Endoscopic sclerotherapy of gastric variceal bleeding with N-butyl-2-cyanoacrylate

Endoscopic management of gastric varices: efficacy and outcomes of gluing with N-butyl-2-cyanoacrylate in a North American patient population

BACKGROUND

Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. Outside of North America, gastric variceal injection of N-butyl-2-cyanoacrylate has been shown to be safe and effective. The majority of studies on this mode of therapy are in Asian populations in which the etiology of portal hypertension differs from North America.

AIM

To assess the safety and efficacy of gastric variceal glue injection in a North American population.

METHODS

Consecutive patients that underwent glue injection of gastric varices in the Calgary Health Region from 2001 to 2006 were assessed.

RESULTS

Thirty-four patients (19 men, 15 women) underwent a total of 47 separate gluing procedures. Of those presenting with active bleeding at endoscopy, immediate hemostasis was achieved in 93.8% of patients. Rebleeding within 48 h of gluing was observed after four procedures. Gastric varices were eradicated in 84.0% of cases. Complications included superior mesenteric vein thrombosis in one patient. Twenty-eight (82.4%) patients were alive at the end of follow-up. The treatment failure-related mortality rate was 2.1%.

CONCLUSIONS

The present study is one of the few to assess the role of gastric variceal gluing in a North American population. Glue injection with cyanoacrylate is safe and effective in the treatment of bleeding gastric varices.

Endoscopic treatment of bleeding gastric varices using large amount of N-butyl-2-cyanoacrylate under fluoroscopic guidance

PURPOSE

We propose the use of fluoroscopic guidance for endoscopic injection of n-butyl-2-cyanoacrylate to treat gastric variceal hemorrhage to achieve placement of the safest quantity of tissue adhesive.

METHODS

Ten patients with gastric varices were treated with n-butyl-2-cyanoacrylate endoscopic injection under fluoroscopic guidance for the purpose of hemostasis or prevention of recurrent bleeding. The glue was infused into the varices in the quantities needed to achieve complete obliteration of the gastric varices.

RESULTS

The median quantity of tissue adhesive required in this series was 6.6 mL. The procedure was initially considered successful in all patients. There were no complications relating to the procedure. The mean duration of follow-up was 20 months.

CONCLUSIONS

Injection of suitable quantities of cyanoacrylate under fluoroscopic guidance seems to be safe and effective for controlling hemorrhagic gastric varices.

The therapeutic effect of cyanoacrylate on gastric variceal bleeding and factors related to clinical outcome

BACKGROUND

Cyanoacrylate has been recommended for the treatment of gastric variceal bleeding.

GOAL

We aimed to evaluate the efficacy and safety of cyanoacrylate injection therapy in patients with gastric variceal bleeding, and to identify the factors predictive of failure, rebleeding, and survival after therapy.

STUDY

One hundred twenty-one patients with gastric variceal bleeding who received cyanoacrylate injections were retrospectively reviewed.

RESULTS

Treatment succeeded in 110 patients (90.9%). Rebleeding and mortality rate during 4-week were 13.2% and 11.6%. A stepwise logistic regression analysis indicated that only the Child-Pugh class was an independent predictive factor of treatment failure [Child-Pugh C vs. Child-Pugh A and B, odds ratio (OR), 5.0; 95% confidence interval (CI), 1.2-19.4; P=0.025]. The actuarial probability of a 4-week absence of rebleeding and survival after the initial therapy was 86.8% and 85.1%, respectively. A stepwise logistic regression analysis showed that a Child-Pugh class C and hepatocellular carcinoma were independent predictive factors for rebleeding (OR, 7.4; 95% CI, 2.0-27.0; P=0.003 and OR, 3.3; 95% CI, 1.0-11.1; P=0.05, respectively) and mortality (OR, 7.4; 95% CI, 2.0-27.0; P=0.003 and OR, 3.3; 95% CI, 1.0-11.1; P=0.05, respectively). Only 2 cases (2.7%) with serious complications, noted as cyanoacrylate embolisms, were observed. At 1-year follow up, the actuarial probability of remaining free of bleeding was 49.0% and hepatitis B virus infection was independent predictive factor of bleeding (OR, 5.3; 95% CI, 1.4-20.0; P=0.015).

CONCLUSIONS

In short-term follow-up, cyanoacrylate injection is an effective treatment method for gastric variceal bleeding and the Child-Pugh class was only independent predictive factor of treatment failure and the Child-Pugh class and the hepatocellular carcinoma were risk factors for rebleeding and survival. In long-term follow-up, the presence of hepatitis B infection was risk factor for rebleeding.

A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos)

BACKGROUND

N-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported.

OBJECTIVE

Our purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using a standardized injection technique and regimen.

DESIGN

Retrospective.

SETTING

Two tertiary referral centers.

PATIENTS

A total of 131 patients (91 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen.

INTERVENTIONS

(1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration.

MAIN OUTCOME MEASUREMENTS

Immediate hemostasis rate, early rebleeding rate, bleeding-related mortality rate, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate.

RESULTS

Initial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively.

CONCLUSION

Obliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.

Avoiding pitfalls: what an endoscopist should know in liver transplantation--part 1

Cirrhosis is associated with global homodynamic changes, but the majority of the complications are usually manifested through the gastrointestinal tract. Therefore, Gastrointestinal Endoscopy has become an important tool in the multidisciplinary approach in the management of these patients. With the ever growing number of cirrhotic patients requiring pre-transplant endoscopic management, it is imperative that the community endoscopists are well aware of the pathologies that can be potentially noted on Gastrointestinal Endoscopy. Their timely management is also considered to have the utmost importance in being able to stabilize the patient until their transfer to a Liver Transplant Center. The aim of this manuscript is to give a comprehensive update and review of various endoscopic findings that a non-transplant endoscopist will encounter in the pre-transplant setting.

Long-term outcomes of acute gastric variceal bleeding in 48 patients following treatment with cyanoacrylate

OBJECTIVES

(1) Study the effectiveness of intravariceal injection of n-butyl-2-cyanoacrylate to treat acute gastric variceal (GV) bleeding and (2) study the impact of the type of GV and hepatic function on endoscopic hemostasis and mortality outcomes.

METHODS

Fourty-eight patients with acute GV bleeding underwent intravariceal injection of n-butyl-2-cyanoacrylate and were followed until death or study conclusion (12-52 months).

RESULTS

Primary hemostasis (no re-bleeding within 48 h) was accomplished in 42 patients (87.5%). Appearance of the bleeding site at the time of initial endoscopy, grade of cirrhosis and location of GV were not significant predictors of immediate hemostasis. Early re-bleeding (48 h to 6 weeks) occurred in 20.5% of patients and late re-bleeding (beyond 6 weeks) in 20.5% of patients. While the Child-Pugh score was predictive of re-bleeding and mortality, the type of GV and stigmata at initial endoscopy were not significant predictors of re-bleeding and mortality. Over a mean follow-up of 18 months, mortality rates were 43.9% and bleeding was the commonest cause of death.

CONCLUSION

Endoscopic injection of n-butyl-2-cyanoacrylate is effective and safe for treating bleeding GV. Patients with poor hepatic function are at higher risk of re-bleeding and death after acute gastric variceal bleed.

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.

Prevalence of gastric varices and results of sclerotherapy with N-butyl 2 cyanoacrylate for controlling acute gastric variceal bleeding

AIM: To study the prevalence, predictors and control of bleeding following N-butyl 2 cyanoacrylate (NBC) sclerotherapy of gastric varix (GV).

METHODS: We analyzed case records of 1436 patients with portal hypertension, who underwent endoscopy during the past five years for variceal screening or upper gastrointestinal (GI) bleeding. Fifty patients with bleeding GV underwent sclerotherapy with a mean of 2 mL NBC for control of bleeding. Outcome parameters were primary hemostasis (bleeding control within the first 48 h), recurrent bleeding (after 48 h of esophago-gastro-duodenoscopy) and in-hospital mortality were analyzed.

RESULTS: The prevalence of GV in patients with portal hypertension was 15% (220/1436) and the incidence of bleeding was 22.7% (50/220). Out of the 50 bleeding GV patients, isolated gastric varices (IGV-I) were seen in 22 (44%), gastro-oesophageal varices (GOV) on lesser curvature (GOV-I) in 16 (32%), and GOV on greater curvature (GOV-II) in 15 (30%). IGV-I was seen in 44% (22/50) patients who had bleeding as compared to 23% (39/170) who did not have bleeding (P < 0.003). Primary hemostasis was achieved with NBC in all patients. Re-bleeding occurred in 7 (14%) patients after 48 h of initial sclerotherapy. Secondary hemostasis was achieved with repeat NBC sclerotherapy in 4/7 (57%). Three patients died after repeat sclerotherapy, one during transjugular intrahepatic portosystemic stem shunt (TIPSS), one during surgery and one due to uncontrolled bleeding. Treatment failure-related mortality rate was 6% (3/50).

CONCLUSION: GV can be seen in 15% of patients with portal hypertension and the incidence of bleeding is 22.7%. NBC is highly effective in controlling GV bleeding. In hospital mortality of patients with bleeding GV is 6%.

Case Report: Cystoscopic Use of Cyanoacrylate Glue for Bleeding during Transurethral Resection of Bladder Tumors

An 81-year-old woman with a history of nephroureterectomy and bladder cuff excision for grade 3 stage pT3N0M0 transitional-cell neoplasia presented with three bladder neoplasms. She also had symptomatic varicose veins in the lower extremities and received low-molecular-weight heparin. During transurethral resection of the tumors, deep ablation of the base of one lesion resulted in significant arterial bleeding that could not be controlled with normal endoscopic techniques. On the basis of previous positive experience, we endoscopically injected 3 mL of cyanoacrylate glue (Glubran 2) deeply (5 mm) into the tissue surrounding the bleeding site, making four injections with a device used for collagen injections. The area was irrigated with mannitol and sorbitol, and within a few seconds, there was complete remission of bleeding. We waited a further 90 seconds with the bladder distended to allow the substance to lose its adhesive properties so as to avoid having the bladder walls stick together. The catheter was removed on the third day, with resumption of micturition and clear urine. This appears to be the first case of cystoscopic use of cyanoacrylate glue to control bleeding.

Review article: recent advances in the management of bleeding gastric varices

Gastric variceal bleeding can be challenging to the clinician. Tissue adhesives can control acute bleeding in over 80%, with rebleeding rates of 20-30%, and should be first-line therapy where available. Endoscopic ultrasound can assist in better eradication of varices. The potential risks of damage to equipment and embolic phenomena can be minimized with careful attention to technique. Variceal band ligation is an alternative to tissue adhesives for the management of acute bleeding, but not for secondary prevention due to a higher rate of rebleeding. Endoscopic therapy with human thrombin appears promising, with initial haemostasis rates typically over 90%. The lack of controlled studies for thrombin prevents universal recommendation outside of clinical trials. Balloon occluded retrograde transvenous obliteration is a recent technique for patients with gastrorenal shunts, although its use is limited to clinical trials. Transjugular intrahepatic portosystemic stent shunt is an option for refractory bleeding and secondary prophylaxis, with uncontrolled studies demonstrating initial haemostasis obtained in over 90%, and rebleeding rates of 15-30%. Non-cardioselective beta-blockers are an alternative to transjugular intrahepatic portosystemic stent shunt for secondary prophylaxis, although the evidence is limited. Shunt surgery should be considered in well-compensated patients. Splenectomy or embolization is an option in patients with segmental portal hypertension.

A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices in humans

BACKGROUND

N-butyl cyanoacrylate injection has been shown to be effective and safe for the endoscopic treatment of gastric varices. N-butyl cyanoacrylate is not available in the United States, but use of a similar agent, 2-octyl cyanoacrylate, recently was approved for skin closure. This pilot study prospectively evaluated the efficacy and safety of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices.

METHODS

Twenty-five patients with large gastric fundal varices with either stigmata of recent hemorrhage, a history of bleeding, or high-risk varices underwent intravariceal injection of undiluted 2-octyl cyanoacrylate. The end points for this study were cessation of active bleeding, successful obliteration of visible varices, and prevention of bleeding.

RESULTS

Within 2 weeks of treatment, 52% of patients had a history of significant variceal bleeding, and 12% had active gastric variceal bleeding at the time of injection. The rate of immediate hemostasis was 100%. Gastric variceal bleeding recurred in 4% of patients (mean follow-up 11 months). The overall mortality rate was 12%; the bleeding-related mortality rate was 4%.

CONCLUSIONS

Injection of 2-octyl cyanoacrylate appears to be efficacious and safe for both prevention and control of gastric variceal hemorrhage. Larger studies are required to further establish the use of 2-octyl cyanoacrylate for treatment of gastric fundal varices.

Endoscopic therapy for upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies and remains a major cause of morbidity and mortality among patients. Although initially employed diagnostically, endoscopy has steadily replaced surgery as a first-line treatment in all but the haemodynamically unstable patient. A vast selection of techniques and devices are now available to the dedicated therapeutic endoscopist, including injection therapy, electrical or thermal coagulation and mechanical banding or clipping. The use of endoscopic ultrasound for targeting treatment is increasing and the development of new technologies, such as capsule endoscopy, is likely to play an important role in future protocols. However, despite numerous randomized controlled trials and meta-analyses comparing the efficacy of different endoscopic interventions, the implementation of obtained results into treatment regimes has so far failed to impact significantly on overall UGIB mortality, which remains stubbornly at 10-14%. Reducing this continues to be one of the main challenges facing the therapeutic endoscopist.