Treatment of Bleeding Esophageal Varices with Cyanoacrylate and Polidocanol, or Polidocanol Alone: Results of a Prospective Study in an Unselected Group of Patients with Cirrhosis of the Liver

Abstract

Background and Study Aims: Data concerning the results with emergency and further elective therapy of esophageal varices using polidocanol and cyanoacrylate, or polidocanol alone, in an unselected group of patients with liver cirrhosis have not previously been available. The aim of the present prospective study was to evaluate acute and repeated cyanoacrylate and polidocanol therapy in the emergency and long-term elective management of esophageal varices.

Methods: In accordance with the protocol of the present prospective study, acutely bleeding esophageal varices of grades 1 to 3 were treated endoscopically with polidocanol injection, while grade 4 varices, large solitary varices (over 5 mm) and otherwise uncontrollable cases of variceal bleeding were treated by injection of cyanoacrylate and polidocanol. Over a period of 62 months, 112 patients (65 men, 47 women) with acute bleeding from esophageal varices due to cirrhosis of the liver (69 % alcohol-related) underwent a total of 245 treatment sessions in hospital. The average age of the patients was 62.0 ± 12.3 years (58.1 % were 60 or older). Hepatic function corresponded to Child-Pugh class A in 38 patients (33.9 %), Child-Pugh class B in 68 patients (60.7 %), and Child-Pugh class C in six (4.5 %).

Results: Sixty-eight patients (60.7 %) were treated with polidocanol alone, and 44 (39.3 %) with cyanoacrylate and polidocanol. Acute hemostasis was achieved in all cases. In 5.7 % of the sclerotherapy procedures, bleeding ulcers were observed, and a pleural effusion was seen in one case. The hospital mortality rate was 24.1 %, resulting from the bleeding in 2.7 % and due to liver failure in the remaining cases. Recurrent bleeding occurred within 24 hours in four patients (3.6 %), and during the later course of the hospital stay in a further 11 patients (9.8 %). The mean survival time was 13.7 ± 17.7 months. Over the entire observation period of 23 ± 21 months, 67 patients died (59.8 %); the cause of death was hemorrhage in 4.5 %, the underlying hepatic disease in 65.7 %, and non-hepatic causes in 29.8 %. Recurrent bleeding occurred in 58 patients (51.7 %). The cumulative survival rate in the patients treated with cyanoacrylate and polidocanol was 66 ± 15 % and 26 ± 32 % after one and five years, respectively, and 56 ± 13 % and 33 ± 19 % in those treated with polidocanol alone.

Conclusions: Endoscopic treatment of esophageal varices with cyanoacrylate and polidocanol, or polidocanol alone, is effective in controlling bleeding, and the complication rate is tolerable. The short-term and long-term mortality rates are determined largely by the underlying liver disease.