CC BY-NC-ND 4.0 · Endosc Int Open 2021; 09(07): E1145-E1157
DOI: 10.1055/a-1401-9880
Original article

Endoscopic band ligation in the treatment of gastric antral vascular ectasia: a systematic review and meta-analysis

Thomas R. McCarty
Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
,
Kelly E. Hathorn
Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
,
Walter W. Chan
Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
,
Kunal Jajoo
Division of Gastroenterology, Hepatology, and Endoscopy. Brigham and Women’s Hospital. Harvard Medical School, Boston, Massachusetts, United States
› Author Affiliations

Abstract

Background and study aims While argon plasma coagulation (APC) is the first-line treatment for gastric antral vascular ectasia (GAVE), endoscopic band ligation (EBL) has shown promising results. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness of EBL for the treatment of GAVE.

Methods Individualized search strategies were developed in accordance with PRISMA and MOOSE guidelines through September 1, 2020. Measured outcomes included endoscopic success (defined as GAVE eradication/improvement), change in hemoglobin, transfusion dependency, number of treatment sessions, adverse events, rebleeding, and bleeding-associated mortality. Outcomes were compared among studies evaluating EBL versus APC.

Results Eleven studies (n = 393; 59.39 % female; mean age 58.65 ± 8.85 years) were included. Endoscopic success was achieved in 87.84 % [(95 % CI, 80.25 to 92.78); I2 = 11.96 %] with a mean number of 2.50 ± 0.49 treatment sessions and average of 12.40 ± 3.82 bands applied. For 8 studies comparing EBL (n = 143) versus APC (n = 174), there was no difference in baseline patient characteristics. However, endoscopic success was significantly higher for EBL [OR 6.04 (95 % CI 1.97 to 18.56; P = 0.002], requiring fewer treatment sessions (2.56 ± 0.81 versus 3.78 ± 1.17; P < 0.001). EBL was also associated with a greater increase in post-procedure hemoglobin [mean difference 0.35 (95 % CI 0.07 to 0.62; P = 0.0140], greater reduction in transfusions required [mean difference –1.46 (95 % CI –2.80 to –0.12; P = 0.033], and fewer rebleeding events [OR 0.11 (95 % CI, 0.04 to 0.36); P < 0.001]. There was no difference in adverse events or bleeding-associated mortality (P > 0.050).

Conclusions EBL appears to be safe and effective for treatment of GAVE, with improved outcomes when compared to APC.

Supplementary material



Publication History

Received: 27 November 2020

Accepted: 15 February 2021

Article published online:
21 June 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Jabbari M, Cherry R, Lough JO. et al. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology 1984; 87: 1165-1170
  • 2 Burak KW, Lee SS, Beck PL. Portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE) syndrome. Gut 2001; 49: 866-872
  • 3 Spahr L, Villeneuve JP, Dufresne MP. et al. Gastric antral vascular ectasia in cirrhotic patients: absence of relation with portal hypertension. Gut 1999; 44: 739-742
  • 4 Charneau J, Petit R, Cales P. et al. Antral motility in patients with cirrhosis with or without gastric antral vascular ectasia. Gut 1995; 37: 488-492
  • 5 Quintero E, Pique JM, Bombi JA. et al. Gastric mucosal vascular ectasias causing bleeding in cirrhosis. A distinct entity associated with hypergastrinemia and low serum levels of pepsinogen I. Gastroenterology 1987; 93: 1054-1061
  • 6 Lowes JR, Rode J. Neuroendocrine cell proliferations in gastric antral vascular ectasia. Gastroenterology 1989; 97: 207-212
  • 7 Rider JA, Klotz AP, Kirsner JB. Gastritis with veno-capillary ectasia as a source of massive gastric hemorrhage. Gastroenterology 1953; 24: 118-123
  • 8 Ito M, Uchida Y, Kamano S. et al. Clinical comparisons between two subsets of gastric antral vascular ectasia. Gastrointest Endosc 2001; 53: 764-770
  • 9 Lee FI, Costello F, Flanagan N. et al. Diffuse antral vascular ectasia. Gastrointest Endosc 1984; 30: 87-90
  • 10 Kruger R, Ryan ME, Dickson KB. et al. Diffuse vascular ectasia of the gastric antrum. Am J Gastroenterol 1987; 82: 421-426
  • 11 Dulai GS, Jensen DM, Kovacs TO. et al. Endoscopic treatment outcomes in watermelon stomach patients with and without portal hypertension. Endoscopy 2004; 36: 68-72
  • 12 Gretz JE, Achem SR. The watermelon stomach: clinical presentation, diagnosis, and treatment. Am J Gastroenterol 1998; 93: 890-895
  • 13 Park RH, Russell RI. Watermelon stomach. Br J Surg 1991; 78: 395-396
  • 14 Sebastian S, OʼMorain CA, Buckley MJ. Review article: current therapeutic options for gastric antral vascular ectasia. Aliment Pharmacol Therap 2003; 18: 157-165
  • 15 Yusoff I, Brennan F, Ormonde D. et al. Argon plasma coagulation for treatment of watermelon stomach. Endoscopy 2002; 34: 407-410
  • 16 Zepeda-Gomez S. Endoscopic treatment for gastric antral vascular ectasia: current options. GE Port J Gastroenterol 2017; 24: 176-182
  • 17 McCarty TR, Rustagi T. New indications for endoscopic radiofrequency ablation. Clin Gastroenterol Hepatol 2018; 16: 1007-1017
  • 18 McCarty TR, Rustagi T. Comparative effectiveness and safety of radiofrequency ablation versus argon plasma coagulation for treatment of gastric antral vascular ectasia: a systematic review and meta-analysis. J Clin Gastroenterol 2019; 53: 599-606
  • 19 Tantau M, Crisan D. Is endoscopic band ligation the gold standard for gastric antral vascular ectasia?. Endosc Int Open 2019; 7: E1630-E1631
  • 20 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Int Med 2009; 151: W65-W94
  • 21 Stroup DF, Berlin JA, Morton SC. et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008-2012
  • 22 DerSimonian R, Laird N. Meta-analysis in clinical trials. Controlled Clin Trials 1986; 7: 177-188
  • 23 Stuart A, Ord JK. Kendall’s Advanced Theory of Statistics. 6th ed. London: Edward Arnold; 1994
  • 24 Riley RD, Higgins JPT, Deeks JJ. Research Methods & reporting: interpretation of random effects meta-analyses. Br Med J 2011; 342: d549
  • 25 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557-560
  • 26 Overton RC. A comparison of fixed-effects and mixed (random-effects) models for meta-analysis tests of moderator variable effects. Psychologl Methods 1998; 3: 354-379
  • 27 Wells G, Shea B, OʼConnell D. et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analysis. 3rd Symposium on Systematic Reviews: Beyond the Basics; July 3–5. Oxford: 2000 Available at (Accessed 24.11.2019): http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
  • 28 Higgins JPT, Altman DG, Sterne JAC. Cochrane Handbook for Systematic Reviews of Interventions. Higgins JPT. http://www.cochrane-handbook.org
  • 29 Fuccio L, Zagari RM, Serrani M. et al. Endoscopic argon plasma coagulation for the treatment of gastric antral vascular ectasia-related bleeding in patients with liver cirrhosis. Digestion 2009; 79: 143-150
  • 30 Borenstein M, Hedges LV, Higgins JP. et al. Introduction to meta-analysis. Hoboken: John Wiley & Sons; 2011
  • 31 Higgins J, Thompson SG, Spiegelhalter DJ. A re-evaluation of random-effects meta-analysis. J R Statist Soc A 2009; 172: 137-159
  • 32 Borenstein M, Higgins JP, Hedges LV. et al. Basics of meta-analysis: I(2) is not an absolute measure of heterogeneity. Res Synth Methods 2017; 8: 5-18
  • 33 Chiu YC, Lu LS, Wu KL. et al. Comparison of argon plasma coagulation in management of upper gastrointestinal angiodysplasia and gastric antral vascular ectasia hemorrhage. BMC Gastroenterol 2012; 12: 67
  • 34 Chaves DM, Sakai P, Oliveira CV. et al. Watermelon stomach: clinical aspects and treatment with argon plasma coagulation. Arquivos de Gastroenterologia 2006; 43: 191-195
  • 35 Boltin D, Gingold-Belfer R, Lichtenstein L. et al. Long-term treatment outcome of patients with gastric vascular ectasia treated with argon plasma coagulation. Europ J Gastroenterol Hepatol 2014; 26: 588-593
  • 36 Wells CD, Harrison ME, Gurudu SR. et al. Treatment of gastric antral vascular ectasia (watermelon stomach) with endoscopic band ligation. Gastrointest Endosc 2008; 68: 231-236
  • 37 Sato T, Yamazaki K, Akaike J. Endoscopic band ligation versus argon plasma coagulation for gastric antral vascular ectasia associated with liver diseases. Diges Endosc 2012; 24: 237-242
  • 38 Keohane J, Berro W, Harewood GC. et al. Band ligation of gastric antral vascular ectasia is a safe and effective endoscopic treatment. Digest Endosc 2013; 25: 392-396
  • 39 Abdelhalim H, Mostafa I, Salah Abdelbary M. et al. Endoscopic band ligation versus argon plasma coagulation for the treatment of gastric antral vascular ectasia in egyptian patients with liver cirrhosis. World J Med Sci 2014; 10: 357-361
  • 40 Zepeda-Gomez S, Sultanian R, Teshima C. et al. Gastric antral vascular ectasia: a prospective study of treatment with endoscopic band ligation. Endoscopy 2015; 47: 538-540
  • 41 Elhendawy M, Mosaad S, Alkhalawany W. et al. Randomized controlled study of endoscopic band ligation and argon plasma coagulation in the treatment of gastric antral and fundal vascular ectasia. United Europ Gastroenterol J 2016; 4: 423-428
  • 42 Fabian A, Bor R, Szabo E. et al. Endoscopic treatment of gastric antral vascular ectasia: a retrospective multicentre clinical study. United Europ Gastroenterol J 2016; 4: 5: A134
  • 43 Abd Al-Wahab NA, Amer kA, Ibrahim AY. Argon plasma coagulation versus endoscopic band ligation in treatment of gastric antral vascular ectasia in cirrhotic patients in Zagazig University Hospitals. Afro-Egypt J Infect Endem Dis 2019; 9: 176-184
  • 44 Abdel Ghaffar MM, Abd El Maguid HM. Endoscopic band ligation versus argon plasma coagulation in management of bleeding from gastric antral vascular ectasia in patients with portal hypertension. J Med Sci Res 2019; 2: 214-219
  • 45 Eccles J, Falk V, Montano-Loza AJ. et al. Long-term follow-up in patients with gastric antral vascular ectasia (GAVE) after treatment with endoscopic band ligation (EBL). Endosc Int Open 2019; 7: E1624-E1629
  • 46 Hasan MH, Habib RB, Das SC. Endoscopic band ligation: as initial therapy for gastric antral vascular ectasia. Dig Endosc 2020; 32: 83
  • 47 Tran A, Villeneuve JP, Bilodeau M. et al. Treatment of chronic bleeding from gastric antral vascular ectasia (GAVE) with estrogen-progesterone in cirrhotic patients: an open pilot study. Am J Gastroenterol 1999; 94: 2909-2911
  • 48 Barbara G, De Giorgio R, Salvioli B. et al. Unsuccessful octreotide treatment of the watermelon stomach. J Clin Gastroenterol 1998; 26: 345-346
  • 49 Park RH, Danesh BJ, Upadhyay R. et al. Gastric antral vascular ectasia (watermelon stomach) – therapeutic options. Postgrad Med J 1990; 66: 720-723
  • 50 Fuccio L, Mussetto A, Laterza L. et al. Diagnosis and management of gastric antral vascular ectasia. World J Gastrointest Endosc 2013; 5: 6-13
  • 51 Novitsky YW, Kercher KW, Czerniach DR. et al. Watermelon stomach: pathophysiology, diagnosis, and management. J Gastrointest Surg 2003; 7: 652-661
  • 52 Ganz RA, Utley DS, Stern RA. et al. Complete ablation of esophageal epithelium with a balloon-based bipolar electrode: a phased evaluation in the porcine and in the human esophagus. Gastrointest Endosc 2004; 60: 1002-1010
  • 53 Zepeda-Gomez S. Endoscopic band ligation versus argon plasma coagulation for the treatment of gastric antral vascular ectasia: a randomized clinical trial. United States National Library of Medicine - NCT01601639. Available at (Accessed 30.08.2020): https://clinicaltrials.gov/ct2/show/NCT01601639
  • 54 Chalhoub JM, Umar J, Groudan K. et al. Endoscopic band ligation compared to thermal therapy for gastric antral vascular ectasia: A systematic review and meta-analysis. United European Gastroenterol J 2020; DOI: 10.1177/2050640620975243.
  • 55 Gilliam 3rd JH, Geisinger KR, Wu WC. et al. Endoscopic biopsy is diagnostic in gastric antral vascular ectasia. The “watermelon stomach”. Dig Dis Sci 1989; 34: 885-888
  • 56 Payen JL, Cales P, Voigt JJ. et al. Severe portal hypertensive gastropathy and antral vascular ectasia are distinct entities in patients with cirrhosis. Gastroenterology 1995; 108: 138-144
  • 57 Davies HT, Crombie IK, Tavakoli M. When can odds ratios mislead?. BMJ 1998; 316: 989-991