Endoscopic Injection Sclerotherapy Assisted by Cyanoacrylate and Clips for Gastroesophageal Varices

[Speaker 1] In this video, we wanna introduce a new endoscopic procedure, CISC, to treat gastroesophageal varices, GEVS, in a liver cirrhosis patient, including cyanoacrylate injection, sclerotherapy, and clips. The procedure was ethically approved by the Second Affiliated Hospital of Soochow University and written informed consent was obtained from this patient. This case involved a 47-year-old male with a 20-year history of Hepatitis B and liver cirrhosis. He was transferred to the hospital for hematemesis and malaena. Liver cirrhosis, splenomegaly, ascites were confirmed by our CT scan. The endoscopy found four gastroesophageal varices, GOV1 Type 1 with red wale signs, and no active bleeding. His Child-Pugh score was seven and MELD score was 12.

[Speaker 2] Position the patient in the supine or lateral position. Ensure the patient is under general anesthesia with tracheal intubation. Firstly, use the titanium clip to block the oral side of the gastroesophageal varices to slow down or cut on the blood flow. Three or four clips were used usually. The puncture site should be chosen on the inner side or the inflow vein of the varices, which can also be called as the cardia, the fundus stomach, or the lower esophagus. Ensure that the needle is punctured into the varices vein before the sclerotherapy. Inject a mixture of lamacrego and methylene blue into the varices vein. The amount of lamacrego depends on the diameter and the length of the varices vein. Inject the cyanoacrylate through the thin needle to occlude the puncture site after the lum macro sclerotherapy. For those who completely sclerotic varices a supplementary injection should be added.

[Speaker 3] In this case, this was performed in the lower esophagus.

[Speaker 2] Interestingly, in this patient, we found that varices veins, which was suggested to be continuous under endoscope, where it is continuous actually. We can see the varices veins in the center of the screen after varices vein A has been injected successfully and turned blue. The varices vein B actually did not turn blue. Therefore we added injections to the varices vein B. Check the esophagus and stomach again endoscopically to ensure that all varices veins have turned blue, which means that the CISC has been completed successfully. After the CISC procedure, routinely treat the patient with ceftizoxime, omidazole, and esomeprazole for three days for preventing infection and re-bleeding. Have the patient start a liquid diet on postoperative day two. Discharge the patient on day four. 30 clips, 40 milliliter of and 3.5 milliliter of cyanoacrylate were used in this procedure.

[Speaker 1] Endoscopic examinations were performed three months and one year after discharge in the follow-up, which showed the varices elimination rate reached nearly 100%. There was no recurrence of bleeding and serious complications occurred before the follow-up.

[Speaker 2] This video, we showed a novel endoscopic treatment CISC for the treatment of GEVS. CISC was suggested as a potential endoscopic treatment for bleeding of gastroesophageal varices, and may be considered as an option for clinical hemostasis.