Endoscopic Histoacryl Injection Research Articles

Endoscopic Histoacryl injection for esophagojejunostomy leakage after total gastrectomy in patients with gastric cancer

Esophagojejunostomy leakage after total gastrectomy for gastric cancer is one of the most serious and sometimes life-threatening adverse events. The purpose of this study was to evaluate complications after total gastrectomy in patients with gastric cancer during the period when Histoacryl (B. Braun) injection was performed. Therapeutic outcome of endoscopic Histoacryl injection for esophagojejunostomy leakage was also determined. This was a single-center retrospective study. Between January 2016 and December 2021, clinicopathologic characteristics and surgical outcomes of 205 patients who underwent total gastrectomy were investigated. Baseline characteristics and clinical outcomes of 10 patients with esophagojejunostomy leakage were also investigated. Postoperative complication and mortality rates of total gastrectomy in 205 patients were 25.4% and 0.9%, respectively. Serious complications more than Clavien-Dindo IIIb accounted for 6.3%. Ten (4.9%) esophagojejunostomy leakages occurred in 205 patients. Among 10 esophagojejunostomy leakage patients, endoscopic Histoacryl injection was performed on eight patients and leakage was successfully managed with endoscopic Histoacryl injection in seven patients (87.5%). Mean postinjection hospital stay of seven successfully managed patients was 13.8 days. They were able to drink water at 1-6 days after injection. Among eight patients with endoscopic Histoacryl injection, six patients were injected once and two patients were injected three times. Endoscopic Histoacryl injection for esophagojejunostomy leakage after total gastrectomy can be considered as a useful treatment for some selected cases.

Endoscopic Histoacryl injection: can simplicity overcome complexity?

Endoscopic Histoacryl injection: can simplicity overcome complexity?

Identification and Treatment of an Unusual Cause of Gastrointestinal Bleeding

Identification and Treatment of an Unusual Cause of Gastrointestinal Bleeding

Safety and Efficacy of Modified BRTO-Assisted Endoscopic Histoacryl Injection for the Treatment of Isolated Gastric Varices with Gastro-Renal Shunt

Safety and Efficacy of Modified BRTO-Assisted Endoscopic Histoacryl Injection for the Treatment of Isolated Gastric Varices with Gastro-Renal Shunt

Spontaneously resolving duodenal obstruction after balloon-occluded retrograde transvenous obliteration–assisted endoscopic Histoacryl injection in duodenal varices

A 46-year-old woman with cirrhosis presented with recurrent upper GI bleeding. EGD revealed small esophageal varices and large ectopic varices in the second part of the duodenum without any active bleeding (A). CT portovenogram revealed a branch of superior mesenteric vein as afferent and right gonadal vein as efferent for the varices (B). Balloon-occluded retrograde transvenous obliteration (BRTO) was done with the balloon inflated in the right gonadal vein. Because superselective cannulation of the ectopic varices could not be achieved, BRTO-assisted endoscopic injection of 12 mL N-butyl-2-cyanoacrylate (Histoacryl) and lipoidal (1:2 ratio) was done into the varices to minimize systemic embolization. Two weeks after discharge, the patient presented with repeated vomiting. EGD revealed partial occlusion of the duodenal lumen by the Histoacryl cast (C). Her symptoms resolved on conservative management (nothing by mouth, nasogastric drainage, and intravenous fluids). She continued to experience intermittent vomiting for the next 2 months. Because spontaneous expulsion of Histoacryl casts after variable intervals is known and each episode of duodenal obstruction subsided with conservative management, we did not plan any surgery. After about 2 months, she became asymptomatic. EGD after 2 months showed no residual Histoacryl cast (D).

Synchronous hybrid procedure combining interventional radiology and endoscopy for esophagogastric varices with large gastro-renal shunt.

Successful treatment of esophagogastric varices (EGV) with giant portal-systemic shunt is challenging. To explore the feasibility and safety of a novel hybrid procedure involving interventional radiology and endoscopy in the same sitting.Three cases clinically diagnosed to have decompensated cirrhosis and EGV with giant gastrorenal shunt (GRS) on contrast-enhanced computed tomography (CT) were included. The hybrid procedures included: indirect portography, hepatic vein pressure gradient (HVPG) measurement, HVPG-based partial splenic embolization (PSE), retrospective GRS balloon occlusion, endoscopic histoacryl injection (EHI), balloon catheter radiography and withdrawal. All the procedures were done in the same operation room. Main outcomes measurements included operation time, complications, and re-bleeding events.Hybrid interventions were performed successfully in 3 cases with a mean operation time of 63.3 minutes without any major intra- and post-operation complications. No rebleeding occurred at 6-month follow-up.Synchronous hybrid intervention combining radiology and endoscopy is feasible and safe for patients with EGV and giant GRS, preliminary study with limited cases deserves further exploration.

Metal clips combined with endoscopic histoacryl injection in the treatment of gastric varices with spontaneous portosystemic shunts (with video)

Objective To evaluate the safety and efficacy of metal clips combined with endoscopic histoacryl injection for gastric varices with spontaneous portosystemic shunts. Methods The clinical data and complications of 32 patients who were treated with metal clips combined with endoscopic histoacryl injection at Beijing Ditan Hospital of Capital Medical University from May 2016 to October 2018 were collected and analyzed. Results Hemostasis was achieved in all patients, and the median volume of histoacryl was 3.8 mL. Varices were eradicated or disappeared in 9 cases, and the degree of varices were lessened in 23 cases. No rebleeding was found at 72 h, 7 d, 14 d and 6 weeks after operation in any patient. No ectopic embolism occurred. Conclusion Metal clips combined with endoscopic histoacryl injection is effective and safe to treat gastric varices with spontaneous portosystemic shunts. Key words: Endoscopy; Esophageal and gastric varices; Spontaneous protosystemic shunt; Histoacryl; Metal clip

Acute variceal bleeding in patients with primary myelofibrosis successfully treated with endoscopic histoacryl injection.

Acute variceal bleeding in patients with primary myelofibrosis successfully treated with endoscopic histoacryl injection.

Hepatoduodenal Fistula Successfully Treated With Enteral Metallic Stent: A Rare Complication Following Trans-catheter Arterial Chemoembolization for Hepatocellular Carcinoma

A 62-year-old man presented with fever and right upper quadrant pain (RUQ) for 1 week. He was recently diagnosed with chronic hepatitis B cirrhosis and hepatocellular carcinoma (HCC). He underwent several sessions of transcatheter arterial chemoembolization (TACE) as a palliative treatment. On physical examination, body temperature was 39°C. Marked tenderness was observed at RUQ. Laboratory tests revealed white blood cell count 8.5x109/L (neutrophil 78%), total bilirubin 2.6 mg/dL, aspartate aminotransferase 37 U/L, alanine aminotransferase 21 U/L and alkaline phosphatase 110 U/L. Computed tomography (CT) showed a fistulous connection between gas-containing cavity in previous HCC area, suggesting an abscess draining to duodenum (Figure 1). Esophagogastroduodenoscopy (EGD) was done to confirm the fistula through a 1.5-cm hole in the second part of duodenum (Figure 2A). A few days later, a repeat upper endoscopy was performed with a therapeutic duodenoscope and a partially-covered enteral metallic stent was placed between duodenum and pylorus (Figure 2B). Follow-up CT (1 month after the intervention) showed complete obliteration of the fistulous tract (Figure 3). The remaining liver abscess was treated by percutaneous drainage and antibiotics. The patient was discharged 1 month later with a significant improvement of symptoms.2283_A Figure 1. Contrast-enhanced computed tomography (A) axial view (B) coronal view showed fistulous connection (arrow) between lipiodol-staining mass at hepatic segment V/VII and second part of duodenum.2283_B Figure 2. (A) Endoscopic finding of fistula tract at second part of duodenum with failure of closure by endoscopic clipping (B) Fluoroscopic view showed successful enteral metallic stent deployment.2283_C Figure 3. Contrast-enhanced computed tomography (A) axial view (B) coronal view showed metallic stent at duodenum and improvement of hepatoduodenal fistula.Hepatoduodenal fistula is a rare complication of HCC after TACE. Only few reports have been previously described. Abscess formation from necrotic tumor after TACE with local inflammation may lead to abnormal connection to surrounding structures. A direct invasion from advanced HCC is also another possible cause of fistula formation. There are several therapeutic approaches for managing fistula, including, conservative treatment, endoscopic Histoacryl injection and surgery. However, the selection is depended on the case scenario and the availability of special devices. Herein, we report the first case of hepatoduodenal fistula, which was successfully treated with enteral metallic stent after a failure of endoscopic clipping due to a large fibrotic fistula defect. Although rare, hepatoduodenal fistula is a serious and fatal condition. Clinical suspicion along with radiologic and endoscopic findings are crucial clues for diagnosis. Stent placement can be considered as an alternative to surgery in a large and difficult-to-close fistula tract.

Value of balloon closure combined with endoscopic therapy for gastric varices with portasystemic shunt

Objective To evaluate the clinical effect of balloon closure combined with endoscopic therapy on spontaneous gastrorenal shunt(SGRS) and spontaneous splenorenal shunt(SSRS). Methods The data of 33 patients of gastric varices with SGRS or SSRS diagnosed in the Chinese PLA General Hospital between January 2009 and February 2016 were collected. All patients were treated with the balloon retrograde distributary channel blocking technique and endoscopic histoacryl injection. Patients′ clinical data, complications and effect of endoscopic therapy were retrospectively analyzed. Results In the 33 patients of gastric varices, gastrorenal shunt was found in 28(84.8%) cases and splenorenal shunt was found in 5(15.2%) cases. After the balloon blocking technique, 24 cases (72.7%) were occluded successfully. Four cases failed in occlusion of SSRS due to tortuosity. There were no postoperative ectopic embolism, infection, hepatic encephalopathy, liver function deterioration, and other complication. Early latex varices were found in 21 cases after three months follow-up. Conclusion The balloon blocking technique combined with tissue adhesive injection could safely and effectively avoid the risk of ectopic embolism and plays an important role in the treatment of gastric varices in merger portasystemic shunt. Key words: Endoscopes; Esophageal and gastric varices; Balloon embolization; Portasystemic shunt

BRTO assisted endoscopic Histoacryl injection in treating gastric varices with gastrorenal shunt

Aims: We evaluated the feasibility, efficacy and safety of a novel technique of balloon-occluded retrograde transvenous obliteration (BRTO) assisted endoscopic Histoacryl (N-buthyl-2-cyanoacrylate) injection.Material and methods: A total with 11 patients were enrolled and analyzed in this single center, open-label, prospective study. Patients with high-risk gastric varices (defined as fundal varices, large GV (>5 mm), presence of a red spot, and Child-Pugh score C) and concurrent gastrorenal shunt underwent endoscopic Histoacryl injection while the gastrorenal shunt was temporarily occluded with an occlusion balloon. Feasibility, hemostatic effect, intra- and postoperative complications, and varices recurrence were evaluated.Results: All procedures were successfully done per protocol. Except for one patient who underwent rescue Histoacryl injection due to residual varices, single therapy was sufficient to eliminate gastric varices in ten patients. Intra-operative hemorrhage occurred in one case and was stopped after additional Histoacryl injection. One patient was confirmed to have treatment-related fungemia. No death or major complications occurred, including ectopic embolism, worsening of hepatic and renal function, etc. No recurrence of the varices was found during a median follow-up time (mean ± SD) of 228 ± 153 days.Conclusions: BRTO assisted endoscopic Histoacryl injection is effective and safe for patients with high-risk gastric varices and concurrent gastrorenal shunt.

Endoscopic management of refractory gastrointestinal non-variceal bleeding using Histoacryl (N-butyl-2-cyanoacrylate) glue.

Background: Histoacryl glue (N-butyl-2-cyanoacrylate) has well-established utility in the endoscopic management of gastrointestinal variceal bleeding. The role of Histoacryl glue in non-variceal bleeding is less clear, and there are few articles describing its use in this setting.Methods: Six patients with intractable non-variceal gastrointestinal bleeding were managed using injection of Histoacryl glue. All patients had previously failed conventional endostasis and/or interventional angioembolization and were not suitable for emergency salvage surgery due to serious comorbidities or unacceptable anaesthetic risk. An endoscopic Lipiodol-Histoacryl-Lipiodol sandwich injection technique was used in these patients. The clinical outcomes and complications were evaluated.Results: There were four females and two males with a mean age of 55 years. Bleeding lesions included gastric ulcers (n = 2), duodenal ulcers (n = 2), duodenal gastrointestinal stromal tumor (GIST) (n = 1) and rectal ulcers (n = 1). All patients had successful Histoacryl endostasis without the requirement for salvage surgery. There was no treatment-related morbidity and no mortality. Two patients had further bleeding after initial Histoacryl endostasis, which was successfully controlled with further endoscopic Histoacryl injection.Conclusion: Histoacryl endostasis should be included in the treatment algorithm for refractory non-variceal gastrointestinal bleeding.

Hepatoduodenal fistula formation following transcatheter arterial chemoembolization and radiotherapy for hepatocellular carcinoma: treatment with endoscopic Histoacryl injection

A 71-year-old male patient was readmitted to our hospital 1 month after discharge because of relapse of abdominal pain. He had been diagnosed with hepatocellular carcinoma (HCC) 1 year prior and had undergone repeated transcatheter arterial chemoembolization and radiotherapy. During the last hospitalization, he was diagnosed with a liver abscess complicated by previous treatments for HCC and was treated with intravenous antibiotics and abscess aspiration. Follow-up abdominal computed tomography revealed a liver abscess with a duodenal fistula, which was successfully treated with endoscopic Histoacryl injection into the fistula. Liver abscesses with duodenal fistulas rarely occur, but they are intractable and possibly fatal in patients with HCC. In the literature, they have frequently been managed only with abscess treatment without fistula management. We herein report the first case of a patient with a liver abscess complicated by a fistula between the duodenum and the abscess, which was treated with endoscopic Histoacryl injection.

Laparoendoscopic Transgastric Histoacryl Injection of Gastric Varices: A New Surgical Approach

Gastric varices (GVs) are a common finding in Egyptian patients with portal hypertension due to cirrhosis or schistosomal hepatic fibrosis. These patients present with an acute attack or history of hematemesis. Endoscopic histoacryl injection is the standard treatment in Egypt; however, because of technical difficulties it is possible to inject only a little amount of this material, as it may endanger the channels of the flexible endoscope. We thought of a new surgical laparoendoscopic technique to obviate the need for repeated endoscopies and complete obliteration of GVs. This study was conducted on 20 patients with portal hypertension and GVs. After the patient was placed under general anesthesia, a small gastrostomy was done in the anterior gastric wall through which a 10-mm trocar was inserted for the laparoscopic camera. Injection of GVs was done via a spinal needle or a central venous line needle inserted directly. Injection of an adequate amount of histoacryl was done under direct vision. This study was conducted from July 2009 to August 2011 on 20 patients with GVs. The age range was from 22 to 56 years, with a mean age of 39.8±7.85 years. There were 14 men (70%) and 6 women (30%). Fourteen patients (70%) showed complete obliteration of GVs after one session of treatment, whereas 6 patients (30%) had unsatisfactory results and were subjected to another session. GVs were completely obliterated after the second session in 4 patients. Two cases of recurrence of GVs were operated on. This new technique enabled us to inject GVs with a suitable amount of glue material under direct vision without harming the endoscope. Use of this procedure is recommended in patients fit for surgery and those who had failed endoscopic injection sclerotherapy.

Long-Term Outcomes of Prophylactic Endoscopic Histoacryl Injection for Gastric Varices with a High Risk of Bleeding

Endoscopic histoacryl injection (EHI) is reported to be an effective treatment modality for bleeding gastric varices (GVs) but controversial as a prophylactic treatment for non-bleeding GVs because efficacy and safety have yet to be determined. The aim of this study was to evaluate safety and long-term outcomes of prophylactic EHI for non-bleeding GVs with a high risk of bleeding. Thirty-three patients (23 males/10 females, mean age 56.6 years old) with a high risk of gastric variceal bleeding (large tumorous (27), red color sign (14) or rapidly growing in size (1)) underwent EHI. According to the grade of GVs, 25 patients belonged to F3, seven to F2, and one to F1. In terms of the locations of GVs, four patients belonged to type IGV1, 21 to type GOV2, and eight to type GOV1. Obliteration of GVs was achieved in all of the treated patients. Twenty-three patients required one session and ten needed more than two sessions to obliterate their GVs. A mean volume of histoacryl used per session was 2.0 ml. Complications related to the procedure included immediate bleeding in two patients and bacteremia in one patient. The mean duration of follow-up was 12.2 months and eradication of GVs was achieved in 21 (95%) of 22 patients who were followed-up more than 3 months. Index GVs recurred in three of 21 patients (14%) and re-bleeding in index GVs after EHI occurred in two of 26 patients (8%). Prophylactic EHI can be a promising procedure for eradication of non-bleeding GVs in case with a high risk of bleeding.

A Hemolytic Transfusion Reaction due to Anti-Ku Antibody in a Patient with Knull Phenotype: The First Case in Korea

Knull phenotype completely lacks all Kell system antigens. Anti-Ku antibody is seen in immunized persons with Knull phenotype by transfusion or pregnancy. It can cause a fatal hemolytic transfusion reaction. A 66-yr-old male patient with liver cirrhosis visited emergency center due to acute bleeding. The patient was at hypovolemic shock status: his blood pressure was 80/50 mmHg, pulse rate was 110/min and hemoglobin level was 4.4 g/dL. Because of the presence of antibody against high incidence antigen, we could not find any compatible blood for the patient. Nevertheless, 4 units of packed RBCs had to be transfused. Moderate hemolytic transfusion reaction was developed after transfusion. At endoscopic examination, blood was spurting from gastric cardiac varix. Endoscopic histoacryl injection was tried, and bleeding was successfully controlled. After bleeding stopped, he was managed for anemia using steroid and other medical therapy instead of transfusion. His hemoglobin level was improved to 7.7 g/dL at the time of discharge. Later he has been proved to have a Knull phenotype, which is very rare, and anti-Ku antibody. This report is the first case of anti-Ku in a Knull phenotype person in Korea, who experienced a moderate hemolytic transfusion reaction.

Long‐term results of balloon‐occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: A 10‐year experience

Balloon-occluded retrograde transvenous obliteration (B-RTO) is a new alternative treatment for gastric varices (GVx), but the long-term efficacy is not known. We investigated the long-term effects of B-RTO on rebleeding, prevention of first bleeding, mortality and occurrence of risky esophageal varices (EVx). B-RTO was performed in 68 cirrhotic patients with GVx. Twenty patients had recent bleeding, transiently treated by endoscopic Histoacryl injection or balloon tamponade. Forty-eight patients had varices likely to bleed, but no bleeding. After B-RTO, the recurrent bleeding, occurrence of EVx and mortality over the long-term were evaluated. B-RTO was successfully performed in 63 of 68 patients (92.6%). Varices eradication was confirmed by endoscopy in 61 of 63 patients (96.6%). During follow up, GVx bleeding occurred in two patients (3.2%). The 8-year cumulative rebleeding rates of patients with bleeding and risky GVx were 14% and 0%, respectively. Risky EVx occurred in 10 patients (17%) and the cumulative occurrence rate was 22% in 8 years. The cumulative occurrence rate of risky EVx was higher in GVx with EVx (GOV2-GVx) compared to GVx without EVx (IGV1, P < 0.05). No ectopic variceal bleeding occurred. No patients died from variceal bleeding. Hepatocellular carcinoma was the only significant prognostic factor (P < 0.05). B-RTO is beneficial over the long-term, despite worsening EVx in some patients, because of excellent treatment efficacy and improved mortality. We believe that B-RTO can become a first-choice radical treatment following hemostasis for gastric variceal bleeding and prophylactic treatment for risky GVx.

Portale Hypertension unter Azathioprin bei Morbus Crohn - ein häufiges Phänomen?

A 45-year-old man with 18 years history of Crohn's disease who was on treatment with azathioprine (AZA) for the past 48 months was admitted because of haematemesis and melaena. Tests showed a slight elevation of bilirubin and a low platelet count. Endoscopy revealed esophageal and gastric fundus varices. Magnetic resonance imaging (MRI) revealed severe portal vein hypertension with a spleen-kidney convolute of varices. Liver biopsy showed hyperplasia of hepatocytes and a reticular fibrosis, consistent with the diagnosis of nodular regenerative hyperplasia (NRH). AZA treatment was stopped. The fundal varices were treated with endoscopic histoacryl injection. The patient is at present in good health and is followed up in our outpatient department. AZA as a widely used immunosuppressive drug has side effects in about 5 - 10 % of the cases. The risk of hepatotoxicity in patients treated with AZA is often underestimated. Therefore, physicians treating patients with inflammatory bowel disease have to be precocious regarding the increase of hepatic enzymes and pathologic signs in liver imaging in relation of AZA treatment. The latter might refer to NRH which would lead to severe portal vein hypertension.

Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: A 10-year experience

The long-term efficacy and safety of endoscopic injection of N-butyl-2-cyanoacrylate (Histoacryl) were evaluated as the initial treatment for bleeding gastric varices. Fifty-two patients with bleeding gastric varices underwent endoscopic injections of Histoacryl for hemostasis over a 10-year period. Histoacryl was injected intravariceally. Among these 52 patients, 32 had active bleeding and 20 had recent bleeding. Most of the varices were large (F2 or F3, 48 cases). After Histoacryl injection, the patients were followed endoscopically with retreatment administered as necessary. The patients were followed for a mean 28.1 months. The rate of initial hemostasis (no bleeding occurred for 48 hours after sclerotherapy) was 96.2%. Cumulative nonbleeding rates were 64.7%, 52.7%, and 48.2% at 1, 5, and 10 years, respectively. When rebleeding occurred, 80.0% was within 1 year after initial injection. Recurrent bleeding was easily stopped with the reinjection of Histoacryl in most patients. The treatment failure-related mortality rate was 4.0% (2 of 52). The cumulative survival rates were 66.9%, 60.4%, and 55.5% at 1, 5, and 10 years, respectively. The mortality depended on either malignancy or liver function (Child-Pugh classification). These results suggest that Histoacryl injection sclerotherapy is highly effective for the treatment of bleeding gastric varices, with rare complications occurring both acutely and long-term. Therefore, Histoacryl injection sclerotherapy is considered to be the first choice of treatment for bleeding gastric varices, but the rate of recurrent bleeding is so high that further methods or devices still need to be developed in order to prevent gastric variceal rebleeding.