The fog is still not clearing!

We read with interest the article by Zhang et al. on clip-assisted endoscopic cyanoacrylate injection for gastric varices with a gastrorenal shunt [1]. The authors concluded that clip-assisted cyanoacrylate injection was convenient to perform, and safe and effective for patients with gastric varices and a gastrorenal shunt. They also stated the efficacy (100 %) of this new technique in managing acute gastrointestinal bleeding. We found this new technique interesting and would like to offer some comments.

The reported rate of hemostasis in the study was 100 %; however, only four patients experienced acute bleeding and, therefore, it is inappropriate to present the result as a percentage.

The study only included patients with large gastrorenal shunts. The reason for inclusion of this specific population while excluding other patients with gastric varices is unclear. The eradication was defined on the basis of computed tomography scan only, and a validated objective criteria used for defining this eradication is not provided. We would also like to know the number of patients who showed complete eradication of varices on repeat endoscopy.

At endoscopic follow-up, 36 patients required reintervention. Were any baseline characteristic and/or anatomic locations of the gastric varices found to predict the need for reintervention?

There were four cases of exacerbation of esophageal varices after therapy. Was the gastrorenal shunt blocked as a result of embolization in these patients? Do the authors have any pathophysiological insights into this phenomenon?

Fever and abdominal pain were reported in 33 % and 17 %, respectively, in a previous series [2], and bacteremia after glue injection has been documented in 15/47 patients with a positive blood culture [3]. It would be useful to know the exact number of patients with these adverse events in the current series.

• References

• 1 Zhang M, Li P, Mou H. et al. Clip-assisted endoscopic cyanoacrylate injection for gastric varices with a gastrorenal shunt: a multicenter study. Endoscopy 2019; DOI: 10.1055/a-0977-3022.
• 2 Choudhuri G, Chetri K, Bhat G. et al. Long-term efficacy and safety of N-butylcyanoacrylate in endoscopic treatment of gastric varices. Trop Gastroenterol 2010; 31: 155-164
• 3 Chen W-C, Hou M-C, Lin H-C. et al. Bacteremia after endoscopic injection of N-butyl-2-cyanoacrylate for gastric variceal bleeding. Gastrointest Endosc 2001; 54: 214-218