| Background and Objective:Although the incidence and bleeding rate of gastric varices in patients with portal hypertension of liver cirrhosis are lower than that of esophageal varices,the bleeding is often more fierce and difficult to control,with a high mortality rate.After the first hemorrhage,if the varices are not treated timely,the rate of patient's re-bleeding is very high.Currently,endoscopic gastric variceal obliteration(GVO)is recommended as the preferred treatment for gastric variceal varices due to its excellent therapeutic effect and relatively few complications,ectopic embolization is a rare but serious complication of GVO,even resulting in death of patients.For patients with gastric varices of GOV2 and IGV1 in Sarin classification,the presence of large(? 5mm)gastro-renal shunt increases the possibility of postoperative ectopic embolism of patients with GVO,which limits the use of GVO in such patients,as it is often accompanied by spontaneous shunt.Balloon-occluded retrograde transvenous obliteration(BRTO),currently commonly used for such patients,has good embolization effect and low re-bleeding rate,but it has problems such as high operational requirements,needing to be completed under high-intensity radioscopy,and postoperative patients with increased portal venous pressure worsening esophageal varices likely.In addition,for tansjugular intrahepatic portosystemic shunt(TIPS),due to the patient's frequent gastro-renal shunt,portal vein pressure was not very high,and the TIPS treatment alone was not effective in preventing re-bleeding.Treatment methods for such patients are still being explored.Based on theoretical analysis,we believe that titanium-clip assisted endoscopic cyanoacrylate injection is a simple and easy treatment method,which can effectively reduce the occurrence of ectopic embolism and may have better efficacy on the premise of ensuring the efficacy of GVO for gastric varices.Therefore,this study aims to introduce the operation method and experience of this technology and make a preliminary evaluation on the operability,safety and clinical efficacy of this treatment method,so as to judge whether this treatment method is worth further study and promotion.Methods:This study included 10 cases of patients with cirrhosis and gastric varices who were treated with titanium-clips assisted endoscopic cyanoacrylate injection in the department of gastroenterology,east hospital of Shandong Provincial Hospital from July 2018 to January 2019 for analysis.All patients were confirmed by gastroscopy to have recent bleeding of gastric fundus varices(?14 days),active bleeding or high-risk gastric fundus varices,and confirmed by enhanced abdominal CT and portal vein imaging to have large gastro-renal shunt(?5mm).Basic information,laboratory examination,imaging examination and endoscopic examination of all patients were collected.All patients were followed up after the operation and regularly reviewed the abdominal enhanced CT and digestive endoscopy.The follow-up was conducted in the form of outpatient service and telephone call,and the supplementary treatment,the time and cause of rebleeding,the time and cause of death,whether ectopic embolism occurred and the location and time of occurrence,and other complications were recorded.The operation success rate,varices elimination rate,re-bleeding rate,ectopic embolism and other complications of this treatment method were analyzed.Results:1.A total of 10 patients were included in this study,with a male to female ratio of 3:2 and an average age of(59.1±8.6)years;the etiology was mainly hepatitis b and alcoholic cirrhosis(70%);Child-Pugh classification included 4 cases of grade A,4 cases of grade B and 2 cases of grade C;in Sarin classification,there were 6 cases of IGV1 and 4 cases of GOV2;there were 9 patients with recent bleeding(?14 days),1 with red signs,and 3 with portal hypertensive gastropathy;the endoscopic morphology was nodular in 6 patients and tuberculiform in 4 patients,all of which were IGV1;the diameter of gastric varices was the smallest(1.5 cm),the largest(3.0 cm),and the mean(2.1±0.5)cm;The diameter of gastro-renal shunt was the smallest(5 mm),the largest(16 mm),and the average(10.3±3.6)mm.2.In this study,all the 10 patients were operated successfully for one time,and the technical success rate was 100%;At least 2 and at most 5 titanium-clips were used during the operation,with an average of(3.1 ± 1);The amount of cyanoacrylate was at least 2.0 ml and at most 7.5 ml,with an average of(4.8 ± 1.8)ml.3.The median follow-up time was 127 days,and the re-examination of enhanced CT showed that all the varices in the gastric fundus were basically disappeared in 10 patients.Endoscopic re-examination was performed in 7 patients,5 patients with gastric varices mass basically disappeared,2 patients with atrophy were treated with GVO as a supplementary treatment.One patient developed recurrent bleeding due to ulcer 2 months after operation,and was treated with BRTO.No patient developed ectopic embolism,and the rate of recurrent bleeding and the overall incidence of complications were 10%.Conclusions:1.The preliminary results are consistent with the expected performance of theoretical analysis.Titanium-clips assisted endoscopic cyanoacrylate inj ection therapy has shown l d high success rate and varices elimination rate in the treatment of patients with gastric tfundus varices with large gastro-renal shunts(?5mm),low re-bleeding rate and effective reduction of ectopic embolism occurrence.2.The safety and efficacy of titanium-clips assisted endoscopic cyanoacrylate injection in the treatment of patients with gastric varices with large gastro-renal shunts(?5mm)are worthy of further study and demonstration in a large multi-center randomized controlled trial,so as to provide a simple,easy,safe and reliable treatment method for such patients. |
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