This protocol presents the management for gastroesophageal varices (GEVs) with endoscopic injection sclerotherapy assisted by cyanoacrylate and clips (CISC), which can improve the effectiveness of sclerotherapy and reduce complications.
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Method Article
Endoscopic Injection Sclerotherapy Assisted by Cyanoacrylate and Clips for Gastroesophageal Varices
* These authors contributed equally
In This Article
Summary
Abstract
Gastroesophageal variceal bleeding (GEVB) is the most common complication of liver cirrhosis and the leading cause of death in patients with liver cirrhosis. Traditional endoscopic sclerotherapy has been widely used for the treatment of variceal bleeding. However, it still has a high rate of rebleeding and may cause esophageal ulceration, stricture, or perforation. Here we present a sclerotherapy method, endoscopic injection sclerotherapy assisted by cyanoacrylate and clips (CISC), as a feasible and safe procedure for gastroesophageal varices (GEVs). The method uses clips to block the oral side (outflow vein) of GEVs, lauromacrogol to sclerose the main body of GEVs, and cyanoacrylate to occlude the puncture site at the anal side (inflow vein) of GEVs. A case involving a 47-year-old male patient with GEVB is presented to illustrate the CISC procedure. In this case, CISC was effective for the treatment of gastroesophageal variceal bleeding. We propose that CISC may be considered as a first option for clinical endoscopic hemostasis.
Introduction
Gastroesophageal varices (GEVs) are a common but significant complication of liver cirrhosis with portal hypertension. The rupture of GEVs can lead to acute hemorrhage, which is the most common fatal complication of cirrhosis1. The most common treatment for gastroesophageal variceal bleeding (GEVB) is endoscopic hemostasis2, including endoscopic variceal ligation (EVL), endoscopic injection sclerotherapy (EIS), and endoscopic injection of n-butyl-2-cyanoacrylate.
Endoscopic injection sclerotherapy (EIS) has been used to treat GEVs since the mid-1970s. It can cause sterile inflammation of the vessels, which is effective in local obliteration and sclerosis of GEVs3. Compared to EVL, EIS has a higher risk of rebleeding and complications. A meta-analysis4, including 1236 patients with esophageal variceal bleeding, had previously shown that the rebleeding rate in the EVL group is lower than that in the EIS group (RR = 0.68, 95%CI: 0.57 ~ 0.81).The overall rebleeding rate in the EVL group was 21.7%, which was 33.1% in the EIS group (The mean follow-up period ranged from 6 to 34 months).The rate of complications (ulceration, stricture, and perforation) in the EVL group was also lower than the EIS group (RR = 0.28; 95%CI: 0.13-0.58).
In 1986, Soehendra et al. first used an endoscopic injection of n-2-butyl cyanoacrylate to treat gastric varices5. Cyanoacrylate injectionhas now been recommended as the standard treatment for Type 1 isolated gastric varices (IGV1) and Type 2 gastroesophageal varices (GOV2)6. Cyanoacrylate can rapidly polymerize when in contact with blood and immediately stop the bleeding, but can increase the risk of ectopic embolism (6 of 140 patients (4.3%))3,7,8.
The titanium clips are useful for treating nonvariceal upper gastrointestinal bleeding9, which can obstruct the vessel through a mechanical method without additional tissue damage10. Clips have also been studied and used for variceal bleeding recently, but they can only be used as a temporary hemostasis method11,12.
In the past two years, in order to increase the effectiveness of EIS, we have worked to develop a CISC method to treat GEVs. This method uses clips to block the oral side (outflow vein) of GEVs, lauromacrogol to sclerose the anastomotic branches of GEVs, and cyanoacrylate to occlude the puncture site at the anal side (inflow vein) of GEVs, which is illustrated in Figure 1. This procedure applies to patients with GEVB (active bleeding or high risk of bleeding), including esophageal varices (EV), gastroesophageal varices type 1 (GOV 1) or gastroesophageal varices type 2 (GOV 2), diagnosed by CT scan and gastroscopy. Patients with contraindications for upper gastrointestinal endoscopy, uncorrectable diffuse intravascular coagulation (DIC) or multiple organ dysfunction syndrome (MODS), or allergy to cyanoacrylate or lauromacrogol are not suitable for this procedure.
Case presentation:
A 47-year-old male with a 20-year history of hepatitis B liver cirrhosis was transferred to the Second Affiliated Hospital of Soochow University, who presented with hematemesis and melena on January 1st, 2023. CT and gastroscopy confirmed the liver cirrhosis, splenomegaly, ascites, and gastroesophageal varices (Figure 2). No evidence of portosystemic vascular shunt was observed upon CT scanning. He underwent splenic embolization in 2002 because of splenomegaly and hypersplenism. From then on, for 20 years, he was treated with antiviral therapy and propranolol. After admission, his Child-Pugh score was 7, and his MELD score was 12.
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Protocol
The procedure was ethically approved by the Second Affiliated Hospital of Soochow University, and written informed consent was obtained from this patient. The approval number is JD-LJ-2023-005-01.
1. Preoperative preparation
- Position the patient in the supine or lateral position. Ensure the patient is under general anesthesia with tracheal intubation.
2. Endoscopic procedures
- Blocking the outflow varices with clips
- Use titanium clips to block the oral side (outflow vein) of the gastroesophageal varices to slow down or cut down the blood flow. 3-4 clips were always used for this particular case.
- Sclerotherapy and cyanoacrylate injection
- Insert a 23 G needle into the varices before the sclerotherapy. The puncture site should be chosen on the anal side (inflow vein) of the varices (the cardia, the fundus of stomach or the lower esophagus).
- Inject a mixture of lauromacrogol and Methylene Blue into the vein. The amount of lauromacrogol depends on the diameter and length of the vein.
- Inject the cyanoacrylate through the same needle to occlude the puncture site after the lauromacrogol sclerotherapy.
- Inspection
- Check the esophagus and stomach again endoscopically to ensure that all varices have turned blue, which means that the CISC has been completed successfully.
- For those incompletely sclerotic varices, perform supplementary injections by following the same steps above until all the varices turn blue.
3. Postoperative care
- After the CISC procedure, treat the patient with ceftizoxime, ornidazole, and esomeprazole for three days to prevent infection and rebleeding.
- Have the patient start a liquid diet on postoperative Day 2.
- Discharge the patient on Day 4.
- Follow up with the patients by repeating gastroscopies after 3 months and 12 months post-discharge to ensure all the varices have been eliminated successfully. Incompletely sclerosed varices and recurrent varices were treated as previously.
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Results
Three clips, 40 mL of lauromacrogol, and 3.5 mL of cyanoacrylate were used in the procedure. Endoscopic examinations were performed at 3 months and 1 year follow-up after discharge, which showed smooth and flat esophageal mucosa without tortuous venous protrusions. One can safely conclude that the variceal elimination rate reached nearly 100% (Figure 3). There was no recurrence of bleeding, and no serious complications occurred during the follow-up.
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Discussion
Both EIS and endoscopic cyanoacrylate injections are safe and effective treatments for GEVB. However, there are complications such as ulceration, stricture, and distal embolism for each technique6,13. To reduce these complications and increase the success rate of hemostasis, various novel procedures have been presented. Recently, clips have been reported to be used to assist endoscopic injections to reduce the risk of distal embolism. A review of clip-assisted en...
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Disclosures
The authors have no conflicts of interest to disclose.
Acknowledgements
This study was supported by the Suzhou Municipal Health and Family Planning Commission No. GSWS2022033.
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Materials
| Name | Company | Catalog Number | Comments |
|---|---|---|---|
| EVIS LUCERA ELITE | QLYMPUS | CF-HQ290L/I | |
| Titanium clips | Micro-Tech(Nanjing)Co. Ltd. | ROCC-D-26-195 | |
| Lauromacrogol Injection | Tianyu Pharmaceutical Co. Ltd. | H20080445 | |
| Methylthioninium Chloride Injection | JUMPCAN PHARMACEUTICAL GROUP CO.LTD | H32024827 | |
| Tissue Adhesive | B. Braun Surgical S.A | 1050060 | |
| Injection Therapy Needle Catheter | Boston Scientific Corporation |
References
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