%) with varying degrees of dilution (1 : 10 to 3 : 4). The injected volume per varix varied widely (1-20 ml). Glue obliteration, band ligation, or both were used by, respectively, 64.2, 18.2, and 17.5% of practitioners. Almost all hepatogastroenterologists (98%) performed secondary prophylaxis: β-blockers 74.7% (75.0 vs. 74.4%, university vs. general hospitals; P=0.93), glue obliteration 66.0% (76.9 vs. 57.6%; P=0.013), and TIPS 30.0% (39.1 vs. 23.3%; P=0.037).

CONCLUSION

The management of gastric varices in France is heterogeneous across centers. University hospitals have better access to techniques such as glue obliteration and TIPS. As bleeding from gastric varices has a poor outcome, guidelines should be established to standardize clinical practices and design further studies.

Cyanoacrylate Injection Versus Band Ligation in the Endoscopic Management of Acute Gastric Variceal Bleeding: Meta-Analysis of Randomized, Controlled Studies Based on the PRISMA Statement

The evidence for optimal endoscopic management of bleeding gastric varices is lacking. The clinical outcome is controversial in trials comparing cyanoacrylate injection and band ligation. To help guide endoscopic decisions regarding acute gastric variceal bleeding, a meta-analysis was conducted.Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched for all randomized controlled trials (RCTs) containing the 2 interventions. The main outcomes evaluated in the meta-analysis were active bleeding control, blood transfusion, rebleeding, recurrence of varices, complications, and survival.Three RCTs were identified, which included 194 patients with active gastric variceal bleeding from Taiwan and Romania. Active bleeding control was achieved in 46 of 49 (93.9%) patients in the cyanoacrylate injection group, compared with 35 of 44 (79.5%) in the band ligation group (P = 0.032), for a pooled odds ratio of 4.44 (95% confidence interval, 1.14-17.30). Rebleeding rate was comparable in type 2 gastroesophageal varices (GOV2) between the 2 interventions (35.7% vs 34.8%, P = 0.895), but cyanoacrylate injection seemed superior for reducing rebleeding rate in type 1 gastroesophageal varices (GOV1, 26.1% vs 47.7%, P = 0.035) and type 1 isolated gastric varices (IGV1, 17.6% vs 85.7%, P = 0.015). Cyanoacrylate injection was also superior in controlling recurrence of gastric varices to band ligation (36.0% vs 66.0%, P = 0.002). There was no difference in complications or mortality between the 2 interventions. The major limitation of this meta-analysis is the small number of studies/patients included.Compared with band ligation, injection cyanocrylate have an advantage in the control of acute gastric variceal bleeding, also with lower recurrence rate and rebleeding (except GOV2). The limited amount of studies included attenuates the strength of this meta-analysis; therefore, more high-quality RCTs are needed.

Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review

The purpose of this article is to describe the various portosystemic collateral pathways pertinent to portal hypertension on multi-detector row computed tomography (MDCT) and their clinical relevance, with special emphasis on the uncommon ones. The knowledge and understanding of the various patterns of portosystemic collateral channels has important implications both for the clinician and the interventionist. MDCT with its advanced post processing capabilities can exquisitely demonstrate these vascular pathways to help in therapeutic decision making.

Teaching points

• Portosystemic collaterals are an important cause of bleeding and hepatic encephalopathy.

• Radiologists should be familiar with the imaging findings to effectively identify them.

• Pre-operative knowledge of portosystemic collaterals is essential to avoid inadvertent vascular injury.

Endoscopic treatment of esophageal varices in patients with liver cirrhosis

Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.

Rare, spontaneous trans-splenic shunt and intra-splenic collaterals with attendant splenic artery aneurysms in an adult patient with compensated cirrhosis and portal hypertension

We present a rare case of spontaneous trans-splenic shunt and intra-splenic collaterals in a patient with liver cirrhosis and portal hypertension. The shunt and presence of cirrhosis and portal hypertension was incidentally detected by abdominal computed tomographic imaging during evaluation for abdominal pain. There has been a single report on the presence of trans-splenic shunt in two children with extra-hepatic portal venous obstruction but no cases that report intra-splenic collaterals: to the best of our knowledge, this is the first reported case of spontaneous trans-splenic shunt in the presence of intra-splenic collaterals and incidental multiple splenic artery aneurysms that developed in an adult with compensated cirrhosis and portal hypertension.

Collateral pathways in portal hypertension

Presence of portosystemic collateral veins (PSCV) is common in portal hypertension due to cirrhosis. Physiologically, normal portosystemic anastomoses exist which exhibit hepatofugal flow. With the development of portal hypertension, transmission of backpressure leads to increased flow in these patent normal portosystemic anastomoses. In extrahepatic portal vein obstruction collateral circulation develops in a hepatopetal direction and portoportal pathways are frequently found. The objective of this review is to illustrate the various PSCV and portoportal collateral vein pathways pertinent to portal hypertension in liver cirrhosis and EHPVO.