Bucrylate treatment of bleeding gastric varices: 12 years' experience

Background and Study Aims: For several years now there has been an increasi ngly widespread use of a tissue adhesive in the treatment of bleeding gastr ic varices to achieve rapid, safe control of hemostasis and prevent rebleed ing. In this study we report on our experience with the use of Bucrylate (H ystoacryl) for the treatment of gastric varices over a period of more than a decade. Patients and Methods: Since 1988, 174 cirrhotic patients with actively blee ding gastric varices have been admitted to our department, where they recei ved emergency treatment with injections of Bucrylate. Any associated nonble eding esophageal varices were subjected to traditional sclerotherapy in com bination with the Bucrylate treatment. The gastric varices were subdivided into four distinct groups according to the method advocated by Sarin in 198 9. The patients under,vent weekly sclerotherapy sessions until their varice s were eradicated, and the follow-up with a mean of 36 months (range 9-90 m onths) consisted of endoscopy at 3, 6, and 12 months during the first year and then yearly checks to confirm obliteration of the varices. Results: The hemostasis (97.1%), early rebleeding (15.5%), and hospital mor tality (19.5%) rates of the patients with bleeding gastric varices, treated with the tissue adhesive, were very similar to those of patients treated f or esophageal varices over the same period (98.1%, 13.0%, and 16.4%, respec tively). The most frequent cause of death at 30 days was liver failure (76% of cases), followed by hemorrhagic shock (8.8%), and other less frequent c auses. Sclerotherapy achieved obliteration rate for gastric varices (70-75% ) similar to that for esophageal varices in those patients with portal hype rtension due to intrahepatic block (alcoholic and posthepatitis cirrhosis), but a rate of only 32% in the group of patients with prehepatic block (spl enoportomesenteric thrombosis), where surgery proved more effective (69%). The medium- and longterm survival rates depended on the stability of the pa tients' liver conditions, on rapid, effective control of variceal hemostasi s, and on complete, lasting obliteration of the gastric varices. Conclusions: The use of Bucrylate in emergency sclerotherapy achieved resul ts in bleeding gastric varices on a par with those obtained in esophageal v arices in cases of alcoholic and posthepatitis cirrhosis. The group of pati ents with portal hypertension due to prehepatic block (splenoportal thrombo sis) showed no benefit from sclerotherapy in terms of obliteration of gastr ic varices, but benefited from elective surgery. The choice of the oblitera ting treatment indicated may be facilitated by classifying gastric varices into distinct groups on the basis of anatomicotopographic criteria.