Endoscopic treatment of bleeding gastric varices with histoacryl (N-butyl-2-cyanoacrylate): a South European single center experience

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.

Safety, Efficacy, and Outcomes of N-Butyl Cyanoacrylate Glue Injection through the Endoscopic or Radiologic Route for Variceal Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

We performed a systematic review and meta-analysis of published studies to assess the efficacy, safety, and outcomes of N-butyl cyanoacrylate (NBCA) injection for the treatment of variceal gastrointestinal bleeding (GIB). The MEDLINE/PubMed, EMBASE, and SCOPUS databases were searched for English-language studies published from January 1980 to December 2019 and including patients who had injection of NBCA for variceal GIB. Two independent reviewers extracted and evaluated the data from eligible studies. Exclusion criteria were sample size < 5, article reporting the use of NBCA with other embolic agents, no extractable data, and duplicate reports. NBCA was injected during endoscopy in 42 studies and through a direct percutaneous approach for stomal varices in 1 study. The study’s endpoints were: Technical success, 30-day rebleeding, and 30-day overall and major complications. The estimated overall rates were computed with 95% confidence intervals, based on each study rate, weighted by the number of patients involved in each study. In total, 43 studies with 3484 patients were included. The technical success rate was 94.1% (95% CI: 91.6–96.1%), the 30-day rebleeding rate was 24.2% (18.9–29.9%), and 30-day overall and major complications occurred in 15.9% (11.2–21.3%) and 5.3% (3.3–7.8%) of patients, respectively. For treating variceal GIB, NBCA injection is a safe and effective method that demonstrates high technical success rate and very low major complication rate.

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.

Endoscopic tissue adhesive injection for treatment of gastric variceal bleeding

Endoscopy is an important means for the prevention and treatment of gastric variceal bleeding. With definite curative effects and mild side effects, endoscopic tissue adhesive injection has become a preferred first-line treatment for gastric variceal hemorrhage and is now widely used in clinical practice. However, it is still controversial regarding surgical technique, long-term efficacy, risk of complications, and the effect of secondary prevention of gastric variceal bleeding. This article makes a summary of the above points of dispute.

Safety and efficacy of 2-octyl-cyanoacrylate in the management of patients with gastric and duodenal varices who are not candidates for transjugular intrahepatic portosystemic shunts

Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension and cirrhosis. Options are limited for patients who are not candidates for transjugular intrahepatic portosystemic shunts (TIPS). Cyanoacrylate injections have been reported to be efficacious in previous case series. The aim of this retrospective study was to report our single-center experience with the safety and efficacy of 2-octyl-cyanoacrylate in patients who were not TIPS candidates. Electronic medical records were reviewed for 16 patients who underwent a total of 18 esophagogastroduodenoscopies for acute gastric or duodenal variceal bleeding and secondary prophylaxis of gastric varices; 14 patients had cirrhosis with an average Model for End-Stage Liver Disease score of 16, and 2 patients had noncirrhotic portal hypertension. Primary endpoints of the study included early and delayed rebleeding rate, complications, and death or liver transplantation. The rebleeding rate (early or delayed) was 7%, and no complications were found. One death was reported (unrelated to the procedure). In conclusion, 2-octyl-cyanoacrylate is a safe and effective alternative for non-TIPS candidates who present with acute gastric variceal bleeding given its low rebleeding and complication rate.

Safe and successful endoscopic initial treatment and long-term eradication of gastric varices by endoscopic ultrasound-guided Histoacryl (N-butyl-2-cyanoacrylate) injection

OBJECTIVE

Optimal endoscopic treatment of gastric varices is still not standardized nowadays. Actively bleeding varices may prohibit a successful endoscopic injection therapy of Histoacryl® (N-butyl-2-cyanoacrylate). Since 2006, we have treated gastric varices by standardized endoscopic ultrasound (EUS) guided Histoacryl injection therapy without severe adverse events.

MATERIAL AND METHODS

We present a large single-center cohort over 7 years with a standardized EUS-guided sclerotherapy of all patients with gastric varices. Application was controlled by fluoroscopy to immediately detect any glue embolization. Only perforating veins located within the gastric wall were treated. In the follow up, we repeated this treatment until varices were eradicated.

RESULTS

Utmost patients (36 of 40) were treated during or within 24 h of active bleeding. About 32.5% of patients were treated while visible bleeding. Histoacryl injection was always technically successful and only two patients suffered a minor complication. Acute bleeding was stopped in all patients. About 15% (6 of 40) of patients needed an alternative rescue treatment in the longer course. Three patients got a transjugular portosystemic shunt and another three underwent an orthotopic liver transplantation. Mean long-term survival of 60 months was excellent.

CONCLUSION

Active bleeding of gastric varices can be treated successfully without the necessity of gastric rinsing with EUS-guided injection of Histoacryl.

Clinical outcomes of gastric variceal obliteration using N-butyl-2-cyanoacrylate in patients with acute gastric variceal hemorrhage

BACKGROUND/AIMS

To evaluate the long-term efficacy and safety of endoscopic injection of N-butyl-2-cyanoacrylate (NBC; Histoacryl) for treatment of bleeding gastric varices.

METHODS

We retrospectively analyzed the records of 455 patients with gastric variceal hemorrhage (GVH) who were consecutively treated with NBC from January 2004 to July 2013, with a mean follow-up period of 582 days. The patients' endoscopic findings, initial hemostasis, complications, rebleeding rates, and bleeding-related death rates were reviewed.

RESULTS

Hemostasis was achieved initially in 96.9% (441/455) of patients; rebleeding occurred in 35.2% (160/455), and the bleeding-related death rate was 6.8% (31/455) during follow-up. Complications included fever (6.8%), abdominal pain (3.7%), diarrhea (1.3%), spontaneous bacterial peritonitis (0.7%), bacteremia (0.4%), and embolism (0.2%). A red-color sign on concomitant esophageal varices (EVs) (p = 0.002) and previous history of variceal bleeding (p < 0.001) were significant risk factors for rebleeding within 1 year. The Child-Pugh score (p < 0.001), presence of hepatocellular carcinoma (p = 0.001), and failure of initial hemostasis (p < 0.001) were the risk factors most closely associated with bleeding-related death.

CONCLUSIONS

This study provides a comprehensive overview of the outcomes and prognostic factors of patients with GVH. The results may help in the selection of effective treatment strategies for patients with GVH.

Clinical outcomes of gastric variceal obliteration using N-butyl-2-cyanoacrylate in patients with acute gastric variceal hemorrhage

BACKGROUND/AIMS

To evaluate the long-term efficacy and safety of endoscopic injection of N-butyl-2-cyanoacrylate (NBC; Histoacryl) for treatment of bleeding gastric varices.

METHODS

We retrospectively analyzed the records of 455 patients with gastric variceal hemorrhage (GVH) who were consecutively treated with NBC from January 2004 to July 2013, with a mean follow-up period of 582 days. The patients' endoscopic findings, initial hemostasis, complications, rebleeding rates, and bleeding-related death rates were reviewed.

RESULTS

Hemostasis was achieved initially in 96.9% (441/455) of patients; rebleeding occurred in 35.2% (160/455), and the bleeding-related death rate was 6.8% (31/455) during follow-up. Complications included fever (6.8%), abdominal pain (3.7%), diarrhea (1.3%), spontaneous bacterial peritonitis (0.7%), bacteremia (0.4%), and embolism (0.2%). A red-color sign on concomitant esophageal varices (EVs) (p = 0.002) and previous history of variceal bleeding (p < 0.001) were significant risk factors for rebleeding within 1 year. The Child-Pugh score (p < 0.001), presence of hepatocellular carcinoma (p = 0.001), and failure of initial hemostasis (p < 0.001) were the risk factors most closely associated with bleeding-related death.

CONCLUSIONS

This study provides a comprehensive overview of the outcomes and prognostic factors of patients with GVH. The results may help in the selection of effective treatment strategies for patients with GVH.

Management of gastric varices

According to their location, gastric varices (GV) are classified as gastroesophageal varices and isolated gastric varices. This review will mainly focus on those GV located in the fundus of the stomach (isolated gastric varices 1 and gastroesophageal varices 2). The 1-year risk of GV bleeding has been reported to be around 10%-16%. Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. Limited data suggest that tissue adhesives, mainly cyanoacrylate (CA), may be effective and better than propranolol in preventing bleeding from GV. General management of acute GV bleeding must be similar to that of esophageal variceal bleeding, including prophylactic antibiotics, a careful replacement of volemia, and early administration of vasoactive drugs. Small sample-sized randomized controlled trials have shown that tissue adhesives are the therapy of choice for acute GV bleeding. In treatment failures, transjugular intrahepatic portosystemic shunt (TIPS) is considered the treatment of choice. After initial hemostasis, repeated sessions with CA injections along with nonselective beta-blockers are recommended as secondary prophylaxis; whether CA is superior to TIPS in this scenario is not completely clear. Balloon-occluded retrograde transvenous obliteration (BRTO) has been introduced as a new method to treat GV. BRTO is also effective and has the potential benefit of increasing portal hepatic blood flow and therefore may be an alternative for patients who may not tolerate TIPS. However, BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension and its related complications. The role of BRTO in the management of acute GV bleeding is promising but merits further evaluation.

A new hemostatic clip for endoscopic surgery that can maintain blood flow after clipping

AIM: To develop a new hemostatic device for endoscopic surgery that can control the bleeding without completely occluding the bleeding vessel.

METHODS: A hemostatic clip and its applier that can stanch bleeding while maintaining blood flow through the clipped vessel was introduced, and the performance of the proposed clip was evaluated using in vitro and in vivo experiments.

RESULTS: During in vitro experiments, no leakage was found after clipping at cuts made in artificial vessels, and flow was maintained through the clipped artificial vessels. In experiments on rats, all the implanted clips occluded the target vessels successfully, and no bleeding or tissue damage was observed at the operative site after the rats were euthanized on postoperative day 7. In experiments on pigs, bleeding stopped immediately after partial clipping of a damaged vessel, and some amount of blood flow was consistently maintained through the clipped vessel after hemostasis.

CONCLUSION: We believe that the proposed hemostatic clip and clip applier can enhance patient safety during laparoscopic surgery.

The safety and efficacy of gastric fundal variceal obliteration using N-butyl-2-cyanoacrylate; the experience of a single canadian tertiary care centre

BACKGROUND/AIM

Bleeding from Gastric Varices (GV) is not only life threatening, but also leads to many hospitalizations, contributes to morbidity and is resource intensive. GV are difficult to diagnose and their treatment can be challenging due to their location and complex structure. To assess the safety and efficacy of endoscopic gastric fundal variceal gluing using periodic endoscopic injections of N-butyl-2-cyanoacylate (NBCA) and to assess the utility of endoscopic ultrasound (EUS) in assessing for the eradication of GV post-NBCA treatment.

MATERIALS AND METHODS

Analysis of prospectively collected data of a cohort of patients with GV who underwent periodic endoscopic variceal gluing from 2005 to 2011. Outcomes included success of GV obliteration, incidence of rebleeding, complications from the procedure, and analysis of factors that might predict GV rebleeding. The success of GV eradication was assessed by both EUS and direct endoscopy.

RESULTS

The cohort consisted of 29 consecutive patients that had undergone NBCA injection for GV. The mean age was 60.8 years standard deviations (SD 13.3, range 20-81). The average follow-up was 28 months (SD 19.61, range 1-64) and the most common cause for GV was alcoholic liver cirrhosis (34.48%). A total of 91 sessions of NBCA injections were carried out for 29 patients (average of 3.14 sessions/patient, SD 1.79, range 1-8) with a total of 124 injections applied (average of 4.28 injections/patient, SD 3.09, range 1-13). 24 patients were treated for previously documented GV bleeding while five were treated for primary prevention. Overall, 79% of patients were free of rebleeding once three sessions of histoacryl ® injection were completed. None of the patients treated for primary prevention developed bleeding during follow-up. 11 of the 24 patients (46%) with previous bleeding however had rebleeding. 4/11 (36%) patients had GV rebleeding while awaiting scheduled additional NBCA sessions. 19/29 (60%) patients had complete eradication of GV, 11/19 (58%) documented by endoscopic assessment alone, 4/19 (21%) by EUS alone and 4/19 (21%) by both techniques. Two of the 11 (18%) patients that had rebleeding had recurrence of GV bleeding after documented eradication by EUS compared to 5/11 (45%) patients documented eradication by endoscopic assessment and 2/11 (18%) patients that had rebleeding after documented eradication by both modalities. Twenty five patients in total had documented residual GV by EUS (14, 56%), direct endoscopic assessment (18, 72%) or both modalities (9, 36%), two of which developed recurrent bleeding (13%). No immediate or long-term complications of NBCA injection occurred, nor any related endoscopic complications were reported in any of these cases during the time of follow-up.

CONCLUSION

NBCA injection of GV is a safe and successful therapeutic intervention. A minimum of three endoscopic sessions is required to significantly decrease the risk of bleeding/rebleeding. In this small sample of patients, neither EUS nor direct endoscopic assessment was reliable in predicting the recurrence of GV bleeding.