A randomized study comparing ligation with propranolol for primary prophylaxis of variceal bleeding in candidates for liver transplantation

Abstract

Whether beta-blockers (BB) or banding is the best therapy for primary prophylaxis of variceal bleeding is subject to debate. A randomized comparison between the 2 treatments was performed in candidates for liver transplantation (LT). A total of 62 patients with Child-Turcotte-Pugh B-C cirrhosis and high risk varices received propranolol (31) or variceal banding (31). The primary endpoint was variceal bleeding. There were 2 variceal hemorrhages (6.5%) in the banding group, related to postbanding ulcers, and 3 (9.7%) in the propranolol group (P ϭ not significant [n.s.]). Deaths and bleeding related deaths were 3 and 1 for banding and 3 and 2 for BB, respectively (P ϭ n.s.). A total of 14 patients underwent LT in the banding group and 10 in the propranolol group (P ϭ n.s.). Adverse events were 2 postbanding ulcer bleedings in ligated patients (1 fatal) and 5 were intolerant to propranolol (P ϭ n.s.). Mean costs per patient were higher with banding than with propranolol treatment (4,289 Ϯ 285 vs. 1,425 Ϯ 460 U.S. dollars, P Ͻ 0.001). In conclusion, propranolol and banding are similarly effective in reducing the incidence of variceal bleeding in candidates for LT, but ligation can be complicated by fatal bleeding and is more expensive. Our results suggest that banding should not be utilized as primary prophylaxis in transplant candidates who can be treated with BB.

Prophylactic variceal ligation is not recommended for patients awaiting live donor liver transplant

“…Our experience is consistent with that of Norberto et al, 1 who found that prophylactic variceal ligation led to clinically significant iatrogenic bleeding. We have since streamlined our policy and have stopped performing prophylactic variceal ligation in patients awaiting LDLT.…”

“…We read the articles by Norberto et al 1 and Boyer 2 with interest. As the authors have highlighted, various randomized controlled studies and meta-analysis have consistently showed that although endoscopic variceal ligation is better at preventing first variceal bleed than beta blockers, it is also associated with adverse effects and, in particular, fatal adverse effects.…”

“…Norberto et al 1 further showed that among candidates for cadaveric liver transplantation, prophylactic variceal ligation was associated with a 6.5% risk (95% confidence interval: 0%-15.2%) of clinically significant postbanding ulcer bleeding.…”

Reply: Prophylactic variceal ligation is not recommended for patients awaiting live donor liver transplant

“…2 Their experience is consistent with ours and different from that reported by Jutabha et al 3 In all 3 studies, the patients were liver transplant candidates and thus constituted a particular subgroup of patients with cirrhosis, as underlined also by Boyer. 4 In our opinion, this favors the use of beta-blockers instead of banding for primary prophylaxis for at least 2 reasons.…”

Management of variceal haemorrhage

“…Krwawienia z owrzodzeń po opaskowaniu obserwowano u 6,5-7% pacjentów, w tym jeden pacjent zmarł. Wystąpiły one 9 i 11 dni po pierwszej eradykacji [206]. Szepke i wsp.…”