Combination therapy versus monotherapy for EUS-guided management of gastric varices: A systematic review and meta-analysis

Abstract

Cyanoacrylate (CYA), coil embolization, and/or combination thereof are available EUS-guided therapies for the treatment of gastric varices (GV). The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the comparative effectiveness of EUS-guided interventions for the treatment of GV. Individualized search strategies were developed for PubMed, EMBASE, and Cochrane Library databases, from inception through November 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This cumulative meta-analysis was performed using calculating pooled proportions. Measured outcomes included technical success, clinical success, adverse events, and rate of rebleeding or reintervention. Comparative subgroup analyses were performed for three treatment cohorts (EUS-guided CYA injection, EUS-guided coil embolization + CYA injection, and EUS-guided coil injection alone). Heterogeneity was assessed with I 2 statistics. Eleven studies (n = 536 patients; 62.20% of males) were included. The mean age was 58.21 ± 4.15 years with an average follow-up of 12.93 ± 7.69 months. Overall technical success, clinical success, and adverse events for EUS treatments was 100% ([95% confidence interval [CI] 98-100]; I 2 = 30.54%), 97% ([95% CI 92-100]; I 2 = 59.99%), and 14% ([95% CI 6-23]; I 2 = 82.23%), respectively. On subgroup analysis, EUS-guided CYA + coil embolization resulted in a better technical and clinical success compared to CYA alone (100% vs. 97%; P < 0.001 and 98% vs. 96%; P < 0.001) and coil embolization alone (99% vs. 97%; P < 0.001 and 96% vs. 90%; P < 0.001). CYA + coil embolization also resulted in lower adverse event rates compared to CYA alone (10% vs. 21%; P < 0.001), and comparable rates to coil embolization alone (10% vs. 3%; P = 0.057). EUS-guided treatment overall appears to be an effective and safe modality for GV. Among a variety of EUS-therapies available, EUS combination therapy with coil embolization + CYA injection appears to be a preferred strategy for the treatment of GV over EUS-based monotherapy.

The Role of Interventional Endoscopic Ultrasound in Liver Diseases: What Have We Learnt?

“…These findings are further validated with a meta-analysis of three modalities; demonstrating better technical and clinical success in combination therapy compared to cyanoacrylate alone (technical success: 100% vs. 97%, clinical success: 98% vs. 96%; p < 0.001) and coil embolization alone (technical success: 99% vs. 97%, clinical success: 96% vs. 90%; p < 0.001). Lower adverse event rates were also observed in combination therapy compared to cyanoacrylate alone (10% vs. 21%) [ 44 ].…”

Novel Endoscopic Therapy for Gastric Varices Using Direct Forward-Viewing Endoscopic Ultrasonography

“…In a pilot study of five patients in whom cyanoacrylate was injected in real time under EUS guidance using oblique viewing (indirect forward-viewing) model unlike the model used in the present study, successful treatment outcome was achieved by using only EUS and fluoroscopy in cases complicated by hemorrhaging wherein it is difficult to secure the visual field of the endoscope [ 7 ]. Recently, coil embolization under EUS guidance has been reported [ 8 , 9 , 10 ], and various methods have been devised to improve treatment results [ 11 , 12 ]. Previous report had compared DFV-EUS and oblique-viewing EUS for drainage of pancreatic fluid collections [ 13 ]; however, this is the first report to use DFV-EUS for the treatment of GV.…”

“…It has been proven that endoscopic ultrasonography (EUS) is useful for accurately evaluating the treatment in varices [ 2 , 3 , 4 , 5 , 6 ]. Moreover, the use of EUS for actual treatment has also been reported [ 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. However, direct forward-viewing EUS (DFV-EUS) for treating GV is less known than oblique viewing therapy.…”

Current state of endohepatology: Diagnosis and treatment of portal hypertension and its complications with endoscopic ultrasound

“…A systematic review and meta-analysis compared combination therapy (cyanoacrylate + coils) to monotherapy with (cyanoacrylate alone vs coil alone or non-cyanoacrylate treatment)[ 31 ]. Eleven studies were included ( n = 536) which included 2 randomized control trials, one prospective study, and 8 retrospective studies.…”