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Comparative safety and efficacy of endoscopic band ligation and variceal obturation for gastric varices: Systematic review and meta-analysis
Usama Tufail, Eman Khalid, Aleena Ihtasham, Fahad Amin, Muhammad Talha Khan, Fazia Khattak, Taha Alam, Amna Iman, Eeman Afroz, Hina Aslam, Ahtisam Akbar Khan, Tooba Fida, Iman Osman Abufatima
Usama Tufail, Aleena Ihtasham, Fahad Amin, Muhammad Talha Khan, Amna Iman, Ahtisam Akbar Khan, Department of Medicine, King Edward Medical University, Lahore 54000, Punjab, Pakistan
Eman Khalid, Department of Medicine, Cairo University, Cairo 12613, Al Qahirah, Egypt
Fazia Khattak, Department of Medicine, Khyber Medical College, Peshawar 25120, Khyber Pakhtunkhwa, Pakistan
Taha Alam, Department of Medicine, Dow University of Health Sciences, Karachi 54600, Sindh, Pakistan
Eeman Afroz, Department of Medicine, Allama Iqbal Medical College, Lahore 54000, Punjab, Pakistan
Hina Aslam, Department of Medicine, Karachi Metropolitan University, Karachi 74700, Sindh, Pakistan
Tooba Fida, Department of Medicine, ISMMS/Valley Health, Paramus, NJ 07652, United States
Iman Osman Abufatima, Department of Medicine, University of Medical Sciences and Technology, Khartoum 11111, Sudan
Author contributions: Tufail U designed the study, was responsible for data curation and formal analysis, developed the methodology, and drafted and revised the manuscript; Khalid E contributed to data curation, formal analysis, and drafting and revision of the manuscript; Iman A contributed to data curation, methodology development, and drafting and revision of the manuscript; Amin F, Talha Khan M, Khattak F, Aslam H, and Afroz E contributed to data curation and drafting and revision of the manuscript; Khan AA, Alam T, Ihtasham A and Osman Abufatima I contributed to drafting and revision of the manuscript; Fida T supervised the study and contributed to drafting and revision of the manuscript; all authors reviewed and approved the final version of the manuscript.
AI contribution statement: We have used Grammarly AI to refine language, improve grammar, clarity, and readability of the manuscript. We have used AI tools only for language polishing and writing assistance at the level of grammar and readability.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Corresponding author: Iman Osman Abufatima, MD, Doctor, Department of Medicine, University of Medical Sciences and Technology, El Riyad area, Square No. 13, Khartoum 11111, Sudan.
drimanadam03@gmail.com
Received: November 7, 2025
Revised: December 29, 2025
Accepted: February 25, 2026
Published online: May 28, 2026
Processing time: 195 Days and 10.9 Hours
BACKGROUND
Gastric variceal hemorrhage (GVH) is among the most life-threatening complications of portal hypertension. Endoscopic variceal ligation (EVL) and cyanoacrylate injection (endoscopic variceal obturation) are the main endoscopic options for hemostasis, but their comparative efficacy and safety remain debated due to variable evidence.
AIM
To investigate the safety and efficacy of endoscopic band ligation vs endoscopic variceal obturation in the management of gastric varices.
METHODS
PubMed, ClinicalTrials.gov, and EMBASE were systematically searched up to September 20, 2025. Eligible studies were randomized controlled trials (RCTs) comparing EVL with cyanoacrylate therapy in patients with GVH. Primary outcomes included initial hemostasis, rebleeding, treatment failure, mortality, variceal obliteration, and adverse events. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model (RevMan 5.4), with subgroup analyses for cyanoacrylate injection vs obturation.
RESULTS
Seven RCTs (n = 631) were included. There was no significant difference between EVL and cyanoacrylate in achieving initial hemostasis (RR = 0.96, 95%CI: 0.88-1.04) or overall mortality (RR = 1.29, 95%CI: 0.84-1.98). However, rebleeding risk was significantly higher with EVL (RR = 1.53, 95%CI: 1.03-2.26), particularly when compared with cyanoacrylate injection (RR = 2.27, 95%CI: 1.18-4.40). No significant differences were found in treatment failure, variceal obliteration, or fatal bleeding. Post-procedural fever was more common following cyanoacrylate use (RR = 0.55, 95%CI: 0.31-0.94).
CONCLUSION
Cyanoacrylate injection provides superior rebleeding control in active GVH without increasing mortality. EVL remains a reasonable alternative in settings where cyanoacrylate or operator expertise is limited. These findings support cyanoacrylate as the preferred endoscopic therapy where resources and training permit.
Core Tip: This meta-analysis of seven randomized controlled trials establishes that while endoscopic variceal ligation (EVL) and endoscopic variceal obturation (EVO) achieve similar initial hemostasis rates for gastric varices, EVO demonstrates superior long-term durability. Specifically, cyanoacrylate injection significantly reduces the risk of rebleeding compared to EVL without increasing overall mortality. These findings support prioritizing cyanoacrylate as the first-line intervention for gastric variceal hemorrhage, reserving EVL as an alternative only when resources for obturation are unavailable.
