Download PDF
Endoscopy 2020; 52(04): 259-267
DOI: 10.1055/a-1098-1817
Systematic Review

Efficacy and safety of endoscopic ultrasound-guided therapy versus direct endoscopic glue injection therapy for gastric varices: systematic review and meta-analysis

Babu P. Mohan
1   Inpatient Medicine, Banner University Medical Center, University of Arizona, Tucson, Arizona, United States
,
Saurabh Chandan
2   Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
,
Shahab R. Khan
1   Inpatient Medicine, Banner University Medical Center, University of Arizona, Tucson, Arizona, United States
,
Lena L. Kassab
3   Mayo Clinic, Rochester, Minnesota, United States
,
Sushruth Trakroo
4   Internal Medicine, St. Vincent Charity Medical Center, Cleveland, Ohio, United States
,
Suresh Ponnada
5   Carilion Roanoke Memorial Hospital, Roanoke, Virginia, United States
,
Ravishankar Asokkumar
6   Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
,
Douglas G. Adler
7   Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Referred to by:

Author commentary on Babu P. Mohan et al.Endoscopy 2020; 52(04): v13-v13
DOI: 10.1055/a-1089-6943

Abstract

Background Gastric variceal bleeding carries significant mortality in the setting of portal hypertension. Among the endoscopic treatment options, endoscopic ultrasound (EUS)-guided glue and/or coil injection is a novel approach, but its role in the treatment of gastric varices is not established due to a lack of robust data.

Methods We conducted a comprehensive search of several databases (inception to June 2019) to identify studies evaluating EUS in the treatment of gastric varices. Our primary goals were to estimate the pooled rates of treatment efficacy, obliteration and recurrence of gastric varices, early and late rebleeding, and adverse events with EUS-guided therapy in gastric varices. We also searched for studies that evaluated direct endoscopic glue (END-glue) injection for treatment of gastric varices, and used the pooled rates as comparators.

Results 23 studies (851 patients) evaluating EUS-guided therapy were included. The pooled treatment efficacy was 93.7 % (95 % confidence interval [CI] 89.5 – 96.3, I 2 = 53.7), gastric varices obliteration was 84.4 % (95 %CI 74.8 – 90.9, I 2 = 77), gastric varices recurrence was 9.1 % (95 %CI 5.2 – 15.7, I 2 = 32), early rebleeding was 7.0 % (95 %CI 4.6 – 10.7, I 2 = 0), and late rebleeding was 11.6 % (95 %CI 8.8 – 15.1, I 2 = 22). The rates were comparable to END-glue therapy (28 studies, 3467 patients) except for obliteration, which was significantly better with EUS-guided therapy. On subgroup analysis, EUS-coil/glue combination showed superior outcomes.

Conclusions EUS-guided therapy demonstrated clinical efficacy for treatment of gastric varices in terms of obliteration, recurrence, and long-term rebleeding, and may be superior to END-glue.

Appendix 1s – 3s, Table 1s, Table 2s, Fig. 1s



Publication History

Received: 12 July 2019

Accepted: 17 December 2019

Article published online:
06 February 2020

© Georg Thieme Verlag KG
Stuttgart · New York

Refers to:

Endoscopic ultrasound-guided intervention for gastric varices: sticky stuff might not (yet) be enoughEndoscopy 2020; 52(04): 244-246
DOI: 10.1055/a-1112-7470

 

  • References

  • 1 Kim T, Shijo H, Kokawa H. et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology 1997; 25: 307-312
    CrossrefPubMedGoogle Scholar
  • 2 Sarin SK, Lahoti D, Saxena SP. et al. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16: 1343-1349
    CrossrefPubMedGoogle Scholar
  • 3 Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest Endosc 1986; 32: 264-268
    CrossrefPubMedGoogle Scholar
  • 4 de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53: 762-768
    CrossrefPubMedGoogle Scholar
  • 5 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
    CrossrefPubMedGoogle Scholar
  • 6 Bang JY, Al-Haddad MA, Chiorean MV. et al. Comparison of direct endoscopic injection (DEI) and EUS-guided fine needle injection (EUS-FNI) of 2-octyl-cyanoacrylate for treatment of gastric varices. Gastrointest Endosc 2015; 1: AB437
    PubMedGoogle Scholar
  • 7 Baptista AJ, Guzman MA, Rass H. et al. Novel EUS-guided treatment of gastric varices with a liquid non-adhesive neurovascular embolization agent. United European Gastroenterol 2017; 5 (05) A784
    PubMedGoogle Scholar
  • 8 Bazarbashi AN, Wang TJ, Hathorn K. et al. For treatment of gastric varices, EUS-guided coil embolization leads to lower transfusion requirements and re-intervention rates compared to traditional cyanoacrylate injection: a matched cohort study. Gastrointest Endosc 2019; 89 (06) AB312-AB313
    PubMedGoogle Scholar
  • 9 Bertroli JA, Abadia MA, Peracaula MM. et al. Preliminary experience with EUS-guided treatment of acute gastric varices bleeding using a forward-viewing echoendoscope. Gastrointest Endosc 2011; 1: AB179
    PubMedGoogle Scholar
  • 10 Bhat YM, Weilert F, Fredrick RT. et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video). Gastrointest Endosc 2016; 83: 1164-1172
    CrossrefPubMedGoogle Scholar
  • 11 Bick BL, Al-Haddad M, Liangpunsakul S. et al. EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding. Surg Endosc 2019; 33: 1837-1845
    CrossrefPubMedGoogle Scholar
  • 12 Binmoeller KF, Weilert F, Shah JN. et al. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc 2011; 74: 1019-1025
    CrossrefPubMedGoogle Scholar
  • 13 Frost JW, Hebbar S. EUS-guided thrombin injection for management of gastric fundal varices. Endosc Int Open 2018; 6: E664-E668
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 George N, Perisetti A, Banerjee D. et al. EUS-guided treatment of gastric varices: a single center experience. Am J Gastroenterol 2017; 112: S437-S439
    PubMedGoogle Scholar
  • 15 Gubler C, Bauerfeind P. Safe and successful endoscopic initial treatment and long-term eradication of gastric varices by endoscopic ultrasound-guided Histoacryl (N-butyl-2-cyanoacrylate) injection. Scand J Gastroenterol 2014; 49: 1136-1142
    CrossrefPubMedGoogle Scholar
  • 16 Khoury T, Massarwa M, Daher S. et al. Endoscopic ultrasound-guided angiotherapy for gastric varices: a single center experience. Hepatol Commun 2019; 3: 207-212
    PubMedGoogle Scholar
  • 17 Krill JT, Othman MO, Munot K. et al. EUS-guided coil application with glue injection for gastric variceal obliteration is associated with less endoscopic reintervention compared to glue injection alone. Gastrointest Endosc 2018; 87 (06) AB345
    PubMedGoogle Scholar
  • 18 Lee YT, Chan FK, Ng EK. et al. EUS-guided injection of cyanoacrylate for bleeding gastric varices. Gastrointest Endosc 2000; 52: 168-174
    CrossrefPubMedGoogle Scholar
  • 19 Lôbo MRA, Chaves DM, De Moura DTH. et al. Safety and efficacy of EUS-guided coil plus cyanoacrylate versus conventional cyanoacrylate technique in the treatment of gastric varices: a randomized controlled trial. Arq Gastroenterol 2019; 56: 99-105
    CrossrefPubMedGoogle Scholar
  • 20 Mathew S, Zacharias P, Menon P. et al. EUS-guided therapy in the management of gastric fundal and ectopic varices – a single center experience. Hepatol Int 2018; 12: S561
    PubMedGoogle Scholar
  • 21 Mukkada RJ, Antony R, Chooracken MJ. et al. Endoscopic ultrasound-guided coil or glue injection in post-cyanoacrylate gastric variceal re-bleed. Indian J Gastroenterol 2018; 37: 153-159
    CrossrefPubMedGoogle Scholar
  • 22 Orourke J, Shekhar C, Tripathi D. et al. Treatment of gastric fundal varices with EUS guided embolisation combining coil placement with thrombin injection. Gut 2018; 67 : A136
    PubMedGoogle Scholar
  • 23 Robles-Medranda C, Valero M, Nebel JA. et al. Endoscopic-ultrasound-guided coil and cyanoacrylate embolization for gastric varices and the roles of endoscopic Doppler and endosonographic varicealography in vascular targeting. Dig Endosc 2019; 31: 283-290
    CrossrefPubMedGoogle Scholar
  • 24 Romero-Castro R, Ellrichmann M, Ortiz-Moyano C. et al. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc 2013; 78: 711-721
    CrossrefPubMedGoogle Scholar
  • 25 Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M. et al. EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases. Gastrointest Endosc 2007; 66: 402-407
    CrossrefPubMedGoogle Scholar
  • 26 Singla V. Role of endoscopic ultrasound guided coiling and cynoacrylate injection in cirrhotic patients with large gastric varices. Indian J Gastroenterol 2018; 37 : A17
    PubMedGoogle Scholar
  • 27 Weilert F, Bhat Y, Kane S. et al. Endoscopic ultrasound (EUS)-guided treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (6 year outcome data). J Gastroenterol Hepatol 2015; 30 : 65-66
    PubMedGoogle Scholar
  • 28 Yague AS, Shah JN, Nguyen-Tang T. et al. EUS-guided therapy of bleeding gastric varices. Gastrointest Endosc 2009; 69: AB138
    PubMedGoogle Scholar
  • 29 Chaves D, Almeida LoboMR, De Moura DT. et al. EUS-guided coil plus cyanoacrylate versus cyanoacrylate conventional technique to treat gastric varices: a prospective randomized study. Gastrointest Endosc 2017; 85 (05) AB412
    PubMedGoogle Scholar
  • 30 Kim J, Shah JN, Marson F. et al. EUS-guided treatment of gastric varices with combined intravariceal coiling and cyanoacrylate glue injection. Gastrointest Endosc 2010; 71: AB282
    PubMedGoogle Scholar
  • 31 Koshy A. Endocoiling with/without cyanoacrylate injection versus cyanoacrylate injection alone in post cyanoacrylate gastric rebleed – a retrospective study. Hepatol Int 2018; 12: S575
    PubMedGoogle Scholar
  • 32 Singh V, Singh R, Bhalla A. et al. Cyanoacrylate therapy for the treatment of gastric varices: a new method. J Dig Dis 2016; 17: 392-398
    CrossrefPubMedGoogle Scholar
  • 33 Akahoshi T, Hashizume M, Shimabukuro R. et al. Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience. Surgery 2002; 131 (01) S176-181
    CrossrefPubMedGoogle Scholar
  • 34 Al-Bawardy B, Gorospe E, Buttar N. et al. 2-octyl-cyanoacrylate injection for acute gastric variceal hemorrhage: 15-year experience of outcomes and predictors of acute rebleeding. Am J Gastroenterol 2015; 110 : S665-S666
    PubMedGoogle Scholar
  • 35 Catron TD, Smallfield GB, Kang L. et al. Endoscopic cyanoacrylate injection with post-injection audible Doppler assessment of gastric varices: a single-institution experience. Dig Dis Sci 2017; 62: 3091-3099
    CrossrefPubMedGoogle Scholar
  • 36 Chandra S, Holm A, El Abiad RG. et al. Endoscopic cyanoacrylate glue injection in management of gastric variceal bleeding: US tertiary care center experience. J Clin Exp Hepatol 2018; 8: 181-187
    CrossrefPubMedGoogle Scholar
  • 37 Cheng LF, Wang ZQ, Li CZ. et al. Treatment of gastric varices by endoscopic sclerotherapy using butyl cyanoacrylate: 10 years’ experience of 635 cases. Chin Med J 2007; 120: 2081-2085
    CrossrefPubMedGoogle Scholar
  • 38 Choudhuri G, Chetri K, Bhat G. et al. Long-term efficacy and safety of N-butylcyanoacrylate in endoscopic treatment of gastric varices. Trop Gastroenterol 2010; 31: 155-164
    PubMedGoogle Scholar
  • 39 Huang YH, Yeh HZ, Chen GH. et al. Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety. Gastrointest Endosc 2000; 52: 160-167
    CrossrefPubMedGoogle Scholar
  • 40 Jun CH, Kim KR, Yoon JH. et al. Clinical outcomes of gastric variceal obliteration using N-butyl-2-cyanoacrylate in patients with acute gastric variceal hemorrhage. Korean J Intern Med 2014; 29: 437-444
    CrossrefPubMedGoogle Scholar
  • 41 Kahloon A, Chalasani N, DeWitt J. et al. Endoscopic therapy with 2-octyl-cyanoacrylate for the treatment of gastric varices. Dig Dis Sci 2014; 59: 2178-2183
    CrossrefPubMedGoogle Scholar
  • 42 Kang EJ, Jeong SW, Jang JY. et al. Long-term result of endoscopic Histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices. World J Gastroenterol 2011; 17: 1494-1500
    CrossrefPubMedGoogle Scholar
  • 43 Khawaja A, Sonawalla AA, Somani SF. et al. Management of bleeding gastric varices: a single session of histoacryl injection may be sufficient. Eur J Gastroenterol Hepatol 2014; 26: 661-667
    CrossrefPubMedGoogle Scholar
  • 44 Kind R, Guglielmi A, Rodella L. et al. Bucrylate treatment of bleeding gastric varices: 12 years’ experience. Endoscopy 2000; 32: 512-519
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Kumar A, Singh S, Madan K. et al. Undiluted N-butyl cyanoacrylate is safe and effective for gastric variceal bleeding. Gastrointest Endosc 2010; 72: 721-727
    CrossrefPubMedGoogle Scholar
  • 46 Kurt M, Akdogan M, Sayilir A. et al. Effect of endoscopic injection therapy with combined cyanoacrylate and lipiodol for bleeding gastric varices: a single center experience. J Dig Dis 2010; 11: 284-290
    CrossrefPubMedGoogle Scholar
  • 47 Lee HA, Chang JM, Goh HG. et al. Prognosis of patients with gastric variceal bleeding after endoscopic variceal obturation according to the type of varices. Eur J Gastroenterol Hepatol 2019; 31: 211-217
    CrossrefPubMedGoogle Scholar
  • 48 Marques P, Maluf-Filho F, Kumar A. et al. Long-term outcomes of acute gastric variceal bleeding in 48 patients following treatment with cyanoacrylate. Dig Dis Sci 2008; 53: 544-550
    CrossrefPubMedGoogle Scholar
  • 49 Monsanto P, Almeida N, Rosa A. et al. Endoscopic treatment of bleeding gastric varices with histoacryl (N-butyl-2-cyanoacrylate): a South European single center experience. Indian J Gastroenterol 2013; 32: 227-231
    CrossrefPubMedGoogle Scholar
  • 50 Mumtaz K, Majid S, Shah H. et al. Prevalence of gastric varices and results of sclerotherapy with N-butyl 2 cyanoacrylate for controlling acute gastric variceal bleeding. World J Gastroenterol 2007; 13: 1247-1251
    CrossrefPubMedGoogle Scholar
  • 51 Ni Z, Chen H, Tang S. et al. The efficacy and the safety of prophylactic N-butyl-2-cyanoacrylate injection for gastric varices using a modified injection technique. Surg Laparosc Endosc Percutan Tech 2016; 26: e85-90
    PubMedGoogle Scholar
  • 52 Prachayakul V, Aswakul P, Chantarojanasiri T. et al. Factors influencing clinical outcomes of Histoacryl glue injection-treated gastric variceal hemorrhage. World J Gastroenterol 2013; 19: 2379-2387
    CrossrefPubMedGoogle Scholar
  • 53 Seewald S, Ang TL, Imazu H. et al. A standardized injection technique and regimen ensures success and safety of N-butyl-2-cyanoacrylate injection for the treatment of gastric fundal varices (with videos). Gastrointest Endosc 2008; 68: 447-454
    CrossrefPubMedGoogle Scholar
  • 54 Sharma BC, Varakanahalli S, Singh JP. et al. Gastric varices in cirrhosis vs. extrahepatic portal venous obstruction and response to endoscopic N-butyl-2-cyanoacrylate injection. J Clin Exp Hepatol 2017; 7: 97-101
    CrossrefPubMedGoogle Scholar
  • 55 Wang J, Tian X-G, Li Y. et al. Comparison of modified percutaneous transhepatic variceal embolization and endoscopic cyanoacrylate injection for gastric variceal rebleeding. World J Gastroenterol 2013; 19: 706-714
    CrossrefPubMedGoogle Scholar
  • 56 Mohan BP, Adler DG. Heterogeneity in systematic review and meta-analysis: how to read between the numbers. Gastrointest Endosc 2019; 89: 902-903
    CrossrefPubMedGoogle Scholar
  • 57 de Franchis R. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
    CrossrefPubMedGoogle Scholar
  • 58 Garcia-Tsao G, Abraldes JG, Berzigotti A. et al. 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; 65: 310-335
    CrossrefPubMedGoogle Scholar