Percutaneous transcatheter super-selective renal arterial embolization with N-butyl cyanoacrylate for iatrogenic renal hemorrhage

Background:To evaluate the safety and efficacy of percutaneous transcatheter super-selective renal arterial embolization(SRAE)with N-butyl cyanoacrylate(NBCA)for iatrogenic renal hemorrhage.Methods:Between January 2014 and December 2019,45 patients(including 18 patients with coagulopathy),who underwent percutaneous transcatheter SRAE with NBCA for iatrogenic renal hemorrhage at our institution,were retrospectively reviewed.The technical success rate,clinical success rate,and embolization-related complications were analyzed.The values of estimated glomerular filtration rate(eGFR),serum creatinine(sCr),and serum urea(sUr)were analyzed at the time of pre-SRAE,post-SRAE,and last follow-up to evaluate the effects of NBCA-based SRAE on renal function.Results:Diagnostic renal arteriography revealed contrast extravasation in 18 patients and pseudoaneurysms in 27 patients.NBCA mixed with iodized oil in a 1:2–1:4 ratio was the sole embolic agent.No procedure-related mortality or major complications occurred.The technical and clinical success rates were both 100%.The values of eGFR,sCr and sUr were not found to be significantly different between pre-SRAE,post-SRAE and last follow-up(eGFR:91.52±21.17 vs.90.98±22.11 vs.92.14±23.51 mL/min/1.73 m^(2),p=0.729;sCr:74.73±11.08 vs.75.27±12.43 vs.73.95±10.14μmol/L,p=0.543;sUr:5.69±0.84 vs.5.71±0.96 vs.5.70±0.79,p=0.515,respectively).Conclusions:Percutaneous transcatheter SRAE with NBCA is a safe and effective treatment modality for iatrogenic renal hemorrhage with no deterioration of renal function.

High-gravity technology intensified Knoevenagel condensation-Michael addition polymerization of poly (ethylene glycol)-poly (n-butyl cyanoacrylate) for blood-brain barrier delivery

Poly(ethylene glycol)-poly(n-butyl cyanoacrylate)(PEG-PBCA)is a remarkable drug delivery carrier for permeating blood-brain barrier.In this work,a novel high-gravity procedure was reported to intensify Knoevenagel condensation-Michael addition polymerization of PEG-PBCA.A series of PEG-PBCA containing different block ratios were synthesized with narrow molecular weight distribution of polydispersity indexes less than 1.1.Furthermore,the reaction time reduced 60%compared to conventional stirred tank reactor process.Chemical structures of as-prepared polymers were characterized.In vitro drug delivery performance was evaluated.The cytotoxicity of PEG-PBCA to brain microvessel endothelial cells(BMVEC)decreases with the extension of the PEG chain and the shortening of the PBCA chain.The polymer cellular uptake to BMVECs was better after improving hydrophilicity by PEG block.Results of bloodbrain barrier permeability demonstrated that medium length of PBCA chain and short PEG chain are favorable for hydrophobic Nile red permeation,while long PEG chain and short PBCA chain are beneficial to delivery water-soluble doxorubicin hydrochloride(Dox).The average apparent permeability coeffi-cient increased 1.7 and 0.25 times than that of raw Nile red and Dox,respectively.High-gravity intensi-fied condensation polymerization should have great potential in brain drug delivery system.

Safety of bronchial arterial embolization with n-butyl cyanoacrylate in a swine model

AIM: To compare the efficacy and safety of bronchial artery embolization (BAE) with n-butyl cyanoacrylate (NBCA) and gelatin sponge particles (GSPs). METHODS: Six healthy female swine were divided into two groups to be treated with BAE using NBCA-lipiodol (NBCA-Lp) and using GSPs. The occlusive durability, the presence of embolic materials, the response of the vessel wall, and damage to the bronchial wall and pulmonary parenchyma were compared. RESULTS: No animals experienced any major complication. Two days later, no recanalization of the bronchial artery was observed in the NBCA-Lp group, while partial recanalization was seen in the GSP group. Embolic materials were not found in the pulmonary artery or pulmonary vein. NBCA-Lp was present as a bubble-like space in bronchial branch arteries of 127-1240 μm, and GSPs as reticular amorphous substance of 107-853 μm. These arteries were in the adventitia outside the bronchial cartilage but not in the fine vessels inside the bronchial cartilage. No damage to the bronchial wall and pulmonary parenchyma was found in either group. Red cell thrombus, stripping of endothelial cells, and infiltration of inflammatory cells was observed in vessels embolized with NBCA-Lp or GSP. CONCLUSION: NBCA embolization is more potent than GSP with regard to bronchial artery occlusion, and both materials were present in bronchial branch arteries≥100 μm diameter.

Efficacy of Cyanoacrylate Tissue Adhesive Application in the Management of Corneal Perforations at Preah Ang Duong Hospital in Cambodia

Purpose: The study was to evaluate the efficacy of cyanoacrylate tissue adhesive (CTA) application in corneal perforations. Method: This was a prospective study on 20 patients of corneal perforations who received cyanoacrylate tissue adhesive application as treatment between March 2021 and March 2022 at Preah Ang Duong Hospital. The primary outcome measure was success rate of CTA application, while the secondary outcome was to measure postoperative best-corrected visual acuity (BCVA) and ocular complications. Results: The mean age of patients was 44.15 ± 16.05 years old and 7 (35%) were female. Causes of perforation were microbial infection in 12 patients (60%), trauma in 5 patients (25%), and sterile melting in 3 patients (15%). The perforation of size smaller than 1.5 mm was in 8 patients (40%) while 12 patients (60%) had perforated size between 1.5 mm to 3 mm. The perforation was 60% (12 patients) central, 25% (5 patients) paracentral, and 15% (3 patients) peripherally. Out of 20 patients, 5 patients (25%) received CTA application more than 1 time. The mean glue retention was 57.60 ± 31.84 days. Success rate of glue application (defined as intact globe without surgical intervention regardless of number of CTA applications) was 85%. At the last visit, 7 patients (35%) had BCVA of 6/120 or better. Common complications were uveitis (45%), ocular hypertension (30%), cataract (25%) and neovascularization (20%). No serious complications were found. Conclusion: Cyanoacrylate tissue adhesive is an effective treatment option in sealing corneal perforations with no serious complications. .

Gastric Variceal Bleeding: The Efficacy and Safety of N-Butyl-2-Cyanoacrylate Glue Injection

Aims: To assess N-2-butyl cyanoacrylate injection’s effectiveness and safety in the treatment of gastric varix hemorrhage. Methods: Endoscopic treatment with N-Butyl-2-cyanoacrylate injection was performed on 32 patients (21 males and 11 females) with gastric variceal bleeding. The socioeconomic status of the patients, initial hemostasis, rebleeding rate, complications, and mortality rate were all reviewed retrospectively. Patients with liver cirrhosis who presented with hematemesis or melena or whose endoscopy revealed gastric variceal bleeding were included. Therefore, patients with hemodynamic instability were excluded. Results: A total of 32 patients underwent Histoacryl® glue injection to treat bleeding gastric varices. The mean age was 56.09 ± 9.29 (mean ± SD) years old. Viral hepatitis is the leading cause of chronic liver disease, both hepatitis B and C accounted for 11 cases (34.4%). IGV1 was the most commonly seen, according to the Sarin classification, with 15 cases (46.8%), followed by GOV1 with 10 cases (31.3%) and GOV2 with 7 cases (21.9%). With 15 cases (46.9%), the majority of patients had a Child-Pugh (CTP) B score. 12 cases (37.5%) and 11 (34.4%), respectively, of hematemesis and melena, were reported. In all patients, initial hemostasis was achieved, and there was no documented complication rate. Conclusion: Given the higher rate of hemostasis and great results, our study’s findings indicate that the injection of N-butyl-2-cyanoacrylate under endoscopic guidance is safe and effective in the management of GV hemorrhage. After the initial injection, hemostasis was achieved in all of our patients.

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

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.

Prevalence of gastric varices and results of sclerotherapy with N-butyl 2 cyanoacrylate for controlling acute gastric variceal bleeding

AIM: To study the prevalence, predictors and control of bleeding following N-butyl 2 cyanoacrylate (NBC) sclerotherapy of gastric varix (GV). METHODS: We analyzed case records of 1436 patients with portal hypertension, who underwent endoscopy during the past five years for variceal screening or upper gastrointestinal (GI) bleeding. Fifty patients with bleeding GV underwent sclerotherapy with a mean of 2 mL NBC for control of bleeding. Outcome parameters were primary hemostasis (bleeding control within the first 48 h), recurrent bleeding (after 48 h of esophago- gastro-duodenoscopy) and in-hospital mortality were analyzed. RESULTS: The prevalence of GV in patients with portal hypertension was 15% (220/1436) and the incidence of bleeding was 22.7% (50/220). Out of the 50 bleeding GV patients, isolated gastric varices (IGV-I) were seen in 22 (44%), gastro-oesophageal varices (GOV) on lesser curvature (GOV-Ⅰ) in 16 (32%), and GOV on greater curvature (GOV-Ⅱ) in 15 (30%). IGV-Ⅰ was seen in 44% (22/50) patients who had bleeding as compared to 23% (39/170) who did not have bleeding (P < 0.003). Primary hemostasis was achieved with NBC in all patients. Re-bleeding occurred in 7 (14%) patients after 48 h of initial sclerotherapy. Secondary hemostasis was achieved with repeat NBC sclerotherapy in 4/7 (57%). Three patients died after repeat sclerotherapy, one during transjugular intrahepatic portosystemic stem shunt (TIPSS), one during surgery and one due to uncontrolled bleeding. Treatment failure-related mortality rate was 6% (3/50). CONCLUSION: GV can be seen in 15% of patients withportal hypertension and the incidence of bleeding is 22.7%. NBC is highly effective in controlling GV bleeding. In hospital mortality of patients with bleeding GV is 6%.

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.

Study of glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding

AIM:To investigate glue extrusion after endoscopic N-butyl-2-cyanoacrylate injection on gastric variceal bleeding and to evaluate the long-term efficacy and safety of this therapy.METHODS:A total of 148 cirrhotic patients in our hospital with esophagogastric variceal bleeding(EGVB) were included in this study.N-butyl-2-cyanoacrylate was mixed with lipiodol in a 1:1 ratio and injected as a bolus of 1-3 mL according to variceal size.Patients underwent endoscopic follow-up the next week,fourth week,second month,fourth month,and seventh month after injection and then every 6 mo to determine the cast shape.An abdominal X-ray fi lm and ultrasound or computed tomographic scan were also carried out in order to evaluate the time of variceal disappearance and complete extrusion of the cast.The average follow-up time was 13.1 mo.RESULTS:The instantaneous hemostatic rate was 96.2%.Early re-bleeding after injection in 9 cases(6.2%) was estimated from rejection of adhesive.Late re-bleeding occurred in 12 patients(8.1%) at 2-18 mo.The glue cast was extruded into the lumen within one month in 86.1% of patients and eliminated within one year.Light erosion was seen at the injection position and mucosa edema in the second week.The glue casts were extruded in 18 patients(12.1%) after one week and in 64 patients(42.8%) after two weeks.All kinds of glue clumping shapes and colors on endoscopic examination were observed in 127 patients(86.1%) within one month,including punctiform,globular,pillar and variform.Forty one patients(27.9%) had glue extrusion after 3 mo and 28 patients(28.9%) after six months.The extrusion time was not related to the injection volume of histoacryl.Obliteration was seen in 70.2%(104 cases) endoscopically.The main complication was re-bleeding resulting from extrusion.The prognosis of the patients depended on the severity of the underlying liver disease.CONCLUSION:Endoscopic injection of cyanoacrylate is highly effective for gastric varices bleeding.The glue clump shape is correlated with anatomic structure of vessels.The time of extrusion was not related to dosage of the glue.

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.

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.

Non-variceal upper gastrointestinal bleeding: Rescue treatment with a modified cyanoacrylate

AIM To evaluate the safety and efficacy of a modified cyanoacrylate [N-butyl-2-cyanoacrylate associated with methacryloxysulfolane(NBCA + MS)] to treat nonvariceal upper gastrointestinal bleeding(NV-UGIB).METHODS In our retrospective study we took into account 579 out of 1177 patients receiving endoscopic treatment for NV-UGIB admitted to our institution from 2008 to 2015; the remaining 598 patients were treated with other treatments. Initial hemostasis was not achieved in 45 of 579 patients; early rebleeding occurred in 12 of 579 patients. Thirty-three patients were treated with modified cyanoacrylate: 27 patients had duodenal, gastric or anastomotic ulcers, 3 had post-mucosectomy bleeding, 2 had Dieulafoy's lesions, and 1 had duodenal diverticular bleeding.RESULTS Of the 45 patients treated endoscopically without initialhemostasis or with early rebleeding, 33(76.7%) were treated with modified cyanoacrylate glue, 16(37.2%) underwent surgery, and 3(7.0%) were treated with selective transarterial embolization. The mean age of patients treated with NBCA + MS(23 males and 10 females) was 74.5 years. Modified cyanoacrylate was used in 24 patients during the first endoscopy and in 9 patients experiencing rebleeding. Overall, hemostasis was achieved in 26 of 33 patients(78.8%): 19 out of 24(79.2%) during the first endoscopy and in 7 out of 9(77.8%) among early rebleeders. Two patients(22.2%) not responding to cyanoacrylate treatment were treated with surgery or transarterial embolization. One patient had early rebleeding after treatment with cyanoacrylate. No late rebleeding during the follow-up or complications related to the glue injection were recorded.CONCLUSION Modified cyanoacrylate solved definitively NV-UGIB after failure of conventional treatment. Some reported life-threatening adverse events with other formulations, advise to use it as last option.

Endoscopic cyanoacrylate injection for the treatment of gastric varices in children

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 m L).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.

Successful balloon-occluded retrograde transvenous obliteration for bleeding duodenal varices using cyanoacrylate

A 76-year-old woman with hepatitis C cirrhosis presented with tarry stools and hematemesis.An endoscopy demonstrated bleeding duodenal varices in the second portion of the duodenum.Contrast-enhanced computed tomography revealed markedly tortuous varices around the wall in the duodenum.Several afferent veins appeared to have developed,and the right ovarian vein draining into the inferior vena cava was detected as an efferent vein.Balloon-occluded retrograde transvenous obliteration (BRTO) of the varices using cyanoacrylate was successfully performed in combination with the temporary occlusion of the portal vein.Although no previous publications have used cyanoacrylate as an embolic agent for BRTO to control bleeding duodenal varices,this strategy can be considered as an alternative procedure to conventional BRTO using ethanolamine oleate when numerous afferent vessels that cannot be embolized are present.

Bleeding gastric varices: Results of endoscopic injection with cyanoacrylate at King Chulalongkorn Memorial Hospital

AIM: To evaluate the efficacy and safety of gastric varices injection with cyanoacrylate in patients with gastric variceal bleeding.METHODS: Twenty-four patients (15 males, 9 females) with gastric variceal bleeding underwent endoscopic treatment with cyanoacrylate injection. Successful hemostasis, rebleeding rate, and complications were retrospectively reviewed. Followed up endoscopy was performed and repeat cyanoacrylate injection was given until gastric varices were obliterated. RESULTS: Seventeen patients achieved definite hemostasis. Of these, 14 patients had primary success after initial endoscopic therapy. Ten patients developed recurrent bleeding. Repeated cyanoacrylate injection stopped rebleeding in three patients. Transjugular intrahepatic portosystemic shunt (TIPS) was performed to control rebleeding in one patient which occured after repeat endoscopic therapy. Six patients died (three from uncontrolled bleeding, two from sepsis, and one from mesenteric vein thrombosis). Minor complications occurred in 11 patients (six epigastric discomfort and five post injection ulcers). Cyanoacrylate embolism developed in two patients. One of these patients died from mesenteric vein thrombosis. The other had pulmonary embolism which resolved spontaneously. Advanced cirrhosis and hepatocellular carcinoma (HCC) were major risk factors for uncontrolled bleeding.CONCLUSION: Endoscopic treatment for bleeding gastric varices with cyanoacrylate injection is effective for immediate hemostasis. Repeat cyanoacrylate injection has a lower success rate than the initial injection.Cyanoacrylate embolism is not a common serious complication.

Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol

Two patients with liver cirrhosis and portal hyper-tension related to hepatitis infection were admitted to Shanghai Ruijin Hospital due to recurrent melena and hematemesis. Isolated gastric varices were observed in the gastric fundus during the retroflexion of gastroscope. We carried out endoscopic sclerotherapy successfully for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol, which disappeared dramatically several months after two courses of sclerotherapy for each patient. No complication and clinical signs of gastrointestinal re-bleeding were observed during the 6-mo endoscopic follow-up. CT portal angiography (CTPA) has been widely used in the assessment of variceal treatment and improves the results of endoscopic injection therapy.

Efficacy and safety of endoscopic prophylactic treatment with undiluted cyanoacrylate for gastric varices

AIM:To evaluate the efficacy and safety of undiluted N-butyl-2 cyanoacrylate plus methacryloxysulfolane(NBCM)as a prophylactic treatment for gastric varices(GV)bleeding.METHODS:This prospective study was conducted at a single tertiary-care teaching hospital between October 2009 and March 2013.Patients with portal hypertension(PH)and GV,with no active gastrointestinal bleeding,were enrolled in primary prophylactic treatment with NBCM injection without lipiodol dilution.Initial diagnosis of GV was based on endoscopy and confirmed with endosonography(EUS); the same procedure was used after treatment to confirm eradication of GV.After puncturing the GV with a regular injection needle,1 mL of undiluted NBCM was injected intranasally into GV.The injection was repeated as necessary to achieve eradication or until a maximum total volume of 3 mL of NBCM had been injected.Patients were followed clinically and evaluated with endoscopy at 3,6 and 12 mo.Later follow-ups were performed yearly.The main outcome measures were efficacy(GV eradication),safety(adverse events related to cyanoacrylate injection),recurrence,bleeding from GV and mortality related to GV treatment.RESULTS:A total of 20 patients(15 male)with PH and GV were enrolled in the study and treated with undiluted NBCM injection.Only 2(10%)patients had no esophageal varices(EV); 18(90%)patients were treated with endoscopic band ligation to eradicate EV before inclusion in the study.The patients were followed clinically and endoscopically for a median of 31 mo(range:6-40 mo).Eradication of GV was observed in all patients(13 patients were treated with 1 session and 7 patients with 2 sessions),with a maximum injected volume of 2 mL NBCM.One patient had GV recurrence,confirmed by EUS,at 6-mo follow-up,and another had late recurrence with GV bleeding after 35 mo of follow-up; overall,GV recurrence was observed in 2 patients(10%),after 6 and 35 mo of follow-up,and GV bleeding rate was 5%(1 patient).Mild epigastric pain was reported by 3 patients(15%).No mortality or major complications,including embolism,or damage to equipment were observed.CONCLUSION:Endoscopic injection with NBCM,without lipiodol,may be a safe and effective treatment for primary prophylaxis of gastric variceal bleeding.

Comparison of modified percutaneous transhepatic variceal embolization and endoscopic cyanoacrylate injection for gastric variceal rebleeding

AIM:To compare the efficacy of modified percutaneous transhepatic variceal embolization(PTVE)with 2-octyl-cyanoacrylate(2-OCA)and endoscopic variceal obturation(EVO)with an injection of 2-OCA for prophylaxis of gastric variceal rebleeding. METHODS:In this retrospective study,the medical records of liver cirrhosis patients with gastric variceal bleeding who underwent either endoscopic 2-OCA(EVO) or modified PTVE using 2-OCA at Shandong Provincial Hospital from January 2006 to December 2008 were reviewed.Patient demographics,rebleeding rate,survival rate,and complications were compared between the two groups(PTVE and EVO).All results were expressed as mean±SD,or as a percentage.Quantitative variables were compared by two sample Student t tests, and qualitative variables were compared by the Fisher exact test or theχ 2 test(with Yates correction)where appropriate.A P value less than 0.05 was considered significant.Statistical computation was performed using SPSS 13.0 software. RESULTS:A total of 77 patients were included;45 patients who underwent EVO and 32 patients who received PTVE.During the follow-up(19.78±7.70 mo in the EVO group,vs 21.53±8.56 mo in the PTVE group) rebleeding occurred in 17 patients in the EVO group and in 4 patients in the PTVE group(37.78%vs 12.5%, P=0.028).The cumulative rebleeding-free rate was 75%,59%,and 49%in 1,2,and 3 years respectively for EVO,and 93%,84%,and 84%for PTVE(P=0.011). Cox analysis was used to identify independent factors that predicted rebleeding after treatment.Variables including age,gender,cause,Child-Pugh classification, size of gastric varices(GV),location of GV,and treatment methods were analyzed.It was revealed that Child-Pugh classification[risk ratio(RR)2.10,95%CI:1.03-4.28,P=0.040],choice of treatment(RR 0.25, 95%CI:0.08-0.80,P=0.019),and size of GV(RR 2.14, 95%CI:1.07-4.28,P=0.032)were the independent factors for predicting rebleeding.Follow-up computed tomography revealed that cyanoacrylate was retained in the varices and in the feeding veins of PTVE patients. During the follow-up,eight patients in the EVO group and four patients in the PTVE group died.The cumulative survival rates at 1,2,and 3 years were 93%,84%, and 67%respectively in the EVO group,and 97%, 88%,and 74%respectively in the PTVE group.The survival rates were not significantly different between the two groups(P=0.432).Cox analysis showed that the Child-Pugh classification was the most significant prognostic factor of survival(RR 2.77,95%CI:1.12-6.80,P=0.027).The incidence of complications was similar in both groups. CONCLUSION:With extensive and permanent obliteration of gastric varices and its feeding veins,PTVE with 2-OCA is superior to endoscopic 2-OCA injection for preventing gastric variceal rebleeding.

Endoscopic management of Dieulafoy's lesion using Isoamyl-2-cyanoacrylate

Dieulafoy's lesion (DL) is a rare but important cause of obscure gastrointestinal bleeding that may be over-looked during diagnostic endoscopy. Mortality rates are similar to those of other causes for gastrointestinal bleeding. Diagnosis by upper endoscopy is the modal-ity of choice during acute bleeding. In the absence of active bleeding, the lesion resembles a raised nipple or visible vessel. There are no guidelines regarding effective selective therapy for DL, when diagnosed, en-doscopist experience is the major determinant of the treatment strategy. Following our strategy, an expert endoscopist with a skilled assistant should have a high rate of successful DL diagnosis when an obscured gas-trointestinal lesion is suspected. Cyanoacryltes com-pounds have been used successfully in management of Gastric varices and DLs. To our knowledge, there have been no previous reports regarding use of isoamyl-2-cyanoacrylate (AMCRYLATE ; Concord Drugs Ltd.,Hyderabad, India) as an effective therapy for gastric DL without serious complications. In our case study, Isoamyl-2-cyanoacrylate (AMCRYLATE) was effective and safe for treating DL. Surgical wedge resection of the lesion should be considered as a therapeutic option if endoscopic therapy fails.

2-Octyl Cyanoacrylate Skin Adhesive for Topical Skin Incision Closure in Female Pelvic Surgery

Background: 2-octyl cyanoacrylate (2OCA) high viscosity tissue adhesive (Medline Industries, Inc., Mundelein, IL) is a liquid topical skin adhesive. 2OCA offers the same design features and clinical utility in terms of flexibility, strength, and low complication rate as the commercially available 2OCA tissue adhesives. Additionally, 2OCA features high viscosity allowing for better control during the application process, polymerization without the use of an external activator, and a distinctive violet color for ease of application visualization. Objective: The aim of this prospective case series is to descriptively report clinical data with the application of 2OCA as a topical incision closure system in female pelvic surgery. The primary outcomes included: incisional pain, incisional dehiscence, and post-operative bleeding. The secondary outcome included drying times of the adhesive with regard to incision length. Methods: A prospective open-label observational case series study was conducted to evaluate the use of 2OCA in surgical wound closure of the topical skin in adult patients undergoing gynecologic surgical procedures. A total of 50 adult women undergoing gynecologic surgery were enrolled. 2OCA was applied only by surgeons who had undergone product training to the incisions in a standardized, protocol-defined fashion. Drying times for the adhesive and photography were recorded intraoperatively. Post treatment follow-up was conducted with queries of pain level, incisional dehiscence, and incisional bleeding immediately post-operatively, 48 hours, 5 - 10 days and 14 days post-treatment. Adverse events were documented. Results: 2OCA was applied to a total of 154 incisions from the 50 patients enrolled to the study. The procedures included: 16 laparoscopic total hysterectomies, 4 diagnostic laparoscopies, 2 laparoscopic myomectomies, 2 laparoscopic bilateral or unilateral salpingo-oophorectomies, 5 total robotic-assisted laparoscopic surgeries (2 total hysterectomies, 1 supracervical hysterectomy, 1 sacrocolpopexy, and one excision of endometriosis), 7 sacral neuromodulation procedures, and 18 midurethral slings. The overall rate of incisional dehiscence was 3% (4/154). The rate of reported incisional bleeding was 3% (4/154). There was 1 incisional infection. The pain reports based on a 10-point scale had a mean of 4.96 immediately post-operatively, which decreased to a mean score < 1 (0.2) by post-op day (POD) 14. The mean drying times for the various lengths of incisions included the following: 1.28 minutes for incisions ≤ 5 mm, 1.53 minutes for 6 - 8 mm, 1.66 minutes for 10 mm - 20 mm, and 1.57 minutes for the 40 - 50 mm incisions. In 23% (36/154) of incisions 2OCA was the sole method of skin closure. Conclusion: This study demonstrates that 2OCA is safe to use in gynecologic surgical incisions with low rates of post-operative incisional bleeding and incisional dehiscence. Post-operative reports of pain maintained expected levels for recovery. 2OCA is a practical alternative or augmentation to traditional suture closure of skin incisions at the time of gynecologic surgery.