Thrombin or glue – you decide

We recently read with great interest an article by Gin-Ho Lo and co-workers entitled “A prospective, randomized trial of thrombin versus cyanoacrylate injection in the control of acute gastric variceal hemorrhage,” which was published in the July 2020 edition of this journal [1]. The authors studied the efficacy of thrombin and cyanoacrylate injection in controlling acute gastric variceal bleeding. They concluded that endoscopic thrombin injection is as efficacious as glue in achieving hemostasis and was shown to be safe, with fewer complications. However, a few concerns remain that need some discussion.

First, in the aforementioned study, gastroesophageal varices type 1 (GOV1) were included in both of the study groups: 15 out of 33 patients who received thrombin and 17 of 35 patients who received glue injection. However, the usual management of GOV1 is variceal band ligation, according to the studies of Sarin [2] and the Baveno VI group [3].

Second, there is no mention of the size of the gastric varices in each group, but size is related to severity of bleeding, as suggested by the study of Zeeshan et al. [4], or of the experience of the endoscopists, and whether the same endoscopists were employed or not is unclear. Because glue injection of gastric varices requires technical skills, subjective error on the part of the operator is a likely scenario [5].

Despite these questions, we really appreciate the efforts of the author and his team, as this study has indeed made thrombin an option for management in the coming years. We suggest that a similar study with higher sample size and similar cohorts in both groups would lead to a better comparison in future.

Publication History

Article published online:
27 January 2021

• References

• 1 Lo GH, Lin CW, Tai CM. et al. A prospective, randomized trial of thrombin versus cyanoacrylate injection in the control of acute gastric variceal hemorrhage. Endoscopy 2020; 52: 548-555
• 2 Sarin SK, Lahoti D, Saxena SP. et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16: 1343-1349
• 3 de Franchis R. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
• 4 Zeeshan AW, Bhat RA, Bhadoria AS. et al. Gastric varices: Classification, endoscopic and ultrasonographic management. J Res Med Sci 2015; 20: 1200-1207
• 5 Williams SG, Peters RA, Westaby D. Thrombin: an effective treatment for gastric variceal hemorrhage. Gut 1994; 35: 1287-1289