Endoscopic cyanoacrylate injection for the treatment of gastric varices in children

Abstract

Aim: To evaluate the efficacy and safety of N-butyl-2-cyanoacrylate in treating acute bleeding of gastric varices in children.

Methods: The retrospective study included 21 children with 47 episodes of active gastric variceal bleeding who were treated by endoscopic injection of N-butyl-2-cyanoacrylate at Asan Medical Center Children's Hospital between August 2004 and December 2011. To reduce the risk of embolism, each injection consisted of 0.1-0.5 mL of 0.5 mL N-butyl-2-cyanoacrylate diluted with 0.5 or 0.8 mL Lipiodol. The primary outcome was incidence of hemostasis after variceal obliteration and the secondary outcome was complication of the procedure.

Results: The 21 patients experienced 47 episodes of active gastric variceal bleeding, including rebleeding, for which they received a total of 52 cyanoacrylate injections. Following 42 bleeding episodes, hemostasis was achieved after one injection and following five bleeding episodes it was achieved after two injections. The mean volume of each single aliquot of cyanoacrylate injected was 0.3 ± 0.1 mL (range: 0.1-0.5 mL). Injection achieved hemostasis in 45 of 47 (95.7%) episodes of acute gastric variceal bleeding. Eleven patients (52.4%) developed rebleeding events, with the mean duration of hemostasis being 11.1 ± 11.6 mo (range: 1.0-39.2 mo). No treatment-related complications such as distal embolism were noted with the exception of abdominal pain in one patient (4.8%). Among four mortalities, one patient died of variceal rebleeding.

Conclusion: Endoscopic variceal obliteration using a small volume of aliquots with repeated cyanoacrylate injection was an effective and safe option for the treatment of gastric varices in children.

Keywords: Children; Complication; Cyanoacrylate; Endoscopic variceal obliteration; Gastric varix.

Figure 1

Endoscopic and radiographic images in one patient with extrahepatic portal vein obstruction. A: Intravariceal injection of cyanoacrylate. The intravariceal pressure was highest at the top of the variceal dome, leading to immediate extrusion of injected cyanoacrylate and massive uncontrollable bleeding. Thus, it was safer to first inject cyanoacrylate on the side of the varix; B: Chest X-ray after injection showing injected cyanoacrylate and Lipiodol without undesired embolism.