The secondary prophylactic efficacy of beta-blocker after endoscopic gastric variceal obturation for first acute episode of gastric variceal bleeding

Risk Factors for Rebleeding After Endoscopic Injection of Cyanoacrylate Glue for Gastric Varices: A Systematic Review and Meta-Analysis

BACKGROUND

Rebleeding is a significant complication of endoscopic injection of cyanoacrylate in gastric varices in cirrhotic patients.

AIM

This systematic review and meta-analysis aimed to evaluate the efficiency of endoscopic cyanoacrylate injection and summarized the risk factors for rebleeding.

METHODS

Databases were searched for articles published between January 2012 and December 2022. Studies evaluating the efficiency of endoscopic injection of cyanoacrylate glue for gastric varices and the risk factors for rebleeding were included.

RESULTS

The final analysis included data from 24 studies. The hemostatic rates ranged from 65 to 100%. The pooled rate of gastric varices recurrence was 34% [95% CI 21-46, I2 = 61.4%], early rebleeding rate was 16% [95% CI 11-20, I2 = 37.4%], late rebleeding rate was 39% [95% CI 36-42, I2 = 90.9%], mild and moderate adverse events rate were 28% [95% CI 24-31, I2 = 91.6%], 3% [95% CI - 2 to 8, I2 = 15.3%], rebleeding-related mortality rate was 6% [95% CI 2-10, I2 = 0%], all-cause mortality rate was 17% [95% CI 12-22, I2 = 63.6%]. Independent risk factors for gastric variceal rebleeding included portal venous thrombosis, ascites, cyanoacrylate volume, fever/systemic inflammatory response syndrome, red Wale sign, previous history of variceal bleeding, active bleeding and paragastric veins. The use of proton pump inhibitors could be a protective factor.

CONCLUSIONS

Endoscopic cyanoacrylate glue injection is an effective and safe treatment for gastric varices. Cirrhotic patients with the above risk factors may benefit from treatment aimed at reducing portal hypertension, antibiotic prophylaxis, and anticoagulation if they meet the indications.

Balloon-occluded retrograde transvenous obliteration and simultaneous endoscopic cyanoacrylate injection for treating gastric varices draining through gastrorenal shunts

BACKGROUND AND STUDY AIMS

Balloon-occluded retrograde transvenous obliteration-assisted endoscopic cyanoacrylate injection (E-BRTO) temporarily treats gastric fundic varices draining through gastrorenal shunts (GRS) occluding the GRS with a balloon, then endoscopically injecting cyanoacrylate. We retrospectively examined the safety, feasibility, and efficacy of E-BRTO.

PATIENTS AND METHODS

We enrolled 85 patients with hepatic cirrhosis plus gastric fundic varices with GRS; 34 underwent E-BRTO. The 51 patients who refused all secondary prophylactic treatments served as controls.

RESULTS

Finally, 33 of the 34 patients underwent successful E-BRTO without major adverse events. Gastric varices were eradicated from all 33 patients in the E-BRTO group; the average follow-up time was 161.0 (74.0) weeks (mean [SD]). Four end-point events (12%) were recorded during the follow-up period. In the control group, 33 patients (65%) suffered repeat variceal bleeding, resulting in seven deaths. The cumulative rebleeding rates of the E-BRTO group on the 6th, 24th, 48th, 96th, 144th, 192nd, 240th, and 288th week were 0%, 3%, 9%, 9%, 13%, 13%, 13%, and 13%, while the cumulative rebleeding rates of the control group in the same period were 10%, 20%, 35%, 46%, 55%, 65%, 76%, and 76%.

CONCLUSIONS

E-BRTO was safe, feasible, and well tolerated by patients with hepatic cirrhosis plus gastric fundic varices with GRS. Over the long-term follow-up period, the E-BRTO group demonstrated a lower rate of repeat bleeding than the control group.

Liver stiffness-spleen diameter to platelet ratio score (LSPS model) predicts variceal rebleeding for cirrhotic patients

PURPOSE

The liver stiffness- spleen diameter to platelet ratio score (LSPS model) can identify a high risk of decompensated events in cirrhotic patients. We aimed to evaluate the value of the LSPS model as a risk stratification strategy in the secondary prevention for cirrhotic patients with esophageal and gastric variceal bleeding (EGVB).

METHODS

Consecutive EGVB patients who underwent liver stiffness measurement by acoustic radiation force impulse, platelet count and ultrasonography were enrolled between January 2013 and December 2019. We calculated the LSPS of all patients and followed up for over 2 years. The primary outcome was rebleeding. Transplant-free survival and overt hepatic encephalopathy (OHE) were the secondary outcomes.

RESULTS

A total of 131 patients were analyzed. The median value of the LSPS model is 0.1879. We developed risk stratification based on the LSPS model and divided the patients into two groups: the high-LSPS (LSPS > 0.1879) group and the low-LSPS (LSPS ≤ 0.1879) group. Sixty-two (47.33%) patients suffered rebleeding, in which there were 21 (31.92%) patients with low LSPS and 41 (63.08%) patients with high LSPS (hazard ratio 2.883; 95% confidence interval, 1.723-4.822, P  < 0.001). For the whole cohort, the rates of transplant-free survival and OHE were consistently similar between the two groups at 2 years.

CONCLUSION

The LSPS is a reliable, noninvasive method for the detection of a high risk of rebleeding for the secondary prevention of EGVB.

The efficacy and safety of beta-blockers versus cyanoacrylate injection for gastric variceal bleeding: A protocol for systematic review and meta-analysis

BACKGROUND

The benefit of beta-blockers for secondary prophylaxis of gastric variceal bleeding has limited evidence. Therefore, a systematic review and meta-analysis was conducted to systematically analyze and compare the effect of beta-blockers versus cyanoacrylate injection for patients with gastric variceal bleeding.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines will be followed to conduct the present meta-analysis. From the inception to June 2021, the Web of Science, EMBASE, PubMed, and Cochrane Library electronic databases will be searched using the key phrases "beta-blockers," "cyanoacrylate," and "gastric variceal bleeding" for all relevant English-language trials. Study included in our meta-analysis has to meet the following criteria: observational or randomized controlled trial focusing on assessing the effectiveness of beta-blockers and cyanoacrylate injection for gastric variceal bleeding; the following outcome measures are reported: bleeding from gastric variceal, overall mortality, bleed related mortality, and complications.

RESULTS

This study expects to provide credible and scientific evidence for the efficacy and safety of beta-blockers versus cyanoacrylate injection for patients with gastric variceal bleeding.

REGISTRATION NUMBER

10.17605/OSF.IO/CPV9T.

Endoscopic Cyanoacrylate Glue Injection in Management of Gastric Variceal Bleeding: US Tertiary Care Center Experience

BACKGROUND/AIMS

Although endoscopic cyanoacrylate glue injection (ECGI) is recommended as first-line treatment for bleeding gastric varices (GV) there is still limited experience with this method in the US. Our aim was to analyze our 10-year experience of ECGI for treatment and prophylaxis of gastric variceal bleeding.

METHODS

Records of patients undergoing ECGI of GV at our US tertiary care center between 6/2005 and 5/2015 were reviewed. Assessed outcomes were primary hemostasis, early rebleeding during hospitalization, recurrent bleeding during follow-up, eradication and recurrence of GV.

RESULTS

Prophylactic ECGI was performed in 16 patients with large GV. Eradication was achieved in 15 (94%). During the median follow-up of 27 (IQR 7-47) months, 4 patients (26.6%) had variceal bleeding; all were treated successfully with ECGI. Fifty-seven patients underwent ECGI for GV bleeding. Primary hemostasis was achieved in all. Early rebleeding occurred in 2 (3.5%) and durable hemostasis could not be achieved. Follow-up beyond initial hospitalization was available in 41 patients. Bleeding recurred in 8 (19.5%) patients during a median follow-up of 12 (IQR, 3-51) months. Eradication of GV was achieved in 92% of patients but recurrent varices were found in 44% during a median follow up period of 33 months.

CONCLUSION

ECGI is effective in achieving hemostasis of bleeding GV and their eradication. Recurrent bleeding and recurrence of varices after complete obliteration however are not infrequent and continued surveillance is advisable.

Management of gastric varices: a French national survey

BACKGROUND AND AIMS

Bleeding from gastric varices is more severe than that from esophageal varices, but its management remains debated. We aimed to determine how French hepatogastroenterologists manage cirrhotic patients with gastric varices.

METHODS

Hepatogastroenterologists (n=1163) working in general or university hospitals received a self-administered questionnaire.

RESULTS

Overall, 155 hepatogastroenterologists (13.3%) from 112 centers (33.3%; 39/40 university hospitals, 73/296 general hospitals) answered. Primary prophylaxis was used by 98.1% of hepatogastroenterologists as follows: β-blockers 96.1% (93.8 vs. 97.0%; university vs. general hospitals respectively; P=0.57), glue obliteration 16.9% (17.2 vs. 16.3%; P=0.88), and transjugular intrahepatic portosystemic shunt (TIPS) 8.0% (12.7 vs. 4.6%; P=0.12). To manage bleeding, university hospitals had greater local access to glue obliteration (95.4 vs. 68.2%; P<0.001) and TIPS (78.5 vs. 3.5%; P<0.001). Early TIPS was proposed by 53.6% (72.1 vs. 39.2%; P<0.001). Glue obliteration was performed under general anesthesia (86.1%) using Glubran (43.1%) or Histoacryl (52.9%), and lipiodol (78.8%) with varying degrees of dilution (1 : 10 to 3 : 4). The injected volume per varix varied widely (1-20 ml). Glue obliteration, band ligation, or both were used by, respectively, 64.2, 18.2, and 17.5% of practitioners. Almost all hepatogastroenterologists (98%) performed secondary prophylaxis: β-blockers 74.7% (75.0 vs. 74.4%, university vs. general hospitals; P=0.93), glue obliteration 66.0% (76.9 vs. 57.6%; P=0.013), and TIPS 30.0% (39.1 vs. 23.3%; P=0.037).

CONCLUSION

The management of gastric varices in France is heterogeneous across centers. University hospitals have better access to techniques such as glue obliteration and TIPS. As bleeding from gastric varices has a poor outcome, guidelines should be established to standardize clinical practices and design further studies.