Comparative Efficacy and Safety of Endoscopic Treatments for Gastric Varices: A Systematic Review and Network Meta-analysis

Background and study aims: It is unclear which is the best endoscopic treatment for gastric varices (GV). We performed a network meta-analysis combining direct and indirect comparisons among the different techniques. Patients and methods: We identified 10 randomized controlled trials (RCTs) (760 patients) comparing endoscopic cyanoacrylate injection, endoscopic thrombin injection, endoscopic ultrasound (EUS)-guided cyanoacrylate injection, EUS-guided coil injection, EUS-guided cyanoacrylate+coil injection, large volume band ligation. The rebleeding rate was the primary outcome, whereas the complete obliteration of GV and adverse event (AE) rate were the secondary outcomes. The results were expressed in terms of risk ratio (RR) with 95% confidence intervals (CIs). Results: EUS-guided cyanoacrylate and EUS-guided cyanoacrylate+coil injection showed significantly inferior rates of rebleeding than direct endoscopic cyanoacrylate injection (RR 0.39, 0.27-0.58 and RR 0.15, 0.03-0.90, respectively). None of the treatments resulted significantly superior to the others in terms of complete obliteration of the GVs but EUS-guided cyanoacrylate injection, large band ligation and thrombin injection determined lower AE rates as compared to endoscopic cyanoacrylate injection (RR 0.59, 0.48-0.72, RR 0.38, 0.19-0.75, and RR 0.30, 0.15-0.61, respectively). Conclusions: EUS-guided cyanoacrylate injection with or without coils was associated with lower rebleeding rates compared to conventional endoscopic cyanoacrylate injection. However, the certainty of evidence was very low and further RCTs are needed before firm conclusions can be drawn regarding the relative efficacy and safety of these treatments.