Endoscopic Therapy with 2-octyl-cyanoacrylate (Dermabond®) for the Treatment of Gastric Varices: Indiana University Experience

Abstract

Purpose: Endoscopic therapeutic options are limited for the management of gastric varices. Cyanoacrylate (CA) has been reportedly used for sclerotherapy in patients with variceal bleeding. This report describes a one institution experience with this intervention. Purpose of the study was to evaluate the effectiveness and safety of endoscopic therapy with cyanoacrylate in patients with gastric variceal bleeding. Methods: Observational study of patients receiving endoscopic therapy for gastric variceal hemorrhage at a tertiary center between Feburary 2006 and May 2011. Patient demographics, laboratory and procedural data were collected in a prospective fashion with IRB approval. Patients were followed to death, liver transplantation or last date of follow-up. Study outcomes were immediate control of bleeding, early rebleeding (within 1-5 days), short-term rebleeding (12 weeks), survival and serious complications. Results: A total of 26 patients including 24 cirrhotic patients undergoing 32 cyanoacrylate injections were identified, of which 77% were males with a mean age of 60. Cirrhosis was caused by Hepatitis C (HCV) ± alcohol (46%) and NASH ± HCV (32%). Mean MELD score at the time of first injection was 17 ± 8.6 and 16 patients were ineligible for TIPS or had previously failed TIPS. Median follow-up duration was 138 days [range 1-1013]. Type 1 and type 2 gastric varices were responsible for bleeding (active or recent) in 8% and 92% of patients respectively. Patients received a median of 2 injections (range 1- 4) to eradication of varices or last follow-up. Mean cyanoacrylate volume was 3.1 ± 1.6cc. Immediate hemostasis was achieved in 5 of the 6 active bleeders and 1 patient died from bleeding ulcer from previous gastric banding. Early rebleeding was seen in 1 patient (4%) and short term rebleeding was seen in 4 patients (1.6%). Four patients had minor bleeding during the procedure which was controlled with hemoclip. There were no other serious complications. Seven patients died during the long-term follow-up: metastatic cancer (2), infections (3), liver failure (1) and rebleeding (1). Conclusion: Endoscopic cyanoacrylate therapy is effective to control bleeding in patients with gastric variceal bleeding who have not undergone previous endoscopic therapy. The risk of serious complications in this study was very low. Further comparative studies involving other interventions including TIPS are warranted.