Reply to Matsumoto et al.

We are grateful for the comments and discussions of Matsumoto et al. with regard to the treatment of isolated fundic varices. There is firm agreement between us that cyanoacrylate is undoubtedly the first-line treatment for acute bleeding from fundic varices. However, we do not agree with the argument of Matsumoto et al. that the rebleeding rates after initial eradication of fundic varices are relatively high [1] [2].

The rebleeding rate quoted by Akahoshi et al. is about 40 % (50 % after less than 1 month, 30 % after 1 - 12 months, and 20 % after more than 12 months). From our point of view, these high rebleeding rates are related to the combination of cyanoacrylate injection with sclerotherapy using ethanolamine oleate as advocated by the authors [1]. Sclerotherapy is hazardous in the treatment of fundic varices and should not be attempted in combination with cyanoacrylate.

In the report by Sarin et al., the rebleeding rate is given as 27 % to 33 %, but only from ulcerated fundic varices, as a result of cyanoacrylate injection. During a mean follow-up of 15.4 months there was no recurrence of fundic varices.

In our experience, the rebleeding rate after cyanoacrylate injection can be reduced if a standardized injection technique is used [3]. A repeat endoscopy on day 4 after the initial session is advisable, to confirm the thoroughness of obliteration. Complete obliteration of all visible varices including their tributaries at the gastric fundus is mandatory to prevent rebleeding. Obliteration is not complete if the varix can be indented with the tip of the injection catheter, and in that case there is a need to repeat the injection. The risk of embolization is very low if the standardized procedure is used [3].

The optimal therapy for elective treatment for fundic varices is still open to debate. In our long-term experience, the rebleeding rate after elective cyanoacrylate obliteration is around 2.2 % [4].

Balloon-occluded retrograde transvenous obliteration (B-RTO) might be a promising treatment modality for the elective therapy of fundic varices in which a gastrorenal shunt is present. Until now B-RTO has mostly been performed only in Japan [5]. The published data on successful treatment of bleeding from fundic varices have involved only a small number of patients and have not been compared with cyanoacrylate injection. Prospective randomized controlled trials are needed to prove whether B-RTO can be recommended as an alternative method for elective treatment of fundic varices. On the other hand, balloon-occluded endoscopic injection sclerotherapy (BO-EIS) [6] should also be evaluated in these randomized controlled trials. Another interesting approach is BO-EIS using α-cyanoacrylate monomer, as decribed by Imazu et al. [7].

We realize that the elective treatment of fundic varices still poses a challenge even to experienced endoscopists, and further attempts should be made to improve the currently available techniques.

References

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• 2 Sarin S K, Jain A K, Jain M. et al . A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices.  Am J Gastroenterol. 2002;  97 1010-1015
• 3 Seewald S, Sriram P VJ, Naga M. et al . Cyanoacrylate glue in gastric variceal bleeding.  Endoscopy. 2002;  34 926-932
• 4 Soehendra N, Grimm H, Maydeo A. et al . Endoscopic obliteration of fundal varices.  Can J Gastroenterol. 1990;  4 643-646
• 5 Kitamoto M, Imamura M, Kamada K. et al . Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage.  AJR Am J Roentgenol. 2002;  178 1167-1174
• 6 Shiba M, Higuchi K, Nakamura K. et al . Efficacy and safety of balloon-occluded endoscopic injection sclerotherapy as a prophylactic treatment for high-risk gastric fundal varices: a prospective, randomized, comparative trial.  Gastrointest Endosc. 2002;  56 522-528
• 7 Imazu H, Matsui T, Kobayasi Y. et al . Balloon catheter-assisted endoscopic sclerotherapy for gastric fundal varices using α-cyanoacrylate monomer.  J Clin Gastroenterol. 2001;  33 49-52