Is endoscopic band ligation the gold standard for gastric antral vascular ectasia?

(GAVE) is a relatively uncharted field with few reliable techniques available for the time being. As is well known, assessed from a histological standpoint, GAVE consists of dilated and tortuous capillaries in the mucosal layer, often associated with intraluminal thrombi and accompanied by dilated and tortuous submucosal veins, without significant inflammation. The typical location of these capillaries is in the gastric antrum, with variations in overall shape and extent. The exact pathophysiological pathway is relatively unknown. Several hypotheses have been proposed, including mechanical stress due to the relatively higher pressure in the antrum, hormone imbalance mostly related to hypergastrinemic states, and an association with tyrosine kinase inhibitors. [1–3] Yet none of the above appears to have any direct implication regarding our current therapeutic options. However, the association with chronic kidney disease, advanced liver disease, systemic sclerosis, and metabolic syndrome is unquestionable, suggesting that optimizing management of these chronic diseases should improve the outcome of secondary conditions such as GAVE. As we currently understand the problem, it appears that we have hit a deadlock regarding our treatment options, as the available methods are few and far from perfect. No pharmacological treatment has proven to be effective in this setting, with only modest endeavors published in this field. The lack of a proper understanding of the pathophysiology might be a feasible explanation. Estrogen-progesterone regimens for cirrhotic patients with GAVE [4] were tried more than 20 years ago, but the data were not strong enough for validation and no significant subsequent studies were performed. An association between proton pump inhibitors (PPIs) and GAVE has also been proposed (acid suppression leading to hypergastrinemia) [5, 6], but discontinuing PPIs can hardly be called a therapeutic option. Surgery is a delicate option in GAVE, because most patients carry the burden of multiple and severe comorbidities. Unfortunately, the risk/benefit analysis can often be tilted towards undesirable events, and operating remains a viable option only for emergency refractory cases. Therefore, the only viable solutions we have for GAVE are concentrated in the field of endoscopic therapy. The array of available options can be divided into two groups, based on layer penetration: superficial (action limited to the mucosa) and deep (including submucosa). Superficial techniques act mostly on the mucosal layer and are represented by argon plasma coagulation (APC) and radiofrequency ablation (RFA). Cryotherapy and Nd:YAG laser therapy have been largely abandoned due to relative ineffectiveness, high complication rates, and availability issues. The only deep submucosal technique available is endoscopic band ligation (EBL). Judging by the histological appearance of GAVE, with dilated and tortuous submucosal veins, along with extensive mucosal lesions, one could empirically imply that reaching a more profound layer should generate better outcomes. However, APC has long been the staple of GAVE treatment. APC generates good immediate results, with therapeutic success ranging between 70% and 90%, although recurrent bleeding and further interventions were frequently required, ranging from a reasonable 35% to an inefficient 78.9% [7–11]. Only recently has the tide appeared to be shifting towards EBL, after first being used as salvage therapy in a case of APC refractory GAVE bleeding [12]. Since then, multiple papers have been published on EBL describing relatively favorable outcomes. One retrospective Is endoscopic band ligation the gold standard for gastric antral vascular ectasia?