Elsevier

Gastrointestinal Endoscopy

Volume 78, Issue 5, November 2013, Pages 711-721
Gastrointestinal Endoscopy

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

Presented at Digestive Disease Week, May 19-22, 2012, San Diego, California (Gastrointest Endosc 2012;75:AB129).
https://doi.org/10.1016/j.gie.2013.05.009Get rights and content

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.

Section snippets

Patients and methods

From February 2008 to May 2012, 30 patients with GV were enrolled in the study. Written informed consent was obtained in all cases. The study protocol was approved by the local ethics committee.

Endoscopy

Linear-array therapeutic echoendoscopes (EG 3830UT; Pentax, Hamburg, Germany or GF-UCT140-AL5; Olympus, Hamburg, Germany) with 3.8- or 3.7-mm working channels and elevator were used, attached to an US console (EUB 525 or Avius Hitachi, Tokyo, Japan or Aloka Prosound Alpha 5, Tokyo, Japan) allowing color Doppler imaging. The accessory channel of the echoendoscope was flushed with povidone-iodine (Meda Pharma, Solna, Sweden) to minimize the risk of contamination while the echoendoscope was passed

Patient characteristics and history of GV

Thirty patients (mean age, 60.1 ± 8.7 years, 22 males) were included in the study. The etiology of GV included alcoholism (n = 10), chronic hepatitis B/C infection (n = 13), liver cirrhosis of unknown etiology (n = 6), hepatocellular carcinoma (n = 3), and nonalcoholic steatohepatitis (n = 1). Patients were classified according to Child-Pugh class: A (n = 10), B (n = 13), and C (n = 7). All patient characteristics are summarized in Table 1.

Twenty-three patients (76.7%) had previously bled from

Discussion

GV hemorrhage is associated with high mortality and rebleeding rates. This is the finding of the controlled clinical trials available.14, 21, 23, 26, 27, 31 There is also some lack of understanding of the local vascular structure and hemodynamics of GV.1 According to the Sarin classification,29 gastroesophageal varices type I can be treated as esophageal varices, whereas GV type 2 (or intragastric varices type 1 (isolated gastric varices type I) should be handled specifically. Their first-line

Acknowledgment

No external funding was received to conduct the study. There was especially no support by the manufacturers of CYA or EUS-placed coils.

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    DISCLOSURE: The authors disclosed no financial relationships relevant to this publication.

    See CME section; p. 763.

    Drs Romero-Castro and Ellrichmann contributed equally to this article.

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