10 - Comparative Outcomes Based on the Duration of Vasoconstrictors After Endoscopic Variceal Ligation in Acute Variceal Bleeding: A Systematic Review and Network Meta-Analysis of Randomized Studies

Award: ACG Lawlor Resident Award

Sushrut Ingawale, MD, MBBS¹, Ankita Singh, DM, MD, MBBS², Sourav Panda, MBBS², Suprabhat Giri, DM, MD, MBBS^3
1Quinnipiac University Frank H. Netter MD School of Medicine / St. Vincent's Medical Center, Bridgeport, CT; ²Seth Gordhandas Sundardas Medical College and KEM Hospital, Mumbai, Maharashtra, India; ³Kalinga Institute of Medical Sciences, Bhubaneshwar, Orissa, India

Introduction: The current guidelines recommend continuing vasoconstrictors for at least 3-5 days after endotherapy for acute variceal bleeding (AVB). However, these recommendations are based primarily on old studies in which sclerotherapy was the primary hemostatic method. Endoscopic variceal ligation (EVL) is the current standard of care for AVB and has superior efficacy over sclerotherapy. Hence, the present systematic review and network meta-analysis was conducted to compare the outcome of vasoconstrictors after EVL based on the duration of therapy.

Methods: A comprehensive literature search from inception to March 2023 was done for randomized controlled trials (RCT), comparing the outcome of continuing vasoconstrictors after EVL in AVB based on the duration of therapy (Group 1: Less than 24 hours, Group 2: 24-72 hours, Group 3: 72-120 hours). Network meta-analyses were performed to compare the risk of rebleeding and mortality.

Results: A total of 11 studies (n=816) were included in the final analysis. There was no difference in the risk of rebleeding in Group 1 (Risk ratio [RR]: 1.36, 95% confidence interval [CI]: 0.48 – 3.52) and Group 2 (RR: 1.34, 95% CI: 0.42 – 4.54), compared to Group 3. Similarly, there was no difference either in the 5-day mortality risk between Group 1 (RR: 0.66, 95% confidence interval [CI]: 0.09 – 2.52) and Group 2 (RR: 1.08, 95% CI: 0.15 – 6.43) compared to Group 3 or 30-days mortality risk between Group 1 (RR: 1.18, 95% confidence interval [CI]: 0.51 – 2.51) and Group 2 (RR: 0.98, 95% CI: 0.36 – 2.52) compared to Group 3. Based on the surface under the cumulative ranking curve (SUCRA) plot analysis for rebleeding, Group 3 was the best with a SUCRA of 72.6, followed by Group 2 (40.5) and Group 1 (36.8). Concerning 5-day mortality, Group 1 had the best rank (71.3), followed by Group 3 (41.1) and Group 2 (37.5), and for 30-day mortality, Group 2 had the best rank (60.4), followed by Group 3 (57.9) and Group 1 (31.7). There was neither significant inconsistency nor publication bias.

Discussion: Our network meta-analysis did not show any benefit of continuing vasoconstrictors after EVL. Vasoconstrictors can be stopped early after EVL. Despite historical precedent, our SUCRA analysis suggests that shorter durations may suffice, potentially enabling earlier hospital discharge without compromising patient outcomes. These results advocate for a re-evaluation of existing protocols, emphasizing the potential benefits of shorter vasoconstrictor courses post-EVL in clinical practice.


Disclosures:


Sushrut Ingawale, MD, MBBS¹, Ankita Singh, DM, MD, MBBS², Sourav Panda, MBBS², Suprabhat Giri, DM, MD, MBBS³, 10, Comparative Outcomes Based on the Duration of Vasoconstrictors After Endoscopic Variceal Ligation in Acute Variceal Bleeding: A Systematic Review and Network Meta-Analysis of Randomized Studies, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.