Comparison of efficacy and safety of endoscopic and radiological interventions for gastric varices: A systematic review and network meta-analysis.

Clin Exp HEPATOL 2023; 9, 1: 57–70 DOI: https://doi.org/10.5114/ceh.2023.126077 Received: 15.11.2022, Accepted: 14.01.2023, Published: 24.03.2023 Original paper Comparison of efficacy and safety of endoscopic and radiological interventions for gastric varices: A systematic review and network meta-analysis Suprabhat Giri1, Vaneet Jearth2, Vishal Seth3, Harish Darak4, Sridhar Sundaram3 Department of Gastroenterology, Nizam’s Institute of Medical Sciences, Hyderabad, India Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India 3 Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, India 4 Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India 1 2 Abstract Aim of the study: There is a paradigm shift in the management of gastric varices with the availability of endoscopic ultrasound and radiologic interventions. The optimal choice of intervention remains a dilemma for most treating physicians. Material and methods: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, and ScienceDirect for studies comparing endoscopic glue injection, endoscopic thrombin injection (THB), variceal band ligation, EUS-guided coiling, EUS-guided glue injection, EUS-guided coiling with glue (EUS-C+G), balloon occluded retrograde transvenous obliteration (BRTO), and transjugular intrahepatic portosystemic shunt (TIPS) for gastric varices in adults. The data on four outcomes – obliteration of varices, rebleeding, adverse effects, and mortality – were pooled using a random-effects model. Treatment estimates were calculated as odds ratios (ORs) along with their 95% confidence interval (CI). The relative ranking of interventions for various outcomes was calculated as their surface under the cumulative ranking curve (SUCRA). Results: We identified 34 studies (10 randomized controlled trials, 24 non-randomized trials) with 2783 patients. Based on SUCRA plots, BRTO (SUCRA 95.1) had the highest rate of variceal obliteration followed by EUS-C+G (SUCRA 80.9). The risk of rebleeding was lowest with BRTO (SUCRA 85.1) followed by EUS-C+G (SUCRA 78.8). Moderate-severe adverse effects were least likely with THB (SUCRA 92.5) and highest with TIPS (SUCRA 3.7). In terms of mortality, EUS-C+G (73.5) had the lowest probability of overall mortality followed by TIPS (69.1). Conclusions: In this network meta-analysis, we found BRTO and EUS-guided therapies to be superior to endoscopic glue injection. However, the level of evidence remains low. Key words: gastric varices, portal hypertension, BRTO, glue injection, EUS-guided interventions. Address for correspondence: Dr. Sridhar Sundaram, Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, India, e-mail: Introduction Portal hypertension is associated with increased portal venous pressure in the presence or absence of cirrhosis. The formation of portosystemic channels is a cardinal feature in portal hypertension, associated with the development of esophageal and gastric varices [1]. Varices are present in up to 40% of patients with cir- rhosis, increasing to 85% in patients with Child-Pugh class C cirrhosis [2]. Compared to esophageal varices, gastric varices are less common, being present in about 2-20% of patients with portal hypertension [3]. Bleeding from varices represents a major decompensating event in the natural history of patients with cirrhosis and portal hypertension, associated with mortality in up to 20% at 6 weeks [4]. Bleeding from gastric varices Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) 57 Suprabhat Giri, Vaneet Jearth, Vishal Seth, Harish Darak, Sridhar Sundaram is known to occur in 16%, 36%, and 44% at follow-up over 1, 3, and 5 years respectively [5]. Among the gastric varices, gastroesophageal varices type 1 (GOV1) is the most common (70%), followed by GOV2 (21%) and isolated gastric varices type 1 (IGV1). The risk of bleeding on the other hand is highest for IGV1 followed by GOV2 [6]. Although less frequent, gastric varices are associated with more profuse bleeding with a higher transfusion requirement, rebleeding and death [7]. While clear guidelines are available for the management of esophageal variceal bleeding, there is a lack of consensus on the management of gastric variceal bleeding. Various therapies, endoscopic and radiological, are available for the management of gastric variceal bleeding. However, the choice of therapy has been a matter of debate. Endoscopic variceal obturation using cyanoacrylate (CYA) glue has been the standard therapy for gastric variceal bleeding, endorsed in the Baveno guidelines as well [8]. However, this technique is fraught with technical issues such as incomplete obturation of the varices, a high rate of glue embolization, and rebleeding [9]. For patients with recurrent gastric variceal bleeding, endoscopic ultrasound (EUS) guided glue with or without coil injection is increasingly becoming popular [10]. Radiological therapies such as balloon occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) have also been used primarily as rescue therapy with emerging data on its role as primary therapy in a select subset of patients [11, 12]. The existing literature has a paucity of head-to-head trials comparing different endoscopic and radiological modalities for gastric variceal therapy. We conducted this network meta-analysis to compare the outcomes of different endoscopic and radiological modalities for the treatment of gastric varices. ence lists of all identified trials, guidelines, and reviews on the topic for relevant trials. Material and methods Data extraction was performed independently by two investigators (SG and SS), and discrepancies were resolved by discussion, referring back to the original article. Data collection was done under the following headings: study author and year, study design, population (cirrhotic vs. non-cirrhotic), type of gastric varices, type of intervention used and the comparator arm, rate of variceal obliteration, the total number of adverse events, and serious adverse events, follow-up duration and number of deaths during follow-up. This systematic review and network meta-analysis is reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network MetaAnalyses (PRISMA-NMA) guidelines [13]. The network meta-analysis was registered with PROSPERO (CRD42021281814). Information sources and search strategy We searched MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Science Direct from January 2000 to September 2021 for all relevant studies. Additionally, we searched the refer- 58 Study selection The titles and abstracts of the retrieved search records were independently screened by two re (...truncated)