Esophageal Variceal Ligation Monotherapy versus Combined Ligation and Sclerotherapy for the Treatment of Esophageal Varices

Abstract

Currently, endoscopic variceal ligation (EVL) monotherapy is the standard therapy for managing esophageal variceal hemorrhage. Patients generally need several sessions of endoscopy to achieve optimal variceal ablation, and the varices can recur afterward. Endoscopic injection sclerotherapy (EIS) is an older technique, associated with certain complications. This study aimed to evaluate the clinical efficacy of EVL alone versus combined EVL and EIS in the treatment of esophageal varices. This retrospective study included 84 patients, of which 40 patients were treated with EVL monotherapy and 44 patients were treated with combined EVL + EIS. The main outcomes were rebleeding rates, recurrence at six months, number of treatment sessions, length of hospital stay, cost of hospitalization, and procedural complications. At six months, the rebleeding rate and recurrence were significantly lower in the EVL + EIS group compared to the EVL group (2.3% versus 15.0%; and 9.1% versus 27.5%, respectively). The number of treatment sessions, length of hospital stay, and cost of hospitalization were significantly lower in the EVL + EIS group compared to those in the EVL group (2.3 ± 0.6 versus 3.2 ± 0.8 times; 14.5 ± 3.4 versus 23.5 ± 5.9 days; and 23918.6 ± 4220.4 versus 26165.2 ± 4765.1 renminbi, respectively). Chest pain was significantly lower in the EVL + EIS group compared to that in the EVL group (15.9% versus 45.0%). There were no statistically significant differences in the presence of fever or esophageal stricture in both groups. In conclusion, combined EVL + EIS showed less rebleeding rates and recurrence at six months and less chest pain and was more cost effective compared to EVL alone in the treatment of gastroesophageal varices.

Esophageal variceal ligation plus sclerotherapy vs. ligation alone for the treatment of esophageal varices

“…Prior to PSM, our study showed that patients treated with EVL plus EIS had significantly less varicose recurrence and rebleeding than patients treated with EVL alone, whether at 6-, 12-, or 18-month follow-up. Our results agree with Mansour et al and Wang et al (2,10,14,15). Compared with EVL alone, the EVL plus EIS group had a significant advantage in variceal recurrence and rebleeding for the following principal reasons.…”

“…Mansour et al and Harras et al performed sclerotherapy at each variceal vein 3-5 cm and 5-10 cm from the esophagogastric junction and then injected sclerosing agent into the variceal vein 2-3 cm above the gastroesophageal junction (14,24). Wang et al ligated each vein and then injected 2-5 ml of a sclerosing agent into the variceal vein at the time of ligation, 2-3 cm from the upper part of the band (10). In our study, we first performed EVL at the nearest location near the gastroesophageal junction, releasing 5-7 bands depending on the varices to maximize blockage of blood flow.…”

“…The advantages of our procedure are as follows: (1) the transparent cap is still present at the tip of the lens after EVL, which can fix the varicose vein and facilitate sclerotherapy and can also be used for compression if there is leakage; (2) performing EVL followed by EIS can also reduce the risk of bleeding after ligation of the thick varicose vein; (3) performing EVL earlier can reduce the pressure in the varicose vein and create conditions for subsequent sclerotherapy (less sclerosing agent, long sclerosing agent dwell time); and (4) the procedure does not require special skills and equipment. But, at present, there are still controversies about the efficacy and adverse events of EVL plus EIS and EVL alone for esophageal varicose (2,10,14,15). A meta-analysis discovered that EVL is superior to the combination of EVL and EIS in safety, while no significant differences were found in efficacy (2).…”

“…In recent years, some evidence suggests that EVL combined with EIS can significantly reduce bleeding and recurrence of esophageal varices (10,11), with similar adverse events compared to EVL alone. Some studies suggest that the addition of sclerotherapy to endoscopic band ligation has not changed the clinically relevant outcomes (variceal rebleeding, death, time to variceal obliteration) (12,13).…”

Therapeutic endoscopy practice at a resource-limited setup: experience from a GI center in Addis Ababa, Ethiopia

“…Nonetheless, most complications can also be managed with endoscopic interventions (29). On the other hand, other studies show that combined variceal ligation and sclerotherapy had less rebleeding rates and recurrence at six months and less chest pain and was more cost-effective compared to endoscopic variceal ligation alone in the treatment of gastroesophageal varices (30).…”