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• W2023534730 abstract "We read with great interest the article by Tan et al.1Tan YM Goh KL Kamarulzaman A Tan PS Ranjeev P Salem O et al.Multiple systemic embolism with septicemia after gastric variceal obliteration.Gastrointest Endosc. 2002; 55: 276-278Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar on multiple systemic embolism with septicemia occurring after elective endoscopic treatment of bleeding gastric fundal varices. We believe the patient they treated had isolated gastric fundal varices (IGV1s) according to the classification of Sarin and Kumar.2Sarin SK Kumar A. Gastric varices: profile, classification, and management.Am J Gastroenterol. 1989; 84: 1244-1249PubMed Google Scholar They treated these varices by injection of a mixture of cyanoacrylate and Lipiodol (diluted 1:1.4). Because most IGV1s-type varices originate from the short and/or posterior gastric veins and drain into a well-developed gastrorenal shunt,3Watanabe 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 blood flow is abundant. When the volume injected and the dilution of cyanoacrylate increase, polymerization of the glue is delayed rather than instantaneous, so that the risk of systemic complications related to embolization through the gastrorenal shunt is increased. There have been reports of pulmonary embolism after injection of cyanoacrylate via this mechanism.4Türler A Wolff M Dorlars D Hirner A Embolic and septic complications after sclerotherapy of fundic varices with cyanoacrylate.Gastrointest Endosc. 2001; 53: 228-230Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 5Hwang SS Kim HH Park SH Kim SE Jung JI Ahn BY et al.N-butyl-2-cyanoacrylate pulmonary embolism after endoscopic injection sclerotherapy for gastric vericeal bleeding.J Comput Assist Tomo. 2001; 25: 16-22Crossref PubMed Scopus (109) Google Scholar Therefore, it would be important to know whether fluoroscopy during the procedure performed by Tan et al.1Tan YM Goh KL Kamarulzaman A Tan PS Ranjeev P Salem O et al.Multiple systemic embolism with septicemia after gastric variceal obliteration.Gastrointest Endosc. 2002; 55: 276-278Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar revealed that a certain portion of the cyanoacrylate had flowed into the inferior vena cava by means of a gastrorenal shunt and left renal vein. Although cyanoacrylate has been highly efficacious for control of acute bleeding from IGV1s, bleeding often recurs, even though the varices are eradicated initially.6Akahoshi T Hashizume M Shimabukuro R Tanoue K Tomikawa M Okita K et al.Long-term results of endoscopic histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience.Surgery. 2002; 131: S176-S181Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar Obliteration of feeding veins is also important for the prevention of recurrent bleeding. Thus, it would also be important to ask whether the varices treated by Tan et al.1Tan YM Goh KL Kamarulzaman A Tan PS Ranjeev P Salem O et al.Multiple systemic embolism with septicemia after gastric variceal obliteration.Gastrointest Endosc. 2002; 55: 276-278Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar changed after therapy. When the varices are not eradicated, additional treatment should be performed. However, the value of cyanoacrylate for treatment of IGV1s in the absence of active bleeding is controversial.7Binmoeller KF. Glue for gastric varices: some sticky issues.Gastrointest Endosc. 2000; 52: 298-301Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar We would be interested to know how Tan et al.1 treat residual varices in such patients. Balloon-occluded retrograde transvenous obliteration (B-RTO), a new radiologic technique, has been safely performed for the treatment of IGV1s associated with a gastrorenal shunt.8Binmoeller KF Borsatto R. Variceal bleeding and portal hypertension.Endoscopy. 2000; 32: 189-199Crossref PubMed Scopus (30) Google Scholar We reported the case of a patient with IGV1s treated by elective B-RTO.9Matsumoto A Matsumoto H Hamamoto N Kayazawa M. Prophylaxis of rebleeding from isolated gastric fundal varices by balloon-occluded retrograde transvenous obliteration.Abdom Imaging. 2001; 26: 578-580Crossref PubMed Scopus (1) Google Scholar After a single treatment with only 18 mL of ethanolamine oleate, the feeding vein, varices, and gastrorenal shunt were obliterated with no recurrence after 21 months. A prospective, randomized trial of cyanoacrylate versus B-RTO for prevention of recurrent bleeding from IGV1s should be performed. However, such a study would be difficult to carry out unless modified endoscopic injection techniques and new cyanoacrylate compounds can be developed. Accordingly, we recommend cyanoacrylate injection followed by B-RTO for the treatment of actively bleeding IGV1s. When IGV1s are not actively bleeding, elective B-RTO seems to be preferable, although further investigation is needed to confirm the long-term efficacy of B-RTO." @default.
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• W2023534730 title "What is the best method of treatment for gastric fundal varices without active bleeding?" @default.
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