Variceal Bleeding and Portal Hypertension: Still a Therapeutic Challenge?

Abstract

In the primary prevention of variceal hemorrhage, beta-blockers continue to be the first-line treatment. Newer nonselective beta-blockers with anti-alpha1-adrenergic activity, such as carvedilol, appear to have a better impact on reducing the hepatic venous pressure gradient than propranolol. The addition of isosorbide mononitrate appears to improve the effectiveness of beta-blockers in primary prophylaxis, but not that of somatostatin in the treatment of acute variceal hemorrhage. The use of vasoactive drugs alone in acute variceal bleeding has not proved to be more effective than endoscopic treatment. The advent of endoscopic variceal ligation (EVL) has strengthened the role of endoscopy in the management of bleeding esophageal varices. EVL has improved the results, particularly in terms of lowering the treatment-related morbidity, compared with endoscopic variceal sclerotherapy (EVS). However, the variceal recurrence rate after initial eradication with EVL is relatively high. In contrast to synchronous combined therapy with EVL plus EVS, metachronous combination of EVL and low-dose EVS may improve the results of EVL alone. For bleeding fundic varices, obliteration using cyanoacrylate is currently the treatment of choice. Endosonography (EUS) is coming into more widespread use in the assessment of variceal eradication and in further attempts to improve the results of endoscopic injection therapy. According to two meta-analysis studies, transjugular intrahepatic portosystemic shunt (TIPS) is not yet capable of replacing endoscopic treatment in the secondary prevention of variceal bleeding.

Efficiency and safety of mesh fixation in laparoscopic inguinal hernia repair using n-butyl cyanoacrylate: long-term biocompatibility in over 1,300 mesh fixations

“…Butyl esters provide stronger but more rigid bonds, octyl esters weaker but more flexible bonds, with much slower degradation due to the longer side chain. Since the 1970s, butyl cyanoacrylate has been used as a medical adhesive, or as hemostatic or embolic agent to repair lacerations, to close the skin in pediatric surgery, to obliterate the processus vaginalis in congenital inguinal hernias, to control hemostasis of parenchymal organs, to perform aortic and thoracic surgery, to treat arteriovenous malformations, or bleeding gastric varices, and to carry out interventional radiology and vascular neuroradiology [1–4]. …”