The effect of shortening vasoactive drug durations alongside endoscopic therapy in esophageal variceal bleeding: an updated systematic review and meta-analysis

Sudheer M. Dhoop; Zohaib Ahmed; Conner Lombardi; Mohammed Abu-Rumeileh; Syeda Faiza Arif; Wasef Sayeh; Rayna Patel; Alborz Sherafati; Wade Lee-Smith; Mona Hassan

Authors Sudheer M. Dhoop, Zohaib Ahmed, Conner Lombardi, Mohammed Abu-Rumeileh, Syeda Faiza Arif, Wasef Sayeh, Rayna Patel, Alborz Sherafati, Wade Lee-Smith, Mona Hassan.

Abstract

Background The recommended duration of vasoactive drugs in esophageal variceal bleeding (EVB) spans 2-5 days. Prior meta-analyses of randomized trials include only a few studies that compared short vs. long vasoactive drug durations approximating this time range, including older management techniques, and only assessed variceal rebleeding at 5 days. We identified several additional randomized controlled trials (RCTs) assessing rebleeding at various durations, with updated management of EVB.

Methods We performed an updated systematic review and meta-analysis assessing the effect of shortening the vasoactive drug duration by 48-72 h. The primary outcome was rebleeding within 5 days. Secondary outcomes included rebleeding, mortality due to rebleeding, and allcause mortality within 4-6 weeks (extended period) with subgroup analysis by vasoactive drug and type of endoscopic therapy. Length of stay, blood transfusion requirements and terlipressinrelated adverse events were additional secondary outcomes.

Results Our comprehensive search strategy and screening process yielded 14 RCTs with 1060 patients (75.1% male): 7 trials used terlipressin, 4 octreotide, and 3 somatostatin. Shortened durations combined with band ligation led to similar rebleeding, with a trend towards less rebleeding when populations with more severe liver disease were excluded. There was greater rebleeding and mortality over an extended period when shorter durations were combined with sclerotherapy. Longer durations were associated with a longer hospital stay and, for terlipressin, more adverse events.

Conclusions Shorter vasoactive drug durations combined with band ligation in selected populations appear safe. Higher powered RCTs are needed, involving patients with different degrees of severity of EVB and liver disease.

Keywords Vasoactive, duration, esophageal variceal bleeding

Ann Gastroenterol 2024; 37 (5): 567-578