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Early and Late Results of Endoscopic Injection of N-Butil-2-Cyanoacrylate in Bleeding Gastric Varices
*W1529 Endoscopic Treatment of Bleeding Gastric Varices by Cyanoacrylate Injection at King Chulalongkorn Memorial Hospital Phadet Noophun, Pradermchai Kongkam, Rungsun Rerknimitr Introduction: This is a retrospective review of the safety and efficacy of endoscopically applied Histoacryl in the treatment of bleeding gastric varices at King Chulalongkorn Memorial Hospital. Method: From January 2000 to January 2003, EGDs were performed in 143 patients for bleeding esophagogastric varices. Twenty-four patients (15 male, 9 female) with bleeding gastric varices underwent endoscopic injection of Histoacryl for hemostasis. Histoacryl was mixed with Lipiodal in 1:1.6 ratio and injected as a bolus dose of 1-3 cc, depending on the size of the GVs. During follow-up endoscopy within 1-3 weeks, reinjection was planned if injectable GVs were still detectable. Result: The rate of immediate hemostasis at 24 hours was 95.8%(23/24). Recurrent bleeding after first 24 hours occurred in 37.5%(9/24) of the patients during the follow-up period (mean duration of follow-up time was 8.3 months, range 1-34 months). Recurrent bleeding was stopped with reinjections of Histoacryl in 12.5%(3/24) of the patients. The rate of definitive hemostasis, absence of recurrent bleeding after Histoacryl injection and during the follow-up period, was 70.8%(17 of 24). The mean number of sessions to achieve definitive treatment was 1.4. The ratio of patient who failed definite hemostasis to definite hemostasis are: hepatocellular carcinoma ( n = 6 / 7 vs n = 1 / 17 ), child C cirrhosis ( n = 5 / 7 vs n = 2 / 17 ). One of seven patients who failed to achieve definitive hemostasis was successfully treated with a TIPS procedure and the remaining 6 of 7 patients have died during follow-up period, mostly as a result of malignancy or liver failure. Two patients had systemic embolization with histoacryl injection, one patient had mesenteric ischemia and died of sepsis later, the other developed pulmonary embolism from histoacryl, fortunately he survived with conservative treatment. Conclusion: Histoacryl is highly effective for the treatment of bleeding gastric varices. The treatment failure-related mortality rate was almost a result of malignancy or underlying liver disease. Serious adverse event may appear although under experienced endoscopist.
*W1530 Early and Late Results of Endoscopic Injection of N-Butil-2-Cyanoacrylate in Bleeding Gastric Varices Petruska Marques, Fauze Maluf-Filho, Sergio Matuguma, Paulo Sakai, Shinichi Ishioka Purpose: despite the recognized efficacy of the endoscopic treatment of bleeding gastric varices by using injection of n-2-butyl-cyanoacrylate (N2BC), there is not enough data about the influence of Child-Pugh score, or type of gastric varix, or endoscopic presentation of bleeding (active vs. stigmata) on the results. Methods: from Oct/98 to Jan/02, 2759 patients were admitted for upper GI bleeding. Gastric varices were the cause of the hemorrhage in 41 (1.5%) of them (mean age= 46.1%, male:female ratio 1.3:1). Postnecrotic cirrhosis was the mean etiology of portal hypertension in 21.9% of the patients. The distribution regarding Child-Pugh classification was: 54.5% Child C, 36.3% Child B and 9.1% Child A. All the patients were treated by using an endoscopic injection of a solution of N2BC (Histoacryl - Braun-Melsungen-Germany) and lipiodol (1:1.4) into the bleeding gastric varix until hemostasis and hardening of the vessel were achieved during the procedure, to a maximum of 2.0g of N2BC. The bleeding episode was graded as clinically moderate or severe in 73.0% of the cases. The definitions of Baveno Consensus (1996) and the Sarin classification of gastric varices were adopted in this study. Results: the initial hemostasis (first 48h) rate was 85.4%. There was no difference when active bleeders were compared to patients with bleeding stigmata on the gastric varix (90.9% vs. 83.3%; P=1.00). Neither Child-Pugh score nor the type of varix (GOV 1 vs. GOV 2) have any influence on the initial hemostasis rate (P=1.00; P=0.71). Early rebleeding (48h to 6 weeks) occurred in 21.0% of the patients and late rebleeding, in 32% of them. The Child-Pugh classification was an independent predictor of late rebleeding and mortality rates. The type of the gastric varix or the endoscopic presentation of the bleeding (active vs. stigmata) were not predictors of early or late rebleeding rates. After a mean fu period of 32 months, an overall mortality rate of 46.3% was observed. In only 21.0% of them, the mortality was related to gastric variceal hemorrhage. Conclusion: Endoscopic injection of N2BC is a very effective treatment for gastric variceal bleeding. Its immediate and early results does not depend on the Child-Pugh score, type of varix and endoscopic presentation of bleeding. On the othe hand, the high rate rebleeding rate indicates the need for close follow-up with possible reinjections.
P248
GASTROINTESTINAL ENDOSCOPY
*W1531 Endoscopic Ligation of Oesophago-Gastric Varices with a New Multiple Band Ligator Paola Billi, Andrea Grilli, Costance Mwangemi, Danilo Baroncini, Carlo Fabbri, Vincenzo Cennamo, Davide Lo Cuoco, Luca De Luca, Nicola D’Imperio Endoscopic ligation of oesophageal varices is a well documented technique for haemostasis and prevention of re-bleeding, with similar results to sclerotherapy but with fewer complications. Furthermore, there is limited data concerning its use in the treatment of gastric varices. The oesophago-gastric varices, GOV 1 and 2 according to Sarins’ classification, account for more than 90% of all gastric varices. The aim of our study was to evaluate the efficacy of endoscopic ligation of oesophagal-gastric varices in retro flexion using a new multiple band ligator (Speedband Superview Super 7, Microvasive, Boston Scientific). Seven male patients (mean age 64 yrs, range 53-78) were treated electively in the Digestive Endoscopy Unit of our Department. All patients had experienced a previous episode of variceal haemorrhage due to portal hypertension (virus-related cirrhosis in 6 patients, portal vein thrombosis in 1); all patients had oesophagalgastric varices, GOV 1 in 4 and GOV 2 in 3 patients. Endoscopic variceal ligation was performed using a new multiple band ligator on the tip of a modified endoscope introduced into the stomach and then retroflexed; bands were applied circumferentially at the cardias junction in the gastric cavity in all visible varices and ligation was continued in the lower third of the oesophagus. The mean number of bands per session were 9 (range 4-14), the mean number of sessions were 2.5 (range 2-4) and the total number of bands applied per patient were 18 (range 9-36) to achieve eradication. One patient re-bled 10 days after the first session, and was treated conservatively. Our preliminary data demonstrate the technical feasibility of endoscopic elective treatment of oesophago-gastric varices using the new multiple band ligators, in retro-flexion.
*W1532 Long-Term Efficacy of Endoscopic Variceal Ligation for Esophageal Variceal Bleeding: The Presence of Portal Hypertensive Gastropathy and Total Number of EVL Sessions Were Risk Factors of Rebleeding Dong Ho Lee, NaYoung Kim, Jin Wook Kim, Jin-Hyeok Hwang, Young Bum Yoon, In Sung Song, Chung Yong Kim Background/Aims: Esophageal variceal bleeding is a catastrophic complication of portal hypertension in cirrhotic patients. Endoscopic variceal ligation(EVL) has been widely used as hemostatic treatment for acute variceal bleeding. Our aims were to evaluate the hemostatic success rate of EVL for acute bleeding, long-term result of varices during follow-up EVL sessions, rebleeding and survival rate, and risk factors for rebleeding. Methods: We performed retrospective descriptive analysis, statistical analysis for survival, rebleeding rate and risk factors for rebleeding in 223 patients. Results: Mean number of EVL sessions was 3.05. Mean number of rubber bands for each EVL session was 4.83. Hemostatic success rate for acute bleeding was 87.1%. During long-term follow-up, eradication rate of varices were 6.0%, downgrading rate of varices were 41.7%, no change of grades were observed in 42.4%, and progression of varices were observed in 9.9%. Mean number of EVL sessions required for eradication of varices were 3.8. Rebleeding rate during follow-up period was 66.3%, in average 10.9 months after EVL . 65% of these rebleeding occurred more than 3 months after EVL. Long-term survival rates after EVL were 98.1% after 12 months, 96.6% after 24 months, and 69.0% after 45 months and further. There was no statistically significant difference of survival rates among three patient groups of EVL only, EVL with terlipressin or octreotide, and EVL with propranolol. Analysis for risk factors of rebleeding revealed that presence of portal hypertensive gastropathy(p<0.05) and total number of EVL sessions(p<0.01) were related to rebleeding ; whereas, clinical status by Child-PughÕs classification, grade of esophageal varices, presence of red color signs, presence of gastric varices, number of bands were not.(p>0.05) Conclusions: Long-term follow-up evaluation revealed that stationary state of variceal grade and even progression were observed in more than 50%, and, rebleeding rate was 66.3%. The presence of portal hypertensive gastropathy and total number of EVL sessions were risk factors of rebleeding. Therefore, adequate follow-up evaluation of variceal status and additional treatment modality (sclerotherapy or pharmacologic therapy) may be required in high risk group.
VOLUME 59, NO. 5, 2004
*W1530 Early and Late Results of Endoscopic Injection of N-Butil-2-Cyanoacrylate in Bleeding Gastric Varices Petruska Marques, Fauze Maluf-Filho, Sergio Matuguma, Paulo Sakai, Shinichi Ishioka Purpose: despite the recognized efficacy of the endoscopic treatment of bleeding gastric varices by using injection of n-2-butyl-cyanoacrylate (N2BC), there is not enough data about the influence of Child-Pugh score, or type of gastric varix, or endoscopic presentation of bleeding (active vs. stigmata) on the results. Methods: from Oct/98 to Jan/02, 2759 patients were admitted for upper GI bleeding. Gastric varices were the cause of the hemorrhage in 41 (1.5%) of them (mean age= 46.1%, male:female ratio 1.3:1). Postnecrotic cirrhosis was the mean etiology of portal hypertension in 21.9% of the patients. The distribution regarding Child-Pugh classification was: 54.5% Child C, 36.3% Child B and 9.1% Child A. All the patients were treated by using an endoscopic injection of a solution of N2BC (Histoacryl - Braun-Melsungen-Germany) and lipiodol (1:1.4) into the bleeding gastric varix until hemostasis and hardening of the vessel were achieved during the procedure, to a maximum of 2.0g of N2BC. The bleeding episode was graded as clinically moderate or severe in 73.0% of the cases. The definitions of Baveno Consensus (1996) and the Sarin classification of gastric varices were adopted in this study. Results: the initial hemostasis (first 48h) rate was 85.4%. There was no difference when active bleeders were compared to patients with bleeding stigmata on the gastric varix (90.9% vs. 83.3%; P=1.00). Neither Child-Pugh score nor the type of varix (GOV 1 vs. GOV 2) have any influence on the initial hemostasis rate (P=1.00; P=0.71). Early rebleeding (48h to 6 weeks) occurred in 21.0% of the patients and late rebleeding, in 32% of them. The Child-Pugh classification was an independent predictor of late rebleeding and mortality rates. The type of the gastric varix or the endoscopic presentation of the bleeding (active vs. stigmata) were not predictors of early or late rebleeding rates. After a mean fu period of 32 months, an overall mortality rate of 46.3% was observed. In only 21.0% of them, the mortality was related to gastric variceal hemorrhage. Conclusion: Endoscopic injection of N2BC is a very effective treatment for gastric variceal bleeding. Its immediate and early results does not depend on the Child-Pugh score, type of varix and endoscopic presentation of bleeding. On the othe hand, the high rate rebleeding rate indicates the need for close follow-up with possible reinjections.
P248
GASTROINTESTINAL ENDOSCOPY
*W1531 Endoscopic Ligation of Oesophago-Gastric Varices with a New Multiple Band Ligator Paola Billi, Andrea Grilli, Costance Mwangemi, Danilo Baroncini, Carlo Fabbri, Vincenzo Cennamo, Davide Lo Cuoco, Luca De Luca, Nicola D’Imperio Endoscopic ligation of oesophageal varices is a well documented technique for haemostasis and prevention of re-bleeding, with similar results to sclerotherapy but with fewer complications. Furthermore, there is limited data concerning its use in the treatment of gastric varices. The oesophago-gastric varices, GOV 1 and 2 according to Sarins’ classification, account for more than 90% of all gastric varices. The aim of our study was to evaluate the efficacy of endoscopic ligation of oesophagal-gastric varices in retro flexion using a new multiple band ligator (Speedband Superview Super 7, Microvasive, Boston Scientific). Seven male patients (mean age 64 yrs, range 53-78) were treated electively in the Digestive Endoscopy Unit of our Department. All patients had experienced a previous episode of variceal haemorrhage due to portal hypertension (virus-related cirrhosis in 6 patients, portal vein thrombosis in 1); all patients had oesophagalgastric varices, GOV 1 in 4 and GOV 2 in 3 patients. Endoscopic variceal ligation was performed using a new multiple band ligator on the tip of a modified endoscope introduced into the stomach and then retroflexed; bands were applied circumferentially at the cardias junction in the gastric cavity in all visible varices and ligation was continued in the lower third of the oesophagus. The mean number of bands per session were 9 (range 4-14), the mean number of sessions were 2.5 (range 2-4) and the total number of bands applied per patient were 18 (range 9-36) to achieve eradication. One patient re-bled 10 days after the first session, and was treated conservatively. Our preliminary data demonstrate the technical feasibility of endoscopic elective treatment of oesophago-gastric varices using the new multiple band ligators, in retro-flexion.
*W1532 Long-Term Efficacy of Endoscopic Variceal Ligation for Esophageal Variceal Bleeding: The Presence of Portal Hypertensive Gastropathy and Total Number of EVL Sessions Were Risk Factors of Rebleeding Dong Ho Lee, NaYoung Kim, Jin Wook Kim, Jin-Hyeok Hwang, Young Bum Yoon, In Sung Song, Chung Yong Kim Background/Aims: Esophageal variceal bleeding is a catastrophic complication of portal hypertension in cirrhotic patients. Endoscopic variceal ligation(EVL) has been widely used as hemostatic treatment for acute variceal bleeding. Our aims were to evaluate the hemostatic success rate of EVL for acute bleeding, long-term result of varices during follow-up EVL sessions, rebleeding and survival rate, and risk factors for rebleeding. Methods: We performed retrospective descriptive analysis, statistical analysis for survival, rebleeding rate and risk factors for rebleeding in 223 patients. Results: Mean number of EVL sessions was 3.05. Mean number of rubber bands for each EVL session was 4.83. Hemostatic success rate for acute bleeding was 87.1%. During long-term follow-up, eradication rate of varices were 6.0%, downgrading rate of varices were 41.7%, no change of grades were observed in 42.4%, and progression of varices were observed in 9.9%. Mean number of EVL sessions required for eradication of varices were 3.8. Rebleeding rate during follow-up period was 66.3%, in average 10.9 months after EVL . 65% of these rebleeding occurred more than 3 months after EVL. Long-term survival rates after EVL were 98.1% after 12 months, 96.6% after 24 months, and 69.0% after 45 months and further. There was no statistically significant difference of survival rates among three patient groups of EVL only, EVL with terlipressin or octreotide, and EVL with propranolol. Analysis for risk factors of rebleeding revealed that presence of portal hypertensive gastropathy(p<0.05) and total number of EVL sessions(p<0.01) were related to rebleeding ; whereas, clinical status by Child-PughÕs classification, grade of esophageal varices, presence of red color signs, presence of gastric varices, number of bands were not.(p>0.05) Conclusions: Long-term follow-up evaluation revealed that stationary state of variceal grade and even progression were observed in more than 50%, and, rebleeding rate was 66.3%. The presence of portal hypertensive gastropathy and total number of EVL sessions were risk factors of rebleeding. Therefore, adequate follow-up evaluation of variceal status and additional treatment modality (sclerotherapy or pharmacologic therapy) may be required in high risk group.
VOLUME 59, NO. 5, 2004