Response

Abstract

We appreciate Dr Lo's comments and would like to respond. Liver cirrhosis was the cause of portal hypertension in the majority of our patients (91/131); other causes of fundal varices included schistosomiasis (34 patients) and noncirrhotic portal fibrosis (6 patients).1Seewald S. Ang T.L. Imazu H. et al.A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos).Gastrointest Endosc. 2008; 68: 447-454Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar We enrolled all patients with fundal varices who were referred for endoscopic treatment. We had no cases of advanced hepatocellular carcinoma with portal vein thrombosis. We agree that, in this situation, the prognosis is usually dismal.We would like to clarify a misconception about our technique. To reduce the rebleeding rate, we advocate complete gastric variceal obliteration. A single injection volume is limited to 1 mL to minimize the risk of embolism. During a treatment session, one can repeat injections at a volume of 1 mL per injection until the varices are all obliterated. The need for further injections of 1-mL aliquot is determined by probing the varices with a catheter tip; patent varices remain soft.We agree that a randomized, controlled trial is the ideal study design. However, even in the absence of such studies, which will be difficult to perform, the excellent results of large case series already attest to the efficacy and safety of treatment with N-butyl-2-cyanoacrylate. We appreciate Dr Lo's comments and would like to respond. Liver cirrhosis was the cause of portal hypertension in the majority of our patients (91/131); other causes of fundal varices included schistosomiasis (34 patients) and noncirrhotic portal fibrosis (6 patients).1Seewald S. Ang T.L. Imazu H. et al.A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos).Gastrointest Endosc. 2008; 68: 447-454Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar We enrolled all patients with fundal varices who were referred for endoscopic treatment. We had no cases of advanced hepatocellular carcinoma with portal vein thrombosis. We agree that, in this situation, the prognosis is usually dismal. We would like to clarify a misconception about our technique. To reduce the rebleeding rate, we advocate complete gastric variceal obliteration. A single injection volume is limited to 1 mL to minimize the risk of embolism. During a treatment session, one can repeat injections at a volume of 1 mL per injection until the varices are all obliterated. The need for further injections of 1-mL aliquot is determined by probing the varices with a catheter tip; patent varices remain soft. We agree that a randomized, controlled trial is the ideal study design. However, even in the absence of such studies, which will be difficult to perform, the excellent results of large case series already attest to the efficacy and safety of treatment with N-butyl-2-cyanoacrylate.