Meta‐analysis: endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding

Abstract

SUMMARYBackground: The treatment effects of primary prophylactic endoscopic variceal ligation are unclear. Aim: To compare the treatment effects of endoscopic variceal ligation and b-blockers for primary prophylaxis of oesophageal variceal bleeding. In addition, a subgroup analysis was done with the purpose to delineate differences in the effects of intervention that were biologically based. Methods: We performed a literature search for randomized controlled trials, which compared the treatment effects of endoscopic variceal ligation with b-blockers for primary prophylaxis of oesophageal variceal bleeding. Of the 955 articles screened, eight randomized-controlled trials including 596 subjects (285 with endoscopic variceal ligation and 311 with b-blockers) were analysed. Outcomes measures evaluated were first gastrointestinal bleed, first variceal bleed, all-cause deaths, bleed-related deaths and severe adverse events. The measure of association employed was relative risk; with heterogeneity and sensitivity analyses. Results: Variceal obliteration was obtained in 261 (91.6%) patients and target b-blockers therapy was achieved in 294 (94.5%) patients (P ¼ 0.19). Endoscopic variceal ligation compared with b-blockers

Controlled trial of ligation plus nadolol versus nadolol alone for the prevention of first variceal bleeding

“…Previous meta-analysis of trials regarding primary prophylaxis revealed that adverse events were associated with EVL in 42.7% and with beta blockers in 56.1%. 20 Moreover, serious complications were noted in 0-6.7% in patients treated with EVL and 6.7-30.3% in patients receiving beta blockers. Thus, the meta-analysis drew the conclusion that severe adverse events were significantly less in EVL compared with beta blockers.…”

“…Two meta-analyses of these studies have been performed and suggested that EVL is superior to beta blockers in the reduction of first bleeding episodes in cirrhosis patients with moderate to large esophageal varices, but with similar survival. 19,20 On the other hand, because EVL is potentially associated with severe complications, the superiority of EVL over beta blockers in the prophylaxis of first variceal bleeding has been questioned by hepatology experts. 21 Thus, the latest Baveno Consensus of portal hypertension suggested that EVL should be offered to patients with medium/large varices and with contraindications or intolerance to beta blockers.…”

“…23 The bleeding rates ranging from 13% to 43% may still be encountered in patients receiving beta blockers for primary prophylaxis. 19,20,24 Severe complications associated with EVL are not as frequent as sclerotherapy. If beta blockers could be combined with EVL in the prophylaxis of first variceal bleed, the effectiveness would be expected to be enhanced.…”

Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver

“…A recent meta-analysis suggests that VBL has greater efficacy in preventing initial bleeding with a 34% relative risk reduction than do b-blockers. However, mortality is same in both treatment groups [68]. The possible benefits of VBL in reducing initial bleeding rates need to be weighed against the low cost and ease of use of b-blockers [62].…”

“…The possible benefits of VBL in reducing initial bleeding rates need to be weighed against the low cost and ease of use of b-blockers [62]. Approximately 25% of patients suffer transient adverse effects following VBL such as dysphagia and chest discomfort, and there is a small risk of life-threatening bleeding from esophageal ulcerations [55,58,68].…”