Re: Transportal Intravariceal Sclerotherapy with N-butyl-2-Cyanoacrylate for Gastric Varices

Abstract

EditorWe read with great interest the article by Kiyosue et al (1Kiyosue H Matsumoto S Yamada Y et al.Transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate for gastric varices.J Vasc Interv Radiol. 2004; 15: 505-509Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar) about the efficacy and safety of transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate for the treatment of gastric varices. Because the precise diagnosis of bleeding from gastric varices is made by endoscopic observation, initial hemostasis should be achieved endoscopically. How did the authors achieve hemostasis? Because the mortality from gastric variceal bleeding is high, prophylactic treatment of high-risk varices may be justifiable (2Matsumoto A Yamauchi H Inokuchi H Balloon occluded transvenous obliteration: a feasible alterative to transjugular intrahepatic portosystemic stent shunt.Gut. 2003; 52: 611-612Crossref PubMed Google Scholar). How did the authors determine what constituted high-risk varices? The most widely used classification of gastric varices is that proposed by Sarin and Kumar (3Sarin SK Kumar A Gastric varices: profile, classification, and management.Am J Gastroenterol. 1989; 84: 1244-1249PubMed Google Scholar). According to this classification (3Sarin SK Kumar A Gastric varices: profile, classification, and management.Am J Gastroenterol. 1989; 84: 1244-1249PubMed Google Scholar), the authors treated two cases of GOV1 (extension of esophageal varices along the lesser curvature; patients 1 and 2), one of GOV2 (extension of esophageal varices toward the fundus; patient 3), and one of IGV1 (varices in the fundus; patient 4). Transjugular intrahepatic portosystemic stent creation alone often fails to prevent recurrent bleeding in patients with fundal varices with a portal pressure gradient of 12 mm Hg or lower (4Rinella ME Shah MD Vogelzang RL Blei AT Flamm SL Fundal variceal bleeding after correction of portal hypertension in patients with cirrhosis.Gastrointest Endosc. 2003; 58: 122-127PubMed Google Scholar, 5Ryan BM Stockbrugger RW Ryan JM A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.Gastroenterology. 2004; 126: 1175-1189Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar). Transportal intravariceal sclerotherapy seems to be too invasive for general use. GOV1 cases with concomitant esophageal varices may be treated by endoscopic sclerotherapy with use of a popular sclerosant such as ethanolamine oleate (4Rinella ME Shah MD Vogelzang RL Blei AT Flamm SL Fundal variceal bleeding after correction of portal hypertension in patients with cirrhosis.Gastrointest Endosc. 2003; 58: 122-127PubMed Google Scholar). Chikamori et al (6Kanagawa H Mima S Kouyama H Gotoh K Uchida T Okuda K Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration.J Gastroenterol Hepatol. 1996; 11: 51-58Crossref PubMed Scopus (422) Google Scholar) found that the main drainage route of fundal varices was via a gastrorenal shunt in 85% of patients, a gastrophrenic shunt in 10%, and a gastropericardiophrenic shunt in 5%. Balloon-occluded retrograde transvenous obliteration can be performed in patients with a gastrophrenic or gastrorenal shunt (7Chikamori F Kuniyoshi N Shibuya S Takase Y Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices.Dig Surg. 2001; 18: 176-181Crossref PubMed Scopus (73) Google Scholar), so only 5% of patients with fundal varices are not potential candidates for this procedure. Patient 3 could have been treated by balloon-occluded retrograde transvenous obliteration if catheterization of the inferior phrenic vein was possible. We strongly agree that IGV1 cases associated with a gastropericardiophrenic shunt should be treated by transportal intravariceal sclerotherapy. However, we have some comments about the procedure used by Kiyosue et al (1Kiyosue H Matsumoto S Yamada Y et al.Transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate for gastric varices.J Vasc Interv Radiol. 2004; 15: 505-509Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar). Why did the author choose n-butyl-2-cyanoacrylate as an obliterative agent? Although cyanoacrylate is highly effective for controlling acute bleeding from fundal varices (8Binmoeller KF Glue for gastric varices: some sticky issues.Gastrointest Endosc. 2000; 52: 298-301Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar), it is not available in the United States. Additionally, coil embolization seems to be too expensive. We recommend the use of a balloon catheter to reduce blood flow in the feeding vein, combined with a common sclerosant such as ethanolamine oleate, rather than n-butyl-2-cyanoacrylate. EditorWe read with great interest the article by Kiyosue et al (1Kiyosue H Matsumoto S Yamada Y et al.Transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate for gastric varices.J Vasc Interv Radiol. 2004; 15: 505-509Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar) about the efficacy and safety of transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate for the treatment of gastric varices. Because the precise diagnosis of bleeding from gastric varices is made by endoscopic observation, initial hemostasis should be achieved endoscopically. How did the authors achieve hemostasis? Because the mortality from gastric variceal bleeding is high, prophylactic treatment of high-risk varices may be justifiable (2Matsumoto A Yamauchi H Inokuchi H Balloon occluded transvenous obliteration: a feasible alterative to transjugular intrahepatic portosystemic stent shunt.Gut. 2003; 52: 611-612Crossref PubMed Google Scholar). How did the authors determine what constituted high-risk varices? The most widely used classification of gastric varices is that proposed by Sarin and Kumar (3Sarin SK Kumar A Gastric varices: profile, classification, and management.Am J Gastroenterol. 1989; 84: 1244-1249PubMed Google Scholar). According to this classification (3Sarin SK Kumar A Gastric varices: profile, classification, and management.Am J Gastroenterol. 1989; 84: 1244-1249PubMed Google Scholar), the authors treated two cases of GOV1 (extension of esophageal varices along the lesser curvature; patients 1 and 2), one of GOV2 (extension of esophageal varices toward the fundus; patient 3), and one of IGV1 (varices in the fundus; patient 4). Transjugular intrahepatic portosystemic stent creation alone often fails to prevent recurrent bleeding in patients with fundal varices with a portal pressure gradient of 12 mm Hg or lower (4Rinella ME Shah MD Vogelzang RL Blei AT Flamm SL Fundal variceal bleeding after correction of portal hypertension in patients with cirrhosis.Gastrointest Endosc. 2003; 58: 122-127PubMed Google Scholar, 5Ryan BM Stockbrugger RW Ryan JM A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.Gastroenterology. 2004; 126: 1175-1189Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar). Transportal intravariceal sclerotherapy seems to be too invasive for general use. GOV1 cases with concomitant esophageal varices may be treated by endoscopic sclerotherapy with use of a popular sclerosant such as ethanolamine oleate (4Rinella ME Shah MD Vogelzang RL Blei AT Flamm SL Fundal variceal bleeding after correction of portal hypertension in patients with cirrhosis.Gastrointest Endosc. 2003; 58: 122-127PubMed Google Scholar). Chikamori et al (6Kanagawa H Mima S Kouyama H Gotoh K Uchida T Okuda K Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration.J Gastroenterol Hepatol. 1996; 11: 51-58Crossref PubMed Scopus (422) Google Scholar) found that the main drainage route of fundal varices was via a gastrorenal shunt in 85% of patients, a gastrophrenic shunt in 10%, and a gastropericardiophrenic shunt in 5%. Balloon-occluded retrograde transvenous obliteration can be performed in patients with a gastrophrenic or gastrorenal shunt (7Chikamori F Kuniyoshi N Shibuya S Takase Y Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices.Dig Surg. 2001; 18: 176-181Crossref PubMed Scopus (73) Google Scholar), so only 5% of patients with fundal varices are not potential candidates for this procedure. Patient 3 could have been treated by balloon-occluded retrograde transvenous obliteration if catheterization of the inferior phrenic vein was possible. We strongly agree that IGV1 cases associated with a gastropericardiophrenic shunt should be treated by transportal intravariceal sclerotherapy. However, we have some comments about the procedure used by Kiyosue et al (1Kiyosue H Matsumoto S Yamada Y et al.Transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate for gastric varices.J Vasc Interv Radiol. 2004; 15: 505-509Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar). Why did the author choose n-butyl-2-cyanoacrylate as an obliterative agent? Although cyanoacrylate is highly effective for controlling acute bleeding from fundal varices (8Binmoeller KF Glue for gastric varices: some sticky issues.Gastrointest Endosc. 2000; 52: 298-301Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar), it is not available in the United States. Additionally, coil embolization seems to be too expensive. We recommend the use of a balloon catheter to reduce blood flow in the feeding vein, combined with a common sclerosant such as ethanolamine oleate, rather than n-butyl-2-cyanoacrylate. We read with great interest the article by Kiyosue et al (1Kiyosue H Matsumoto S Yamada Y et al.Transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate for gastric varices.J Vasc Interv Radiol. 2004; 15: 505-509Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar) about the efficacy and safety of transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate for the treatment of gastric varices. Because the precise diagnosis of bleeding from gastric varices is made by endoscopic observation, initial hemostasis should be achieved endoscopically. How did the authors achieve hemostasis? Because the mortality from gastric variceal bleeding is high, prophylactic treatment of high-risk varices may be justifiable (2Matsumoto A Yamauchi H Inokuchi H Balloon occluded transvenous obliteration: a feasible alterative to transjugular intrahepatic portosystemic stent shunt.Gut. 2003; 52: 611-612Crossref PubMed Google Scholar). How did the authors determine what constituted high-risk varices? The most widely used classification of gastric varices is that proposed by Sarin and Kumar (3Sarin SK Kumar A Gastric varices: profile, classification, and management.Am J Gastroenterol. 1989; 84: 1244-1249PubMed Google Scholar). According to this classification (3Sarin SK Kumar A Gastric varices: profile, classification, and management.Am J Gastroenterol. 1989; 84: 1244-1249PubMed Google Scholar), the authors treated two cases of GOV1 (extension of esophageal varices along the lesser curvature; patients 1 and 2), one of GOV2 (extension of esophageal varices toward the fundus; patient 3), and one of IGV1 (varices in the fundus; patient 4). Transjugular intrahepatic portosystemic stent creation alone often fails to prevent recurrent bleeding in patients with fundal varices with a portal pressure gradient of 12 mm Hg or lower (4Rinella ME Shah MD Vogelzang RL Blei AT Flamm SL Fundal variceal bleeding after correction of portal hypertension in patients with cirrhosis.Gastrointest Endosc. 2003; 58: 122-127PubMed Google Scholar, 5Ryan BM Stockbrugger RW Ryan JM A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.Gastroenterology. 2004; 126: 1175-1189Abstract Full Text Full Text PDF PubMed Scopus (259) Google Scholar). Transportal intravariceal sclerotherapy seems to be too invasive for general use. GOV1 cases with concomitant esophageal varices may be treated by endoscopic sclerotherapy with use of a popular sclerosant such as ethanolamine oleate (4Rinella ME Shah MD Vogelzang RL Blei AT Flamm SL Fundal variceal bleeding after correction of portal hypertension in patients with cirrhosis.Gastrointest Endosc. 2003; 58: 122-127PubMed Google Scholar). Chikamori et al (6Kanagawa H Mima S Kouyama H Gotoh K Uchida T Okuda K Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration.J Gastroenterol Hepatol. 1996; 11: 51-58Crossref PubMed Scopus (422) Google Scholar) found that the main drainage route of fundal varices was via a gastrorenal shunt in 85% of patients, a gastrophrenic shunt in 10%, and a gastropericardiophrenic shunt in 5%. Balloon-occluded retrograde transvenous obliteration can be performed in patients with a gastrophrenic or gastrorenal shunt (7Chikamori F Kuniyoshi N Shibuya S Takase Y Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices.Dig Surg. 2001; 18: 176-181Crossref PubMed Scopus (73) Google Scholar), so only 5% of patients with fundal varices are not potential candidates for this procedure. Patient 3 could have been treated by balloon-occluded retrograde transvenous obliteration if catheterization of the inferior phrenic vein was possible. We strongly agree that IGV1 cases associated with a gastropericardiophrenic shunt should be treated by transportal intravariceal sclerotherapy. However, we have some comments about the procedure used by Kiyosue et al (1Kiyosue H Matsumoto S Yamada Y et al.Transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate for gastric varices.J Vasc Interv Radiol. 2004; 15: 505-509Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar). Why did the author choose n-butyl-2-cyanoacrylate as an obliterative agent? Although cyanoacrylate is highly effective for controlling acute bleeding from fundal varices (8Binmoeller KF Glue for gastric varices: some sticky issues.Gastrointest Endosc. 2000; 52: 298-301Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar), it is not available in the United States. Additionally, coil embolization seems to be too expensive. We recommend the use of a balloon catheter to reduce blood flow in the feeding vein, combined with a common sclerosant such as ethanolamine oleate, rather than n-butyl-2-cyanoacrylate.