N-butyl-2-cyanoacrylate (Histoacryl) complication: a case report

[Gastrointestinal bleeding due to the expulsion of cyanoacrylate glue after endoscopic embolization of gastric varices: a case report]

Embolization of gastric varices with cyanoacrylate glue is the treatment of choice for digestive bleeding due to rupture of gastric varices. Gastrointestinal bleeding due to the expulsion of cyanoacrylate glue after gluing of gastric varices is a rare complication. We here report the case of a 65-year-old female patient on cirrhosis and decompensation treatment, undergoing cyanoacrylate glue of gastric varices 3 months before her admission for upper gastrointestinal bleeding; oesogastroduodenal fibroscopy objectified oesophageal varices grade 2 with ulcerated gastric varices and active bleeding due to the expulsion of cyanoacrylate glue. The patient received blood transfusion and sandostatin as well as cyanoacrylate gluing of GOV2 with no complications. Gastrointestinal bleeding after expulsion of cyanoacrylate glue is a serious complication of gluing. Few cases have been described in the literature that required, most often, endoscopic hemostasis.

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 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.

Transjugular intrahepatic portosystemic shunt in the treatment of portal vein thrombosis: a critical review of literature

Reports of successful transjugular intrahepatic portosystemic shunt (TIPS) surgery in patients with portal vein thrombosis (PVT) are considered anecdotal owing to the technical difficulty of the procedure and potential procedure-related complications. A literature review was undertaken to determine the feasibility and safety of TIPS in the treatment of PVT. All studies in which TIPS was attempted in patients with PVT were identified by searching through the PUBMED and MEDLINE databases. A total of 424 PVT patients undergoing TIPS were reported in 54 articles. The success rate of TIPS insertion was 67-100% in 19 case series. Further, 85 patients with portal cavernoma underwent successful TIPS insertions. Three therapeutic strategies of TIPS placement were used: (1) TIPS placement followed by portal vein recanalization via the shunt, (2) portal vein recanalization via percutaneous approaches followed by TIPS placement, and (3) TIPS insertion between a hepatic vein and a large collateral vessel without portal vein recanalization. Four approaches were used to access the portal vein: transjugular, transhepatic, transsplenic, and transmesenteric. Intra-abdominal hemorrhage secondary to hepatic capsule perforation was lethal in only three patients. No episode of pulmonary embolism was reported. Other procedure-related complications were reversible. The overall incidence of shunt dysfunction and hepatic encephalopathy was 8-33% and 0-50%, respectively. In conclusion, the reviewed studies uniformly support the feasibility and safety of TIPS for PVT even in the presence of portal cavernoma. Further, several major issues that remain unresolved are discussed.

In vitro and in vivo studies on the use of Histoacryl(®) as a soft tissue glue

The skin adhesive Histoacryl(®) consists of n-butyl-2-cyanoacrylate which polymerises in contact with moisture. It is not fully biodegradable, produces heat during polymerisation and releases products which are toxic and inhibit cell growth. Clinical application is exclusively approved to glue skin. However, there are also clinical studies and case reports in the scientific literature, which discuss the application of Histoacryl(®) as a soft tissue adhesive. In parallel to an analysis of the literature which discusses the usage of Histoacryl(®) in head and neck surgery, we performed in vitro and in vivo investigations with this adhesive. In vitro, the vitality of cultured cell lines which where treated with extracts of Histoacryl(®) was determined with a viability assay. In addition, Histoacryl(®) was examined by fixing defined mucous membrane of the nasal septum in an animal study in rabbits. The analysis of the literature shows both positive and negative results for the application of Histoacryl(®) as a soft tissue adhesive depending on the manner and place of the application as well as the applied amount of glue. Our own results confirm a negative influence of Histoacryl(®) on the viability of cultured cells and soft tissue. The histological examination showed that a better biocompatibility is achieved if the glue is used in small amounts. Both the literature study as well as the in vitro and in vivo examinations showed that the usage of Histoacryl(®) as a soft tissue glue may be arguable. Critical factors are the moisture at the application area and the applied amount of glue.

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.

Study of glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding

AIM: To investigate glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding and to evaluate the long-term efficacy and safety of this therapy.

METHODS: A total of 148 cirrhotic patients in our hospital with esophagogastric variceal bleeding (EGVB) were included in this study. N-butyl-2-cyanoacrylate was mixed with lipiodol in a 1:1 ratio and injected as a bolus of 1-3 mL according to variceal size. Patients underwent endoscopic follow-up the next week, fourth week, second month, fourth month, and seventh month after injection and then every 6 mo to determine the cast shape. An abdominal X-ray film and ultrasound or computed tomographic scan were also carried out in order to evaluate the time of variceal disappearance and complete extrusion of the cast. The average follow-up time was 13.1 mo.

RESULTS: The instantaneous hemostatic rate was 96.2%. Early re-bleeding after injection in 9 cases (6.2%) was estimated from rejection of adhesive. Late re-bleeding occurred in 12 patients (8.1%) at 2-18 mo. The glue cast was extruded into the lumen within one month in 86.1% of patients and eliminated within one year. Light erosion was seen at the injection position and mucosa edema in the second week. The glue casts were extruded in 18 patients (12.1%) after one week and in 64 patients (42.8%) after two weeks. All kinds of glue clumping shapes and colors on endoscopic examination were observed in 127 patients (86.1%) within one month, including punctiform, globular, pillar and variform. Forty one patients (27.9%) had glue extrusion after 3 mo and 28 patients (28.9%) after six months. The extrusion time was not related to the injection volume of histoacryl. Obliteration was seen in 70.2% (104 cases) endoscopically. The main complication was re-bleeding resulting from extrusion. The prognosis of the patients depended on the severity of the underlying liver disease.

CONCLUSION: Endoscopic injection of cyanoacrylate is highly effective for gastric varices bleeding. The glue clump shape is correlated with anatomic structure of vessels. The time of extrusion was not related to dosage of the glue.