{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T12:51:52Z","timestamp":1788871912330,"version":"build-2803163510"},"reference-count":47,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"6","license":[{"start":{"date-parts":[[2021,12,27]],"date-time":"2021-12-27T00:00:00Z","timestamp":1640563200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2021,12,27]],"date-time":"2021-12-27T00:00:00Z","timestamp":1640563200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":["Liver Transpl"],"published-print":{"date-parts":[[2022,6]]},"abstract":"<jats:p>There is no clear consensus regarding the optimal approach for secondary prophylaxis of gastric variceal bleeding (GVB) in patients with cirrhosis. We conducted a systematic review and network meta\u2010analysis (NMA) to compare the efficacy of available treatments. A comprehensive search of several databases from each database's inception to March 23, 2021, was conducted to identify relevant randomized controlled trials (RCTs). Outcomes of interest were rebleeding and mortality. Results were expressed as relative risk (RR) and 95% confidence interval (CI). We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to rate the certainty of evidence. We included 9 RCTs with 647 patients who had histories of GVB and follow\u2010ups &gt;6\u00a0weeks. A total of 9 interventions were included in the NMA. Balloon\u2010occluded retrograde transvenous obliteration (BRTO) was associated with a lower risk of rebleeding when compared with \u03b2\u2010blockers (RR, 0.04; 95% CI, 0.01\u20100.26; low certainty), and endoscopic injection sclerotherapy (EIS)\u2013cyanoacrylate (CYA) (RR, 0.18; 95% CI, 0.04\u20100.77; low certainty). \u03b2\u2010blockers were associated with a higher risk of rebleeding compared with most interventions and with increased mortality compared with EIS\u2010CYA (RR, 4.12, 95% CI, 1.50\u201011.36; low certainty), and EIS\u2010CYA + nonselective \u03b2\u2010blockers (RR, 5.61; 95% CI, 1.91\u201016.43; low certainty). Analysis based on indirect comparisons suggests that BRTO may be the best intervention in preventing rebleeding, whereas \u03b2\u2010blocker monotherapy is likely the worst in preventing rebleeding and mortality. Head\u2010to\u2010head RCTs are needed to validate these results.<\/jats:p>","DOI":"10.1002\/lt.26383","type":"journal-article","created":{"date-parts":[[2021,12,3]],"date-time":"2021-12-03T11:57:48Z","timestamp":1638532668000},"page":"945-958","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":25,"title":["Secondary Prophylaxis of Gastric Variceal Bleeding: A Systematic Review and Network Meta\u2010Analysis"],"prefix":"10.1097","volume":"28","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0453-9831","authenticated-orcid":false,"given":"Karim T.","family":"Osman","sequence":"first","affiliation":[{"name":"Department of Internal Medicine,Lahey Hospital and Medical Center,Beth Israel Lahey Clinic,Burlington,MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tarek","family":"Nayfeh","sequence":"additional","affiliation":[{"name":"Evidence\u2010Based Practice Center,Mayo Clinic,Rochester,MN"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmed M.","family":"Abdelfattah","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology,Lahey Hospital and Medical Center,Beth Israel Lahey Clinic,Burlington,MA"},{"name":"Department of Medicine,Division of Gastroenterology,University of Massachusetts Medical School,Worcester,MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Khaled","family":"Alabdallah","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine,Lincoln Medical Center,Bronx,NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bashar","family":"Hasan","sequence":"additional","affiliation":[{"name":"Evidence\u2010Based Practice Center,Mayo Clinic,Rochester,MN"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammed","family":"Firwana","sequence":"additional","affiliation":[{"name":"Evidence\u2010Based Practice Center,Mayo Clinic,Rochester,MN"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Homam","family":"Alabaji","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine,Wertachklinik Schwabm\u00fcnchen,Bavaria,Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lina","family":"Elkhabiry","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine,University of Alexandria,Alexandria,Egypt"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jehan","family":"Mousa","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine,Damascus University,Damascus,Syria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Larry J.","family":"Prokop","sequence":"additional","affiliation":[{"name":"Department of Library Services,Mayo Clinic,Rochester,MN"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M. Hassan","family":"Murad","sequence":"additional","affiliation":[{"name":"Evidence\u2010Based Practice Center,Mayo Clinic,Rochester,MN"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fredric","family":"Gordon","sequence":"additional","affiliation":[{"name":"Division of Gastroenterology,Lahey Hospital and Medical Center,Beth Israel Lahey Clinic,Burlington,MA"},{"name":"Department of Transplantation and Hepatobiliary Diseases,Lahey Hospital and Medical Center,Beth Israel Lahey Health,Burlington,MA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","published-online":{"date-parts":[[2021,12,27]]},"reference":[{"key":"lt26383-bib-0001-20250824","doi-asserted-by":"crossref","first-page":"1343","DOI":"10.1002\/hep.1840160607","article-title":"Prevalence, classification and natural history of gastric varices: a long\u2010term follow\u2010up study in 568 portal hypertension patients","volume":"16","year":"1992","journal-title":"Hepatology"},{"key":"lt26383-bib-0002-20250824","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1002\/hep.510250209","article-title":"Risk factors for hemorrhage from gastric fundal varices","volume":"25","year":"1997","journal-title":"Hepatology"},{"key":"lt26383-bib-0003-20250824","first-page":"95","article-title":"Gastric and ectopic varices\u2010newer endoscopic options","volume":"20","year":"2007","journal-title":"Ann Gastroenterol"},{"key":"lt26383-bib-0004-20250824","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1002\/hep.28906","article-title":"Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases","volume":"65","year":"2017","journal-title":"Hepatology"},{"key":"lt26383-bib-0005-20250824","doi-asserted-by":"crossref","first-page":"1098","DOI":"10.1016\/j.cgh.2021.01.027","article-title":"AGA clinical practice update on management of bleeding gastric varices: expert review","volume":"19","year":"2021","journal-title":"Clin Gastroenterol Hepatol"},{"key":"lt26383-bib-0006-20250824","doi-asserted-by":"crossref","first-page":"743","DOI":"10.1016\/j.jhep.2015.05.022","article-title":"Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension","volume":"63","year":"2015","journal-title":"J Hepatol"},{"key":"lt26383-bib-0007-20250824","doi-asserted-by":"crossref","first-page":"1010","DOI":"10.1111\/j.1572-0241.2002.05622.x","article-title":"A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices","volume":"97","year":"2002","journal-title":"Am J Gastroenterol"},{"key":"lt26383-bib-0008-20250824","doi-asserted-by":"crossref","first-page":"548","DOI":"10.1055\/a-1127-3170","article-title":"A prospective, randomized trial of thrombin versus cyanoacrylate injection in the control of acute gastric variceal hemorrhage","volume":"52","year":"2020","journal-title":"Endoscopy"},{"key":"lt26383-bib-0009-20250824","doi-asserted-by":"crossref","first-page":"487","DOI":"10.1055\/s-2007-966267","article-title":"Improvement of tissue\u2010adhesive obliteration of bleeding gastric varices using adjuvant hypertonic glucose injection: a prospective randomized trial","volume":"39","year":"2007","journal-title":"Endoscopy"},{"key":"lt26383-bib-0010-20250824","doi-asserted-by":"crossref","first-page":"398","DOI":"10.1055\/s-2007-1005490","article-title":"Endoscopic treatment of bleeding fundic varices with 50% glucose injection","volume":"28","year":"1996","journal-title":"Endoscopy"},{"key":"lt26383-bib-0011-20250824","doi-asserted-by":"crossref","first-page":"168","DOI":"10.1067\/mge.2000.107911","article-title":"EUS\u2010guided injection of cyanoacrylate for bleeding gastric varices","volume":"52","year":"2000","journal-title":"Gastrointest Endosc"},{"key":"lt26383-bib-0012-20250824","doi-asserted-by":"crossref","first-page":"1164","DOI":"10.1016\/j.gie.2015.09.040","article-title":"EUS\u2010guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video)","volume":"83","year":"2016","journal-title":"Gastrointest Endosc"},{"key":"lt26383-bib-0013-20250824","first-page":"434","article-title":"Portal hemodynamics in patients with gastric varices. 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