Randomised trial of variceal banding ligation versus injection sclerotherapy for bleeding oesophageal varices

Gimson, Alexander; Ramage, John; Panos, Marios Z.; Hayllar, Karen M.; Harrison, Philip M.; Williams, Roger; Westaby, David

doi:10.1016/0140-6736(93)92812-8

Cited by 273 publications

(136 citation statements)

References 15 publications

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“…In recent years, EVL has proven to be a viable substitute for EIS. [7][8][9][10][11] EVL is associated with fewer complications as compared with EIS. 7,8,10,11,15 Additionally, EVL can achieve variceal obliteration more rapidly, thereby resulting in lower rebleeding rates.…”

Section: Discussionmentioning

confidence: 99%

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The additive effect of sclerotherapy to patients receiving repeated endoscopic variceal ligation: A prospective, randomized trial

Lai

Cheng

et al. 1998

Hepatology

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Endoscopic variceal ligation (EVL) is a new techniquedesigned to manage esophageal varices. The effect of sclerotherapy following repeated banding ligation remains unknown. Seventy-two patients with a history of esophageal variceal bleeding received regular EVL until variceal disappearance or until left with residual small varices. Subsequently, patients were randomized to receive sclerotherapy (Group 1, 37 patients) or serve as a control (Group 2, 35 patients). Group 1 received one to two sessions of low-dose sclerotherapy to achieve complete variceal disappearance. After a mean follow-up of 2 years, 4 months, recurrent esophageal varices developed in 14% of Group 1 and 43% of Group 2 (P F .02). Rebleeding was encountered in 8% of Group 1 versus 31% of Group 2 (P ‫؍‬ .01). One case of esophageal stricture (2.7%) was encountered in Group 1. Endoscopic injection sclerotherapy (EIS) has been well documented as a valuable tool to help control acute variceal bleeding, to prevent recurrent bleeding, and perhaps to improve survival. [1][2][3][4] However, it may be associated with substantial complications. 5 Endoscopic variceal ligation (EVL) has emerged in recent years as a new tool in the management of bleeding esophageal varices. 6 Controlled studies have demonstrated that EVL is superior to EIS in terms of obliterating esophageal varices, i.e., fewer treatment sessions are required with EVL than that with EIS. 7-11 On the other hand, varices, when reduced to minimal size by EVL, become inaccessible to EVL. Whether the addition of EIS may be of benefit to those patients remains unknown. This study was undertaken to investigate this issue. PATIENTS AND METHODSBetween July 1991 and July 1993, patients with a history of esophageal variceal bleeding admitted to Veterans General HospitalKaohsiung were considered for enrollment. Patients admitted with acute esophageal variceal bleeding between January 1992 and July 1993 were included in a trial comparing EIS and EVL, which has been published elsewhere. 10 During the overlapping period, only patients who were admitted to prevent variceal rebleeding but not eligible for prior study were enrolled in the current study. In this study, all the patients were treated with repeated EVL, and then randomized to receive additional EIS or not. The patient population was different from the previous study. The aims of the current study were to observe whether recurrent varices and rebleeding could be reduced in patients receiving EIS following repeated EVL. The inclusion criteria of this study were: 1) patients were cirrhotic and had a history of esophageal variceal bleeding; and 2) patients received repeated EVL until variceal disappearance or until left with residual small varices (defined below). The exclusion criteria were: 1) association with gastric variceal bleeding; 2) association with malignancy, uremia, or other debilitating disease; and 3) history of sclerotherapy or shunt operation. ␤-Blocker was not administered during the study. An informed consent was obtained from all o...

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Section: Discussionmentioning

confidence: 99%

“…7,8,10,11,15 Additionally, EVL can achieve variceal obliteration more rapidly, thereby resulting in lower rebleeding rates. [9][10][11] Therefore, it seems appropriate to recommend EVL over EIS as the first choice in the management of bleeding esophageal varices.…”

Section: Discussionmentioning

confidence: 99%

The additive effect of sclerotherapy to patients receiving repeated endoscopic variceal ligation: A prospective, randomized trial

Lai

Cheng

et al. 1998

Hepatology

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“…[3][4][5] Moreover, endoscopic injection sclerotherapy (EIS) has been replaced almost universally by endoscopic variceal ligation (EVL), because variceal eradication is faster and provides a lower variceal rebleeding rate with fewer secondary effects than in EIS. [6][7][8][9][10][11][12][13] In addition, a meta-analysis has shown a lower mortality in EVL than in EIS. 14 Some studies comparing band ligation with ␤-blockers plus isosorbide mononitrate show contradictory results regarding the effectiveness of both treatments in the prevention of variceal rebleeding.…”

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confidence: 99%

Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: A multicenter trial

et al. 2005

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and the EVL Study Group ␤-Blockers and endoscopic variceal ligation (EVL) have proven to be valuable methods in the prevention of variceal rebleeding. The aim of this study was to compare the efficacy of EVL combined with nadolol versus EVL alone as secondary prophylaxis for variceal bleeding. Patients admitted for acute variceal bleeding were treated during emergency endoscopy with EVL or sclerotherapy and received somatostatin for 5 days. At that point, patients were randomized to receive EVL plus nadolol or EVL alone. EVL sessions were repeated every 10 to 12 days until the varices were eradicated. Eighty patients with cirrhosis (alcoholic origin in 66%) were included (Child-Turcotte-Pugh A, 15%; B, 56%; C, 29%). The median follow-up period was 16 months (range, 1-24 months). The variceal bleeding recurrence rate was 14% in the EVL plus nadolol group and 38% in the EVL group (P ‫؍‬ .006). Mortality was similar in both groups: five patients (11.6%) died in the combined therapy group and four patients (10.8%) died in the EVL group. There were no significant differences in the number of EVL sessions to eradicate varices: 3.2 ؎ 1.3 in the combined therapy group versus 3.5 ؎ 1.3 in the EVL alone group. The actuarial probability of variceal recurrence at 1 year was lower in the EVL plus nadolol group (54%) than in the EVL group (77%; P ‫؍‬ .06). Adverse effects resulting from nadolol were observed in 11% of the patients. In conclusion, nadolol plus EVL reduces the incidence of variceal rebleeding compared with EVL alone. A combined treatment could lower the probability of variceal recurrence after eradication. V ariceal bleeding is a serious complication of portal hypertension and a leading cause of death in patients with liver cirrhosis. The patients who survive an initial episode have a risk of rebleeding approaching 80% at 2 years. 1 After the first episode of hemorrhage from esophageal varices, ␤-blockers and endoscopic treatment are effective therapies in the secondary prevention of variceal bleeding. 2 Unfortunately, nonselective ␤-blockers achieve target reductions in hepatic venous pressure gradient in only approximately one third of patients. [3][4][5] Moreover, endoscopic injection sclerotherapy (EIS) has been replaced almost universally by endoscopic variceal ligation (EVL), because variceal eradication is faster and provides a lower variceal rebleeding rate with fewer secondary effects than in EIS. [6][7][8][9][10][11][12][13] In addition, a meta-analysis has shown a lower mortality in EVL than in EIS. 14 Some studies comparing band ligation with ␤-blockers plus isosorbide mononitrate show contradictory results regarding the effectiveness of both treatments in the prevention of variceal rebleeding. [15][16][17] The rationale behind the use of a combination therapy is that agents acting through different mechanisms may have additive or even synergistic benefits. 5 There are few studies analyzing the efficacy of associating both therapeutic methods, ␤-blockers and EVL, in the prevention of recurrent hemor...

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“…A introdução por STIEGMANN et al (15) , em 1986, das ligaduras com bandas elásticas, representou importante avanço no tratamento das varizes esofágicas, por ser método de simples realização, apresentar menores índices de complicações e necessitar menor número de sessões para sua erradicação quando comparadas à esclerose (2,7,18) .…”

Section: Discussionunclassified

Tratamento endoscópico das varizes esofágicas utilizando alças pré-atadas confeccionadas com fio de poliamida

Koyama

Hashiba

Bromberg

et al. 2006

Arq. Gastroenterol.

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Randomised trial of variceal banding ligation versus injection sclerotherapy for bleeding oesophageal varices

Cited by 273 publications

References 15 publications

The additive effect of sclerotherapy to patients receiving repeated endoscopic variceal ligation: A prospective, randomized trial

The additive effect of sclerotherapy to patients receiving repeated endoscopic variceal ligation: A prospective, randomized trial

Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: A multicenter trial

Tratamento endoscópico das varizes esofágicas utilizando alças pré-atadas confeccionadas com fio de poliamida

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