Sa1566 Efficacy and Safety of 2-Octyl-Cyanoacrylate Injection for the Treatment of Gastric Variceal Hemorrhage

Abstract

Endoscopic injection of cyanoacrylate (glue) is effective for the treatment of gastric variceal hemorrhage (GVH). Although n-butyl-2 cyanoacrylate (Histoacryl®) is the most commonly used agent worldwide, it is not readily available in the U.S. As an alternative, our group has utilized 2-octyl cyanoacrylate (Dermabond®), an FDA-approved agent for wound closure. The off-label, intravariceal injection of 2-octyl cyanoacrylate (OCA) for GVH has been a treatment option at our institution since 2000. To assess the efficacy and safety of OCA injection for the treatment of GVH. The medical records of patients treated with OCA injection for GVH from 1/2000 to 7/2010 were reviewed retrospectively. Data were extracted for patient demographics, type of gastric varices (GV) according to Sarin classification, bleeding stigmata, OCA dose and number of sites injected per treatment session, initial hemostasis and rebleeding rates, procedure-related complications, and mortality. Undiluted OCA was injected at a rate of 1 ml/15 sec until bleeding cessation and/or hardening of the varix. Repeat endoscopy was performed at 4 wks to assess for variceal obliteration and treatment of any residual GV. Follow-up endoscopy was performed at 6-12 months thereafter. A total of 62 patients (40 men) were identified. Cirrhotic portal hypertension was the cause of GV in 70% of cases. GV were classified as GOV1 in 2%, GOV2 in 63% and IGV1 in 35% of cases. Active bleeding, stigmata of recent bleeding (e.g., fibrin plug) and presumed bleeding from large GV were noted in 24%, 53% and 23% of patients, respectively. The mean volume of OCA injected was 6.5 ml (range 2-16 ml) with a mean of 2 injection sites (range 1-6) per treatment session. In patients with actively bleeding GV (n=15), immediate hemostasis was achieved in 93% of cases following OCA injection. The overall rebleeding rate was 6%. In 2 patients, early (< 1 wk) recurrent massive GVH required rescue TIPS which failed to control bleeding in one patient who subsequently died. Late (> 1 wk) recurrent GVH occurred in 2 patients; one patient was successfully retreated with OCA injection and the other patient opted for comfort care in the setting of multiorgan failure. Glue-related pulmonary embolism occurred in 2 (3%) patients, which was fatal in one. The mean (SD) follow-up was 17 (15) months. Bleeding-related mortality was 6% and the overall mortality was 23%. Endoscopic injection of 2-octyl cyanoacrylate is a relatively safe and effective endoscopic treatment option for gastric variceal hemorrhage. The outcomes are comparable to those reported for endoscopic variceal injection using n-butyl-2 cyanoacrylate.