Post written by Cynthia Florencio de Mesquita from Federal University of Pernambuco, Recife, Brazil, and Stefano Baraldo, MD, from the Institute for Teaching and Research, Barretos Cancer Hospital, Barretos, Brazil.

We aimed to compare 2 techniques for managing gastric varices: EUS-guided coiling plus glue versus endoscopic glue injection (EGI) through a systematic review and meta-analysis.

Although widely used, EGI carries a potential risk of systemic embolization, bleeding from needle site ulcers, and peritonitis. Recent studies have suggested that EUS-guided embolization involving coils in combination with glue could mitigate some of these risks by reducing the volume of glue required and, especially, by allowing targeted obliteration of varices under real-time imaging.

Gastric varices are prevalent among the population, with high rates of rebleeding and mortality reported in the literature. Advances in treatment have aimed to improve outcomes while minimizing adverse events.

Initially, our idea was to evaluate how adding coils affected systemic embolization rates in managing gastric varices. However, during our search, we observed a growing body of evidence highlighting the potential of EUS-guided coiling and glue injection to provide superior clinical outcomes in rebleeding and reintervention rates compared with EGI.

Our study found no significant differences between EUS-guided coiling plus glue injection and EGI alone in systemic embolization rates (3.5% vs 5.8%, respectively). Yet, we observed a substantial reduction in rebleeding (odds ratio, .22; 95% confidence interval, .11-.45; P < .001; I² = 0%) and reintervention rates (odds ratio, .29; 95% confidence interval, .09-.89; P = .03; I²=49%) in the EUS group.

Importantly, trial sequential analysis confirmed the robustness of these findings, suggesting that the observed reduction in rebleeding rates is unlikely to be a Type I error. These findings contribute to previous evidence suggesting that EUS improves visualization of varices and feeder vessels, facilitating more precise interventions and allowing vessel embolization to be verified.

Reducing rebleeding and reintervention rates impacts patient morbidity, healthcare costs, and survival. However, EUS-guided techniques remain limited by several factors, including higher costs, a steep learning curve, and restricted availability in resource-limited settings. Future research should focus on cost-effectiveness analyses, strategies to improve accessibility of EUS-guided procedures, and availability of endoscopist training programs.

EUS-guided embolization represents a promising advancement in the management of gastric varices, but its widespread adoption faces challenges. The cost of EUS-guided procedures is notably higher than that of EGI, driven by the need for specialized equipment (echoendoscopes) and longer procedural times. In addition, training a new generation of endoscopists in therapeutic EUS is resource-intensive and requires experienced mentors, often limited to high-volume tertiary care centers.

Availability is another critical issue, particularly in low- and middle-income countries where access to advanced technologies is scarce. For example, in Brazil, EUS-guided embolization is performed in few centers, with many relying on traditional glue injection because of its accessibility. Addressing these disparities will require collaborative efforts to reduce costs, expand training programs, and develop simplified, cost-effective EUS techniques that can be implemented in resource-limited settings.

Pooled analysis of primary outcomes. A, Embolism rates. B, Recurrent bleeding rates. C, Reintervention rates. EGI, Endoscopic glue injection; OR, odds ratio; CI, confidence interval.

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