Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension

Clinical effects of endoscopic ligation combined with tissue glue injection in treatment of esophageal variceal bleeding

AIM: To evaluate the clinical effects and security of endoscopic variceal ligation (EVL) combined with tissue glue injection in the treatment of esophageal variceal bleeding.

METHODS: A total of 229 patients with gastric variceal bleeding (EGVB) treated at Wuhan No. 3 Hospital from January 2007 to March 2013 were selected. The patients were divided into three groups: a sclerotherapy plus tissue glue group (n = 65), a conservative treatment group (n = 76) and an EVL plus tissue glue group (n = 88). The clinical effects of the three groups were observed. According to the use of painless endoscopy or not, the EVL plus tissue glue group was divided into two groups: a painless group (n = 46) and a normal group (n = 42). Blood pressure (BP), heart rate (HR), and hemoglobin oxygen saturation levels (SpO₂) were compared.

RESULTS: In the EVL plus tissue glue group, there were 6 (6.8%) cases of early hemorrhage (6.8%), 8 (9.0%) cases of late hemorrhage, 2 (2.3%) cases of complications, and 3 (3.4%) of death. Except the incidence of complications (the conservative treatment group had no complications), the above parameters were significantly less in the EVL plus tissue glue group than in the other two groups (P < 0.05). With regards to endoscopic curative effect, in the EVL plus tissue glue group, marked improvement was achieved in 57 (64.8%) cases, improvement in 21 (23.8%) and no improvement in 10 (11.3%), with a total effective rate of 88.6%. Compared with the other two groups, the endoscopic curative effect and total effective rate were significantly better in the EVL plus tissue glue group (P < 0.05). Between the painless and normal groups, there were no significant differences in heart rate or blood oxygen saturation before and after operation. Postoperative blood pressure was lower in the painless group than in the normal group.

CONCLUSION: The curative effect of EVL combined with tissue adhesives is better, the complication and mortality are very low, and the total effective rate is higher.

Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension

BACKGROUND

In people with portal hypertension, gastric varices are less prevalent than oesophageal varices. The risk of bleeding from gastric varices seems to be lower than from oesophageal varices; however, when gastric varices bleed, it is often severe and associated with higher mortality. Endoscopic sclerotherapy of bleeding gastric varices with N-butyl-2-cyanoacrylate glue (cyanoacrylate) is considered the best haemostasis with a lower risk of re-bleeding compared with other endoscopic methods. However, there are some inconsistencies between trials regarding mortality, incidence of re-bleeding, and adverse effects.

OBJECTIVES

To assess the benefits and harms of sclerotherapy using cyanoacrylate compared with other endoscopic sclerotherapy procedures or with variceal band ligation for treating acute gastric variceal bleeding with or without vasoactive drugs in people with portal hypertension and to assess the best dosage of cyanoacrylate.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded from inception to September 2014 and reference lists of articles. We included trials irrespective of trial setting, language, publication status, or date of publication.

SELECTION CRITERIA

Randomised clinical trials comparing sclerotherapy using cyanoacrylate versus other endoscopic methods (sclerotherapy using alcohol-based compounds or endoscopy band ligation) for acute gastric variceal bleeding in people with portal hypertension.

DATA COLLECTION AND ANALYSIS

We performed the review following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the Cochrane Hepato-Biliary Module.We presented results as risk ratios (RR) with 95% confidence intervals (CI), with I(2) statistic values as a measure of intertrial heterogeneity. We analysed data with both fixed-effect and random-effects models, and reported the results with random-effects models. We performed subgroup, sensitivity, and trial sequential analyses to evaluate the robustness of the overall results, risk of bias, sources of intertrial heterogeneity, and risk of random errors.

MAIN RESULTS

We included six randomised clinical trials with three different comparisons: one trial compared two different doses of cyanoacrylate in 91 adults, bleeding actively from all types of gastric varices; one trial compared cyanoacrylate versus alcohol-based compounds in 37 adults with active or acute bleeding from isolated gastric varices only; and four trials compared cyanoacrylate versus endoscopic band ligation in 365 adults, with active or acute bleeding from all types of gastric varices. Main outcomes in the included trials were bleeding-related mortality, failure of intervention, re-bleeding, adverse events, and control of bleeding. Follow-up varied from six to 26 months. The participants included in these trials had chronic liver disease of different severities, were predominantly men, and most were from Eastern countries. We judged all trials at high risk of bias. Application of quality criteria for all outcomes yielded very low quality grade of the evidence in the three analyses, except for the low quality evidence rated for the re-bleeding outcome in the cyanoacrylate versus endoscopic band ligation comparison. Two different doses of cyanoacrylate: we found very low quality evidence from one trial for the effect of 0.5 mL compared with 1.0 mL of cyanoacrylate on all-cause mortality (20/44 (45.5%) with 0.5 mL versus 21/47 (45%) with 1.0 mL; RR 1.02; 95% CI 0.65 to 1.60), 30-day mortality (RR 1.07; 95% CI 0.41 to 2.80), failure of intervention (RR 1.07; 95% CI 0.56 to 2.05), prevention of re-bleeding (RR 1.30; 95% CI 0.73 to 2.31), adverse events reported as fever (RR 0.56; 95% CI 0.32 to 0.98), and control of bleeding (RR 1.04; 95% CI 0.78 to 1.38). Cyanoacrylate versus alcohol-based compounds: we found very low quality evidence from one trial for the effect of cyanoacrylate versus alcohol-based compounds on 30-day mortality (2/20 (10%) with cyanoacrylate versus 4/17 (23.5%) with alcohol-based compound; RR 0.43; 95% CI 0.09 to 2.04), failure of intervention (RR 0.36; 95% CI 0.09 to 1.35), prevention of re-bleeding (RR 0.85; 95% CI 0.30 to 2.45), adverse events reported as fever (RR 0.43; 95% CI 0.22 to 0.80), and control of bleeding (RR 1.79; 95% CI 1.13 to 2.84). Cyanoacrylate versus endoscopic band ligation: we found very low quality evidence for the effect of cyanoacrylate versus endoscopic band ligation on bleeding-related mortality (44/185 (23.7%) with cyanoacrylate versus 50/181 (27.6%) with endoscopic band ligation; RR 0.83; 95% CI 0.52 to 1.31), failure of intervention (RR 1.13; 95% CI 0.23 to 5.69), complications (RR 2.81; 95% CI 0.69 to 11.49), and control of bleeding (RR 1.07; 95% CI 0.90 to 1.27). There was low quality evidence for the prevention of re-bleeding (RR 0.60; 95% CI 0.41 to 0.88). Trial sequential analysis showed that the analyses were underpowered (diversity-adjusted required information size was 5290 participants for bleeding-related mortality).

AUTHORS' CONCLUSIONS

This review suggests that endoscopic sclerotherapy using cyanoacrylate may be more effective than endoscopic band ligation in terms of preventing re-bleeding from gastric varices. However, due to the very low quality of the evidence, we are very uncertain about our estimates on all-cause and bleeding-related mortality, failure of intervention, adverse events, and control of bleeding. The trials were at high risk of bias; the number of the included randomised clinical trials and number of participants included in each trial was small; and there was evidence of internal heterogeneity across trials, indirectness of evidence in terms of population, and possible publication bias.The effectiveness of different doses of cyanoacrylate and the comparison of cyanoacrylate versus alcohol compounds to treat variceal bleeding in people with portal hypertension is uncertain due to the very low quality of the evidence.The shortcomings mentioned call for more evidence from larger trials that need to be conducted according to the SPIRIT statement and reported according to CONSORT guidelines.