Endoscopic Injection of 2-Octyl Cyanoacrylate (DERMABOND) for the Treatment of Bleeding Gastric Varices

Abstract

Purpose: Endoscopic glue injection of N-butyl cyanoacrylate (HISTOACRYL) is effective for treating bleeding gastric varices (GV), but it is not available in the United States. A potential alternative is 2-octyl cyanoacrylate (DERMABOND), an FDA-approved agent for wound closure that shares similar properties with HISTOACRYL. The off-label usage of DERMABOND for bleeding GV has been a treatment option at our institution since 2002. The aim of this study is to describe the efficacy and safety of this technique in our patient population. Methods: A review of GV patients (pts) treated with DERMABOND was performed (01/2002–05/2005). Pts were contacted, if necessary, as part of an IRB-approved protocol and F/U was complete in all. DERMABOND was injected at a rate of 1 cc/15–20 sec until bleeding cessation and/or variceal hardening. The practice of mixing DERMABOND with LIPIODOL was abandoned early on due to the perceived increased risk of embolization from delayed polymerization of the glue. Pts were subsequently injected with undiluted DERMABOND. Results: Seventeen cirrhotic pts (5 Child's class A; 6 class B; 6 class C) with a mean age of 56 yrs (SD 13) were treated with DERMABOND. The median F/U duration was 4 mo (interquartile range 1.5–13). Active bleeding, stigmata of recent bleeding and presumed bleeding from GV were noted in 5 (29%), 8 (47%) and 4 (24%) pts, respectively. The mean volume injected was 7 cc (range 3–16) and among 1–3 sites were injected per session. Four pts required 2 sessions for complete variceal obliteration. Initial hemostasis was achieved in 15/17 pts (88%). DERMABOND injection failed in 2 pts who presented with massive GV hemorrhage, requiring placement of a Minnesota tube or TIPS as salvage therapy. Both pts died within 2 wks due to complications from bleeding and multi-organ failure. Re-bleeding occurred in one pt 3 wks after the initial treatment; this was successfully retreated. One of 3 pts treated with the DERMABOND-LIPIODOL mixture developed a non-fatal, glue-related pulmonary embolism. In pts injected with DERMABOND only, none developed complications. Bleeding-related mortality was 12% (2/17 pts) and the overall mortality was 35% at last F/U. Conclusions: Endoscopic injection with DERMABOND appears to be safe and effective in the treatment of patients with bleeding gastric varices. DERMABOND should be used without LIPIODOL to minimize the risk of embolization.