Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
권호 표지
DOI QR코드

DOI QR Code

Endoscopic ultrasound-guided coiling and glue is safe and superior to endoscopic glue injection in gastric varices with severe liver disease: a retrospective case control study

  • Kapil D. Jamwal (Department of Gastroenterology, Artemis Hospitals) ;
  • Rajesh K. Padhan (Department of Gastroenterology, Artemis Hospitals) ;
  • Atul Sharma (Department of Gastroenterology, Artemis Hospitals) ;
  • Manoj K. Sharma (Institute of Liver and Biliary Sciences)
  • Received : 2021.04.15
  • Accepted : 2021.10.04
  • Published : 2023.01.30
Download PDF
⟨ Previous Next ⟩

Abstract

Background/Aims: Gastric varices (GV) are present in 25% of cirrhotic patients with high rates of rebleeding and mortality. Data on endoscopic ultrasound (EUS)-guided treatment in severe liver disease (model for end stage liver disease sodium [MELD-Na] >18 and Child-Turcotte-Pugh [CTP] C with GV) are scarce. Thus, we performed a retrospective comparison of endoscopic glue injection with EUS-guided therapy in cirrhotic patients with large GV. Methods: A retrospective study was performed in the tertiary hospitals of India. A total of 80 patients were recruited. The inclusion criteria were gastroesophageal varices type 2, isolated gastric varices type 1, bleeding within 6 weeks, size of GV >10 mm, and a MELD-Na >18. Treatment outcomes and complications of endoscopic glue injection and EUS-guided GV therapy were compared. Results: In this study, the patients' age, sex, liver disease severity (CTP, MELD-Na) and clinical parameters were comparable. The median number of procedures, injected glue volume, complications, and GV obturation were better in the EUS group, respectively. On subgroup analysis of the EUS method (e.g., direct gastric fundus vs. paragastric collateral [PGC] coil placement), PGC coil placement showed decreased coil requirement, less injected glue volume, decreased luminal coil extrusion, and increased successful GV obturation. Conclusions: EUS-guided treatment is more efficient and safer, and requires a smaller number of treatment sessions, as compared to endoscopic treatment in severe liver disease patients with large GV. Furthermore, PGC coil placement increases the complete obliteration of GV.

Keywords

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. Kim T, Shijo H, Kokawa H, et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology 1997;25:307-312.
  3. Pereira P, Peixoto A. Left-sided portal hypertension: a clinical challenge. GE Port J Gastroenterol 2015;22:231-233.
  4. Jamwal K, Padhan RK, Sharma A. Refractory variceal bleeding: approach to management (mini review). World J Gastroenterol Hepatol Endosc 2020;3:1-3.
  5. Lahoti S, Catalano MF, Alcocer E, et al. Obliteration of esophageal varices using EUS-guided sclerotherapy with color Doppler. Gastrointest Endosc 2000;51:331-333.
  6. Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest Endosc 1986;32:264-268.
  7. Sarin SK, Kumar A. Endoscopic treatment of gastric varices. Clin Liver Dis 2014;18:809-827.
  8. Henry Z, Uppal D, Saad W, et al. Gastric and ectopic varices. Clin Liver Dis 2014;18:371-388.
  9. Weilert F, Binmoeller KF. EUS-guided vascular access and therapy. Gastrointest Endosc Clin N Am 2012;22:303-314.
  10. Saraswat VA, Verma A. Gluing gastric varices in 2012: lessons learnt over 25 years. J Clin Exp Hepatol 2012;2:55-69.
  11. 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.
  12. Mishra SR, Sharma BC, Kumar A, et al. Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection and beta-blockers: a randomized controlled trial. J Hepatol 2011;54:1161-1167.
  13. Weilert F, Binmoeller KF. New endoscopic technologies and procedural advances for endoscopic hemostasis. Clin Gastroenterol Hepatol 2016;14:1234-1244.
  14. McCarty TR, Bazarbashi AN, Hathorn KE, et al. Combination therapy versus monotherapy for EUS-guided management of gastric varices: a systematic review and meta-analysis. Endosc Ultrasound 2020;9:6-15.
  15. 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.
  16. Lobo MR de A, Chaves DM, DE Moura DTH, et al. Safety and efficacy of EUS-guided coil plus cyanoacrylate versus conventional cyanoacrylate technique in the treatment of gastric varices: a randomized controlled trial. Arq Gastroenterol 2019;56:99-105.
  17. 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.
  18. Romero-Castro R, Ellrichmann M, Ortiz-Moyano C, et al. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc 2013;78:711-721.
  19. 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.
  20. Iwase H, Suga S, Morise K, et al. Color Doppler endoscopic ultrasonography for the evaluation of gastric varices and endoscopic obliteration with cyanoacrylate glue. Gastrointest Endosc 1995;41:150-154.
  21. Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M, et al. EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases. Gastrointest Endosc 2007;66:402-407.
  22. Kakutani H, Hino S, Ikeda K, et al. Use of the curved linear-array echo endoscope to identify gastrorenal shunts in patients with gastric fundal varices. Endoscopy 2004;36:710-714.
  23. Bick BL, Al-Haddad M, Liangpunsakul S, et al. EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding. Surg Endosc 2019;33:1837-1845.
  24. Jamwal K, Sharma M, Sarin S, et al. A comparitive analysis of endoscopic management of gastric varices: is EUS guided treatment safe, more efficacious and cost effective as compared to standard treatment in advanced liver disease? J Gastroenterol Hepatol 2019;34(Suppl 3):72.
  25. Jamwal K, Sharma A, Padhan R, et al. EUS in management of gastric varices: targeting paraesophageal collateral is safe and better in severe liver disease as compared to gastric varices itself. Gastroenterology 2020;158(Suppl 1):S-1478.
  26. Fujii-Lau LL, Law R, Wong Kee Song LM, et al. Endoscopic ultrasound (EUS)-guided coil injection therapy of esophagogastric and ectopic varices. Surg Endosc 2016;30:1396-1404.
  27. Jamwal K. Gastric varices treatment: is it possible to individualise therapy for bleeding patients. World J Gastroenterol Hepatol Endosc 2021;3:1-2.