Safety and efficacy of endoscopic cyanoacrylate injection in the management of gastric varices: A systematic review and meta‐analysis

BACKGROUND AND AIM: Bleeding from gastric varices is a catastrophic event and poses difficulty in management. The efficacy and safety of cyanoacrylate injection remain unclear. We performed a systematic review and meta‐analysis to evaluate the effect of endoscopic cyanoacrylate injection in the management of gastric varices. METHODS: We conducted a comprehensive search of MEDLINE, Embase, Web of Science, Scopus databases, and Cochrane Database of Systematic Reviews through November 2020 and manually reviewed the literature. Trial‐specific risk ratios (RRs) were estimated and pooled using random‐effect model meta‐analysis. RESULTS: We included seven randomized controlled trials (six for secondary prophylaxis and one for primary prophylaxis) at low risk of bias in which 126 deaths were reported among 583 patients with gastric varices. All studies reported the use of N‐butyl‐2‐cyanoacrylate glue. Cyanoacrylate use was associated with significantly lower all‐cause mortality (RR, 0.59; 95% confidence interval [CI], 0.36–0.98; I(2) = 41%) and rebleeding rate after hemostasis (RR, 0.49; 95% CI, 0.35–0.68, I(2) = 0%) compared with any other treatment approach not involving cyanoacrylate. When cyanoacrylate was compared with each individual treatment approach (propranolol only, band ligation, sclerotherapy with alcohol or ethanolamine), data comprised sparse limited comparative conclusions. The use of cyanoacrylate injection was not associated with an increase in serious adverse events. The quality of evidence is moderate, graded down due to the small number of events and wide CIs. CONCLUSION: The use of endoscopic cyanoacrylate injection therapy for gastric varices may be associated with lower all‐cause mortality and better hemostasis compared with other therapies.