Prophylactic Portacaval Anastomosis in Cirrhotic Patients with Esophageal Varices

Conn, Harold O.; Lindenmuth, W. W.

doi:10.1056/nejm196204122661502

Cited by 25 publications

(4 citation statements)

References 26 publications

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“…Four prophylactic shunt trials, which were the first randomized controlled trials in portal hypertension, have been reported and included 302 patients 26 –29 . Variceal bleeding was significantly reduced (odds ratio 0.31; 95% CI: 0.17–0.56) in the treated group, but survival was significantly worse (odds ratio 1.6; 95% CI: 1.02–2.57) compared to no treatment.…”

Section: Randomized Controlled Trials For the Prevention Of First Varmentioning

confidence: 99%

Review article: primary prophylaxis for portal hypertensive bleeding in cirrhosis

Vlachogiannakos

Goulis

Patch

et al. 2000

Aliment Pharmacol Ther

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Variceal bleeding is a consequence of portal hypertension, which in turn is the major complication of hepatic cirrhosis. Given the high rate of mortality of the first bleeding episode, primary prophylaxis to prevent bleeding from varices and portal hypertensive gastropathy is the current optimal therapeutic approach. The difficulty in identification of patients with varices who will bleed, before they do so, can justify a strategy of treating all patients with varices prophylactically. We evaluated the various therapies that have been assessed in randomized controlled trials for prevention of first bleeding, using meta-analysis where applicable. The current first choice treatment is non-selective beta-blockers; it is cheap, easy to administer, and is effective in preventing the first variceal haemorrhage and bleeding from gastric mucosa. Combination drug therapy of beta-blockers and nitrates looks promising, but needs further evaluation in randomized controlled trials. The conflicting results of the randomized studies of endoscopic banding ligation and the small number of patients and clinical events, as well as the cost, do not warrant any change in current practice. However, endoscopic banding ligation may be a reasonable alternative for patients who cannot tolerate, or have contraindications to beta-blockers or no haemodynamic response to the drug therapy, but this must be proved in randomized trials.

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Section: Randomized Controlled Trials For the Prevention Of First Varmentioning

confidence: 99%

Review article: primary prophylaxis for portal hypertensive bleeding in cirrhosis

Vlachogiannakos

Goulis

Patch

et al. 2000

Aliment Pharmacol Ther

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“…For example, the American Association for the Study of Liver Diseases (AASLD) cites increased rates of HE and reductions in overall survival. 20 21 22 23 24…”

Section: Gastroesophageal Varices Without a Splenorenal Shuntmentioning

confidence: 99%

Variceal Hemorrhage: Decompression, Obliteration, or Both?

McCafferty

Khudari

Salei

et al. 2022

Digestive Disease Interventions

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Variceal hemorrhage is a morbid condition that frequently mandates the involvement of interventional radiology to achieve successful and sustained hemostasis. Primary image-guided therapies for variceal hemorrhage include a transjugular intrahepatic portosystemic shunt and transvenous obliteration. Knowledge of variceal pathophysiology and anatomy, current techniques, and the evidence supporting therapeutic selection is paramount to successful patient outcomes. The purpose of this review is to provide the reader a framework of the available literature on image-guided management of bleeding varices to assist in clinical management.

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“…Four noteworthy surgical RCTs launched in 1958. A New Haven study randomized patients to prophylactic portocaval anastomosis or medical management for esophageal varices 23 . A research group in Cambridge, England, randomized subjects to simple or radical mastectomy; all patients also received radiation treatment 24 .…”

Section: From Alternate Allocation To Randomizationmentioning

confidence: 99%

“…A New Haven study randomized patients to prophylactic portocaval anastomosis or medical management for esophageal varices. 23 A research group in Cambridge, England, randomized subjects to simple or radical mastectomy; all patients also received radiation treatment. 24 A team in Seattle and one in Kansas City used random allocation and sham controls to test internal mammary artery ligation.…”

Section: From Alternate Allocation To Randomizationmentioning

confidence: 99%

Innovation and Tribulation in the History of Randomized Controlled Trials in Surgery

Bothwell

Jones

2019

Annals of Surgery

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Despite persistent critiques of the rigor of surgical research, surgeons have actually pursued careful empirical studies for centuries. Their work has enriched not only surgical science but also the development of evidencebased medicine. From conducting landmark controlled trials, to using statistics, alternate patient allocation, randomization, and sham controls, surgeons have long embraced innovative trial approaches and played important roles in the development of key methods of RCTs. However, historical contexts unique to surgery have shaped the implementation of RCTs in this field. Unlike the history of pharmaceuticals, in which substantial research funding has been devoted to testing new drugs before their approval, surgical trials have followed a different trajectory. New operations have repeatedly come into wide use in the absence of RCTs. On many occasions, when established procedures have become controversial, surgeons have then marshaled the resources to conduct RCTs reassessing the operations. Such trials have triggered powerful debates in which proponents of surgical RCTs battled against ingrained practices and preferences. In such cases, RCTs often were not decisive factors in determining the fate of surgical practices but supporting tools that followed and reflected changes in surgical judgment already underway. Surgical trialists also have encountered specific, recurring challenges, especially with the methodological and ethical complexity of blinded and sham-controlled trials. The history of surgical trials thus reveals major contributions from surgeons to the advancement of evidence-based medicine, as well as ongoing challenges. Strengthened and systematic trial support could advance the future of surgical RCTs.

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Prophylactic Portacaval Anastomosis in Cirrhotic Patients with Esophageal Varices

Cited by 25 publications

References 26 publications

Review article: primary prophylaxis for portal hypertensive bleeding in cirrhosis

Review article: primary prophylaxis for portal hypertensive bleeding in cirrhosis

Variceal Hemorrhage: Decompression, Obliteration, or Both?

Innovation and Tribulation in the History of Randomized Controlled Trials in Surgery

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