Reply to Dr. Lo

We appreciate the comments from Dr. Lo. Uncontrolled gastric variceal hemorrhage has a 20 % mortality rate. Endoscopic cyanoacrylate injection is the standard of care; however, 35 % of patients will rebleed within 2 years, with a 6.8 % – 12.5 % bleeding-related death rate [1]. Additionally, there are nonfatal and fatal reported adverse events in up to 13 % – 20 % of patients [1].

In our study, we found that 2 /5 patients in both the endoscopic ultrasonography (EUS)-guided therapy groups died from bleeding gastric varices, with a 6.6 % rate of mortality related to gastric variceal bleeding [2]. A significant difference in terms of recurrence, rebleeding, and the need for reintervention in favor of EUS-guided combined therapy was observed. However, there was no difference in terms of overall (30 % versus 26 %) or bleeding-related mortality (17 % for both techniques). We did not record any procedure-related fatal adverse events. We agree with Dr. Lo on the importance of techniques that decrease the mortality related to bleeding gastric varices, and these should be compared in larger multicenter randomized trials.

Recently, a meta-analysis including all EUS modalities for the management of gastric varices found that these had a significantly superior obliteration rate in comparison to endoscopic glue injection (84.4 % versus 62.6 %; P = 0.002) [3]. The authors showed an inferior but non-significant difference in the rate of recurrence of gastric varices (9.1 % versus 18 %; P = 0.06); however, EUS-guided combined coil/glue injection had a significantly lower incidence of recurrence (5.2 %; P = 0.01) than other EUS-guided methods. Finally, we must consider that all techniques require skilled operators with appropriate training.

Based on the increasing amount of clinical data on EUS-guided endovascular therapy, EUS has proven superiority in the management of gastric varices, with implications for the morbidity and healthcare-related costs of patients with gastric varices [4]. Therefore, should we change the paradigm from endoscopic cyanoacrylate injection to EUS-guided endovascular therapy?

Publication History

Article published online:
28 July 2020

• References

• 1 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: 437-444
• 2 Robles-Medranda C, Oleas R, Valero M. et al. Endoscopic ultrasonography-guided deployment of embolization coils and cyanoacrylate injection in gastric varices versus coiling alone: a randomized trial. Endoscopy 2020; 52: 268-275
• 3 Mohan BP, Chandan S, Khan SR. et al. Efficacy and safety of endoscopic ultrasound-guided therapy versus direct endoscopic glue injection therapy for gastric varices: systematic review and meta-analysis. Endoscopy 2020; 52: 259-267
• 4 Robles-Medranda C, Valero M, Puga-Tejada M. et al. Mo1232 Cost-effectiveness of cyanoacrylate glue injections versus endoscopic ultrasound guided treatment in the management of gastric varices. Gastrointest Endosc 2017; 85: AB466-AB467