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• W2023473636 abstract "To the Editor: We read with great interest the article by Rengstorff and Binmoeller on the efficacy and the safety of 2-octyl cyanoacrylate for the treatment of gastric fundal varices.1.Rengstorff D.S. Binmoeller K.F. A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices in humans.Gastrointest Endosc. 2004; 59: 553-558Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar Although they stated that an advantage of 2-octyl cyanoacrylate was its longer polymerization time, compared with n-butyl-2-cyanoacrylate, the former might be washed away from the injection site when blood flow in a fundal varix is extremely rapid. Rengstorff and Binmoeller also stated that immediate control of acute variceal bleeding was achieved in 100% (3/3) of patients with 2-octyl cyanoacrylate injection. Did any of these 3 patients have isolated fundal varices (FV) that were type 1 IGV according to the classification of Sarin and Kumar?2.Sarin S.K. Kumar A. Gastric varices: profile, classification and management.Am J Gastroenterol. 1989; 84: 1244-1249PubMed Google Scholar Because most FV originate from the short and/or posterior gastric veins with a well-developed gastrorenal shunt, blood flow is more abundant than in other types of gastric varices.3.Watanabe K. Kimura K. Matsutani S. Ohto M. Okuda K. Portal hemodynamics in patients with gastric varices: a study in 230 patients with esophageal and/or gastric varices using portal vein catheterization.Gastroenterology. 1988; 95: 434-440Abstract PubMed Google Scholar Multidetector row CT angiography4.Willmann J.K. Weishaupt D. Bvhm T. Pfammatter T. Seifert B. Marincek B. et al.Detection of submucosal gastric fundal varices with multi-detector row CT angiography.Gut. 2003; 52: 886-892Crossref PubMed Scopus (52) Google Scholar provides excellent visualization of varices, as well as the feeding and the draining veins. Because Rengstorff and Binmoeller used undiluted 2-octyl cyanoacrylate, which cannot be visualized fluoroscopically, they could not assess the extent of the agent in the injected varices or in the feeding and the draining vessels. In addition, obliteration of feeding veins is important for the prevention of recurrent bleeding.5.Iwase H. Maeda O. Shimada M. Tsuzuki T. Peek R.M. Nishio Y. et al.Endoscopic ablation with cyanoacrylate glue for isolated gastric variceal bleeding.Gastrointest Endosc. 2001; 53: 585-592Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar Accordingly, 2-octyl cyanoacrylate diluted with a contrast agents, e.g., Lipiodol (Laboratoire Guerbet, Aulnay-Sous-Bois, France), should be injected under fluoroscopic monitoring in the elective or the prophylactic setting to avoid migration of the polymer into collateral veins, e.g., a gastrorenal shunt, and to confirm obliteration of the feeding veins (Figure 1, Figure 2, Figure 3). Irisawa et al.6.Irisawa A. Obara K. Sato A. Saito A. Orikasa H. Ohira H. et al.Adherence of cyanoacrylate which leaked from gastric varices to the left renal vein during endoscopic injection sclerotherapy: a histopathologic study.Endoscopy. 2000; 32: 804-806Crossref PubMed Scopus (38) Google Scholar proposed that the dilution rate of cyanoacrylate with Lipiodol should be more than 62.5% or that another method should be selected when the diameter of the FV is over 12 mm. Therefore, we need to know the dilution rate of n-butyl-2-cyanoacrylate that has the same obliterative effect on FV as undiluted 2-octyl cyanoacrylate.Figure 2Fluoroscopic image during endoscopic injection of n-butyl-2-cyanoacrylate–Lipiodol mixture (1:1), showing filling of varices and feeding vein.View Large Image Figure ViewerDownload (PPT)Figure 3Multidetector row CT angiography after cyanoacrylate injection, showing obliteration of varices and feeding vein.View Large Image Figure ViewerDownload (PPT) We recommend cyanoacrylate injection followed by balloon-occluded retrograde transvenous obliteration (B-RTO) for the treatment of actively bleeding FV,7.Izumiya T. Matsumoto A. Nomura T. Itabashi T. Balloon-occluded retrograde transvenous obliteration as adjunctive treatment for gastric varices: case report.Gatrointest Endosc. 2004; 59: 156-158Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar whereas elective B-RTO seems to be preferable if the FV are not actively bleeding8.Matsumoto A. Matsushita M. Inokuchi H. How should isolated gastric fundal varices be treated?.Endoscopy. 2003; 35: 794-795Crossref PubMed Scopus (1) Google Scholar and are associated with a gastrorenal shunt. A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices in humansGastrointestinal EndoscopyVol. 59Issue 4PreviewN-butyl cyanoacrylate injection has been shown to be effective and safe for the endoscopic treatment of gastric varices. N-butyl cyanoacrylate is not available in the United States, but use of a similar agent, 2-octyl cyanoacrylate, recently was approved for skin closure. This pilot study prospectively evaluated the efficacy and safety of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices. Full-Text PDF Response:Gastrointestinal EndoscopyVol. 60Issue 6PreviewWe appreciate the opportunity to respond to the comments of Drs. Matsumo, Takimoto, Kuchide, Yamauchi, and Takemura. One of the main issues regarding the use of cyanoacrylate injection for treatment of gastric varices is proper polymerization time. If the glue polymerizes too quickly, the injector needle will clog and possibly become affixed to the varix. This has been reported with the use of n-butyl 2-cyanoacrylate.1 If polymerization occurs too slowly, the glue will not solidify within the varix and may lead to embolization. Full-Text PDF" @default.
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• W2023473636 title "Is the cyanoacrylate analogue, 2-octyl cyanoacrylate, a promising treatment for gastric fundal varices?" @default.
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