Endoscopic ultrasound-guided coil or glue injection in post-cyanoacrylate gastric variceal re-bleed

  • Roy J. Mukkada
  • Rajesh Antony
  • Mathew J. Chooracken
  • Jose V. Francis
  • Antony P. Chettupuzha
  • Pradeep G. Mathew
  • Philip Augustine
  • Abraham Koshy
Original Article
  • 22 Downloads

Abstract

Background and Aims

N-butyl-cyanoacrylate injection is recommended in bleeding/recently bled gastric varices. However, cyanoacrylate injection is associated with re-bleed in 25% to 50% of patients. Endoscopic ultrasound (EUS)-guided coil application is an emerging treatment modality for bleeding gastric varices. The aim of this study was to compare EUS-guided coil application combined with or without cyanoacrylate glue injection to injection alone in post-glue gastric variceal re-bleed.

Methods

A retrospective analysis of a prospectively maintained database was performed. Thirty patients who re-bled after cyanoacrylate injection and who had EUS-guided coil application to gastric varices were included. The comparison was done with data of 51 patients who had only repeat cyanoacrylate injection. Both groups had a follow up for 12 months. EUS-guided coil application was done under endosonographic guidance. A single coil was placed in 7, two coils in each of 13 patients, three in 5, four in 3, five in one, and 6 coils in one patient. In addition, cyanoacrylate glue injection was given in 15 patients. Eight patients had repeat EUS-guided coil application 1 month later. Re-bleed and mortality were assessed.

Results

Coilng: Six out of 30 (20%) patients re-bled during follow up of 9 to 365 days. Three out of 30 (10%) died. One patient died 9 days after the procedure due to acute respiratory distress syndrome, one died 4 months after the procedure due to a re-bleed and one 5 months after the procedure due to spontaneous bacterial peritonitis. Glue only: 26/51 (51%) re-bled during follow up of 45 to 365 days. EUS-guided coil application resulted in significantly less re-bleed than glue-only (Kaplan-Meir survival analysis with log-rank test, z = 5.4, p < 0.001). Two out of 51 (4%) died 59 and 186 days after the procedure.

Conclusion

EUS-guided coil application with/without cyanoacrylate injection for the obliteration of gastric varices is effective for post-cyanoacrylate gastric variceal re-bleed.

KEYWORDS

EUS-guided coil application N-butyl-cyanoacrylate injection Portal hypertension Post-cyanoacrylate gastric variceal re-bleed 

Notes

Acknowledgements

We are thankful to Sherrin Sajan, VPS Lakeshore Hospital, Cochin, India for drawing Fig. 1. We are grateful to Dr. Mohan A Mathew and other members of the Anesthesia Department, VPS Lakeshore Hospital, Cochin, India for giving anesthesia to the patients.

Compliance with ethical standards

Conflict of interest

RJM, RA, MJC, JVF, APC, PGM, PA, and AK declare that they have no conflict of interest.

Ethical clearance

The authors declare that the study was performed in a manner conforming to the Helsinki declaration of 1975, as revised in 2000 and 2008 concerning human and animal rights, and the authors followed the policy concerning informed consent as shown on Springer.com.

Consent

Research guidelines of the Ethical Committee, V P S Lakeshore Hospital, Kochi, India, for the protection of human subjects were followed. Consent was obtained from the patient after full explanation of the purpose, nature, and risks of all procedures used.

References

  1. 1.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–38.CrossRefPubMedGoogle Scholar
  2. 2.
    Jun CH, Kim KR, Yoon JH, et al. Clinical outcomes of gastric variceal obliteration using N-butyl-2-cyanoacrylate in patients with acute gastric variceal hemorrhage. Korean J Intern Med. 2014;29:437–44.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992;16:1343–9.CrossRefPubMedGoogle Scholar
  4. 4.
    de FR. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53:762–8.CrossRefGoogle Scholar
  5. 5.
    Mahmoudi N, Whittaker JS. Glueing of fundal varices. Can J Gastroenterol. 2006;20:691–3.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Ryan BM, Stockbrugger RW, Ryan JM. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Gastroenterology. 2004;126:1175–89.CrossRefPubMedGoogle Scholar
  7. 7.
    Binmoeller KF, Weilert F, Shah JN, Kim J. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc. 2011;74:1019–25.CrossRefPubMedGoogle Scholar
  8. 8.
    Lee YT, Chan FK, Ng EK, et al. EUS-guided injection of cyanoacrylate for bleeding gastric varices. Gastrointest Endosc. 2000;52:168–74.CrossRefPubMedGoogle Scholar
  9. 9.
    Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M, et al. EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases. Gastrointest Endosc. 2007;66:402–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Bhat YM, Weilert F, Fredrick RT, et al. 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. 2016;83:1164–72.CrossRefPubMedGoogle Scholar
  11. 11.
    Fujii-Lau LL, Law R, Wong Kee Song LM, Gostout CJ, Kamath PS, Levy MJ. Endoscopic ultrasound (EUS)-guided coil injection therapy of esophagogastric and ectopic varices. Surg Endosc. 2016;30:1396–404.CrossRefPubMedGoogle Scholar
  12. 12.
    Levi Sandri GB, Lai Q, Mennini G, Trentino P, Berloco PB, Rossi M. Massive bleeding from a gastric varix coil migration in a liver transplant patient. J Gastrointestin Liver Dis. 2013;22:249.PubMedGoogle Scholar
  13. 13.
    Bhatia V. Endoscopic ultrasound (EUS) for esophageal and gastric varices: how can it improve the outcomes and reduce complications of glue injection. J Clin Exp Hepatol. 2012;2:70–4.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Romero-Castro R, Pellicer-Bautista F, Giovannini M, et al. Endoscopic ultrasound (EUS)-guided coil embolization therapy in gastric varices. Endoscopy. 2010;42 Suppl 2:E35–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Romero-Castro R, Ellrichmann M, Ortiz-Moyano C, et al. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc. 2013;78:711–21.CrossRefPubMedGoogle Scholar

Copyright information

© Indian Society of Gastroenterology 2018

Authors and Affiliations

  1. 1.Departments of Gastroenterology and RadiologyVPS Lakeshore Hospital and Research CentreKochiIndia

Personalised recommendations