Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension

BACKGROUND Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension(LSPH).The hemorrhage is fatal and requires safe and effective interventions.AIM To evaluate the clinical safety and efficacy of modified endoscopic ultrasound(EUS)-guided selective N-butyl-2-cyanoacrylate(NBC)injections for gastric variceal hemorrhage in LSPH.METHODS A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted.Preoperative EUS evaluations were performed.Enrolled patients were divided into modified and conventional groups according to the NBC injection technique.The final selection of NBC injection technique depended on the patients’preferences and clinical status.The technical and clinical success rates,operation time,NBC doses,perioperative complications,postoperative hospital stay,and recurrent bleeding rates were analyzed,respectively.RESULTS A total of 27 patients were enrolled.No statistically significant differences were observed between the two groups regarding baseline characteristics.In comparison to patients in the conventional group,patients in the modified group demonstrated significantly reduced NBC doses(2.0±0.6 mL vs 3.1±1.0 mL;P=0.004)and increased endoscopic operation time(71.9±11.9 min vs 22.5±6.7 min;P<0.001).Meanwhile,the two groups had no significant difference in the technical and clinical success rates,perioperative complications,postoperative hospital stay,and recurrent bleeding rates.CONCLUSION Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage,with advantages of reduced injection dose and no radiation risk.Drawbacks were time consumption and technical challenge.

Cerebral and splenic infarctions after injection of N-butyl-2-cyanoacrylate in esophageal variceal bleeding

Variceal bleeding is the most serious complication of portal hypertension,and it accounts for approximately one fifth to one third of all deaths in liver cirrhosis patients.Currently,endoscopic treatment remains the predominant method for the prevention and treatment of variceal bleeding.Endoscopic treatments include band ligation and injection sclerotherapy.Injection sclerotherapy with N-butyl-2-cyanoacrylate has been successfully used to treat variceal bleeding.Although injection sclerotherapy with N-butyl-2-cyanoacrylate provides effective treatment for variceal bleeding,injection of N-butyl-2-cyanoacrylate is associated with a variety of complications,including systemic embolization.Herein,we report a case of cerebral and splenic infarctions after the injection of N-butyl-2-cyanoacrylate to treat esophageal variceal bleeding.

N-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and hypertonic glucose with 72% chromated glycerin in gastric varices

AIM: To compare n-butyl-2-cyanoacrylate, iso-amyl-2-cyanoacrylate and a mixture of 72% chromated glycerin with hypertonic glucose solution in management of gastric varices. METHODS: Ninety patients with gastric varices presented to Endoscopy Unit of Ain Shams University Hospital were included. They were randomly allocated into three groups; each group included 30 patients treated with intravariceal sclerosant injections in biweekly sessions till complete obturation of gastric varices; Group I(n-butyl-2-cyanoacrylate; Histoacryl), Group II(iso-amyl-2-cyanoacrylate; Amcrylate) and Group III(mixture of 72% chromated glycerin; Scleremo with glucose solution 25%). All the procedures were performed electively without active bleeding. Recruited patients were followed up for 3 mo. RESULTS: 26% of Scleremo group had bleeding during puncture vs 3.3% in each of the other two groups with significant difference,(P < 0.05). None of Scleremo group had needle obstruction vs 13.3% in each of the other two groups with no significant difference,(P > 0.05). Rebleeding occurred in 13.3% of Histoacryl and Amcrylate groups vs 0% in Scleremo group with no significant difference. The in hospital mortality was 6.6% in both Histoacryl and Amcrylate groups, while it was 0% in Scleremo group with no significant difference. In the first and second sessions, the amount of Scleremo needed for obturation was significantly high, while the amount of Histoacryl was significantly low. Scleremo was the less costly of the two treatments. CONCLUSION: All used sclerosant substances showed efficacy and success in management of gastric varices with no significant differences except in total amount, cost and bleeding during puncture.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension:A case report

BACKGROUND Left-sided portal hypertension(LSPH),also known as sinistral portal hypertension or regional portal hypertension,refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis.N-butyl-2-cyanoacrylate(NBC)has been widely used in the endoscopic hemostasis of portal hypertension,but adverse events including renal or pulmonary thromboembolism,mucosal necrosis and gastrointestinal(GI)bleeding may occur after treatment.Herein,we report successfully managing gastric variceal(GV)hemorrhage secondary to LSPH using modified endoscopic ultrasound(EUS)-guided selective NBC injections.CASE SUMMARY A 35-year-old man was referred to our hospital due to an upper GI hemorrhage.Gastroscopy revealed GV hemorrhage and computed tomography venography(CTV)confirmed LSPH.The patient requested endoscopic procedures and rejected surgical therapies including splenectomy.EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose.The“sandwich”method using undiluted NBC and hypertonic glucose was applied.No complications occurred.The patient was followed up regularly after discharge.Three months later,the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH.No recurrent GI hemorrhage was reported during this follow-up period.CONCLUSION EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Endovascular treatment of traumatic direct carotid cavernous fistulas with n-Butyl-2-Cyanoacrylate

Objective To explore the method and safety of endovascular treatment of traumatic direct carotid cavernous fistulas with n-Butyl-2-Cyanoacrylate. Method A total of 11 patients with traumatic direct carotid cavernous fistulas treated by endovascular embolization with n-Butyl-2-Cyanoacrylate. (n-BCA) were retrospectively analyzed,including the

Endovascular embolization of cerebral arteriovenous malformation with N-butyl-2 cyanoacrylate

objective:To explore the characteristics and preparation of N-butyl-2 cyanoacrylate (NBCA) as anembolic material for cerebral arteriovenous malformation (AVM) and to discuss the indications, and technicalnote of transcatheter arterial embolization (TAE) and the prevention of its complications. Methods:Forty patients with AVM were treated using microcatheterization techniques with NBCA through intravascular approach under supervision of digital subtraction angiography (DSA ). Results: of these 40 patients whoseAVMs were ernbolized 57 times, 8 were cured, 31 had significant improvement of clinical symptoms withoutrebleeding. Complications included headache, neurological dysfunction, normal perfusion pressure breakthrough. Intracranial hemorrhage occurred in one case due to rupture of an arterial feeder which required surgical operation. Visual field defect was found and did not recover in one. Conclusion:TAE with NBCA is aneffective therapeutic mesure for AVM. Domestic NBCA is of good quality and low price, therefore, it can beused to substitute for similar imported products.

Proton pump inhibitor administration delays rebleeding after endoscopic gastric variceal obturation

AIM:To clarify the efficacy of proton pump inhibitors(PPIs)after endoscopic variceal obturation(EVO)with N-butyl-2-cyanoacrylate.METHODS:A retrospective study was performed on16 liver cirrhosis patients with gastric variceal bleeding that received EVO with injections of N-butyl-2-cyanoacrylate at a single center(Kyung Hee University Hospital at Gangdong)from January 2008 to December 2012.Medical records including patient characteristics and endoscopic findings were reviewed.Treatment results,liver function,serum biochemistry and cirrhosis etiology were compared between patients receiving PPIs and those that did not.Furthermore,the rebleeding interval was compared between patients that received PPI treatment after EVO and those who did not.RESULTS:The patient group included nine males and seven females with a mean age of 61.8±11.7years.Following the EVO procedure,eight of the 12patients that received PPIs and three of the four nonPPI patients experienced rebleeding.There were no differences between the groups in serum biochemistry or patient characteristics.The rebleeding rate was not significantly different between the groups,however,patients receiving PPIs had a significantly longer rebleeding interval compared to non-PPI patients(22.2±11.2mo vs 8.5±5.5 mo;P=0.008).The duration of PPI use was not related to the rebleeding interval.A total of six patients,who had ulcers at the injection site,exhibited a shorter rebleeding interval(16.8±5.9 mo)than patients without ulcers(19.9±3.2 mo),though this difference was not statistically significant.CONCLUSION:PPI therapy can extend the rebleeding interval,and should therefore be considered after EVO treatment for gastric varices.

Procedure-related complications in gastric variceal obturation with tissue glue

AIM To focus on procedure-related complications,evaluate their incidence,analyze the reasons and discuss the solutions.METHODS Overall,628 endoscopic gastric variceal obturation(EGVO) procedures(case-times) with NBC were performed in 519 patients in the Department of Endoscopy of the Third Affiliated Hospital of Sun Yat-Sen University from January 2011 to December 2016. The clinical data of patients and procedure-related complications of EGVO were retrospectively analyzed.RESULTS In the 628 EGVO procedures,sticking of the needle to the varix occurred in 9 cases(1.43%),including 1 case that used lipiodol-diluted NBC and 8 cases that used undiluted NBC(P = 0.000). The needle was successfully withdrawn in 8 cases. Large spurt bleeding occurred in one case,and hemostasis was achieved by two other injections of undiluted glue. The injection catheter became blocked in 17 cases(2.71%) just during the injection,and 4 cases were complicated with the needle sticking to the varix. Large glue adhesion to the endoscope resulted in difficulty withdrawing the endoscope in 1 case. Bleeding from multiple sites was observed in the esophagus and gastric cardia after the endoscope was withdrawn. Hemostasis was achieved by 1% aethoxysklerol injection and intravenous somatostatin. The ligation device stuck to the varices in two cases during the subsequent endoscopic variceal ligation. In one case,the ligation device was successfully separated from the esophageal varix after all bands were released. In another case,a laceration of the vein and massive bleeding were observed. The bleeding ceased after 1% aethoxysklerol injection.CONCLUSION Although EGVO with tissue glue is usually safe and effective,a series of complications can occur during the procedure that may puzzle endoscopists. There is no standard operating procedure for addressing these complications. The cases described in the current study can provide some reference for others.

Successful endovascular treatment of endoscopically unmanageable hemorrhage from a duodenal ulcer fed by a renal artery: A case report

A 52-year-old woman was admitted with hypovolemic shock. Emergency endoscopy revealed three hemorrhagic duodenal ulcers(all stage A1) with exposed vessels. Two ulcers were successfully treated by endoscopic clipping; however, the remaining ulcer on the posterior wall of the horizontal portion of the duodenum could not be clipped. Because her vital signs were rapidly worsening, we performed transcatheter arterial embolization(TAE) as it is less invasive than surgery. Computed tomography aortography showed that the duodenal hemorrhage was sourced from the lower branch of the right renal artery. In general, the duodenum is fed by branches from the gastroduodenal artery or superior mesenteric artery. However, this patient had three right renal arteries. The lower branch of the right renal artery at the L3 vertebral level was at the same level as the horizontal portion of the duodenum. Complete hemostasis was achieved by TAE using metallic coils and n-butyl-2-cyanoacrylate. After TAE, she recovered from the hypovolemic shock and was discharged from hospital. She has had no recurrence of the hemorrhagic duodenal ulcer for over 1 yr, and followup endoscopy showed no necrosis or stricture of the duodenum. Although she developed a small infarct of her right kidney, her renal function was satisfactory. In summary, the present case is the first reported case of hemorrhagic duodenal ulcer in which the culprit vessel was a renal artery that was successfully treated by TAE. Computed tomography aortography before TAE provides valuable information regarding the source of a duodenal hemorrhage.

An ultra-sensitive and easy-to-use assay for sensing human UGT1A1 activities in biological systems

The human UDP-glucuronosyltransferase 1A1(UGT1A1),one of the most essential conjugative enzymes,is responsible for the metabolism and detoxification of bilirubin and other endogenous substances,as well as many different xenobiotic compounds.Deciphering UGT1A1 relevance to human diseases and characterizing the effects of small molecules on the activities of UGT1A1 requires reliable tools for probing the function of this key enzyme in complex biological matrices.Herein,an easy-to-use assay for highly-selective and sensitive monitoring of UGT1A1 activities in various biological matrices,using liquid chromatography with fluorescence detection(LC-FD),has been developed and validated.The newly developed LC-FD based assay has been confirmed in terms of sensitivity,specificity,precision,quantitative linear range and stability.One of its main advantages is lowering the limits of detection and quantification by about 100-fold in comparison to the previous assay that used the same probe substrate,enabling reliable quantification of lower amounts of active enzyme than any other method.The precision test demonstrated that both intra-and inter-day variations for this assay were less than 5.5%.Furthermore,the newly developed assay has also been successfully used to screen and characterize the regulatory effects of small molecules on the expression level of UGT1A1 in living cells.Ove rall,an easy-to-use LC-FD based assay has been developed for ultra-sensitive UGT1A1 activities measurements in various biological systems,providing an inexpensive and practical approach for exploring the role of UGT1A1 in human diseases,interactions with xenobiotics,and characterization modulatory effects of small molecules on this conjugative enzyme.

Sustained volume decreases in simple renal cysts after sclerotherapy using NBCA with or without hydrodissection

The present study aimed to determine the effectiveness of sclerotherapy using NBCA(Histoacryl Blue(?);B.Braun,Melgungen,Germany),with or without hydrodissection,for the treatment of simple renal cysts.Materials and Methods:Patients who presented to an interventional radiology clinic for the diagnosis of symptomatic renal cysts which had previously been identified at an outpatient clinic were selected for inclusion in this study.A total of 28 patients were randomly divided into 2 groups,based on whether or not they underwent hydrodissection along with ultrasound-guided NBCA-based sclerotherapy.Sonographs were performed at 0,7,and 180 days postprocedure to record the residual volume of the renal cysts and to determine the efficacy of the procedure.Results:A total of 32 cysts in 28 patients were treated with sclerotherapy,18(64%) females and 10(36%) males.The average age of the patients was 61.8 years(range:33-89 years).All patients reported an improvement in symptoms associated with the existing renal cysts at 7 and 180 days post-procedure,and at 7 days post-procedure a statistically significant reduction in cyst volume was observed(all patients:96.8%;group A:96%;group B:97.6%).The reduced cyst volume was still observed 180 days post-procedure(all patients:98.6%;group A:98.2%;group B:98.9%).There was no significant difference between the two treatment groups.Conclusion: There is a significant and persistent reduction in the volume of renal cysts,in addition to an improvement of the associated symptoms,after treatment with NBCA-based sclerotherapy,with or without hydrodissection.

组织粘合剂(N-butyl-2-cyanoacrylate)应用于顽固性非静脉曲张性胃肠出血的内镜治疗

目的:组织粘合剂(N-butyl-2-cyanoacrylate)在胃肠静脉曲张出血的应用价值已经得到了良好的体现,但其在非静脉曲张出血中的应用情况却不甚明了,也鲜有报道。方法:对6例顽固性胃肠非静脉曲张出血患者实施组织粘合剂注射止血。所有6例患者经保守止血和/或介入栓塞治疗无效,且由于严重的合并症或麻醉风险不宜行急诊手术。内镜止血采用“碘化油-组织粘合剂-碘化油”三明治注射技术。评估这些病例的临床结局和并发症。结果:6例患者中女性4例,男性2例,平均年龄55岁。出血原因包括胃溃疡2例,十二指肠溃疡2例,十二指肠胃肠间质瘤1例,直肠溃疡1例。所有患者经组织粘合剂注射均成功止血,无需补救性手术,亦无治疗相关的并发症和死亡发生。2例患者在初次组织粘合剂注射后仍有出血,经再次组织粘合剂注射成功止血。结论:组织粘合剂止血应作为顽固性非静脉曲张性胃肠出血的一种治疗选择。

Pulmonary embolism with septicemia after N-butyl-2-cyanoacrylate injection for bleeding gastric varices

Despite many advances in the treatment of gastric variceal bleeding in the two past decades, its management continues to present a clinical challenge. Various treatment modalities have been proposed and since the first report in 1986 endoscopic injection sclerotherapy with cyanoacrylate tissue adhesives has become widely established in many countries as the treatment of choice for bleeding gastric varices. Severe complications of the treatment are infrequent.