Nylon ring with titanium clip assists endoscopic cyanoacrylate injection for the treatment of GOV1-type gastric varices

There is an estimated approximately 20 % chance of having gastric varices in patients with portal hypertension [1]. Gastric varices bleed less frequently than esophageal varices but are much more severe when they do occur. Therefore, effective treatment of such bleeding or prevention of rebleeding is vital. According to the Baveno VI Consensus Symposium, endoscopic injection of cyanoacrylate is the recommended treatment for hemostasis and prevention of rebleeding from gastric varices [2] (de Franchis and Baveno 2015). However, a number of serious adverse events has been reported including ectopic embolism, especially in bleeding patients with gastric varices and gastrorenal shunts (GOV2 or IGV1 varices) [3] [4]. As an alternative to endoscopic therapy guided by endoscopic ultrasound (EUS) and balloon-occluded retrograde transvenous obliteration, we hope to provide a new simple and effective method for the treatment of GOV1 gastric varices. By using nylon rings and clips we attempted to completely block blood flow to the gastric varices before injecting cyanoacrylate into the gastric varices. This method can effectively reduce the risk of ectopic embolism in GOV1 gastric varices and reduce the dosage of cyanoacrylate.

A 45-year-old man presented to our hospital with edema, fatigue, and anemia for 1 year. Contrast-enhanced computed tomography (CT) confirmed liver cirrhosis and gastrorenal shunt, which was 18 cm in diameter. Gastroscopy (GIF-Q260J; Olympus, Tokyo, Japan) showed the isolated gastric varices type 1 [IGV1]) ([Fig. 1]). To ensure that the blood flow at the root of the gastric varices was blocked completely, a metal clip (AGS-5108–1950–135) carrying a nylon ring (HX-400u-30, Olympus) was placed on the normal mucosa around the isolated gastric varices, and the nylon ring was slowly tightened ([Fig. 2]). Endoscopic ultrasound (EUS) showed that the gastrorenal shunt was almost completely blocked. The gastric varices became smaller and gradually turned cyanotic ([Fig. 3]). The polycyanoacrylate was injected into the gastric varices using the “modified sandwich method” (4 ml lauromacrogol, 2 ml polycyanoacrylate (Compant, Beijing, China), and 3 ml lauromacrogol) [5]. EUS showed that cyanoacrylate injected adequately filled the gastric varices ([Fig. 4]). Endoscopy showed regression of the gastric fundus varices 3 months after the operation ([Fig. 5]). We thus present a new safe and effective method for the treatment of GOV1-type gastric varices ([Video 1]).

Fig. 1 Computed tomography confirmed gastrorenal shunt and gastroscopy showed the isolated gastric varices type 1 (IGV1).

Fig. 2 A metal clip carrying a nylon ring was placed on the normal mucosa around the isolated gastric varices, and the nylon ring was slowly tightened.

Fig. 3 Gastric varices became smaller and gradually turned cyanotic after tightening. Endoscopic ultrasound (EUS) showed that the gastrorenal shunt was almost completely blocked (red arrow).

Fig. 4 The polycyanoacrylate was injected into the gastric varices. EUS showed that cyanoacrylate injected adequately filled the gastric varices (red arrow).

Fig. 5 Endoscopy showed regression of gastric fundus varices 3 months after operation.

Video 1 Nylon ring with titanium clip assists endoscopic cyanoacrylate injection for the treatment of GOV1-type gastric varices.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 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. Hepatology 1992; 16: 1343-1349
• 2 de Franchis R. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
• 3 Koksal AS, Kayacetin E, Torun S. et al. Splenic infarction after N-butyl2-cyanoacrylate injection for gastric varices: why does it happen?. Surg Laparosc Endosc Percutan Tech 2013; 23: e191-e193
• 4 Upadhyay AP, Ananthasivan R, Radhakrishnan S. et al. Cortical blindness and acute myocardial infarction following injection of bleeding gastric varices with cyanoacrylate glue. Endoscopy 2005; 37: 1034
• 5 Kok K, Bond RP, Duncan IC. et al. Distal embolization and local vessel wall ulceration after gastric variceal obliteration with N-butyl-2-cyanoacrylate: a case report and review of the literature. Endoscopy 2004; 36: 442-446

Publication History

Article published online:
03 April 2023