Ultrasound (EUS) Guided Cyanoacrylate Injection for Variceal Obturation as Secondary Prophylaxis for Patients at High Risk for Recurrent Gastroesophageal Variceal Bleeding: A Pilot Study.
Refereed conference paper presented and published in conference proceedings

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AbstractIntroduction: Patients with hepatocellular carcinoma (HCC) and/or portal vein thrombosis (PVT) are at higher risk for recurrent variceal bleeding and worse clinical outcome. Prior studies reported a rebleeding rate of 28%–42% in patients with HCC and oesophageal variceal bleeding treated with endoscopic cyanoacrylate
(CYA) injection or band ligation. Recent evidence suggested prophylaxis against rebleeding may improve outcomes in patients with HCC. However, the optimal approach for secondary prophylaxis in such patients has not been well
defined. The utility of endoscopic ultrasound (EUS)-guided CYA injection for variceal obturation in these high-risk patients has not been studied.
Aims & Methods: This is a prospective pilot study evaluating EUS-guided CYA injection for variceal obturation as secondary prophylaxis for patients at high risk for recurrent variceal bleeding. Consecutive patients with HCC and/or PVT, or patients with non-HCC malignancy with PVT who had gastroesophageal variceal bleeding within 12 weeks were recruited. EUS-guided CYA injection was performed within 12 weeks of the index variceal bleeding for secondary
prophylaxis. Oesophagogastroduodenoscopy (OGD) was performed before EUS to assess for presence of active bleeding or stigmata of recent bleeding from oesophageal varices (OV) and gastric vaices (GV). EUS was subsequently performed with a linear echoendoscope. OV and GV were assessed by B-mode imaging and Doppler on EUS for size measurement and vascular flow. Varices >= 3mm were treated. CYA (0.5 ml of Histoacryl + 0.7 ml of lipiodol per injection) was injected with a 19G needle under EUS guidance. Doppler was used to confirm variceal obliteration. Chest and abdominal x-rays were obtained to confirm satisfactory position of CYA/lipiodol. Patients were followed for 6 months after EUS or till death if patients died within 6 months of EUS. Follow-up EUS would be performed on day 90 and day 180 during which CYA injection may be repeated for recurrent varices. Outcome measures include cumulative incidence of rebleeding at day 30 and day 90, and complications related to the procedures. Death occurring prior to recurrent bleeding was considered a competing risk event in analysis.
Results: 23 patients were initially screened, with 20 patients meeting inclusion criteria and undergone EUS guided CYA injection (mean age 64þ/-10; 85.0% male) successfully. 17 patients had HCC þ cirrhosis, in which 88.2% also had PVT. Among these patients, the Barcelona Clinic Liver Cancer (BCLC) stage for the HCC were: A (5.9%), B (5.9%), C (88.2%), D (0%), and the Child-Pugh class were: A (41.1%), B (58.8%). The other 3 patients had non-HCC malignancy (gastric cancer, pancreatic neuroendocrine tumour, lymphoma) + PVT. In this cohort, 14 patients had OV bleeding and 6 patients had GV bleeding in the index bleeding episode before recruitment. In the 1st EUS, CYA injection was done for OV, GV, and OV + GV in 12, 6, 2 patients, respectively. 6 had varices >= 5mm on EUS, while 14 had varices < 5mm on EUS. The mean number of CYA injections performed in EUS was 1.4+/-1. The death adjusted cumulative incidence of rebleeding at 30-day and 90-day after EUS guided CYA injection were 15%
(95% CI, 4 – 34) and 20% (95% CI, 6 – 40), respectively. 1 patient had mild dysphagia after CYA injection, but no serious adverse event occurred. Death occurred during the follow-up period were due to malignancy progression, organ failure or infection. 12 patients (60%) were alive and returned for 2nd EUS follow up at day 90 and 3 of the 12 patients (25%) needed additional CYA injection for treatment of recurrent OV or GV.
Conclusion: In this pilot study, EUS-guided CYA injection for variceal obturation as secondary prophylaxis for patients at high risk for recurrent variceal bleeding is safe and achieves a lower rate of recurrent variceal rebleeding when
compared to previously reported data in the literature.
All Author(s) ListTang RS, Wong JC, Kyaw M, Teoh AY, Tse YK, Lam TY, Chan HL, Lau JY
Name of ConferenceUnited European Gastroenterology Week
Start Date of Conference15/10/2016
End Date of Conference19/10/2016
Place of ConferenceVienna
Country/Region of ConferenceAustria
Proceedings TitleUnited European Gastroenterology Journal
Year2016
Month10
Volume Number4
Issue Number5
PublisherSAGE Publishing
Place of PublicationUK
PagesA601 - A602
ISSN20506406
LanguagesEnglish-United Kingdom
KeywordsEUS, varices, glue injection

Last updated on 2020-31-03 at 02:17