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EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding

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Abstract

Background

Endoscopic injection of cyanoacrylate into gastric varices may be performed by EUS-guided fine needle injection (EUS-FNI) or direct endoscopic injection (DEI). The aim of this study is to compare the rate of recurrent GV bleeding and adverse events between DEI and EUS-FNI for treatment of GV.

Methods

In a single-center study, a retrospective cohort of patients with actively/recently bleeding or high-risk GV treated with DEI were compared with a prospective cohort of similar patients treated with EUS-FNI. Repeat endoscopy after index treatment was performed 3 months later or earlier if rebleeding occurred. The main outcomes assessed were rates of GV or overall rebleeding and adverse events.

Results

Forty patients (mean age 57.2 ± 9.1 years, 73% male) and 64 patients (mean age 58.0 ± 12.5 years, 52% male) underwent DEI and EUS-FNI, respectively. Compared to the DEI group, the frequency of isolated gastric varices type 1 (IGV1) were higher (p < 0.001) but MELD scores were lower (p = 0.004) in the EUS-FNI group. At index endoscopy, EUS-FNI utilized a lower mean volume of cyanoacrylate (2.0 ± 0.8 mL vs. 3.3 ± 1.3 mL; p < 0.001) and injected a greater number of varices (1.6 ± 0.7 vs. 1.1 ± 0.4; p < 0.001) compared to DEI. Overall, GV rebleeding [5/57 (8.8%) vs. 9/38 (23.7%); p = 0.045] and non-GV-related gastrointestinal bleeding [7/64 (10.9%) vs. 11/40 (27.5%); p = 0.030] were less frequent in the EUS-FNI group compared to the DEI group, respectively. Adverse event rates were similar (20.3% vs. 17.5%, p = 0.723).

Conclusions

EUS-guided CYA injection of active or recently bleeding GV in patients with portal hypertension appears to decrease the rate of GV rebleeding despite injection of more varices and less CYA volume during the initial endoscopic procedure. Adverse events are similar between the two groups. EUS-FNI appears to be the preferred strategy for treatment of these patients.

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References

  1. Shah V, Kamath P (2016) Portal hypertension and variceal bleeding. In: Feldman M, Friedman L, Brandt L (eds) Sleisenger and Fordtran’s gastrointestinal and liver disease: pathophysiology, diagnosis and management, 10 edn. Elsevier, Philadelphia, pp 1524–1552

    Google Scholar 

  2. Kim T, Shijo H, Kokawa H, Tokumitsu H, Kubara K, Ota K, Akiyoshi N, Iida T, Yokoyama M, Okumura M (1997) Risk factors for hemorrhage from gastric fundal varices. Hepatology 25(2):307–312. https://doi.org/10.1053/jhep.1997.v25.pm0009021939

    Article  CAS  PubMed  Google Scholar 

  3. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK (1992) Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 16(6):1343–1349

    Article  CAS  Google Scholar 

  4. Weilert F, Binmoeller KF (2014) Endoscopic management of gastric variceal bleeding. Gastroenterol Clin N Am 43(4):807–818. https://doi.org/10.1016/j.gtc.2014.08.010

    Article  Google Scholar 

  5. Trudeau W, Prindiville T (1986) Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest Endosc 32(4):264–268

    Article  CAS  Google Scholar 

  6. Sarin SK (1997) Long-term follow-up of gastric variceal sclerotherapy: an eleven-year experience. Gastrointest Endosc 46(1):8–14

    Article  CAS  Google Scholar 

  7. Soehendra N, Nam VC, Grimm H, Kempeneers I (1986) Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy 18(1):25–26. https://doi.org/10.1055/s-2007-1013014

    Article  CAS  PubMed  Google Scholar 

  8. Franco MC, Gomes GF, Nakao FS, de Paulo GA, Ferrari AP Jr, Libera ED Jr (2014) Efficacy and safety of endoscopic prophylactic treatment with undiluted cyanoacrylate for gastric varices. World J Gastrointest Endosc 6(6):254–259. https://doi.org/10.4253/wjge.v6.i6.254

    Article  PubMed  PubMed Central  Google Scholar 

  9. Huang YH, Yeh HZ, Chen GH, Chang CS, Wu CY, Poon SK, Lien HC, Yang SS (2000) Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 52(2):160–167. https://doi.org/10.1067/mge.2000.104976

    Article  CAS  PubMed  Google Scholar 

  10. Kahloon A, Chalasani N, DeWitt J, Liangpunsakul S, Vinayek R, Vuppalanchi R, Ghabril M, Chiorean M (2014) Endoscopic therapy with 2-octyl-cyanoacrylate for the treatment of gastric varices. Dig Dis Sci 59(9):2178–2183. https://doi.org/10.1007/s10620-014-3148-9

    Article  CAS  PubMed  Google Scholar 

  11. Mahadeva S, Bellamy MC, Kessel D, Davies MH, Millson CE (2003) Cost-effectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue injections versus transjugular intrahepatic portosystemic shunt in the management of acute gastric variceal bleeding. Am J Gastroenterol 98(12):2688–2693. https://doi.org/10.1111/j.1572-0241.2003.08769.x

    Article  CAS  PubMed  Google Scholar 

  12. Procaccini NJ, Al-Osaimi AM, Northup P, Argo C, Caldwell SH (2009) Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: a single-center U.S. analysis. Gastrointest Endosc 70(5):881–887. https://doi.org/10.1016/j.gie.2009.03.1169

    Article  PubMed  Google Scholar 

  13. Rengstorff DS, Binmoeller KF (2004) A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices in humans. Gastrointest Endosc 59(4):553–558

    Article  Google Scholar 

  14. Seewald S, Ang TL, Imazu H, Naga M, Omar S, Groth S, Seitz U, Zhong Y, Thonke F, Soehendra N (2008) A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos). Gastrointest Endosc 68(3):447–454. https://doi.org/10.1016/j.gie.2008.02.050

    Article  PubMed  Google Scholar 

  15. Soehendra N, Grimm H, Nam VC, Berger B (1987) N-butyl-2-cyanoacrylate: a supplement to endoscopic sclerotherapy. Endoscopy 19(6):221–224. https://doi.org/10.1055/s-2007-1018288

    Article  CAS  PubMed  Google Scholar 

  16. Tan PC, Hou MC, Lin HC, Liu TT, Lee FY, Chang FY, Lee SD (2006) A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation. Hepatology 43(4):690–697. https://doi.org/10.1002/hep.21145

    Article  PubMed  Google Scholar 

  17. Berry PA, Cross TJ, Orr DW (2007) Clinical challenges and images in GI. Pulmonary embolization of histoacryl “glue” causing hypoxia and cardiovascular instability. Gastroenterology 133(5):1413. https://doi.org/10.1053/j.gastro.2007.09.051 1748.

    Article  PubMed  Google Scholar 

  18. Romero-Castro R, Ellrichmann M, Ortiz-Moyano C, Subtil-Inigo JC, Junquera-Florez F, Gornals JB, Repiso-Ortega A, Vila-Costas J, Marcos-Sanchez F, Munoz-Navas M, Romero-Gomez M, Brullet-Benedi E, Romero-Vazquez J, Caunedo-Alvarez A, Pellicer-Bautista F, Herrerias-Gutierrez JM, Fritscher-Ravens A (2013) EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc 78(5):711–721. https://doi.org/10.1016/j.gie.2013.05.009

    Article  PubMed  Google Scholar 

  19. Saracco G, Giordanino C, Roberto N, Ezio D, Luca T, Caronna S, Carucci P, De Bernardi Venon W, Barletti C, Bruno M, De Angelis C, Musso A, Repici A, Suriani R, Rizzetto M (2007) Fatal multiple systemic embolisms after injection of cyanoacrylate in bleeding gastric varices of a patient who was noncirrhotic but with idiopathic portal hypertension. Gastrointest Endosc 65(2):345–347. https://doi.org/10.1016/j.gie.2006.07.009

    Article  PubMed  Google Scholar 

  20. Wahl P, Lammer F, Conen D, Schlumpf R, Bock A (2004) Septic complications after injection of N-butyl-2-cyanoacrylate: report of two cases and review. Gastrointest Endosc 59(7):911–916

    Article  Google Scholar 

  21. Wright G, Matull WR, Zambreanu L, O’Neill S, Smith R, O’Beirne J, Morgan MY (2009) Recurrent bacteremia due to retained embolized glue following variceal obliteration. Endoscopy 41(Suppl 2):E56–E57. https://doi.org/10.1055/s-2008-1077564

    Article  PubMed  Google Scholar 

  22. Cheng PN, Sheu BS, Chen CY, Chang TT, Lin XZ (1998) Splenic infarction after histoacryl injection for bleeding gastric varices. Gastrointest Endosc 48(4):426–427

    Article  CAS  Google Scholar 

  23. Yu LK, Hsu CW, Tseng JH, Liu NJ, Sheen IS (2005) Splenic infarction complicated by splenic artery occlusion after N-butyl-2-cyanoacrylate injection for gastric varices: case report. Gastrointest Endosc 61(2):343–345

    Article  Google Scholar 

  24. Liu CH, Tsai FC, Liang PC, Lee CZ, Yang PM (2006) Splenic vein thrombosis and Klebsiella pneumoniae septicemia after endoscopic gastric variceal obturation therapy with N-butyl-2-cyanoacrylate. Gastrointest Endosc 63(2):336–338. https://doi.org/10.1016/j.gie.2005.08.025

    Article  PubMed  Google Scholar 

  25. Shim CS, Cho YD, Kim JO, Bong HK, Kim YS, Lee JS, Lee MS, Hwang SG (1996) A case of portal and splenic vein thrombosis after histoacryl injection therapy in gastric varices. Endoscopy 28(5):461. https://doi.org/10.1055/s-2007-1005514

    Article  CAS  PubMed  Google Scholar 

  26. Gubler C, Bauerfeind P (2014) Safe and successful endoscopic initial treatment and long-term eradication of gastric varices by endoscopic ultrasound-guided Histoacryl (N-butyl-2-cyanoacrylate) injection. Scand J Gastroenterol 49(9):1136–1142. https://doi.org/10.3109/00365521.2014.929171

    Article  CAS  PubMed  Google Scholar 

  27. Hikichi T, Obara K, Nakamura S, Irisawa A, Ohira H (2015) Potential application of interventional endoscopic ultrasonography for the treatment of esophageal and gastric varices. Dig Endosc 27(Suppl 1):17–22. https://doi.org/10.1111/den.12436

    Article  PubMed  Google Scholar 

  28. Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M, Marcos-Sanchez F, Caunedo-Alvarez A, Ortiz-Moyano C, Gomez-Parra M, Herrerias-Gutierrez JM (2007) EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases. Gastrointest Endosc 66(2):402–407. https://doi.org/10.1016/j.gie.2007.03.008

    Article  PubMed  Google Scholar 

  29. Storm AC, Kumbhari V, Saxena P, Canto MI, Azola A, Messallam AA, O’Broin-Lennon AM, Khashab MA (2014) EUS-guided angiotherapy. Gastrointest Endosc 80(1):164–165. https://doi.org/10.1016/j.gie.2014.04.005

    Article  PubMed  Google Scholar 

  30. Sarin SK, Kumar A (1989) Gastric varices: profile, classification, and management. Am J Gastroenterol 84(10):1244–1249

    CAS  PubMed  Google Scholar 

  31. Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, Jacobson BC, Mergener K, Nemcek A Jr, Petersen BT, Petrini JL, Pike IM, Rabeneck L, Romagnuolo J, Vargo JJ (2010) A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 71(3):446–454. https://doi.org/10.1016/j.gie.2009.10.027

    Article  PubMed  Google Scholar 

  32. Mishra SR, Chander Sharma B, Kumar A, Sarin SK (2010) Endoscopic cyanoacrylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial. Gut 59(6):729–735. https://doi.org/10.1136/gut.2009.192039

    Article  CAS  PubMed  Google Scholar 

  33. Rio Castellanos E, Seron P, Gisbert J (2015) Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD010180.pub2

    Article  Google Scholar 

  34. Levy MJ, Wong Kee Song LM, Kendrick ML, Misra S, Gostout CJ (2008) EUS-guided coil embolization for refractory ectopic variceal bleeding (with videos). Gastrointest Endosc 67(3):572–574. https://doi.org/10.1016/j.gie.2007.06.063

    Article  PubMed  Google Scholar 

  35. Romero-Castro R, Pellicer-Bautista F, Giovannini M, Marcos-Sanchez F, Caparros-Escudero C, Jimenez-Saenz M, Gomez-Parra M, Arenzana-Seisdedos A, Leria-Yebenes V, Herrerias-Gutierrez JM (2010) Endoscopic ultrasound (EUS)-guided coil embolization therapy in gastric varices. Endoscopy 42(Suppl 2):E35–E36. https://doi.org/10.1055/s-0029-1215261

    Article  PubMed  Google Scholar 

  36. Bhat YM, Weilert F, Fredrick RT, Kane SD, Shah JN, Hamerski CM, Binmoeller KF (2016) EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video). Gastrointest Endosc 83(6):1164–1172. https://doi.org/10.1016/j.gie.2015.09.040

    Article  PubMed  Google Scholar 

  37. Binmoeller KF, Weilert F, Shah JN, Kim J (2011) EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc 74(5):1019–1025. https://doi.org/10.1016/j.gie.2011.06.030

    Article  PubMed  Google Scholar 

  38. Fujii-Lau LL, Law R, Wong Kee Song LM, Gostout CJ, Kamath PS, Levy MJ (2016) Endoscopic ultrasound (EUS)-guided coil injection therapy of esophagogastric and ectopic varices. Surg Endosc 30(4):1396–1404. https://doi.org/10.1007/s00464-015-4342-3

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Gastroenterology & Hepatology, Indiana University, Indianapolis, IN, USA

    Benjamin L. Bick, Mohammad Al-Haddad, Suthat Liangpunsakul, Marwan S. Ghabril & John M. DeWitt

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Benjamin L. Bick, Mohammad Al-Haddad, Suthat Liangpunsakul, Marwan S. Ghabril, and John M. DeWitt have no conflicts of interest or financial ties to disclose.

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Bick, B.L., Al-Haddad, M., Liangpunsakul, S. et al. EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding. Surg Endosc 33, 1837–1845 (2019). https://doi.org/10.1007/s00464-018-6462-z

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