EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video).

BACKGROUND AND AIMS: Conventional endoscopic treatment of gastric fundal varices (GFV) with cyanoacrylate (CYA) glue may be complicated by embolization and rebleeding. We evaluated the long-term outcomes of EUS-guided injection of coils and CYA glue for therapy of GFV. METHODS: A retrospective chart review of patients treated for GFV was performed. The main outcomes measured were hemostasis, obliteration on surveillance EUS, post-treatment bleeding rate, and adverse events. RESULTS: From March 2009 to 2015, 152 patients with GFV were treated. Seven (5%) had active hemorrhage, 105 (69%) had recent bleeding, and 40 (26%) were treated for primary prophylaxis. Treatment was technically successful in 151 patients (>99%). Mean number of coils was 1.4 (range, 1-4 coils), and mean volume of CYA was 2 mL (range, 0.5-6). Follow-up was available for 125 patients with treated GFV (mean, 436 days; range, 30-2043). Among 100 patients with follow-up EUS examinations, complete obliteration (on Doppler study) of GFV was confirmed in 93 (93%). Post-treatment bleeding from obliterated GFV occurred in 3 of 93 patients (3%). Twenty-five patients who had clinical and/or EGD follow-up had 3 post-treatment bleeding episodes after a median follow-up of 324 days (range, 41-486). Among the 40 patients treated for primary prophylaxis, 28 underwent follow-up EUS and 27 (96%) had confirmed obliteration. Mild postprocedure abdominal pain occurred in 4 of 125 patients (3%), and clinical signs of pulmonary embolization were seen in 1 patient (1%). Another 4 of 125 patients (3%) presented with minor delayed upper GI bleeding from coil/glue extrusion. CONCLUSIONS: EUS-guided combined coil and CYA glue injection of high-risk GFV appears to be highly effective for hemostasis in active bleeding and primary and secondary bleeding prophylaxis. Once obliteration was achieved, post-treatment bleeding from GFV occurred in only 3% during long-term follow-up. Combination therapy appears safe and may reduce the risk of CYA embolization.

Role of growth factors in the treatment of patients with HIV/HCV coinfection and patients with recurrent hepatitis C following liver transplantation.

Hepatitis C (HCV) contributes significantly to the morbidity and mortality of patients coinfected with human immunodeficiency virus (HIV) and those with recurrent hepatitis C after successful liver transplantation. Treatment of hepatitis C in these patient populations, while crucial, can be quite challenging. Baseline cytopenias, in particular, may limit dosing of interferon and/or ribavirin or preclude therapy entirely when standard guidelines are followed. Concomitant medications, opportunistic infections, and other bone marrow insults account for the anemia, neutropenia, and thrombocytopenia frequently encountered in these patients. Sustained virologic response rates in published series for HIV/HCV and post-transplantation HCV have not reached those seen in treatment of HCV alone, despite the highly selected patient populations chosen for these studies. Hematopoietic growth factors such as erythropoietin and granulocyte-colony stimulating factors may be used to improve the anemia and neutropenia seen during treatment of HCV. Reported experience with these growth factors is limited in HIV/HCV coinfected patients, but studies are underway to determine if growth factors improve adherence to therapy and perhaps virologic response rates. Post-transplantation studies of HCV therapy have reported more liberal use of growth factors; however, discontinuation rates have been high and virologic response rates have been disappointing. Further study of growth factors as a means to increase sustained virologic response rates and maintain adequate dosing and duration of interferon and ribavirin therapy in these patient populations is needed.