Endoscopic clipping prior to GVO vs. GVO in IGV1 bleeding: a multicenter retrospective clinical trial

Abstract

Background and study aims Bleeding from isolated gastric varices type I (IGV1) is more dangerous and fatal than other types of esophageal variceal hemorrhages. However, optimum treatment for bleeding from IGV1 remains undefined. This retrospective study compared the efficacy of endoscopic clipping prior to N-butyl-2-cyanoacrylate injection (GVO) and only GVO for treatment of IGV1.

Patients and methods Data were collected retrospectively at three medical centers. Ninety-six patients were enrolled between March 2015 and April 2017 and divided into two groups: group I (patients with endoscopic clipping prior to GVO, n = 46) and group II (patients with only GVO, n = 50). Computed tomography angiography (CTA) was performed to evaluate the status of gastrorenal shunts (GRS).

Results GRS was found in 59 of 66 patients (59/66). The groups did not differ in baseline characteristics. Initial hemostasis was successfully achieved in all patients. There was a significant difference in volume of N-butyl-2-cyanoacrylate administered (3.39 ± 1.20 mL in group I versus 2.53 ± 1.05 mL in group II (P = 0.03). Rebleeding occurred in 4.35% of patients in group I and 18.00 % in group II (P = 0.007). Variceal obliteration was achieved in all patients in group I and 72 % in group II (P < 0.001) with only one session. Rate of complications was similar in both the groups with the exception of one patient in group II who developed ectopic cerebral embolism.

Conclusions Endoscopic clipping prior to GVO may be an appropriate alternative to GVO as a treatment modality for IGV1 bleeding.

• References

• 1 Helmy A, Hayes PC. Review article: current endoscopic therapeutic options in the management of variceal bleeding. Aliment Pharmacol Ther 2001; 15: 575-594
• 2 Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest Endosc 1986; 32: 264-268
• 3 Sarin SK, Lahoti D, Saxena SP. et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients[J]. Hepatology 1992; 16: 1343-1349
• 4 Cheng LF, Wang ZQ, Li CZ. et al. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol 2010; 8: 760-766
• 5 Marion-Audibert AM, Wallet F, Duperret S. et al. Acute fatal pulmonary embolism during cyanoacrylate injection in gastric varices. Gastroenterol Clin Biol 2008; 32: 926-930
• 6 Hashizume M, Kitano S, Yamaga H. et al. Endoscopic classification of gastric varices. Gastrointest Endosc 1990; 36: 276-280
• 7 Hou MC, Lin HC, Kuo BI. et al. Clinical implications of the white nipple sign and its role in the diagnosis of esophageal variceal hemorrhage. Am J Gastroenterol 1996; 91: 2103-2109
• 8 Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis[J]. N Engl J Med 2010; 362: 823-832
• 9 de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal ypertension[J]. J Hepatol 2010; 53: 762-768
• 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: 1164-1172
• 11 Artifon ELA, Marson FP, Khan MA. Endoscopic ultrasonography-guided hemostasis techniques. Gastrointest Endosc Clin N Am 2017; 27: 741-747
• 12 Watanabe K, Kimura K, Matsutani S. et al. Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 1988; 95: 434-440
• 13 Matsumoto A, Hamamoto N, Nomura T. et al. Balloon-occluded retrograde transvenous obliteration of high risk gastric fundal varices. Am J Gastroenterol 1999; 94: 643-649
• 14 Zhao LQ, He W, Ji M. et al. 64-row multidetector computed tomography portal venography of gastric variceal collateral circulation. World J Gastroenterol 2010; 16: 1003-1007
• 15 Hayashi T, Yonezawa M, Kuwabara T. The study on stanch clip for the treatment by endoscopy. Gastroenterol Endosc 1975; 17: 92-101
• 16 Yol S, Belviranli M, Toprak S. et al. Endoscopic clipping versus band ligation in the management of bleeding esophageal varices. Surg Endosc 2003; 17: 38-42
• 17 Arantes V, Albuquerque W. Fundal variceal hemorrhage treated by endoscopic clip [J]. Gastrointest Endosc 2005; 61: 732
• 18 Morimoto T, Fu KI, Konuma H. et al. Endoscopic hemostasis with hemoclips for active gastric variceal bleeding[J]. Endoscopy 2010; 42: 333-334
• 19 Li HX, YE D, Kong DR. Endoscopic clipping prior to n-butyl-2-cyanoacrylate injection for gastric varices with a large gastrorenal shunt. Endoscopy 2018; 50: E102-E103
• 20 Wang YM, Cheng LF, Li N. et al. Study of glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding. World J Gastroenterol 2009; 15: 4945-4951