Long-term result of endoscopic Histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices

Abstract

Aim: To evaluate the long-term efficacy and safety of endoscopic obliteration with Histoacryl(®) for treatment of gastric variceal bleeding and prophylaxis.

Methods: Between January 1994 and March 2010 at SoonChunHyang University Hospital, a total of 127 patients with gastric varices received Histoacryl(®) injections endoscopically. One hundred patients underwent endoscopic Histoacryl(®) injections because of variceal bleeding, the other 27 patients received such injections as a prophylactic procedure.

Results: According to Sarin classification, 56 patients were GOV1, 61 patients were GOV2 and 10 patients were IGV. Most of the varices were large (F2 or F3, 111 patients). The average volume of Histoacryl(®) per each session was 1.7 ± 1.3 cc and mean number of sessions was 1.3 ± 0.6. (1 session-98 patients, 2 sessions-25 patients, ≥ 3 sessions-4 patients). Twenty-seven patients with high risk of bleeding (large or fundal or RCS+ or Child C) received Histoacryl(®) injection as a primary prophylactic procedure. In these patients, hepatitis B virus was the major etiology of cirrhosis, 25 patients showed GOV1 or 2 (92.6%) and F2 or F3 accounted for 88.9% (n = 24). The rate of initial hemostasis was 98.4% and recurrent bleeding within one year occurred in 18.1% of patients. Successful hemostasis during episodes of rebleeding was achieved in 73.9% of cases. Median survival was 50 mo (95% CI 30.5-69.5). Major complications occurred in 4 patients (3.1%). The rebleeding rate in patients with hepatocellular carcinoma or GOV2 was higher than in those with other conditions. None of the 27 subjects who were treated prophylactically experienced treatment-related complications. Cumulative survival rates of the 127 patients at 6 mo, 1, 3, and 5 years were 92.1%, 84.2%, 64.2%, and 45.3%, respectively. The 6 mo cumulative survival rate of the 27 patients treated prophylactically was 75%.

Conclusion: Histoacryl(®) injection therapy is an effective treatment for gastric varices and also an effective prophylactic treatment of gastric varices which carry high risk of bleeding.

Keywords: Gastric varix; Histoacryl® (N-butyl-2-cyanoacrylate); Histoacryl® injection; Prophylaxis; Treatment of gastric varix.

Figure 1

Endoscopic Histoacryl® injection for treatment of gastric varices. A: Endoscopic image showing a large gastric varix; B: Injection of Histoacryl^® into the gastric varix using the catheter.

Figure 2

X-ray showing lipiodol in the gastric varix during the procedure.

Figure 3

Embolic complications of Histoacryl® injection. A: Chest radiography showing pulmonary embolism after Histoacryl^® injection; B: Computed tomography showing the presence of lipiodol in the splenic vein after Histoacryl^® injection.

Figure 4

Adrenal abscess after Histoacryl® injection. A: Computed tomography scan showing adrenal abscess after Histoacryl^® injection; B: Adrenal abscess was resolved after PCD insertion.

Figure 5

The 1-year rebleeding rate using the Kaplan-Meier method and then log rank test. A: Comparing the groups with hepatocellular carcinoma (HCC) or without HCC; B: Comparing GOV1 and GOV2. GOV: Gastro-esophageal varices.

Figure 6

Survival of Histoacryl® injected patients. A: Survival of 127 Histoacryl®-injected patients using the Kaplan-Meier method. The cumulative survival rates of the 127 patients at 6 mo, and 1, 3 and 5 years were 92.1%, 84.2%, 64.2%, and 45.3%, respectively; B: Survival of the 27 patients who underwent primary prophylaxis, using the Kaplan-Meier method. The 6 mo cumulative survival rate of these patients was 75%.