Endoscopic Variceal Ligation Against or in Combination With Vasoactive Drugs for Acute Treatment of Bleeding Oesophageal Varices: a Systematic Review And Meta-Analysis

Aims Variceal haemorrhage is the commonest life-threatening complication of liver cirrhosis. Current guidelines recommend endoscopic variceal ligation (EVL) in combination with vasoactive drugs as first-line treatment; yet this is without a firm direct evidence-base. We aimed to assess the comparative benefits and harms of EVL against or in combination with vasoactive drugs (terlipressin, somatostatin, octreotide, vapreotide) for the treatment of acute oesophageal variceal bleeding in cirrhotic patients.

Methods We searched Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Science Citation Index Expanded; ClinicalTrials.gov and WHO International Clinical Trials Registry Platform. We included randomised controlled trials, regardless of language or publication status. We calculated relative risk (RR), rate ratio and mean differences with 95 % confidence interval using both random-effects and fixed-effect meta-analysis models in Review Manager. We assessed quality of evidence using Cochrane risk of bias tool and GRADEpro GDT.

Results We identified 12 trials (1339 participants); follow-up ranged from 14-42 days. All studies were high risk of bias and overall quality of evidence was low-to-very low for most outcomes. Short-term mortality was significantly reduced with combination of endoscopic treatment plus vasoactive drug compared to either treatment alone. There was no evidence of significant difference in serious adverse events. Meta-analysis found evidence that failure of initial haemostasis was significantly reduced with EVL alone(RR = 0.14; p = 0.0004); and with combination treatment(RR = 0.35; p = 0.002); both compared to vasoactive drug alone. Very early rebleeding rate was significantly lower with combination treatment compared to both EVL alone(RR = 0.22; p = 0.002); and vasoactive drug alone(RR = 0.08; p = 0.01).

Conclusions Based on generally low-quality evidence, EVL seems to be superior to vasoactive drug treatment; and the combination of EVL plus vasoactive drug appears superior to either treatment alone in the acute treatment of bleeding oesophageal varices in cirrhotic patients. Therefore, our results support current guidelines. However, more high-quality RCTs are needed; and future research should include a network meta-analysis.

Citation: Roberts D, Mwebe H, Gurusamy K. eP47 ENDOSCOPIC VARICEAL LIGATION AGAINST OR IN COMBINATION WITH VASOACTIVE DRUGS FOR ACUTE TREATMENT OF BLEEDING OESOPHAGEAL VARICES: A SYSTEMATIC REVIEW AND META-ANALYSIS. Endoscopy 2021; 53: S112.

Publication History

Article published online:
19 March 2021