Secondary Prophylaxis of Gastric Variceal Bleeding: A Systematic Review and Network Meta-analysis

Department of Internal Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA, 01803, USA. Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA. Division of Gastroenterology, Lahey Hospital and Medical Center, Beth Israel Lahey Clinic, Burlington, MA, 01803, USA. Department of Medicine, Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA, 01778, USA. Department of Internal Medicine, Lincoln Medical Center, NY, USA. Department of Internal Medicine, Wertachklinik Schwabmünchen, Bavaria, Germany. Department of Internal Medicine, University of Alexandria, Alexandria, Egypt. Department of Internal Medicine, Damascus University, Damascus, Syria. Department of Library Services, Mayo Clinic, Rochester, MN, USA. Department of Transplantation and Hepatobiliary Diseases, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, MA, 01805, USA.

Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 2021

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Abstract
BACKGROUND There is no clear consensus regarding the optimal approach for secondary prophylaxis of gastric variceal bleeding (GVB) in patients with cirrhosis. We conducted a systematic review and network metanalysis (NMA) to compare the efficacy of available treatments. METHODS A comprehensive search of several databases from each database's inception to March 23rd, 2021 was conducted to identify relevant randomized controlled trials (RCTs). Outcomes of interest were rebleeding and mortality. Results were expressed as relative risk (RR) and 95% confidence interval (CI). We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to rate the certainty of evidence. RESULTS We included 9 RCTs with 579 patients, who had history of GVB and follow-up > 6 weeks. Nine interventions were included in the NMA. Balloon-occluded retrograde transvenous obliteration (BRTO) was associated with a lower risk of rebleeding when compared to beta-blockers (RR 0.04, 95%CI 0.01-0.26; low certainty), endoscopic injection sclerotherapy (EIS-CYA) (RR 0.18, 95%CI 0.04-0.77; low certainty). Beta-blockers were associated with a higher risk of rebleeding compared to most interventions and with increased mortality compared to EIS-CYA (RR 4.85, 95%CI 1.04-22.67; low certainty) and EIS-CYA+BB (RR 5.47, 95% CI 1.07-28.01; low certainty). CONCLUSION Analysis based on indirect comparisons suggests that BRTO may be the best intervention in preventing rebleeding whereas beta-blocker monotherapy is likely the worst in preventing rebleeding and mortality. Head-to-head RCTs are needed to validate these results.
Study details
Study Design : Systematic Review
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine