Endoscopic Ultrasound (EUS)-Guided Therapy of Gastric Varices: A Systematic Review and Pooled Analysis

Abstract

Introduction: Gastric varices (GV) contribute to high mortality in patients with advanced cirrhosis due to life-threatening bleeding and endoscopic management options are limited. Transjugular intrahepatic portosystemic shunt (TIPS) is commonly used in management of GV but poses several complications including worsening encephalopathy and may not be feasible in cases with portal vein thrombosis. Endoscopic ultrasound (EUS)-guided therapy with glue injection and/or coil placement is a novel method for treatment and eradication of GV. Our aim is to report the efficacy and safety of EUS-guided therapy for treatment of GV. Methods: A systematic review of existing literature on EUS-guided therapy was performed. Outcomes of interest were: pooled rates of technical success, clinical success as indicated by absence of early posttreatment bleeding (early 6 months), durable success rate (obliteration of varices confirmed by EUS), and procedure-related adverse events (pain, embolization, and bleeding within 120 hours). Pooled analysis was performed using the OpenMetaAnalyst software. Results: A total of 6 retrospective studies (263 patients with mean age 61.4 years, 64% males, 89% with cirrhosis) were analyzed. Active bleeding was noted in 12% on endoscopy, while 69% had stigmata of recent bleed. Average follow-up post endoscopy was 20.4 months. Technical success rate of the EUS-guided therapy was 99%. Clinical success was noted in 95.8%. EUS-guided therapy resulted in obliteration of GV in 80.3% of patients (95% CI: 64.5%-96.1%, I2 94.5%). Among patients with EUS confirmed obliteration of GV, 79% needed only a single EUS session. Among patients with EUS and/or clinical follow-up, recurrent bleeding from GV was observed in 9.3% (22/236, early 11, late 11). Of these, 50% underwent additional EUS-guided therapy successfully. Overall peri-procedural adverse event rate was 10%. The systemic embolization reported in 7% was asymptomatic and mostly associated with glue injection. There were no reported strokes. Only 1 death was directly attributed to the procedure. Conclusion: EUS-guided therapy of GV has high technical and clinical success rates with durability, and should be considered as an alternative to conventional endoscopic therapies and TIPS in carefully selected patients.