Long-term efficacy and safety of N-butylcyanoacrylate in endoscopic treatment of gastric varices
Endoscopic glue (N-butyl-2-cyanoacrylate) injection has emerged as promising therapy for bleeding gastric varices (GV). We evaluated safety and long term efficacy of this technique in patients with portal hypertension and large bleeding GV.
170 patients (mean age 40.9 +/- 14y; 132 male; 142 had cirrhosis, 40 Child A, 62 Child B, 40 Child C) underwent glue injection into GV (F3 140, F2 30; fundal 114) as emergency procedure for active bleeding in 62 and electively for prevention of rebleeding in 108. Glue was injected intra-variceally under endoscopic vision, 0.5-4 ml/aliquot, repeated at 3 weeks till varices were eradicated/solidified. The efficacy was assessed by hemostasis at 48 h, primary, secondary, definitive success and treatment failure.
The overall hemostasis rate at 48h was 82.3% (51/62). Follow up was available in 158 patients for mean of 30.7 + 17.2 months. Repeat injections were performed in 76. The mean number of injections were 1.9 +/- 1.0 (1-4); total volume was 2.5 +/- 1.7 ml/patient. The status of GVs at last follow up was: disappeared in 32 (22.6%); F1 solidified in 46 (32.3%); F2 solidified in 64 (45.0%). Bleeding recurred in 14.5% (23/158); 60% within 2 weeks of injection. The primary, secondary and definitive success rates were 85.4% (135/158), 4.4% (7/158) and 89.9% (142/158) respectively and treatment failure rate was 10% (16/158). No significant complications were noticed except for injection site ulceration in 32. Twenty patients died on follow up (9 died of uncontrolled bleeding, 11 died of liver failure).
Endoscopic glue injection into bleeding GVs was effective in achieving hemostasis in 82% with a definitive success rate of 90% and had a good safety profile on long-term follow up.
Available from: Majid A Al-madi
- "Therapeutic options are mainly dependent on the individual endoscopist and differ between institutions. Endoscopic injection of NBCA is thought to be relatively safe and is the treatment of choice for the control of active bleeding of GV and prevention of rebleeding, but its use has not been studied in a randomized clinical setting for primary prevention and therefore, is not currently recommended for primary prevention of GV bleeding. As the 1-year risk of bleeding of GV in a patient with Child C cirrhosis with red marks visualized endoscopically on a large fundal varix is estimated at 65%, treatment of GV with such high-risk features is logical. "
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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.
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.
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.
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ABSTRACT: Bleeding from gastric varices (GV) continues to pose a challenge to the endoscopist and no consensus has been reached on the best way for treating these patients. Gastric variceal obturation (GVO) with the tissue adhesive, N-2-butyl-cyanoacrylate (NBC), is considered the treatment of first-choice for this condition in most parts of the world. The liquid monomer polymerizes into a solid cast, obturating the vessel within 10–20 s of coming in contact with ionic solutions such as blood. Gastric variceal obturation achieves hemostasis in over 90% of patients with active bleeding, eradicates GV in over 80% of these patients, and re-bleeding occurs in 3–30%. These results are comparable with those of transjugular intrahepatic portosystemic shunting (TIPS; over 90% hemostasis in acute bleeding with re-bleeding in 15–30%). Though, there has been no direct comparison with GVO, balloon-occluded retrograde transvenous obliteration of GV (BRTO) achieves near 100% obliteration with recurrence in 0–10% and is superior to TIPS for hemostasis in active bleeding when used in combination with transcatheter sclerotherapy. Several complications have been described for GVO including thromboembolic complications which occur in 0.5–4.3% and may be devastating in some. Many of the complications and the variability in results of GVO can be attributed to variations in injection technique. The use of a standardized injection technique has been reported to achieve 100% hemostasis and obliteration with 6.9% re-bleeding and no embolic complications. Gastric variceal obturation with NBC continues to be the first-choice therapy for GV bleeding outside Japan. Adherence to a standard injection technique will maximize hemostasis and eradication of GV while minimizing complications of therapy.
Available from: onlinelibrary.wiley.com
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