Endoscopic ultrasound-guided therapy of gastric varices with coils plus cyanoacrylate injection versus coiling alone: getting evidence-based data but are they comparable?

Gastric varices can be treated using endoscopic ultrasound (EUS) guidance for injection of cyanoacrylate [1], coil deployment [2] or a combination of both techniques [3].

Robles-Medranda et al. prospectively compared EUS-guided therapy of gastric varices using coil deployment plus additional injection of cyanoacrylate versus coil alone [4]. They obtained overall impressive results with technical and clinical success in both groups with lower rates of rebleeding and reinterventions in the combination treatment group. However, some issues have been raised.

The sample size was calculated on the basis of a study comparing EUS-guided coil deployment versus EUS-guided injection of cyanoacrylate, without combination of coils/cyanoacrylate [5]. Bhat et al. reported on the combination approach [3], achieving a technical success rate of > 99 %. So, the calculation should be based on success rates of 82 % for EUS-guided coil deployment and > 99 % for EUS guided coils/cyanoacrylate therapy. Therefore, the current study seems considerably underpowered with 30 patients per group.

No criteria determining the number of coils to be deployed are reported. The two groups in the study are not comparable because the coil-only group was treated with an arbitrary median number of 3 coils whereas the combination group received a similar median number of 2 coils plus additional cyanoacrylate injection. In the study cited by Robles-Medranda et al., comparing EUS-guided injection of cyanoacrylate versus coil deployment, as many coils as needed were used (median 5.8) with the aim of obtaining a thick mesh [5].

Robles-Medranda et al. also observed significantly higher rates of active bleeding in the coil-only group and reinterventions in 40 % (12/30) compared to 16.7 % (5/30) after combination therapy, probably explained by undertreatment. Moreover, of the 7 patients in this subgroup whose initial reintervention was with coils and cyanoacrylate, 2 patients needed two sessions of the combination therapy, probably indicating a more severe portal hypertension stage.

Finally, the study by Robles-Medranda et al. provides new data on EUS-guided therapy of gastric varices, as well-designed comparative studies defining the most accurate and safest technique are awaited.

Publication History

Article published online:
17 December 2020

• References

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