Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli

Fatal acute pulmonary embolism following endoscopic cyanoacrylate injection for gastric fundal varices

Acute gastric variceal bleeding is a rare but serious complication of portal hypertension. Initial therapy for bleeding gastric varices focuses on acute hemostasis. In this regard, endoscopic cyanoacrylate injection (ECI) is the first-line approach. Cyanoacrylate diluted with Lipiodol acts as a tissue adhesive that polymerizes on contact with blood. Glue-induced pulmonary embolism is a very rare but severe complication of ECI. This paper describes a case of fatal glue pulmonary embolism during ECI for prevention of bleeding from gastric fundal varices in a patient with polycythemia vera and the presence of portosystemic shunts.

[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.

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.

Acute pericarditis: A rare complication of gastric variceal obturation with cyanoacrylate glue

Endoscopic obturation by cyanoacrylate glue is currently the treatment of reference of gastric varices bleeding in patients with portal hypertension with a good efficacy for bleeding control and secondary prophylaxis. However, several adverse events related to this treatment have been described including immediate rebleeding and glue embolism. Here we present a case of gastric variceal obturation by cyanoacrylate inducing an acute pericarditis due to glue embolism in mediastinal, pericardial and phrenic veins that was managed conservatively. We also discussed pathophysiological explanations and surveillance modality.

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.

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.

A rare complication of endoscopic intervention

A 56-year-old woman with alcohol-related liver cirrhosis presented with haematemesis and melena. On arrival, observations were oxygen saturation measured by pulse oximetry 97% on room air, blood pressure 77/44 mmHg, heart rate 127 per min, respiratory rate 24 per min, temperature 36.5°C and alert. The blood tests showed haemoglobin 65 g⋅L⁻¹ and urea 23 mg⋅dL⁻¹. After initial resuscitation with intravenous fluids, she was given a transfusion of 2 units packed red cells, 2 units fresh frozen plasma, 1 unit platelets and 2 mg terlipressin.

Can you diagnose this rare complication following an endoscopic intervention in this patient with alcohol-related liver cirrhosis presenting with haematemesis and melena?http://ow.ly/z7Yg30jEHxw

Thromboembolic Events Secondary to Endoscopic Cyanoacrylate Injection: Can We Foresee Any Red Flags?

BACKGROUND

Gastric varices (GV) are associated with high morbidity and mortality in patients with portal hypertension. Endoscopic cyanoacrylate injection is the first-line recommended therapy for GV obliteration. This study aims to explore the reason behind related adverse events and better prevent its occurrence.

METHODS

A retrospective case series study was conducted from January 1, 2013, to December 31, 2016, to identify patients who experienced severe adverse events secondary to endoscopic cyanoacrylate injection. A literature review of similar cases was performed on two medical databases, Medline and Embase.

RESULTS

A total of 652 patients underwent cyanoacrylate injection at our center within the study duration. Five cases of severe adverse events related to the use of tissue adhesives were identified. Detailed clinical presentation, patient treatment, and outcomes were reviewed and analyzed. Twenty-seven similar cases were identified based on the literature review providing further insight into the study.

CONCLUSION

Although rare in incidence, systemic embolism associated with cyanoacrylate injection is often fatal or debilitating. This report may raise awareness in treatment protocol, including the necessity of preoperative angiographic studies, to avoid similar adverse events in clinical practice.

Death from pulmonary embolism of cyanoacrylate glue following gastric varix endoscopic injection

We present the case of a 25 year old woman with a complex past medical history including Crigler-Najjar syndrome (Type 1) with a liver transplant in 1993 and subsequent development of cirrhosis with portal hypertension in the transplanted liver. The deceased presented to hospital with hematemesis and investigations showed a large gastric varix. The varix was injected with cyanoacrylate glue. Within 30 min of injection the patient became acutely hypoxic. Urgent chest X-ray demonstrated radio opaque glue within the pulmonary arteries. It was evident that future treatment was futile and supportive treatment was withdrawn. The deceased was referred for medico legal post mortem examination. The post mortem CT scan performed prior to autopsy showed widespread radio-opaque material within the pulmonary arteries. At autopsy, rubbery grey/tan "clot" occluded the major proximal and segmental pulmonary arteries. Microscopic examination of the "clot" showed clumps of erythrocytes surrounded by foreign material. We discuss this relatively uncommon but well recognized complication of variceal injection with cyanoacrylate glue.

Upper gastrointestinal ectopic variceal bleeding treated with various endoscopic modalities: Case reports and literature review

RATIONALE

Ectopic variceal bleeding is a rare (2-5%) but fatal gastrointestinal bleed in patients with portal hypertension. Patients with ectopic variceal bleeding manifest melena, hematochezia, or hematemesis, which require urgent managements. Definitive therapeutic modalities of ectopic varices are not yet standardized because of low incidence. Various therapeutic modalities have been applied on the basis of the experiences of experts or availability of facilities, with varying results.

PATIENT CONCERNS

We have encountered eight cases of gastrointestinal ectopic variceal bleeding in five patients in the last five years.

DIAGNOSES

All patients were diagnosed with liver cirrhosis presenting melena or hematemesis.

INTERVENTIONS

All patients were treated with various endoscopic modalities (endoscopic variceal obturation [EVO] with cyanoacrylate in five cases, endoscopic variceal band ligation (EVL) in two cases, hemoclipping in one case).

OUTCOMES

Satisfactory hemostasis was achieved without radiologic interventions in all cases. EVO and EVL each caused one case of portal biliopathy, and EVL induced ulcer bleeding in one case.

LESSONS

EVO generally accomplished better results of variceal obturations than EVL or hemoclipping, without serious adverse events. EVO may be an effective modality for control of ectopic variceal bleeding without radiologic intervention or surgery.

Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension

BACKGROUND

In people with portal hypertension, gastric varices are less prevalent than oesophageal varices. The risk of bleeding from gastric varices seems to be lower than from oesophageal varices; however, when gastric varices bleed, it is often severe and associated with higher mortality. Endoscopic sclerotherapy of bleeding gastric varices with N-butyl-2-cyanoacrylate glue (cyanoacrylate) is considered the best haemostasis with a lower risk of re-bleeding compared with other endoscopic methods. However, there are some inconsistencies between trials regarding mortality, incidence of re-bleeding, and adverse effects.

OBJECTIVES

To assess the benefits and harms of sclerotherapy using cyanoacrylate compared with other endoscopic sclerotherapy procedures or with variceal band ligation for treating acute gastric variceal bleeding with or without vasoactive drugs in people with portal hypertension and to assess the best dosage of cyanoacrylate.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded from inception to September 2014 and reference lists of articles. We included trials irrespective of trial setting, language, publication status, or date of publication.

SELECTION CRITERIA

Randomised clinical trials comparing sclerotherapy using cyanoacrylate versus other endoscopic methods (sclerotherapy using alcohol-based compounds or endoscopy band ligation) for acute gastric variceal bleeding in people with portal hypertension.

DATA COLLECTION AND ANALYSIS

We performed the review following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the Cochrane Hepato-Biliary Module.We presented results as risk ratios (RR) with 95% confidence intervals (CI), with I(2) statistic values as a measure of intertrial heterogeneity. We analysed data with both fixed-effect and random-effects models, and reported the results with random-effects models. We performed subgroup, sensitivity, and trial sequential analyses to evaluate the robustness of the overall results, risk of bias, sources of intertrial heterogeneity, and risk of random errors.

MAIN RESULTS

We included six randomised clinical trials with three different comparisons: one trial compared two different doses of cyanoacrylate in 91 adults, bleeding actively from all types of gastric varices; one trial compared cyanoacrylate versus alcohol-based compounds in 37 adults with active or acute bleeding from isolated gastric varices only; and four trials compared cyanoacrylate versus endoscopic band ligation in 365 adults, with active or acute bleeding from all types of gastric varices. Main outcomes in the included trials were bleeding-related mortality, failure of intervention, re-bleeding, adverse events, and control of bleeding. Follow-up varied from six to 26 months. The participants included in these trials had chronic liver disease of different severities, were predominantly men, and most were from Eastern countries. We judged all trials at high risk of bias. Application of quality criteria for all outcomes yielded very low quality grade of the evidence in the three analyses, except for the low quality evidence rated for the re-bleeding outcome in the cyanoacrylate versus endoscopic band ligation comparison. Two different doses of cyanoacrylate: we found very low quality evidence from one trial for the effect of 0.5 mL compared with 1.0 mL of cyanoacrylate on all-cause mortality (20/44 (45.5%) with 0.5 mL versus 21/47 (45%) with 1.0 mL; RR 1.02; 95% CI 0.65 to 1.60), 30-day mortality (RR 1.07; 95% CI 0.41 to 2.80), failure of intervention (RR 1.07; 95% CI 0.56 to 2.05), prevention of re-bleeding (RR 1.30; 95% CI 0.73 to 2.31), adverse events reported as fever (RR 0.56; 95% CI 0.32 to 0.98), and control of bleeding (RR 1.04; 95% CI 0.78 to 1.38). Cyanoacrylate versus alcohol-based compounds: we found very low quality evidence from one trial for the effect of cyanoacrylate versus alcohol-based compounds on 30-day mortality (2/20 (10%) with cyanoacrylate versus 4/17 (23.5%) with alcohol-based compound; RR 0.43; 95% CI 0.09 to 2.04), failure of intervention (RR 0.36; 95% CI 0.09 to 1.35), prevention of re-bleeding (RR 0.85; 95% CI 0.30 to 2.45), adverse events reported as fever (RR 0.43; 95% CI 0.22 to 0.80), and control of bleeding (RR 1.79; 95% CI 1.13 to 2.84). Cyanoacrylate versus endoscopic band ligation: we found very low quality evidence for the effect of cyanoacrylate versus endoscopic band ligation on bleeding-related mortality (44/185 (23.7%) with cyanoacrylate versus 50/181 (27.6%) with endoscopic band ligation; RR 0.83; 95% CI 0.52 to 1.31), failure of intervention (RR 1.13; 95% CI 0.23 to 5.69), complications (RR 2.81; 95% CI 0.69 to 11.49), and control of bleeding (RR 1.07; 95% CI 0.90 to 1.27). There was low quality evidence for the prevention of re-bleeding (RR 0.60; 95% CI 0.41 to 0.88). Trial sequential analysis showed that the analyses were underpowered (diversity-adjusted required information size was 5290 participants for bleeding-related mortality).

AUTHORS' CONCLUSIONS

This review suggests that endoscopic sclerotherapy using cyanoacrylate may be more effective than endoscopic band ligation in terms of preventing re-bleeding from gastric varices. However, due to the very low quality of the evidence, we are very uncertain about our estimates on all-cause and bleeding-related mortality, failure of intervention, adverse events, and control of bleeding. The trials were at high risk of bias; the number of the included randomised clinical trials and number of participants included in each trial was small; and there was evidence of internal heterogeneity across trials, indirectness of evidence in terms of population, and possible publication bias.The effectiveness of different doses of cyanoacrylate and the comparison of cyanoacrylate versus alcohol compounds to treat variceal bleeding in people with portal hypertension is uncertain due to the very low quality of the evidence.The shortcomings mentioned call for more evidence from larger trials that need to be conducted according to the SPIRIT statement and reported according to CONSORT guidelines.

Endoscopic ultrasound-guided intravascular therapy

The gastrointestinal tract provides a unique "window" to access vascular structures in the mediastinum and abdomen. The advent of interventional endoscopic ultrasound (EUS) has enabled access to these structures with a standard fine-needle aspiration (FNA) needle. Sclerosants, cyanoacrylate, and coils can be delivered through the lumen of the FNA needle. EUS-guided treatment of gastric varices has theoretical advantages over conventional endoscopy-guided treatment. Controlled studies are needed to determine the role of EUS-guided treatment for primary and secondary prevention of variceal bleeding. There is a growing list of novel indications for EUS-guided vascular therapy that include portal vein angiography and pressure measurements, intrahepatic portosystemic shunt placement, and micro coil embolization of vascular structures. Additionally, access and therapy of the heart and surrounding structures appears feasible.

Delayed onset pulmonary glue emboli in a ventilated patient: a rare complication following endoscopic cyanoacrylate injection for gastric variceal haemorrhage

Cyanoacrylate injection is a recognised endoscopic treatment option for variceal haemorrhage. We describe a 34-year old man with hepatitis B cirrhosis who presented to the hospital with upper gastrointestinal haemorrhage from gastric and oesophageal varices. Haemostasis was achieved via cyanoacrylate injection sclerotherapy and banding. Ten days later, the patient developed acute hypoxia and fever. His chest radiograph showed wide-spread pulmonary shadowing. A non-contrast CT scan confirmed multiple emboli of injected glue material from the varix with parenchymal changes either suggesting acute lung injury or pulmonary oedema. He gradually recovered with supportive treatment and was discharged home. On follow-up, he remained asymptomatic from a chest perspective. This case report discusses the rare complication of pulmonary embolisation of cyanoacrylate glue from variceal injection sites and the diagnostic dilemmas involved. Emphasis is placed on the importance of maintaining high index of clinical suspicion when assessing patients with possible procedure related complications.

Endoscopic therapy with 2-octyl-cyanoacrylate for the treatment of gastric varices

BACKGROUND

Gastric variceal bleeding is associated with significant morbidity and mortality and limited endoscopic therapeutic options.

AIM

The aim of this study was to evaluate the short- and long-term efficacy and safety of endoscopic therapy with 2-octyl-cyanoacrylate in patients with gastric variceal bleeding.

METHODS

A single-center retrospective review of patients receiving endoscopic therapy for gastric variceal hemorrhage. Patient demographics, laboratory, and procedural data were collected. Patients were followed to death, liver transplantation, or last follow-up. Success rates were defined as immediate control of bleeding; early re-bleeding (1-7 days), short-term re-bleeding (1-12 weeks), overall survival, and serious procedure complications.

RESULTS

A total of 41 patients (39 with cirrhosis) underwent 54 cyanoacrylate injections during study period. Mean age was 57 and 73 % were males. Twenty-four (58.5 %) patients had failed or were deemed ineligible for transjugular intra-hepatic portosystemic shunt, and 5 % were done for primary prophylaxis. Immediate hemostasis was achieved in five active bleeders. During a median survival time of 117 days, early re-bleeding was seen in 1 (2.4 %), short-term re-bleeding in five patients (12 %), and varices were eradicated in 15 (46.8 %) patients on follow-up. Mean MELD score at the time of the first injection was 17.1 ± 7.8. Mean volume injected was 3.4 cc and median number of varices injected per session was one. Eight patients died during the long-term follow-up: metastatic cancer (2), infections (3), liver failure (1), and re-bleeding (2). There were no serious procedure-related complications.

CONCLUSIONS

Endoscopic cyanoacrylate therapy appears effective and safe for treatment of patients with bleeding from gastric varices or high-risk stigmata.

Guidelines for the use of NBCA in vascular embolization devised by the Committee of Practice Guidelines of the Japanese Society of Interventional Radiology (CGJSIR), 2012 edition

Cyanoacrylates are a group of fast-acting adhesives. They form low viscosity liquids in the monomer state and instantly polymerize to become adhesive upon contact with ionic substances. Since the 1950s, they have been used around the world for industrial and household purposes. N-butyl cyanoacrylate (NBCA) is a cyanoacrylate that is commonly used for medical care, and the closure of skin wounds with NBCA has been found to promote hemostasis. However, in Japan, the intravascular injection of NBCA is considered to be off-label use, except during the treatment of gastric varices under endoscopy. The use of NBCA in embolotherapy is considered when the target vessels cannot be cannulated superselectively, for vascular diseases that require long segments of the target vessel to be embolized, or for patients in a hypocoagulable state. NBCA-based embolotherapy can be used to treat vascular malformations, acute hemorrhaging, tumors, and venous disease. The complications associated with NBCA-based embolotherapy include tissue ischemia, hemorrhaging, systemic or local reactions, and catheter adhesion to blood vessels. NBCA is mixed with Lipiodol to make it radiopaque and to adjust its polymerization time. Since there are various technical aspects to performing NBCA-based embolotherapy safely, it should be carried out by, or with the assistance of, proficient interventional radiologists.

Safety analysis of a hemostatic powder in a porcine model of acute severe gastric bleeding

BACKGROUND

Non-variceal upper gastrointestinal (UGI) bleeding is a common condition that requires prompt lifesaving therapy and traditional endoscopic treatments require high technical proficiency to perform.

AIMS

This study was conducted to identify any local or systemic histopathologic effects of a hemostatic powder in a porcine model of active, severe, non-variceal UGI hemorrhage.

METHODS

This prospective, non-blinded animal study was performed in accordance with Good Laboratory Practice and Animal Care and Use Guidelines. Six animals underwent gastrotomy and creation of a looped vascular bundle, which was placed into the stomach lumen. The transplanted vascular bundle was punctured with an endoscopic needle-knife to create Forrest grade Ia or Ib bleeding. The hemostatic powder was then applied until hemostasis was achieved.

RESULTS

Initial hemostasis was achieved in all animals. Results of pre- and post-treatment coagulation studies were similar. All animals survived at least 9 days post-procedure. The hemostatic powder was not found in any local, regional, or systemic tissues. Gross and histologic analysis of systemic organs showed no infarct, particulate, or embolic effects. No gross or microscopic necropsy findings were treatment-related.

CONCLUSIONS

The hemostatic powder achieved initial hemostasis (even in animals with spurting arterial bleeding) with no bowel obstruction or unintended luminal effects, no local or regional particulate effects, no systemic embolic effects, and no systemic coagulopathic effects.

Emergencies after endoscopic procedures

Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.

Duodenal varices successfully treated with cyanoacrylate injection therapy

Duodenal varices are a rare complication of portal hypertension secondary to liver cirrhosis. Compared to oesophageal varices, they bleed less often but are also more difficult to diagnose and treat. There is no established treatment for bleeding duodenal varices and different treatment strategies have been employed with variable results. The authors present a case of 52-year-old male who was admitted with melaena. Upper gastrointestinal endoscopy was performed which identified bleeding varices in the second part of duodenum. The varices were injected with cyanoacrylate and the outcome was favourable. Subsequent endoscopies showed complete resolution of the varices. The authors conclude that cyanoacrylate injection is an effective first-line treatment for bleeding duodenal varices.

Embolization of cyanoacrylate glue in systemic circulation in a case of hepatocellular carcinoma: an autopsy report

We report a case of embolism of the sclerosant dye with subsequent formation of foreign-body giant cell reaction within the veins of pulmonary and portal circulation in an autopsy case of hepatocellular carcinoma developing over an underlying primary biliary cirrhosis.

A modified percutaneous transhepatic variceal embolization with 2-octyl cyanoacrylate versus endoscopic ligation in esophageal variceal bleeding management: randomized controlled trial

BACKGROUND

Conventional percutaneous transhepatic varices embolization (PTVE) has rarely been used in recent years due to high rates of variceal recurrence and rebleeding. Herein we report a modified PTVE with 2-octyl cyanoacrylate (2-OCA) in which the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the advertitial plexus of the cardia and fundus were sufficiently obliterated. We compared this PTVE with endoscopic band ligation (EVL) in the treatment of esophageal variceal bleeding.

METHODS

In this prospective randomized controlled trial, cirrhotic patients with acute or recent esophageal variceal bleeding were assigned randomly to PTVE (52 patients) or EVL (50 patients) groups. Upper gastrointestinal (UGI) rebleeding, esophageal variceal rebleeding, and survival were followed-up. Computerized tomography (CT) scanning and portal venography were used to observe 2-OCA distribution.

RESULTS

During the follow-up period (median 24 and 25 months in the PTVE and EVL groups, respectively) UGI rebleeding developed in eight patients in the PTVE group and 21 patients in EVL group (P = 0.004). Recurrent bleeding from esophageal varices occurred in three patients in the PTVE group and twelve in the EVL group (P = 0.012, relative risk 0.24, 95% confidence interval 0.05-0.74). Multivariate Cox analysis indicated that the treatment was the only factor predictive of rebleeding. A Kaplan-Meier curve showed there was no significant difference between survival in the two groups (P = 0.054).

CONCLUSIONS

With the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the adventitial plexus of the cardia and fundus sufficiently obliterated by 2-OCA, this modified PTVE was more effective than EVL in the management of esophageal varices recurrence and rebleeding. Survival in these two groups was not significantly different, however.

Treatment of gastric varices by endoscopic sclerotherapy using butyl cyanoacrylate: 10 years' experience of 635 cases

BACKGROUND

Gastric varices (GV) are life-threatening for patients with portal hypertension. Endoscopic injection with butyl cyanoacrylate (BC), the mainstay of the therapy for GV, has been reported to be effective for hemostasis of bleeding varices, but its efficacy in the obliteration of GV and impact on the survival of patients still needs clarification. Here we summarized our experience of 10 years' practice to evaluate the efficacy and safety of endoscopic therapy using BC for GV patients.

METHODS

From January 1997 to April 2006, GV cases treated with endoscopic injection using BC were collected. The "sandwich method" and the "modified sandwich method" were used to inject BC intravascularly. Retrograde analysis was made on the data of treatment and follow-up.

RESULTS

A total of 635 GV cases treated with endoscopic injection using BC were collected, most of them (90.2%) suffered from post-hepatitis cirrhosis. Emergency hemostasis was achieved in 139 out of 146 sessions (95.2%). Complications occurred in 32 cases (5.2%), including hemorrhage due to early expulsion of tissue glue (3.1%), septicemia (1%) and ectopic thrombosis (0.5%), such as spleen infarction. Endoscopic follow-up in 503 patients showed complete disappearance (76.9%), collapse (17.3%) or remnants (5.8%) of gastric varices. A total of 550 patients were followed up clinically for 3 to 115 months. Of these patients, 44 had recurrent bleeding (8.0%) and 44 died from hepatic failure, recurrent bleeding, hepatic carcinoma or other causes. The longest survival was 115 months, with a median survival of 25 months. Survival rates at 1, 2, 3, 4 and 5 year were 95%, 92%, 90%, 83% and 81%, respectively.

CONCLUSIONS

Endoscopic sclerotherapy with BC is effective for the hemostasis of bleeding GV, as well as obliteration of GV which contributes to less rebleeding and better survival. The modified sandwich method may be useful to minimize ectopic embolism, which we speculated to result from excess iodized oil.