Endoscopic ultrasound-guided coil or glue injection in post-cyanoacrylate gastric variceal re-bleed
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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.
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.
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.
EUS-guided coil application with/without cyanoacrylate injection for the obliteration of gastric varices is effective for post-cyanoacrylate gastric variceal re-bleed.
KEYWORDSEUS-guided coil application N-butyl-cyanoacrylate injection Portal hypertension Post-cyanoacrylate gastric variceal re-bleed
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.
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.
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.