Esophageal sinus formation as a complication of cyanoacrylate injection

Cyanoacrylate glue for gastrointestinal bleeding

PURPOSE OF REVIEW

Cyanoacrylate (CYA) therapy has become an important component of the therapeutic toolbox of the interventional endoscopists with direct endoscopic injection accepted as first-line therapy of gastric varices. However, its generalized use has been cautioned by its serious adverse event profile.

RECENT FINDINGS

Endoscopic ultrasound guided therapy has several conceptual advantages over free-hand injection, particularly as it ensures intravascular delivery of therapy. This has allowed innovation with the use of vascular coils with or without CYA therapy, and very encouraging long-term results are now published showing reduced serious adverse events and low rebleeding rates.

SUMMARY

Direct endoscopic ultrasound guided intravascular injection of CYA is gaining widespread acceptance and offers reduced complication rates and significantly lower rebleeding rates. Data are supportive of CYA use both for primary and secondary prophylaxis of gastric varices.

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.

Care of the liver transplant candidate

Care of the liver transplant candidate is one of the most challenging, yet rewarding aspects of hepatology. Anticipation and intervention for the major complications of advanced liver disease increase the likelihood of survival until transplant.

[Esophageal sinus formation due to cyanoacrylate injection for esophageal variceal ligation-induced ulcer bleeding in a cirrhotic patient]

Intravariceal injection of N-butyl-2-cyanoacrylate is widely used for the hemostasis of bleeding gastric varices, but not routinely for esophageal variceal hemorrhage because of various complications such as pyrexia, bacteremia, deep ulceration, and pulmonary embolization. We report a rare case of esophageal sinus formation after cyanoacrylate obliteration therapy for uncontrolled bleeding from post-endoscopic variceal ligation (EVL) ulcer. A 50-year-old man with alcoholic liver cirrhosis presented with hematemesis. Emergent esophagogastroscopy revealed bleeding from large esophageal varices with ruptured erosion, and bleeding was initially controlled by EVL, but rebleeding from the post-EVL ulcer occurred at 17th day later. Although we tried again EVL and the injections of 5% ethanolamine oleate at paraesophageal varices, bleeding was not controlled. Therefore, we administered 1 mL cyanoacrylate diluted with lipiodol and bleeding was controlled. Three months after the endoscopic therapy, follow-up endoscopy showed medium to large-sized esophageal varices and sinus at lower esophagus. Barium esophagography revealed an outpouching in esophageal wall and endoscopic ultrasonography demonstrated an ostium with sinus. It is noteworthy that esophageal sinus can be developed as a rare late complication of endoscopic cyanoacrylate obliteration therapy.

Acrylate glue injection for acutely bleeding oesophageal varices: A prospective cohort study

BACKGROUND

Acrylate glue injection is seldom performed in patients with bleeding oesophageal varices.

AIM

To assess efficacy and safety of acrylate glue injection in patients with bleeding oesophageal varices, as well as the impact of this technique on subsequent variceal ligation.

METHODS

Prospective study on 133 consecutive cirrhotic patients treated by intravariceal injection of undiluted N-butyl-2-cyanoacrylate into the bleeding varix. Outcome measures were initial haemostasis, recurrent bleeding, complications and mortality at 6 weeks.

RESULTS

52 patients were actively bleeding at endoscopy and 81 showed stigmata of recent haemorrhage. Initial haemostasis was achieved in 49/52 active bleeders (94.2% [95% CI 85.1-98.5]). Overall, early recurrent bleeding occurred in 7 patients (5.2% [95% CI 2.3-10.1]). No major procedure-related complication was recorded. At 6 weeks, death occurred in 11 patients, with an overall bleeding-related mortality of 8.2% [95% CI 5.8-15.3]. Mortality was higher in active (15.4% [95% CI 6.9-28.1]) than non-active bleeders (3.7% [95% CI 0.8-10.4], OR 4.7 [95% CI 1.05-28.7], p=0.02). Of those surviving the first bleeding episode, 112 patients subsequently underwent ligation. No technical difficulties were encountered in performing the banding procedure which was successfully completed in all cases.

CONCLUSIONS

Emergency injection of acrylate glue is safe and effective for the treatment of acute bleeding oesophageal varices and does not hamper subsequent variceal ligation.