Introduction

There is significant interpersonal variation in management of gastric varices. In real life scenario both large esophageal and gastric varices coexist in a significant number of cases. In patients presenting with variceal bleed, source of bleed whether esophageal or gastric varices is not clear in most patients. How aggressively to manage the large gastric varices in patients who had variceal bleed is not defined. The aim of this study was to compare aggressive management of gastric varices with conservative management of gastric varices in patient with variceal bleed.

Aims & Methods

Consecutive patients with cirrhosis presenting with 1^st episode of variceal bleed and having large gastric varices (Gastroesophageal varices (GOV)1, GOV2, Isolated gastric varices (IGV) 1) were randomized to receive aggressive (Group A, n=66) or conservative therapy (Group B, n=68) for gastric varices. Aggressive group received glue injection for all types of gastric varies followed by band ligation of the oesophageal varies. While group B patients were treated primarily with band ligation for oesophageal and GOV 1 varies and glue was used only those IGV or GOV 2 varies which revealed stigma of recent haemorrhage ( SRH) (Table 1). Primary outcomes were variceal rebleed, rate of obliteration of varices or death at 1 year follow up.
Table 1: Endoscopic management on index and follow up endoscopy

Results

There was no difference in the number of rebleed events among groups at 1 year (p=0.639).
Mortality due to variceal rebleed was comparable in both groups at 1 year (p=0.261), 6 months and 1 month. 1-year all-cause mortality was comparable in both groups.
The mean number of sessions required for obliteration of varices was lower in Group A than in Group B (1.24 ± 0.69 and 2.49 ± 1.38 respectively, p=0.01).
There was no significant difference between the two groups regarding the adverse events.

Conclusion

Aggressive approach to management of gastric varices using cyanoacrylate glue leads to early obliteration of varices but has similar rebleeding rates and survival benefit as compared to a more conservative approach.

Introduction

^​Gastrointestinal stromal tumors (GISTs) greater than 2 cm are considered for resection.¹ Those with muscularis propria (MP) involvement as seen on endoscopic ultrasound and/or radiology, require full-thickness resection (FTR), surgery, or a combined laparoscopic/endoscopic approach.² Dedicated endoscopic FTR (EFTR) devices are available but limited to lesions less than 2 cm. We present a GIST resected by EFTR and over-the-scope suture (TTSS) defect closure.

Aims & Methods

This video case report shows the full thickness resection of large gastric GIST in the antrum and successful closure of full thickness defect with endoscopic suturing.

Results

A 55yr old gentlemen with history of dyspeptic symptoms suffering from 6 months. There were no history of vomitings, pain abdomen and weight loss. On upper gastrointestinal endoscopy, a sub epithelial lesion of size 3x3 cms size seen in antrum with normal overlying mucosa. On cross sectional imaging with contrast CT, no extramural extension noted. Endoscopic ultrasound of the lesion showed a capsulated heteroechoic lesion arising from muscularis propria 4th layer. After discussing with the patient about the treatment options such as surgery and endoscopic submucosal dissection (ESD). Patient opted for ESD and was taken up for the procedure. It was challenging in the dissection of the lesion in total preserving the muscularis propria but invariably as the lesion involving muscularis propria. The full thickness resection was done and lesion retrieved successfully. As the defect was large and full thickness opening up the peritoneum, endoscopic suturing would be ideal for the effective closure. Using Overstitch Endoscopic suturing system (Boston Scientific), taking full thickness sutures, defect was successfully closed. Patient was allowed orally with liquid initially after 24 hrs. patient was successfully discharged after 36hrs of observation in the hospital. Histopathology of the specimen revealed low risk type Gastrointestinal stromal tumour (GIST).

Conclusion

This case report highlights the use of endoscopic full thickness resection of large gastric GIST and achieving the complete closure using full thickness suturing by endoscopic suturing technique using Overstitch system.

References

1. Kaan HL, Ho KY. Endoscopic Full Thickness Resection for Gastrointestinal Tumors - Challenges and Solutions. Clin Endosc. 2020
2. Kim HH. Endoscopic treatment for gastrointestinal stromal tumor: Advantages and hurdles. World J Gastrointest Endosc. 2015