EUS-Guided Thrombin Injection and Coil Implantation for Gastric Varices: Feasibility, Safety, and Outcomes.

BACKGROUND AND AIMS: Gastric varices (GV) are reported in up to 20% of patients with portal hypertension, and bleeding is often more severe and challenging than oesophageal variceal bleeding. There is limited data on prophylaxis of GV bleeding or management in the acute setting, and different techniques are utilised. This study aims to evaluate outcomes following endoscopic ultrasound (EUS) guided placement of coils in combination with thrombin to manage GV. METHODS: We retrospectively reviewed all patients treated with combination EUS-guided therapy with coils and thrombin between October 2015 and February 2020. RESULTS: 20 patients underwent 33 procedures for GV therapy; 16/20 (80%) were type 1 Isolated GV (IGV1), and the remainder were type 2 Gastroesophageal Varices (GOV2). Median follow-up was 842 days (Interquartile range (IQR) 483-961). 17/20 (85%) had underlying cirrhosis, the most common aetiologies being alcohol-related liver disease and non-alcoholic steatohepatitis (NASH). The median Child-Pugh (CP) score was 6 (IQR 5-7). In 11/20 (55%) cases, the indication was secondary prophylaxis to prevent rebleeding; in 2/20 (10%), the bleeding was acute. Technical success was achieved in 19/20 (95%) of cases. During follow-up, the obliteration of flow within the varices was achieved in 17/20 (85%) cases. The 6-week survival was 100%, and 2 adverse events were reported: cases of rebleeding at day 5 and day 37; both rebleeds were successfully managed endoscopically. CONCLUSIONS: EUS-guided GV obliteration combining coil placement with thrombin, in our experience, is technically safe with good medium-term efficacy. A multicenter randomised controlled trial comparing different treatment strategies would be desirable to understand options better.

Technical and clinical outcomes following EUS-guided thrombin injection and coil implantation for parastomal varices.

BACKGROUND AND AIMS: Bleeding from parastomal varices causes significant morbidity and mortality. Treatment options are limited, particularly in high-risk patients with significant underlying liver disease and other comorbidities. The use of EUS-guided embolisation coils combined with thrombin injection in gastric varices has been shown to be safe and effective. Our institution has applied the same technique to the treatment of parastomal varices. METHODS: A retrospective review was performed of 37 procedures on 24 patients to assess efficacy and safety of EUS-guided injection of thrombin, with or without embolisation coils for treatment of bleeding parastomal varices. All patients had been discussed in a multidisciplinary team meeting, and correction of portal hypertension was deemed to be contraindicated. Rebleeding was defined as stomal bleeding that required hospital admission or transfusion. RESULTS: All patients had significant parastomal bleeding at the time of referral. 100% technical success rate was achieved. 70.8% of patients had no further significant bleeding in the follow-up period (median 26.2 months) following one procedure. 1-year rebleed-free survival was 80.8% following first procedure. 7 patients (29.1%) had repeat procedures. There was no significant difference in rebleed-free survival following repeat procedures. Higher age was associated with higher risk of rebleeding. No major procedure-related complications were identified. CONCLUSIONS: EUS-guided thrombin injection, with or without embolisation coils, is a safe and effective technique for the treatment of bleeding parastomal varices, particularly for patients for whom correction of portal venous hypertension is contraindicated.

Endoscopic ultrasound-guided pancreatic fluid collections' transmural drainage outcomes in 100 consecutive cases of pseudocysts and walled off necrosis: a single-centre experience from the United Kingdom.

BACKGROUND AND AIM: Endoscopic ultrasound-guided drainage is a minimally invasive first-line modality for the drainage of pancreatic fluid collection (PFC) resulting in a shorter hospital stay and less morbidity compared with surgical cystogastrostomy. Our aim is to evaluate potential differences in the outcomes of endoscopic ultrasound (EUS) guided transmural drainage (EUS-TD) drainage of pancreatic pseudocyst (PP) and walled-off necrosis (WON). METHOD: We retrospectively reviewed 100 consecutive EUS-guided drainages of PFC utilising EUS reports; clinical notes and imaging with follow-up (FU) to 12 months. All procedures were undertaken under conscious sedation with EUS guidance alone (without fluoroscopy) and placement of plastic double pigtail stents. RESULTS: In these 100 sequential cases, there were 78 cases of PP and 22 cases of WON. All 22/22(100%) cases of WON had successful EUS-guided stent placement. In 2/22(9%), there was little or no clinical improvement. These two patients required further computed tomography (CT)-guided drainage and one of these patients (1/22) (4.5%) developed recurrence within 12 months FU after removal of stents. In case of PP, overall stent placement was successful in 76/78 (97%) patients, but 6/78(8%) required 2nd EUS procedure after failure to show clinical improvement; 3/78(2.5%) required further CT-guided drainage. The overall complication rate was 9%(9/100) with 4%(4/100) requiring endoscopic or CT-guided intervention with no overall 30-day mortality. CONCLUSION: This is the largest series from a single UK centre demonstrating that EUS-guided cystogastrostomy of PFC drainage using plastic double pigtail stents is sufficient in majority of cases with PFC including that of WON, with or without infection.