Cyanoacrylate glue in gastric variceal bleeding

Endoscopic devices and techniques for the management of gastric varices (with videos)

BACKGROUND AND AIMS

Gastric variceal bleeding occurs less commonly than bleeding from esophageal varices (EVs), although it is associated with higher morbidity and mortality. Bleeding from gastroesophageal varices type 1 (GOV1) is treated like EVs. In contrast, other forms of gastric variceal bleeding, including gastroesophageal varices type 2 (GOV2) and isolated gastric varices types 1 (IGV1) and 2 (IGV2), are treated with varying endoscopic approaches. Nonendoscopic methods include transjugular intrahepatic portosystemic shunt (TIPS) or balloon-occluded retrograde transvenous obliteration (BRTO). This technology report focuses on endoscopic management of gastric varices (GVs).

METHODS

The MEDLINE database was searched through August 2022 for relevant articles by using key words such as gastric varices, glue, cyanoacrylate, thrombin, sclerosing agents, band ligation, topical hemostatic spray, coils, EUS, TIPS, and BRTO. The article was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee and approved by the Governing Board of the ASGE.

RESULTS

Endoscopic injection with cyanoacrylate (CYA) glue has been the primary endoscopic method to treat GVs. EUS-guided angiotherapy with CYA glue and coil embolization has emerged as an alternative method enabling improved detection of GVs with a high technical success for targeting and obliterating GVs. Combining CYA glue with coil therapy allows the coil to act as a scaffold for the glue, reducing the risk of glue embolization and improving outcomes. Alternative injectates or topical treatments have been described but remain poorly studied.

CONCLUSIONS

The mainstay paradigm for the endoscopic management of gastric variceal bleeding is the injection of CYA glue. The published success of EUS-guided angiotherapy using CYA glue with or without embolization coils has increased our treatment armamentarium.

Glue and Ethanol Mixture for Aneurysm Endovascular Treatment: Animal Lab Study, Imaging, and Histopathological Findings

Background: This study aims to investigate the degree of penetration, permanence of occlusion, and vascular changes induced by a newly modified mixture of n-butyl cyanoacrylate (Glubran 2®), ethanol, and Lipidol® (GEL) in the endovascular treatment of experimental aneurysms induced in swine. Methods: Bilateral pouch aneurysms were created in the wall of the internal carotid artery in eighteen pigs. The sixteen aneurysms were treated with a new mixture of GEL with different component proportions. Angiograms were obtained at the time of treatment and at 1, 4, and 16 weeks after treatment. According to the scheduled experimental design, subjects were sacrificed at the time of treatment and 7, 30, and 90 days after the embolization of experimentally induced aneurysms. The internal carotid artery and aneurysms were removed en bloc and sampled for histopathologic study. Results: The mixture induced complete and stable occlusion without recanalization in all experimentally induced aneurysms throughout the study period. Histopathological studies showed focal angionecrosis and acute inflammatory reactions from 7 dpi, followed by chronic inflammation and vessel wall thickening. Conclusions: The GEL mixture may be useful in future clinical applications for the embolization of arteriovenous malformations, the control of acute bleeding, and the isolation of aneurysms due to its very short polymerization time and minimal adhesion to the microcatheter.

Impact of medical adhesives on persistent fluid extravasation at needle injection sites in patients with severe edema: a randomized controlled trial

OBJECTIVE

To investigate the efficacy of medical glue in halting fluid extravasation at needle insertion sites in patients with severe edema.

METHODS

Sixty patients with severe edema were recruited between June 2022 and June 2023 and randomly allocated into either the control group or the experimental group, with 30 cases in each. In the experimental group, after intramuscular injection, medical glue was administered at the needle insertion site, and covered with gauze dressing upon curing, and subsequently subjected to pressure bandaging. Patients were instructed to limit their activity. Meanwhile, the control group received conventional nursing procedures involving pressure bandaging and activity restriction. The effectiveness of nursing interventions in halting exudation, duration of hospitalization, duration of exudation, nursing expenses, skin complications (infection, rash, abrasion, abnormal sensation, etc.), and patient satisfaction with nursing care were monitored.

RESULTS

Comparison between the two groups revealed statistically significant differences in several aspects: the success rate of halting exudation, duration of exudation, total skin complication rate, and overall satisfaction [83.3% vs. 20.0%, (2.20 ± 2.76) days vs. (7.33 ± 3.28) days, 6.67% vs. 33.33%, 80.00% vs. 36.67%, P < 0.05]. However, there were no statistically significant differences in hospitalization time and nursing expenses [(14.50 ± 5.17) days vs. (14.00 ± 3.95) days, (537.53 ± 264.19) yuan vs. (661.97 ± 305.55) yuan, P > 0.05].

CONCLUSION

Medical glue demonstrates effectiveness in halting fluid extravasation at needle insertion sites among patients experiencing severe edema. Additionally, it reduces the duration of exudation, diminishes skin complications resulting from exudation, and significantly enhances patient satisfaction with nursing care. Given these benefits, its clinical adoption and application are highly recommended.

EUS-guided coil and glue injection versus endoscopic glue injection for gastric varices: International multicentre propensity-matched analysis

BACKGROUND

Gastric varices (GVs) are conventionally managed with endoscopic cyanoacrylate (E-CYA) glue injection. Endoscopic ultrasound (EUS)-guided therapy using combination of coils and CYA glue (EUS-CG) is a relatively recent modality. There is limited data comparing the two techniques.

METHODOLOGY

This international multicentre study included patients with GV undergoing endotherapy from two Indian and two Italian tertiary care centres. Patients undergoing EUS-CG were compared with propensity-matched E-CYA cases from a cohort of 218 patients. Procedural details such as amount of glue, number of coils used, number of sessions required for obliteration, bleeding after index procedure rates and need for re-intervention were noted.

RESULTS

Of 276 patients, 58 (male 42, 72.4%; mean age-44.3 ± 12.1 years) underwent EUS-CG and were compared with 118 propensity-matched cases of E-CYA. In the EUS-CG arm, complete obliteration at 4 weeks was noted in 54 (93.1%) cases. Compared to the E-CYA cohort, EUS-CG arm showed significantly lower number of session (1.0 vs. 1.5; p < 0.0001) requirement, lower subsequent-bleeding episodes (13.8% vs. 39.1%; p < 0.0001) and lower re-intervention (12.1% vs. 50.4%; p < 0.001) rates. On multivariable regression analysis, size of the varix (aOR-1.17; CI 1.08-1.26) and technique of therapy (aOR-14.71; CI 4.32-50.0) were significant predictors of re-bleeding. A maximum GV size >17.5 mm had a 69% predictive accuracy for need for re-intervention.

CONCLUSION

Endoscopic ultrasound-guided therapy of GV using coil and CYA glue is a safe technique with better efficacy and lower re-bleeding rates on follow-up compared to the conventional endoscopic CYA therapy.

Progress of tissue adhesives based on proteins and synthetic polymers

In recent years, polymer-based tissue adhesives (TAs) have been developed as an alternative to sutures to close and seal incisions or wounds owing to their ease of use, rapid application time, low cost, and minimal tissue damage. Although significant research is being conducted to develop new TAs with improved performances using different strategies, the applications of TAs are limited by several factors, such as weak adhesion strength and poor mechanical properties. Therefore, the next-generation advanced TAs with biomimetic and multifunctional properties should be developed. Herein, we review the requirements, adhesive performances, characteristics, adhesive mechanisms, applications, commercial products, and advantages and disadvantages of proteins- and synthetic polymer-based TAs. Furthermore, future perspectives in the field of TA-based research have been discussed.

Association of endoscopic variceal treatment with portal venous system thrombosis in liver cirrhosis: a case-control study

BACKGROUND

The association of endoscopic variceal treatment (EVT) with portal venous system thrombosis (PVST) in liver cirrhosis is still unclear.

METHODS

PVST was assessed by contrast-enhanced CT or MRI in 406 cirrhotic patients from our prospective database. Case and control groups, which are defined as patients with and without PVST, respectively, were matched at a ratio of 1:1 according to age, gender, Child-Pugh class, and MELD score. History of EVT was reviewed. Logistic regression analysis was used to identify the risk factors for PVST. Odds ratios (ORs) were calculated. Subgroup analyses were further performed in terms of degree and location of PVST.

RESULTS

Overall, 109 patients each were included in case and control groups. The case group had a significantly higher proportion of patients who had undergone EVT than the control group (53.2% versus 18.3%; p < 0.001). In detail, the case group had significantly higher proportions of patients who had undergone EVT for controlling bleeding (45.9% versus 14.7%; p < 0.001), endoscopic variceal ligation (EVL) alone (19.3% versus 9.2%; p = 0.033), and EVL combined with endoscopic cyanoacrylate glue injection (24.8% versus 5.5%; p < 0.001). EVT was independently associated with PVST (OR = 4.258; p < 0.001). In subgroup analyses, EVT remained independently associated with partial PVST (OR = 10.063; p < 0.001), complete PVST/fibrotic cord (OR = 4.889; p = 0.008), thrombosis within main portal vein (OR = 5.985; p < 0.001), and thrombosis within superior mesenteric and splenic veins (OR = 5.747; p < 0.001).

CONCLUSIONS

EVT may lead to a higher risk of PVST, especially more severe PVST, in liver cirrhosis. Screening for and prophylaxis of PVST after EVT should be further explored.

Endoscopic Detection and Management of Esophagogastric Varices

Introduction

Gastrointestinal (GI) varices are abnormally dilated submucosal veins in the digestive tract caused due to portal hypertension. Esophagus and stomach are common locations of varices induced by portal hypertension. Their presence correlates with the severity of the liver disease. Endoscopic variceal band ligation is one of the preferred methods for bleeding and nonbleeding large varices to decrease bleeding risk. Tissue adhesives such as N-butyl-2-cyanoacrylate have been used for gastric variceal obturation.

Methods

This descriptive study was conducted in the Department of Gastroenterology, National Academy of Medical Sciences, Kathmandu, Nepal, from March 2014 to January 2020. The endoscopic detection of esophageal and gastric varices was observed. Endoscopic variceal ligation (EVL) was done for esophageal varices and injection of N-butyl 2-cyanoacrylate for gastric varices.

Results

Esopahageal varices were detected in 1266 patients (8%) and gastric varices were in 36 patients (0.2%) among 15,657 patients undergoing upper gastrointestinal (UGI) endoscopy. Nine hundred seven (71.6%) were male. Large esophageal varices were endoscopically detected in 54.8% patients, small varices in 31.4% and both (large and small varices) in 13.4%. EVL was done in 30.7% and EVL with cyanoacrylate glue injection in 35 patients (2.7%).

Conclusion

Esophageal and gastric varices are seen commonly in patients with chronic liver disease. This study was conducted to describe the different types of GI varices in patients undergoing UGI endoscopy. Variceal band ligation for esophageal varices and glue injection for gastric varices are viable options of management.

Complications and management of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices

OBJECTIVE

To report the complications and evaluate the risk factors of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices in cirrhotic patients.

METHODS

A total of 583 elective endoscopic tissue adhesives procedures were performed in 439 patients in our hospital from January 2015 to December 2016. The clinical characteristics and complications were retrospectively collected and evaluated.

RESULTS

The median age was 56 ± 11 years, and 290 (66.1%) patients were male. The main etiology of liver cirrhosis was hepatitis virus (63.3%). Two hundred fifty-nine (59.0%) patients were classified as Child-Pugh Class A. Bleeding occurred in 44 patients (7.5%) during procedures. Two patients developed distant embolism (0.5%; one pulmonary, one cerebra). In perioperative period, fever was a common complication; however, only 16 cases had high fever and one case had sepsis. Bleeding was observed in 7 (1.2%) patients. Overall incidence of the major perioperative complication was 3.8%. The major postoperative complication rate was 10.4% (60/582, 26 rebleeds, 27 ascites increase, 12 new-onset portal vein thrombosis). The complication-related death was 1.6% (one death from embolism, five deaths from rebleeding, one death from refractory ascites). Injection point was the only factor related to the major perioperative complications [odds ratio (OR) = 1.581, 95% CI, 1.086-2.301; P < 0.05]. Etiology of cirrhosis and injection point were independent risk factors of major postoperative complications (OR = 1.830, 95% CI, 1.005-3.331, P = 0.048; OR = 1.373, 95% CI, 1.089-1.731, P = 0.007).

CONCLUSION

The incidence of complications after elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices was low. The injection point was the risk factor for both perioperative and postoperative complications.

Two Cases of Fungemia after Endoscopic Variceal Obturation for Gastric Variceal Bleeding

Fever is a common complication of endoscopic variceal obturation (EVO) therapy for gastric variceal bleeding. However, fungemia related to EVO therapy has not yet been reported. Herein, we report two cases of post-EVO fungemia in cirrhotic patients who underwent therapeutic EVO for gastric variceal bleeding. Both patients developed sustained high fever after repeated EVO procedures while on prophylactic antibiotic use. In both patients, blood cultures revealed yeast, and they were finally diagnosed with Candida infection. Candida is a common member of the intestinal flora; however, it can cause invasive infection with consequent poor prognosis in cirrhotic patients. The route of Candida invasion is unclear; however, repeated EVO may predispose patients to Candida infection, particularly those who are in the end stage of liver disease and receiving prophylactic antibiotics. Our cases highlight that repeated invasive procedures can increase the risk of fungal infections, and fungemia should be considered in the differential diagnosis of post-EVO fever.

Modified 'sandwich' injection with or without ligation for variceal bleeding in patients with both esophageal and gastric varices: a retrospective cohort study

OBJECTIVES

Esophagogastric variceal bleeding (EGVB) is a serious disease with high mortality. Endoscopic therapy has long been shown to be effective but the optimum technique is still unclear. We aimed to investigate the efficacy, safety and predictive factors of 1-year rebleeding of modified 'sandwich' injection combined with esophageal variceal ligation (EVL) for treating EGVB.

METHODS

A retrospective analysis was performed of 100 patients with EGVB who underwent modified 'sandwich' injection with or without EVL (EVL + and EVL - group). Patient follow-up was 1 year. Outcomes such as control of bleeding, rebleeding, complication rate and mortality were compared. Further, prognostic factors for rebleeding at one year were estimated.

RESULTS

No significant differences between two groups regarding initial bleeding control, complications, 6-week rebleeding or mortality in 1-year were observed. Rebleeding rate at 1-year of EVL - group was significantly higher than EVL + group (40 vs 20%, p = .029). Independent predictors of rebleeding at 1-year were gender, bilirubin and whether EVL was combined with injection.

CONCLUSIONS

Based on this single-center retrospective study, both of the two kinds therapies appeared to have relatively favorable outcomes. With respect to the rebleeding rate at 1-year, modified 'sandwich' injection combined with EVL may be superior to modified 'sandwich' injection alone.

Use of n-Butyl 2 Cyanoacrylate without Lipiodol, Using a Modified Protocol in Gastric Variceal Bleed Management: Retrospective Analysis of 2299 Patients

Aim To assess the feasibility and amount of cyanoacrylate glue that can be injected safely per session, complications, and long-term results in GOV1, GOV2 and IGV1 varices, using a modified method.

Method All patients from October 2008 to December 2019 presenting to us with variceal bleeding were included. We injected 0.5 mL of cyanoacrylate glue followed by 1.5 mL to 3 mL distilled water in all GOV 1, GOV 2 and IGV varices. Number of glues used were not restricted. Esophageal variceal ligation (EVL) was done for esophageal varices. Follow-up was done at 4 weeks and 3 to 6 months and analyzed.

Results 2299 patients received therapy. Male:female, 69%:31%. Causes of varices–cirrhosis (84.9%) and extrahepatic portal vein obstruction (EHPVO) (15.1%). Causes of cirrhosis–alcohol (38.4%), nonalcoholic fatty liver disease (NAFLD) (29%), hepatitis B (19.9%), hepatitis C (10.1%), Wilson’s disease (1.8%), and autoimmune diseases (0.9%). As much as 41.1% had blood in stomach and 10.2% had active spurt on index endoscopy. As much as 14.5% required endotracheal intubation (active bleed [53.1%], encephalopathy [40.5%], respiratory distress [6.6%]). As much as 30.9% had GOV1 + GOV2, 1.5% had GOV2 + IGV1, 21.3% had GOV1 + IGV1 and 16.4% had GOV1 + GOV2 + IGV1. Hemostasis could be achieved in 99.2% on index endoscopy. A total of 18 (0.8%) patients had uncontrolled bleed of whom 10 (55.6%) had hepatocellular carcinoma. Ongoing bleed was treated with transjugular intrahepatic portosystemic shunt (TIPSS) (61.1%) and endoscopic ultrasound (EUS)-guided coiling (38.8%). Amount of glue required for gastric variceal obturation was 3.6 on index endoscopy, 1.6 on follow-up at 4 to 6 weeks, and 1.2 at 3 months follow up. Glue extrusion with ulcers were seen in 6.4% at 4 to 6 weeks and 4.3% at 3 months. Rebleed occurred in 2.1% and 0.7% patients before 4 weeks and 3 months follow-up, respectively. As much as 1.3% and 1.2% patients were lost to follow-up before 4 weeks and 3 months follow-up sessions, respectively. Complications include pulmonary aspiration in 0.9% and bleeding from ulcers 2.8%. No evidence of pulmonary embolism was seen. In two endoscopic procedures, glue splashing into operator’s eyes occurred. Incidents of needle getting stuck in the varix occurred in three patients.

Conclusions Our modified protocol for glue in gastric varices is safe and feasible, as it has less rebleed, no pulmonary embolism and less ulcers with glue extrusion as compared with available literature.

Comparison of embolic agents for varices during transjugular intrahepatic portosystemic shunt for variceal bleeding: Tissue gel or coil?

Purpose

We aimed to compare treatment efficacy, safety and material cost between tissue gel and coil regarding variceal embolization during transjugular intrahepatic portosystemic shunt (TIPS).

Materials & Methods: This retrospective study including cirrhotic patients with variceal bleeding treated with TIPS combined with variceal embolization between January 2016 and August 2017. Patients were divided into three groups according to embolic agents used in variceal embolization: tissue gel group (Group A), combination group (Group B), and coil group (Group C). The primary endpoint was 1-year rebleeding rate after TIPS creation. The secondary endpoints included shunt dysfunction, overt hepatic encephalopathy, liver function, and embolic agents-related expense.

Results

A total of 60 patients (30, 10, and 20 in Group A, B, and C) were included. Variceal rebleeding occurred in 3 (10%), 0 (0%), and 4 (20%) patients within one year after TIPS creation in Group A, B, and C, respectively. Stent dysfunction occurred in 2 (3.3%) patients and 9 (15.0%) patients experienced overt hepatic encephalopathy. No significant differences were observed between three groups regarding primary and secondary endpoints except embolic agents-related expense, with a significantly lower cost in Group A when compared to the other two groups. Stent dysfunction occurred in two patients, with one patient in Group A developed acute occlusion caused by thrombus and another patient in Group C underwent stent stenosis during follow-up.

Conclusions

Compares to coil alone or combines with coil, tissue gel has similar treatment efficacy and safety, but with significantly lower cost for variceal bleeding during TIPS.

Retrospective Evaluation of the Effectiveness of a Synthetic Glue and a Fibrin-Based Sealant for the Prevention of Seroma Following Axillary Dissection in Breast Cancer Patients

Introduction: Seroma formation represents one of the most frequent postoperative complications of axillary dissection in breast cancer (BC) patients. We aimed to retrospectively explore the effectiveness of the intraoperative use of a synthetic cyanoacrylate glue (specifically Glubran®2) vs. the intraoperative use of a fibrin sealant (specifically Tisseel) in reducing seroma formation compared to the use of nonsealant in BC patients who underwent breast surgery and axillary dissection. Materials and Methods: We conducted a retrospective, monocentric observational study on BC patients who underwent axillary dissection associated with breast surgery. The axillary dissection was completed with the application of a closed suction drain and was preceded by the application of either Glubran®2 glue or Tisseel sealant or nonsealant. We analyzed the quantity of serum drained in the first 3 postoperative days, length of hospitalization, days of permanence of axillary drain, seroma development, and presence of postoperative infection signs. Results: Forty-one BC patients were considered. Based on the device used during the surgical treatment, the patients were divided into three groups: group A (17 patients), to whom suction axillary drain was applied; group B (7 patients), to whom Tisseel and axillary suction drain were applied; and group C (17 patients), to whom Glubran®2 and axillary suction drain were applied. Among the three groups, we did not find significant differences in terms of amount of serum drained in the first 3 postoperative days, length of hospitalization, and incidence of seroma. Group C maintained the axillary drain in a significantly lower number of days compared to the other two groups (p = 0.02); it also had a lower incidence of postoperative infections (6%) compared to group A (23%) and group B (57%) (p = 0.02). Conclusions: We did not find any evidence that the use of surgical glues may reduce the formation of seroma following axillary dissection in BC patients. Nevertheless, the use of cyanoacrylate glue in association with closed suction axillary drain seems to contribute to the reduction in days of axillary drain permanence and of postoperative infections, which are known factors delaying the schedule of any adjuvant oncological therapies.

The recent progress of tissue adhesives in design strategies, adhesive mechanism and applications

Tissue adhesives have emerged as an effective method for wound closure and hemostasis in recent decades, due to their ability to bond tissues together, preventing separation from one tissue to another. However, existing tissue adhesives still have several limitations. Tremendous efforts have been invested into developing new tissue adhesives by improving upon existing adhesives through different strategies. Therefore, highlighting and analyzing these design strategies are essential for developing the next generation of advanced adhesives. To this end, we reviewed the available strategies for modifying traditional adhesives (including cyanoacrylate glues, fibrin sealants and BioGlue), as well as design of emerging adhesives (including gelatin sealants, methacrylated sealants and bioinspired adhesives), focusing on their structures, adhesive mechanisms, advantages, limitations, and current applications. The bioinspired adhesives have numerous advantages over traditional adhesives, which will be a wise direction for achieving tissue adhesives with superior properties.

Comparison of cyanoacrylate and hookwire for localizing small pulmonary nodules: A propensity-matched cohort study

BACKGROUND

Localizing small pulmonary nodules (SPNs) is a challenge during thoracoscopic resection, but preoperative computed tomography (CT)-guided localization using either cyanoacrylate or hookwire can be helpful. This study compared the safety, efficiency, and operability of the two techniques.

METHODS

From September 2013 to November 2018, 269 patients (269 SPNs) who underwent preoperative CT-guided SPN localization were enrolled. A propensity-matched analysis, incorporating 13 variables, was performed to control potential selection bias.

RESULTS

All the patients were divided into two groups: CT-guided cyanoacrylate localization group (Group C, n = 149) and CT-guided hookwire localization group (Group H, n = 120). Eighty-six patients were propensity-matched in each group. All SPNs were successfully removed thoracoscopically, and no conversion was required. Localization-related complications in the two groups were similar, including intrapulmonary focal hemorrhage (p = 0.823), pneumothorax (p = 1.000), or hemoptysis (p = 0.121). For pain assessment and management, the cyanoacrylate localization saw a lower pain score (p < 0.001) and less morphine use (p < 0.001). In Group H, the localization took a significantly longer time (p < 0.001). Covering only the patients in Group C, the sub-analysis found that cyanoacrylate localization on the day before surgery did not compromise the accuracy of intraoperative targeting or increase the incidence of complications, compared with the localization on the day of surgery (all p > 0.05).

CONCLUSION

Compared to hookwire localization, CT-guided cyanoacrylate localization decreased pain and morphine use and allowed flexible surgical schedules, suggestive of its preferability for the resection of SPNs.

Selective transarterial embolization of acute renal hemorrhage: a retrospective study

Introduction: Selective transarterial embolization (STAE) is a minimally invasive treatment method developed as am alternative to surgery for acute renal haemorrhage (ARH). The aim of this study was to evaluate the efficacy and outcome of STAE in ARH patients.Material and methods: The data of patients who underwent STAE with signs of ARH were collected retrospectively. The etiology of renal haemorrhage, localization and type of lesion, embolizing agent used, the amount of contrast material given, duration of fluoroscopy and perioperative and postoperative complications were recorded. Lesions were classified as pseudoaneurysm (PA), arteriovenous fistula (AVF), arterio pelvic fistula (ACF), pathological tumoral vasculature and extravasation.Results: A total of 51 patients were included in the study. The most common symptom was gross hematuria (76.4%) and the most common underlying cause was iatrogenic renal injury (64.7%). Embolizing agents used were n-BCA-iodized oil in 29 patients, coils alone in six patients, coils + n-BCA in four patients, ethanol-iodized oil in three patients, combination of n-BCA-iodized oil and ethanol-iodized oil in two patients, polyvinyl alcohol particles in three patients and covered stent in one patient. Technical success was 100% in all patients and there was no need for reintervention.Conclusions: STAE is a safe, effective and minimally invasive method in emergency treatment of ARH.

Computed tomography-guided cyanoacrylate localization of small pulmonary nodules: feasibility and initial experience

OBJECTIVES

We report our initial technical experience with computed tomography (CT)-guided cyanoacrylate localization for resection of small pulmonary nodules (SPNs) and evaluate the feasibility of this technique.

METHODS

Between June 2016 and December 2017, the diagnostic results of 55 consecutive patients (69 SPNs) who underwent preoperative CT-guided cyanoacrylate localization and consequent video-assisted thoracoscopic surgery (VATS) resection were retrospectively evaluated. Localization-related outcomes and perioperative outcomes were assessed.

RESULTS

Preoperative CT-guided cyanoacrylate localization was successfully performed in all the cases. Simultaneous localization was achieved in 8 (14.5%) patients with 2 nodules and 3 (5.5%) patients with 3 nodules. The mean size of the nodules was 8.5 ± 3.2 mm (range 5-20 mm), and their mean depth from the nearest pleural surface was 10.9 ± 7.7 mm (range 2-36 mm). The overall mean localization procedural time was 13.7 ± 7.2 min (range 6-37 min). Two localization-related complications (intrapulmonary focal haemorrhage and pneumothorax) were observed in 7 (12.7%) and 12 (21.8%) patients, respectively. All patients with complications were asymptomatic and received conservative treatment only. All SPNs were resected under VATS without any conversion to minithoracotomy or thoracotomy.

CONCLUSIONS

CT-guided cyanoacrylate localization is a feasible procedure to localize SPNs. The advantages of this technique include flexibility between insertion and excision, the ability to be applied to the whole lung field, a high success rate, patient comfort after insertion and a fast learning curve. Further studies are warranted to confirm the efficacy of this technique.

Endoscopic management of bleeding gastrointestinal tumors

Bleeding due to primary or metastatic gastrointestinal (GI) tumors remains clinically challenging. Bleeding is further complicated in the setting of underlying friable neovascularization of tumors and coagulopathy. Endoscopic hemostatic therapeutic options have traditionally involved the use of thermal/mechanical therapy in conjunction with injection therapy. This review looks at the role of endoscopy in managing tumor-related GI bleeding, specifically contact and non-contact thermal therapy, radiofrequency ablation, endoloops, epinephrine and ethanol injection, and, most recently, Hemospray. Overall, current data show that endoscopic therapy is limited, with high rebleeding rates and a failure to improve overall outcomes. Larger clinical trials are needed to determine the efficacy of current techniques and establish therapeutic algorithms, with the goal of achieving primary hemostasis and reducing rebleeding rates.

Endoscopic management of tracheoesophageal fistulas

Tracheoesophageal fistulas (TEF) are pathologic communications between the trachea and esophagus. TEF can lead to significant respiratory distress that may result in lethal respiratory compromise, often due to recurrent and intractable infections. Through the use of endoscopy, some TEF can be successfully repaired using different approaches depending on the size, location, availability, and experience of the treating endoscopist. The aim of this manuscript is to provide an up-to-date review of the endoscopic management of TEF for gastroenterologists.

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.

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 Post-injection Audible Doppler Assessment of Gastric Varices: A Single-Institution Experience

BACKGROUND AND AIMS

Gastric varices (GV) have higher rates of morbidity and mortality from hemorrhage than esophageal varices. Several studies have shown the safety and efficacy of cyanoacrylate (CA) injection for acute gastric variceal hemorrhage. We report data from our experience with CA injection for GV before and after routine use of post-injection audible Doppler assessment (ADA) for GV obturation and describe long-term outcomes after this therapy.

METHODS

We retrospectively identified patients who had documented GV, underwent CA injection, and had at least 2 weeks of follow-up. We recorded and analyzed the survival and rebleeding rates with patient demographics, clinical data, and endoscopy findings between two groups of patients who were categorized by CA injection prior to and after inception of the ADA technique.

RESULTS

Seventy-one patients were identified with 16 patients analyzed in a group where ADA was not used (Pre-ADA) and 55 analyzed where ADA was used (Post-ADA). No rebleeding events were observed within 1 week of initial CA injection. No embolic events were reported after any initial CA injection within 4 weeks. The rate of bleed-free survival at 1 year was 69.6% in the Pre-ADA group and 85.8% in the Post-ADA without statistical significance. The all-cause 1-year mortality was 13.8% in the Pre-ADA group and 10.7% in the Post-ADA group without statistical significance.

CONCLUSIONS

ADA of CA-injected GV does not appear to significantly affect adverse events or clinical outcomes; however, our findings are limited by small sample size and cohort proportions allowing for significant type II statistical error. Further prospective investigation is required to determine the impact of ADA on clinical outcomes after GV obturation.

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.

Management of gastroesophageal varices in cirrhotic patients: current status and future directions

Bleeding from gastroesophageal varices (GEV) is a serious event in cirrhotic patients and can cause death. According to the explosion theory, progressive portal hypertension is the primary mechanism underlying variceal bleeding. There are two approaches for treating GEV: primary prophylaxis to manage bleeding or emergency treatment for bleeding followed by secondary prophylaxis. Treatment methods can be classified into two categories: 1) Those used to decrease portal pressure, such as medication (i.e., nonselective β-blockers), radiological intervention [transjugular intrahepatic portosystemic shunt (TIPS)] or a surgical approach (i.e., portacaval shunt), and 2) Those used to obstruct GEV, such as endoscopy [endoscopic variceal ligation (EVL), endoscopic injection sclerotherapy (EIS), and tissue adhesive injection] or radiological intervention [balloon-occluded retrograde transvenous obliteration (BRTO)]. Clinicians should choose a treatment method based on an understanding of its efficacy and limitations. Furthermore, elastography techniques and serum biomarkers are noninvasive methods for estimating portal pressure and may be helpful in managing GEV. The impact of these advances in cirrhosis therapy should be evaluated for their effectiveness in treating GEV.

Non-variceal upper gastrointestinal bleeding: Rescue treatment with a modified cyanoacrylate

AIM

To evaluate the safety and efficacy of a modified cyanoacrylate [N-butyl-2-cyanoacrylate associated with methacryloxysulfolane (NBCA + MS)] to treat non-variceal upper gastrointestinal bleeding (NV-UGIB).

METHODS

In our retrospective study we took into account 579 out of 1177 patients receiving endoscopic treatment for NV-UGIB admitted to our institution from 2008 to 2015; the remaining 598 patients were treated with other treatments. Initial hemostasis was not achieved in 45 of 579 patients; early rebleeding occurred in 12 of 579 patients. Thirty-three patients were treated with modified cyanoacrylate: 27 patients had duodenal, gastric or anastomotic ulcers, 3 had post-mucosectomy bleeding, 2 had Dieulafoy’s lesions, and 1 had duodenal diverticular bleeding.

RESULTS

Of the 45 patients treated endoscopically without initial hemostasis or with early rebleeding, 33 (76.7%) were treated with modified cyanoacrylate glue, 16 (37.2%) underwent surgery, and 3 (7.0%) were treated with selective transarterial embolization. The mean age of patients treated with NBCA + MS (23 males and 10 females) was 74.5 years. Modified cyanoacrylate was used in 24 patients during the first endoscopy and in 9 patients experiencing rebleeding. Overall, hemostasis was achieved in 26 of 33 patients (78.8%): 19 out of 24 (79.2%) during the first endoscopy and in 7 out of 9 (77.8%) among early rebleeders. Two patients (22.2%) not responding to cyanoacrylate treatment were treated with surgery or transarterial embolization. One patient had early rebleeding after treatment with cyanoacrylate. No late rebleeding during the follow-up or complications related to the glue injection were recorded.

CONCLUSION

Modified cyanoacrylate solved definitively NV-UGIB after failure of conventional treatment. Some reported life-threatening adverse events with other formulations, advise to use it as last option.

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.

Cyanoacrylate therapy for the treatment of gastric varices: a new method

OBJECTIVE

Cyanoacrylate (CYA) injection is recommended for bleeding gastric varices (GV) but with significant adverse effects. Transesophageal endoscopic ultrasound-guided therapy of large GV with a combined coil and CYA injection has shown promising results. However, it is expensive and requires technical expertise. In this study, we aimed to compare the safety and efficacy of a new method with UCYA [undiluated CYA (UCYA) followed by lipiodol-diluated CYA (DCYA)] in the management of large bleeding GV.

METHODS

Fifteen consecutive patients with bleeding from large GV (>1 cm) were prospectively treated with DCYA and another 15 patients treated with UCYA retrospectively. All patients in the DCYA group underwent thoracic computed tomography scan to identify glue embolism.

RESULTS

Baseline characteristics were similar between the two groups. Rates of GV obliteration and rebleeding were 100% vs 93.3% (P = 0.309) and 6.7% vs 33.3% (P = 0.06) in the DCYA and UCYA groups, respectively. One patient in the UCYA group had needle fixation which led to fatal bleeding after forceful needle extraction. In DCYA group none had glue embolism.

CONCLUSIONS

Both UCYA and DCYA are effective in treating bleeding from large GV. DCYA has lower rebleeding rates and tends to have fewer adverse events than UCYA injection, although the differences are not statistically significant. Large-sample-sized prospective randomized trials are required.

Management of gastric varices: a French national survey

BACKGROUND AND AIMS

Bleeding from gastric varices is more severe than that from esophageal varices, but its management remains debated. We aimed to determine how French hepatogastroenterologists manage cirrhotic patients with gastric varices.

METHODS

Hepatogastroenterologists (n=1163) working in general or university hospitals received a self-administered questionnaire.

RESULTS

Overall, 155 hepatogastroenterologists (13.3%) from 112 centers (33.3%; 39/40 university hospitals, 73/296 general hospitals) answered. Primary prophylaxis was used by 98.1% of hepatogastroenterologists as follows: β-blockers 96.1% (93.8 vs. 97.0%; university vs. general hospitals respectively; P=0.57), glue obliteration 16.9% (17.2 vs. 16.3%; P=0.88), and transjugular intrahepatic portosystemic shunt (TIPS) 8.0% (12.7 vs. 4.6%; P=0.12). To manage bleeding, university hospitals had greater local access to glue obliteration (95.4 vs. 68.2%; P<0.001) and TIPS (78.5 vs. 3.5%; P<0.001). Early TIPS was proposed by 53.6% (72.1 vs. 39.2%; P<0.001). Glue obliteration was performed under general anesthesia (86.1%) using Glubran (43.1%) or Histoacryl (52.9%), and lipiodol (78.8%) with varying degrees of dilution (1 : 10 to 3 : 4). The injected volume per varix varied widely (1-20 ml). Glue obliteration, band ligation, or both were used by, respectively, 64.2, 18.2, and 17.5% of practitioners. Almost all hepatogastroenterologists (98%) performed secondary prophylaxis: β-blockers 74.7% (75.0 vs. 74.4%, university vs. general hospitals; P=0.93), glue obliteration 66.0% (76.9 vs. 57.6%; P=0.013), and TIPS 30.0% (39.1 vs. 23.3%; P=0.037).

CONCLUSION

The management of gastric varices in France is heterogeneous across centers. University hospitals have better access to techniques such as glue obliteration and TIPS. As bleeding from gastric varices has a poor outcome, guidelines should be established to standardize clinical practices and design further studies.

Evaluation of three-dimensional chitosan-agarose-gelatin cryogel scaffold for the repair of subchondral cartilage defects: an in vivo study in a rabbit model

In this study, the potential of a chitosan-agarose-gelatin (CAG) cryogel scaffold for the repair of subchondral cartilage defects was explored in female New Zealand white rabbits. Custom-made CAG cryogel scaffold was implanted in a surgically created subchondral defect (diameter of 4 mm, depth of 4 mm) in knee joint of rabbit. The repair of the subchondral defect was evaluated at regular time interval by both macroscopic as well as microscopic examinations. The gross evaluation of the scaffold-implanted site showed integration of the scaffold with the surrounding tissue. Scanning electron microscopy and histological staining of the remnants of implanted cryogel scaffold showed infiltration of the host cells. The repair of the subchondral defect along with well-integrated regenerated cartilage was confirmed by the histology analysis of the joint. Results showed significant cartilage regeneration by the fourth week until eighth week after implantation. Immunohistochemical analysis confirmed that regenerated tissue is hyaline cartilage and absence of hypertrophy marker was reported. In addition, the CAG scaffolds did not elicit any adverse immunological rejection as shown by hematological analysis. Enzyme-linked immunosorbent assay did not show any statistically significant change in the concentration of tumor necrosis factor-α in the serum, and remained in a nontoxic range. Rabbits with a surgically created defect but no scaffold did not show any cartilage regeneration throughout the experiment of 8 weeks. These results demonstrate that CAG cryogel scaffolds promote repair of an osteochondral defect at a load-bearing site in rabbits.

N-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and hypertonic glucose with 72% chromated glycerin in gastric varices

AIM: To compare n-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and a mixture of 72% chromated glycerin with hypertonic glucose solution in management of gastric varices.

METHODS: Ninety patients with gastric varices presented to Endoscopy Unit of Ain Shams University Hospital were included. They were randomly allocated into three groups; each group included 30 patients treated with intravariceal sclerosant injections in biweekly sessions till complete obturation of gastric varices; Group I (n-butyl-2-cyanoacrylate; Histoacryl^®), Group II (iso-amyl-2-cyanoacrylate; Amcrylate^®) and Group III (mixture of 72% chromated glycerin; Scleremo^® with glucose solution 25%). All the procedures were performed electively without active bleeding. Recruited patients were followed up for 3 mo.

RESULTS: 26% of Scleremo group had bleeding during puncture vs 3.3% in each of the other two groups with significant difference, (P < 0.05). None of Scleremo group had needle obstruction vs 13.3% in each of the other two groups with no significant difference, (P > 0.05). Rebleeding occurred in 13.3% of Histoacryl and Amcrylate groups vs 0% in Scleremo group with no significant difference. The in hospital mortality was 6.6% in both Histoacryl and Amcrylate groups, while it was 0% in Scleremo group with no significant difference. In the first and second sessions, the amount of Scleremo needed for obturation was significantly high, while the amount of Histoacryl was significantly low. Scleremo was the less costly of the two treatments.

CONCLUSION: All used sclerosant substances showed efficacy and success in management of gastric varices with no significant differences except in total amount, cost and bleeding during puncture.

Endoscopic treatment of gastric varices

Gastric varices (GV) are present in one in 5 patients with portal hypertension and variceal bleeding. GV bleeds tend to be more severe with higher mortality. High index of suspicion, early detection and proper locational diagnosis are important. An algorithmic approach to the management of GV bleeding prevents rebleeds and improves survival. Vasoactive drugs should be started with in 30 minutes (door to needle time) and early endotherapy be done. Cyanoacrylate injection in experienced hands achieves hemostasis in >90% patients. A repeat session is sometimes needed for complete obturation of GV. Transjugular intrahepatic portosystemic shunt and balloon retrograde transvenous obliteration are effective rescue options. Secondary prophylaxis of GV bleeding is done with beta-blocker and endotherapy.

Endoscopic management of biliary leaks after laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the procedure of choice for management of symptomatic cholelithiasis. Although it has distinct advantages over open cholecystectomy, bile leak is more common. Endoscopic retrograde cholangiopancreatography is the diagnostic and therapeutic modality of choice for management of postcholecystectomy bile leaks and has a high success rate with the placement of plastic biliary stents. Repeat endoscopic retrograde cholangiopancreatography with placement of multiple plastic stents, a covered metal stent, or possibly cyanoacrylate therapy may be effective in refractory cases. This review will discuss the indications, efficacy, and complications of endoscopic therapy.

Systematic review of cyanoacrylate embolization for refractory gastrointestinal fistulae: a promising therapy

BACKGROUND

Surgical management of gastrointestinal fistulae has been reported to carry a 30-day morbidity rate up to 82% and a mortality rate ranging from 2% to 4.8%; thus nonoperative alternatives are required. The aim of the present study was to assess the current experience on the use of cyanoacrylates in the management of these fistulae.

METHODS

A systematic review was carried out on Medline, Embase, The Cochrane database, Academic Search Complete, MedicLatina, and SciELO for English, Spanish, and Portuguese articles dealing with refractory fistulae by means of cyanoacrylate embolization therapy. Publication dates were restricted from 1969 to present. Outcome parameters were study design, number of participants, etiology of the fistula, approach, material used, success rate, complications, and mortality.

RESULTS

Electronic search yielded a total of 377 articles. After a meticulous screening, only 14 studies dealing with foregut/midgut fistulae and 6 addressing hindgut fistulae were included. All the included articles were prospective and retrospective case series. Cumulative success rate was 81% (range 0% to 100%) and 3 out of 203 patients (1%) developed minor complications.

CONCLUSION

Cyanoacrylate embolization of nearly all types of refractory gastrointestinal fistulae is a feasible and harmless technique. Prospective controlled studies are required to support the available evidence.

EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos)

BACKGROUND

Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative.

OBJECTIVES

To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability.

DESIGN

Retrospective analysis of a prospectively maintained database.

SETTING

Multicenter study, tertiary referral centers.

PATIENTS AND INTERVENTIONS

Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment.

RESULTS

There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 [57.9%]; ECA, 1/11 [9.1%]; P < .01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding.

LIMITATIONS

Nonrandomized; EUS expertise necessary.

CONCLUSIONS

EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data.

[Mexican consensus on portal hypertension]

The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.

In vitro degradation and drug release of a biodegradable tissue adhesive based on functionalized 1,2-ethylene glycol bis(dilactic acid) and chitosan

Biodegradability and adhesive-associated local drug release are important aspects of research in tissue adhesive development. Therefore, this study focuses on investigating the in vitro degradation and drug release of a tissue adhesive consisting of hexamethylene diisocyanate functionalized 1,2-ethylene glycol bis(dilactic acid) and chitosan chloride. To prevent infections, ciprofloxacin hydrochloride (CPX·HCl) was incorporated into the adhesive. The influence of CPX·HCl on the adhesive reaction and adhesive strength was analyzed by FTIR-ATR-spectroscopy and tensile tests. The CPX·HCl release was investigated by HPLC. The degradation-induced changes at 37 °C were evaluated by gravimetric/morphological analyzes and micro-computer tomography. The antibiotic potential of the CPX·HCl loaded adhesive was determined by agar diffusion tests. The degradation tests revealed a mass loss of about 78 % after 52 weeks. The adhesive reaction velocity and tensile strength were not influenced by CPX·HCl. Using a 2 mg/g CPX·HCl loaded adhesive an inhibition of all tested bacteria was observed.

Balloon-assisted N-butyl-2-cyanoacrylate closure of an iatrogenic femoral arteriovenous fistula

Femoral arteriovenous fistula (AVF) is an abnormal communication between femoral artery and vein, which is frequently caused by an iatrogenic or traumatic event. Surgery and endovascular approach with coil and stent graft placement are the most frequent choices of treatment. Herein, we present 2 cases of iatrogenic superficial femoral AVF, which were treated with percutaneous balloon-assisted N-butyl-2-cyanoacrylate glue (N-BCA). Both fistulae had a short tract, and 1 of the patients had previously undergone a failed coil embolization. The occlusions with N-BCA were achieved immediately, and both fistulae remained obliterated at 1 and 12 months of follow-up.