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Poster Session D - Tuesday Morning

Category: Interventional Endoscopy

D0440 - Endoscopic Ultrasound (EUS) Guided Therapies for Primary and Secondary Prophylaxis in Gastric Varices – An Updated Systematic Review and Meta-Analysis

Tuesday, October 25, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

Saurabh Chandan, MD

CHI Health Creighton School of Medicine
Omaha, NE

Saurabh Chandan, MD¹, Andrew Nguyen, MD², Babu P. Mohan, MD, MS², Smit Deliwala, MD³, Daryl Ramai, MD, MPH², Lena Kassab, MD⁴, Antonio Facciorusso, MD, PhD⁵, Faisal Kamal, MD⁶, Mohammad Bilal, MD⁷, Jayanta Samanta, MBBS, MD, DM⁸, Douglas G. Adler, MD, FACG⁹
¹CHI Health Creighton School of Medicine, Omaha, NE; ²University of Utah School of Medicine, Salt Lake City, UT; ³Michigan State University, East Lansing, MI; ⁴Mayo Clinic, Rochester, MN; ⁵University of Foggia, Foggia, Puglia, Italy; ⁶University of California, San Francisco, San Francisco, CA; ⁷University of Minnesota, Minneapolis VA Medical Center, Minneapolis, MN; ⁸Post Graduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India; ⁹Centura Health-Porter Adventist Hospital, Salt Lake City, UT

Introduction: Gastric varices (GV) account for about 20% of all variceal bleeds and are associated with more risk of uncontrolled bleeding, higher transfusion requirements, and higher rates of rebleeding and death when compared to esophageal varices. While endoscopic glue injection therapy has been traditionally used for secondary prophylaxis in GV, data regarding treatment options for primary prophylaxis continues to emerge. Recently, endoscopic ultrasound (EUS) guided therapies have been employed in GV bleeding. We conducted a systematic review and meta-analysis exploring the safety and efficacy of EUS-guided treatments for primary and secondary prophylaxis of GV.

Methods: We conducted a comprehensive search of major databases from inception to June 2022, to identify studies of interest. Our primary goals were to estimate the pooled rates of treatment efficacy, GV obliteration, GV recurrence, and re-bleeding with EUS guided therapy in primary and secondary prophylaxis. Random-effects model was used for our meta-analysis and heterogeneity was assessed using the I2% statistics.

Results: 604 patients (18 studies) were included. EUS guided therapies for primary GV prophylaxis were performed in 162 patients, whereas secondary prophylaxis for active and recent bleeding from GV was performed in 442 patients. In primary prophylaxis, pooled rate of GV obliteration was 90.2% (CI 81.1–95.2; I2 0). With combination EUS-glue and coil therapy, the rate was 95.4% (CI 86.7–98.5; I2 0). Pooled rate of post therapy GV bleeding was 4.9% (CI 1.8–12.4; I2 0). In secondary prophylaxis, pooled rate of treatment efficacy was 91.9% (CI 86.8–95.2; I2 12). With EUS-glue, EUS-coil and combination EUS-glue and coil, the rates were 92% (CI 80.7–96.9; I2 60), 95.5% (CI 83.6–98.9; I2 0) and 88.8% (CI 79.8–94.1; I2 16), respectively.

Pooled rate of GV obliteration was 84% (CI 71.5–91.2; I2 74). With EUS-glue, EUS-coil and combination EUS-glue and coil, the rates were 84.6% (CI 75.9–90.6; I2 31), 92.3% (CI 81.1–97.1; I2 0) and 84.5% (CI 50.8–96.7; I2 75), respectively. Pooled rates of GV re-bleeding and recurrence were 18.1% (CI 13.1–24.3; I2 16) and 20.6% (CI 9.3–39.5; I2 66), respectively. Mean number of sessions to achieve GV obliteration was 1.4 (range 1-5). Overall pooled rate of adverse events was 11.9% with systemic embolization occurring in 14 patients.

Discussion: Our analysis shows that EUS-guided therapy for gastric varices is technically feasible and clinically successful in both primary and secondary prophylaxis in GV.

Figure: Figure 1

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STUDY

DESIGN

Type of prophylaxis

TOTAL N

EUS MODALITY USED (COIL/GLUE/ COMBINATION)

VOLUME/NO. OF COILS

GV TYPE

NO. OF SESSIONS

M/F

AGE

Lee 2000

Prospective, single center, July 1996 to October 1998, China

Secondary

EUS-glue

Median 3 doses of CYA (1-8)

GOV1 20, GOV2 18, IGV1 16

2.2 ± 1.7

34/20

61 ± 14

Romero-Castro 2013

Retrospective, multi-center, February 2008 to May 2012, Spain and Germany

Primary/ Secondary (7/23)

30 - 19 (CYA); 11 (Coil)

EUS-glue/EUS-Coil

1 mL/session (mean 1.5±0.1 mL, range 1-3 mL)/ Mean of 5.8±1.2 coils (range 2-13)

1.5 ± 0.1 / 5.8 ± 1.2

IGV1 15, GOV2 14, GOV1 1

1.4±0.1 (range 1-3)

22/8

60.6 ± 8.7

Gubler 2014

Retrospective, single center, 2006 to 2013, Switzerland

Primary

4/40

EUS-glue

1.9 ml (range 1–10)

3.7 ± 2.6 (vol)

IGV1

2.7 ± 1.8

25/15

65 (14–79)

Secondary

36/40

Bick 2018

Retrospective, single center, January 2013 and November 2017, USA

Primary

EUS-glue (62), glue+coil (2)

2 ml ± 0.8/2 coils

2 ± 0.8/2 ± 1

IGV1:30, GOV1: 2, GOV2: 32

1.2 ± 0.2

33/31

58.0 ± 12.5

Secondary

Frost 2018

Retrospective, single center, October 2013 and January 2017, Ireland

Primary

EUS-thrombin

600 - 5000 IU of thrombin

GOV2: 4, IGV1: 4

3/0

61.8 ± 10

Secondary

EUS-thrombin

4250-10,000 IU of thrombin

4/1

61.8 ± 10

Mukkada 2018

Retrospective, single center, October 2013 - December 2016, India

Secondary

EUS glue or coil

2ml (1-10)/1-6 coils [1 (7n), 2 (13n), 3 (5n), 4 (3n), 5 (1n), 6 (1n)]

3.75 ± 2.6 / 2.3 ± 1.5

GOV1: 12, GOV2: 8, IGV1: 10

"Multiple"

57.5 ± 12.7

Khoury 2019

Case series, single center, March 2015 and March 2018, Israel

Secondary

EUS-glue+coil

1-2ml/2-8 coils

1.5 ± 0.3 / 1.8 ± 1.5

GOV1: 2, GOV2: 5, IGV1: 3

1-4

7/3

46.7 ± 19.3

Lobo 2019

Randomized controlled trial, single center, November 2014 to December 2016, Brazil

Primary + Secondary (6/10)

EUS-glue+coil

1.40±0.74 ml/1-3 coils (11/2/2)

1.4 ± 0.74 / 1.4 ± 0.5

GOV2 13, IGV1 3

1 session - 6/16, 2 sessions - 4/15

8/8

49.3 ± 14.8

Bazarbashi 2020

Retrospective, case series, single center, October 2017 and November 2018, USA

Secondary

EUS-coil/ gelatin sponge

2.5 ± 0.7 ml absorbable sponge/ 8 ± 2.9 coils

2.5 ± 0.7 / 8 ± 2.9

GOV2: 3, IGV1: 7

4/6

64 ± 11.5

Irisawa 2020

Prospective, single center, case series, Japan

Primary

EUS guided coil with sclerotherapy

7.8 mL±6.7/5.6±2.9 coils

7.8 ± 6.7 / 5.6 ± 2.9

IGV1

1.9 ± 1.0

6/2

69 ± 9

Kozeil 2020

Retrospective, single center, Poland

Primary

EUS-glue+coil

2ml (1-9)/1.7 (1–3) coils

3.5 ± 2.3 / 1.85 ± 0.6

GOV2 8, IGV1 6, IGV2 2

9/7

51 (29–75)

Secondary

Robles-Medranda 2020 (a)

Randomized controlled trial, single center, March 2016 - October 2018, Ecuador,

Primary

4/30

EUS coil

3 (1 – 7) coils

3.5 ± 1.7

GOV2 12, IGV 1 18

19/11

61.6 (12.3)

Secondary

21/30

Robles-Medranda 2020 (b)

Randomized controlled trial, single center, March 2016 - October 2018, Ecuador,

Primary

3/30

EUS-glue+coil

1.8 ml (1.2–2.4)/2 (1 – 3) coils

1.8 ± 0.4 / 2 ± 0.6

GOV2 19, IGV1 11

16/14

61.8 (7.8)

Secondary

26/30

Kouanda 2021

Retrospective, single center, June 2009 and December 2019. USA

Primary

EUS-glue+coil

2 ml (0.5 - 5)/1.5 (1-3) coils

2.4 ± 1.3 / 1.75 ± 0.6

IGV1 69, GOV2 8, GOV1 3

1.3 ± 0.5

55/25

60.5 ± 10.4

Mosquera-Klinger 2021

Retrospective, single center, case series, June 2014 - June 2018, Colombia

Secondary

EUS guided hydro coils

2 coils

2 ± 0.5

3/1

37 ± 12

Seven 2022 (a)

Retrospective, single center, January 1, 2011, and January 31, 2021, Turkey

Primary

EUS-coil

5 (3–9)

5.5 ± 1.7

55.9 ± 12.9

Secondary

GOV2 8, IGV1 3

7/4

Seven 2022 (b)

Retrospective, single center, January 1, 2011, and January 31, 2021, Turkey

Secondary

EUS-glue+coil

5 (3–9)

5.5 ± 1.7

GOV2 7, IGV1 2

5/4

52.1 ± 13.4

Alali 2022

Retrospective, case series, single center, October 2017 to October 2021, Kuwait

Primary + Secondary (5/10)

EUS-glue+coil

1.5ml (0.74)/1.5 (1.4) coils

1.5 ± 0.74 / 1.5 ± 1.4

GOV2 12, IGV1 3

1.25 ± 0.38

12/3

58 (12)

Bazarbashi 2022 (a)

Retrospective case series, single center, 2018 - 2021, USA

Primary + Secondary (11/68)

EUS coils/coil/gelatin sponge

2.5 ml ± 2.05/4.29 ± 3.27 coils

2.5 ± 2.0 / 4.29 ± 3.27

IGV1 49, IGV2 4, GOV1 7, GOV2 19

44/35

60.3 ± 13

Samanta 2022 (a)

Randomized controlled trial, multi center, India - Italy

Primary + Secondary (8/44)

EUS-glue+coil

2ml (1-3)/2 (1 - 3) coils

2 ± 0.6 / 2 ± 0.6

1 +/- 0.25

32/20

48.59 ± 13

Table: Table 1

Disclosures:

Saurabh Chandan indicated no relevant financial relationships.

Andrew Nguyen indicated no relevant financial relationships.

Babu Mohan indicated no relevant financial relationships.

Smit Deliwala indicated no relevant financial relationships.

Daryl Ramai indicated no relevant financial relationships.

Lena Kassab indicated no relevant financial relationships.

Antonio Facciorusso indicated no relevant financial relationships.

Faisal Kamal indicated no relevant financial relationships.

Mohammad Bilal indicated no relevant financial relationships.

Jayanta Samanta indicated no relevant financial relationships.

Douglas Adler: Boston Scientific – Consultant.

Saurabh Chandan, MD¹, Andrew Nguyen, MD², Babu P. Mohan, MD, MS², Smit Deliwala, MD³, Daryl Ramai, MD, MPH², Lena Kassab, MD⁴, Antonio Facciorusso, MD, PhD⁵, Faisal Kamal, MD⁶, Mohammad Bilal, MD⁷, Jayanta Samanta, MBBS, MD, DM⁸, Douglas G. Adler, MD, FACG⁹. D0440 - Endoscopic Ultrasound (EUS) Guided Therapies for Primary and Secondary Prophylaxis in Gastric Varices – An Updated Systematic Review and Meta-Analysis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.