Evaluation of EUS in Preventing Rebleeding After Endoscopic Cyanoacrylate Injection for Gastric Varices

• ClinicalTrials.gov Identifier: NCT05515861
• Recruitment Status: Not yet recruiting
• First Posted: August 25, 2022
• Last Update Posted: August 25, 2022
• Sponsor: Renmin Hospital of Wuhan University
• Collaborators: Beijing Friendship Hospital; Southwest Hospital, China; Zunyi Medical College; Shanxi Coal Center Hospital
• Information provided by (Responsible Party): ChenMingkai, Renmin Hospital of Wuhan University

Tracking Information

• First Submitted Date: August 24, 2022
• First Posted Date: August 25, 2022
• Last Update Posted Date: August 25, 2022
• Estimated Study Start Date: September 2022
• Estimated Primary Completion Date: June 2024 (Final data collection date for primary outcome measure)

Current Primary Outcome Measures (submitted: August 24, 2022)

Rebleeding [ Time Frame: 12 months ]

Rebleeding is defined as recurrent melena or hematemesis and is evaluated via endoscopy whenever possible.

• Original Primary Outcome Measures: Same as current
• Change History: No Changes Posted

Current Secondary Outcome Measures (submitted: August 24, 2022)

• Mortality [ Time Frame: 12 months ]
  Including all-cause mortality.
• The eradication rate of gastric varices [ Time Frame: 12 months ]
  Eradication of the gastric varices is defined as absence of gastric varices on endoscopy or absence of blood flow of gastric varices on endoscopic ultrasound.
• Calculating the total cost of treatment [ Time Frame: 12 months ]
  Cost-effectiveness
• number of treatment sessions [ Time Frame: 12 months ]
  Cost-effectiveness

• Original Secondary Outcome Measures: Same as current
• Current Other Pre-specified Outcome Measures: Not Provided
• Original Other Pre-specified Outcome Measures: Not Provided

Descriptive Information

• Brief Title: Evaluation of EUS in Preventing Rebleeding After Endoscopic Cyanoacrylate Injection for Gastric Varices
• Official Title: Evaluation of Endoscopic Ultrasound in Preventing Rebleeding After Endoscopic Cyanoacrylate Injection for Gastric Varices

Brief Summary

The aim of this study is to explore whether using endoscopic ultrasound (EUS) to assess gastric varices (GV) and giving additional treatment according to the diameter and blood flow of residual after endoscopic cyanoacrylate injection for GV can reduce the rate of GV rebleeding, mortality, the risk of adverse events, and cost-effectiveness.

This study is a multicenter prospective, open-label, randomized controlled study, including 5 study centers: Renmin Hospital of Wuhan University, Beijing Friendship Hospital, Capital Medical University, The Southwest Hospital of Army Medical University, Affiliated Hospital of Zunyi Medical University and Shanxi Coal Center Hospital. The total sample size is 150 patients, with 75 patients in the EUS evaluation group and 75 patients in the control group, respectively.

The patients who meet the inclusion and exclusion criteria are randomly assigned to EUS evaluation group and control group by using block randomization. The EUS evaluation group uses EUS to observe the diameter and blood flow of residual variceal veins after endoscopic cyanoacrylate injection for GV to evaluate the embolization effect. Endoscopic cyanoacrylate injection is performed again if the diameter of variceal vein is larger than 5 mm and with blood flow signal. After the injection, the blood flow signal is confirmed disappear by EUS. The control group return to the ward after endoscopic cyanoacrylate injection, without EUS evaluation. During the study, the patients are followed up for at least 12 months, and they are requested to return to the hospital for follow-up at 1 month, 3 months, 6 months and 12 months after the treatment, respectively. The data of baseline, treatment, postoperative and follow-up of the two groups are need to collect.

The primary outcome of this study is rebleeding rate. Secondary outcomes are eradication rate of GV, mortality rate, retreatment, and cost-effectiveness.

• Detailed Description: Patients are considered eligible when they meet the following criteria: (1) age≥18 years; (2) cirrhosis diagnosis is based on liver biopsy, medical history, and physical, biochemical, or radiological findings; (3) receive endoscopic cyanoacrylate injection for GV for secondary prophylaxis for the first time; (4) patients or a designated relative provide informed consent for the procedures. Exclusion criteria are as follows: (1) with contraindications to endoscopic treatment; (2)combine with malignant tumors, hepatic encephalopathy, hepatorenal syndrome, cavernous transformation of the portal vein or multiple organ failure; (3) with spontaneous shunts that the diameter is large than 5 mm; (4)previously received endoscopic treatment, interventional treatment or surgical surgery for GV, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), etc; (5) pregnant.
• Study Type: Interventional
• Study Phase: Not Applicable
• Study Design: Allocation: Randomized; Intervention Model: Parallel Assignment; Masking: None (Open Label); Primary Purpose: Prevention

Condition

• Liver Cirrhosis
• Gastric Varix
• Portal Hypertension

Intervention

Procedure: Endoscopic ultrasound

Using endoscopic ultrasound (EUS) to observe the diameter and blood flow of residual variceal veins after endoscopic cyanoacrylate injection for gastric varices to evaluate the embolization effect. Endoscopic cyanoacrylate injection is performed again if the diameter of variceal vein is larger than 5 mm and with blood flow signal. After the injection, the blood flow signal is confirmed disappear by endoscopic ultrasound. Patients in the EUS group required endoscopic ultrasound assessment at each stage of the follow-up period.

Study Arms

• Experimental: EUS group
  The EUS group uses endoscopic ultrasound to observe the diameter and blood flow of residual variceal veins after endoscopic cyanoacrylate injection for gastric varices to evaluate the embolization effect.
  Intervention: Procedure: Endoscopic ultrasound
• No Intervention: Control group
  The control group doesn't perform endoscopic ultrasound after endoscopic cyanoacrylate injection for gastric varices.

Publications *

• Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology. 1992 Dec;16(6):1343-9. doi: 10.1002/hep.1840160607.
• Kim T, Shijo H, Kokawa H, Tokumitsu H, Kubara K, Ota K, Akiyoshi N, Iida T, Yokoyama M, Okumura M. Risk factors for hemorrhage from gastric fundal varices. Hepatology. 1997 Feb;25(2):307-12. doi: 10.1053/jhep.1997.v25.pm0009021939.
• Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017 Jan;65(1):310-335. doi: 10.1002/hep.28906. Epub 2016 Dec 1. No abstract available. Erratum In: Hepatology. 2017 Jul;66(1):304.
• D'Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. 1995 Jul;22(1):332-54. doi: 10.1002/hep.1840220145. No abstract available.
• Kahana LM, Cole FM, Richardson H. Clinical aspects of atypical mycobacterial infection. Can Med Assoc J. 1975 Feb 8;112(3):321-4.
• Bosch J, Garcia-Pagan JC. Prevention of variceal rebleeding. Lancet. 2003 Mar 15;361(9361):952-4. doi: 10.1016/S0140-6736(03)12778-X.
• Rice JP, Lubner M, Taylor A, Spier BJ, Said A, Lucey MR, Musat A, Reichelderfer M, Pfau PR, Gopal DV. CT portography with gastric variceal volume measurements in the evaluation of endoscopic therapeutic efficacy of tissue adhesive injection into gastric varices: a pilot study. Dig Dis Sci. 2011 Aug;56(8):2466-72. doi: 10.1007/s10620-011-1616-z. Epub 2011 Feb 19.
• Henry Z, Patel K, Patton H, Saad W. AGA Clinical Practice Update on Management of Bleeding Gastric Varices: Expert Review. Clin Gastroenterol Hepatol. 2021 Jun;19(6):1098-1107.e1. doi: 10.1016/j.cgh.2021.01.027. Epub 2021 Jan 22.
• Lee YT, Chan FK, Ng EK, Leung VK, Law KB, Yung MY, Chung SC, Sung JJ. EUS-guided injection of cyanoacrylate for bleeding gastric varices. Gastrointest Endosc. 2000 Aug;52(2):168-74. doi: 10.1067/mge.2000.107911.
• Iwase H, Suga S, Morise K, Kuroiwa A, Yamaguchi T, Horiuchi Y. Color Doppler endoscopic ultrasonography for the evaluation of gastric varices and endoscopic obliteration with cyanoacrylate glue. Gastrointest Endosc. 1995 Feb;41(2):150-4. doi: 10.1016/s0016-5107(05)80599-1. No abstract available.
• Rajoriya N, Forrest EH, Gray J, Stuart RC, Carter RC, McKay CJ, Gaya DR, Morris AJ, Stanley AJ. Long-term follow-up of endoscopic Histoacryl glue injection for the management of gastric variceal bleeding. QJM. 2011 Jan;104(1):41-7. doi: 10.1093/qjmed/hcq161. Epub 2010 Sep 25.
• Lo GH, Liang HL, Chen WC, Chen MH, Lai KH, Hsu PI, Lin CK, Chan HH, Pan HB. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy. 2007 Aug;39(8):679-85. doi: 10.1055/s-2007-966591.
• Lo GH, Lai KH, Cheng JS, Chen MH, Chiang HT. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology. 2001 May;33(5):1060-4. doi: 10.1053/jhep.2001.24116.
• Hung HH, Chang CJ, Hou MC, Liao WC, Chan CC, Huang HC, Lin HC, Lee FY, Lee SD. Efficacy of non-selective beta-blockers as adjunct to endoscopic prophylactic treatment for gastric variceal bleeding: a randomized controlled trial. J Hepatol. 2012 May;56(5):1025-1032. doi: 10.1016/j.jhep.2011.12.021. Epub 2012 Jan 17.
• Huang YH, Yeh HZ, Chen GH, Chang CS, Wu CY, Poon SK, Lien HC, Yang SS. Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc. 2000 Aug;52(2):160-7. doi: 10.1067/mge.2000.104976.
• Liao SC, Yang SS, Ko CW, Lien HC, Tung CF, Peng YC, Yeh HZ, Chang CS. A miniature ultrasound probe is useful in reducing rebleeding after endoscopic cyanoacrylate injection for hemorrhagic gastric varices. Scand J Gastroenterol. 2013 Nov;48(11):1347-53. doi: 10.3109/00365521.2013.838995. Epub 2013 Sep 30.

Recruitment Information

• Recruitment Status: Not yet recruiting
• Estimated Enrollment (submitted: August 24, 2022): 150
• Original Estimated Enrollment: Same as current
• Estimated Study Completion Date: June 2024
• Estimated Primary Completion Date: June 2024 (Final data collection date for primary outcome measure)

Eligibility Criteria

Inclusion Criteria:

• age≥18 years;
• cirrhosis diagnosis is based on liver biopsy, medical history, and physical, biochemical, or radiological findings;
• receive endoscopic cyanoacrylate injection for gastric varices for secondary prophylaxis for the first time;
• patients or a designated relative provide informed consent for the procedures.

Exclusion Criteria:

• with contraindications to endoscopic treatment;
• combined with malignant tumors, hepatic encephalopathy, hepatorenal syndrome, cavernous transformation of the portal vein or multiple organ failure; with spontaneous shunts that the diameter is large than 5 mm;
• previously received endoscopic treatment, interventional treatment or surgical surgery for GV, including transjugular intrahepatic portosystemic shunt (TIPS), balloon-occluded retrograde transvenous obliteration (BRTO), etc;
• pregnant.

Sex/Gender

• Sexes Eligible for Study: All

• Ages: 18 Years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Contacts

Contact: Mingkai Chen; +8613720330580; kaimingchen@163.com

• Listed Location Countries: China

Administrative Information

• NCT Number: NCT05515861
• Other Study ID Numbers: WDRY2022-K042
• Has Data Monitoring Committee: No

U.S. FDA-regulated Product

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No

IPD Sharing Statement

• Plan to Share IPD: Yes

• Current Responsible Party: ChenMingkai, Renmin Hospital of Wuhan University
• Original Responsible Party: Same as current
• Current Study Sponsor: Renmin Hospital of Wuhan University
• Original Study Sponsor: Same as current

Collaborators

• Beijing Friendship Hospital
• Southwest Hospital, China
• Zunyi Medical College
• Shanxi Coal Center Hospital

Investigators

• Study Director: Mingkai Chen; Renmin Hospital of Wuhan University

• PRS Account: Renmin Hospital of Wuhan University
• Verification Date: August 2022