346 Loop Combined Endoscopic Clip and Cyanoacrylate Injection to Treat the Severe Gastric Varices With Spleno-Renal Shunt

INTRODUCTION: Endoscopic cyanoacrylate injection has been successfully used in the management of gastric variceal bleeding and recommended as firest line treatment in China. However, one of the most severe complications such as systemic embolism is fatal, especially for the gastric varice with a huge shunt. With the aim of reducing the risk of embolization, we here report on the use of a loop combined an endoscopic clipping prior to cyanoacrylate injection as a therapy to obstruct gastric varices with a large slpeno-renal shunt. CASE DESCRIPTION/METHODS: A 53-year-old woman was admitted with gastrointestinal hemorrhage a week ago, who underwent the subtotal gastrectomy and Billroth-II anstomosis because of obscure hemorrhage shock 18 years ago. Physical examination showed spleen was touched 4 cm below the rib cage. Lab test showed red blood cell, white blood cell and platelet were all decreased. Upper endoscopy revealed a large gastric fundal varix about 12 mm diameter and computed tomography (CT) scan showed a massive spleno-renal shunt and cavernous transformation of the portal vein (Figure 1). The prophylactic endoscopic therapy was performed for recurrent bleeding. According to the CT scan, we assessed the shunt direction from gastric fundal to cardia. A clip fixed on the middle of the varix as a pivot, a loop encircled the afferent branch and tightened up the loop gradully to obstruct the partial blood flow, simultaneously sucking slowly. After released the loop, a mixture (including 2 ml lauromacrogol, 1 ml cyanoacrylate and 2 ml sodium chloride solution) was injected into the circled vein to break further the blood flow. Then 3 mixtures were injected into the afferent vein and 1 mixture was injected into the efferent vein at different point separately to block thoroughly. One week later, upper endoscopy showed the gastric fundal varix were obstructed and CT showed the huge spleno-renal shunt were also breaking (Figure 2). Moreover, no systemic embolism was occurred. No bleeding was happened during the 6-week follow-up period. 3 month and a half year later, endoscopy view showed the fundal varix gradually disappeared and CT scan showed the varix solidified (Figure 3). DISCUSSION: In this case, we used a novel method which is a loop combained an endoscopic clipping to block the main stem of huge isolated gastric varice and cut back the cyanoacrylate injection. It suggested that this new way could operate more easier and simpler, avelliate the fatal embolism. More importantly, for patients, they can pay less cost. Watch the video: http://bit.ly/2Z4ivXq