A Prospective, Randomized Controlled Trial of Chronic Esophageal Variceal Sclerotherapy

Korula, Jacob; Balart, Luis A.; Radvan, George H.; Zweiban, Bruce; Larson, Alan; Kao, H. W.; Yamada, Suyenori

doi:10.1002/hep.1840050410

Cited by 236 publications

(37 citation statements)

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“…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.…”

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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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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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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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“…1 rate could be lowered [3][4][5][6][7][8] and survival prolonged. 4,6,9,10 Studies Patients who have bled from varices remain at risk with rubber band ligation have shown that in addition to for rebleeding.…”

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confidence: 99%

Endoscopic Variceal Ligation Is Superior to Combined Ligation and Sclerotherapy for Esophageal Varices: A Multicenter Prospective Randomized Trial

et al. 1997

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rate could be lowered [3][4][5][6][7][8] and survival prolonged. 4,6,9,10 Studies Patients who have bled from varices remain at risk with rubber band ligation have shown that in addition to for rebleeding. There is interest in methods that would being safer than sclerotherapy, 11-14 ligation can further lower enable rapid eradication of varices. The present trial the rebleeding rate 12,13 and further improve survival. 11 Howwas designed to study whether combining ligation with ever, the problem of rebleeding has not been eliminated. Besclerotherapy will allow quicker eradication of varices cause most episodes of rebleeding occur early, methods that than either modality alone. Patients with bleeding eradicate varices more rapidly by reducing the ''period at esophageal varices were randomized into ligation or risk'' might further improve outcome. combination therapy groups. Patients in the ligationIn our first multicenter trial, an average of five sessions group were treated with endoscopic rubber band ligawere required to eradicate varices with sclerotherapy, tion alone. In combination group patients, each variceal whereas four sessions were required with ligation. 11 To furcolumn was ligated distally and 1 mL of ethanolamine ther optimize efficiency, we asked whether a lower dose of was injected proximal to each ligated site. Subsequent sclerotherapy in conjunction with ligation would eradicate treatment sessions were at 7-to 14-day intervals until esophageal varices more quickly than either modality alone, varices were eradicated. The clinical and endoscopic while maintaining the lower complication rate associated characteristics of 25 patients in the ligation group were with ligation. In an initial single-arm study, we ligated each similar to those of 22 patients in the combination group.variceal column distally and injected 1 mL of sclerosing soluFollow-up was up to 30 months. Active bleeding was contion proximal to each ligated site. With this approach, varices trolled in 100% of patients in the ligation group and 75%were eradicated with an average of approximately three sesof those in combination group (P Å NS). It took 3.3 { .4sions. 15 The aim of the present prospective randomized trial (range, 1-7) sessions to eradicate varices with ligation was to determine whether combination therapy would eradiand 4.1 { .6 (1-7) with combination therapy (P Å NS).cate varices more quickly than ligation alone. The rebleeding rate in patients who survive an episode of geal varices with red color signs, and absence of other lesions such as variceal hemorrhage is higher than that associated with any ulcers, erosions, vascular malformations, or mucosal tears. Exclusion other cause of upper gastrointestinal hemorrhage.1 An early criteria were (1) previous endoscopic or operative treatment, i.e., study of the ''natural history'' of variceal bleeding showed rubber band ligation, sclerotherapy, or shunt; (2) gastric varices more that approximately one third of patients who survived the than 2 cm from the gastroesophageal jun...

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“…90-3.86). In general, nonselective shunt surgery was associated with significantly lower rebleeding rates, but the incidence of hepatic encephalopathy was significantly higher [89][90][91]. The mortality rates between the two groups were similar.…”

Section: Endoscopic Therapy Versus Surgerymentioning

confidence: 58%

Update on Treatment of Variceal Hemorrhage

Sung²

2002

Dig Dis

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Variceal hemorrhage accounts for one third of all deaths related to cirrhosis. To date, many modalities of treating variceal bleeding have been devised, including pharmacological therapy. Treatment of variceal hemorrhage includes resuscitation, initial hemostasis, and prevention of complications and recurrent bleeding. Intravenous vasoactive agents such as terlipressin, somatostatin, octreotide, or vapreotide should be administered in patients with suspected variceal bleeding. Endoscopic treatment remains the mainstay of treatment. Endoscopic variceal ligation is safer and more efficacious than sclerotherapy as initial treatment of bleeding esophageal varices, whereas cyanoacrylate injection is the endoscopic treatment of choice for gastric varices. An adjuvant vasoactive agent is useful for the prevention of early rebleeding. Prophylactic antibiotics are increasingly used for prevention of infection, notably spontaneous bacterial peritonitis. Follow-up endoscopic treatment is necessary in order to obliterate residual varices. The combination of a beta blocker and nitrate is an essential component of secondary prophylaxis for recurrent variceal bleeding. Transjugular intrahepatic portosystemic shunt or surgery offers the best salvage therapy in patients with failed hemostasis or breakthrough recurrent bleeding despite medical and endoscopic therapy. Endoscopic ultrasonography is useful in the prediction of recurrence of varices and facilitates visualization and guidance of further treatment of gastric varices. Despite advances in the treatment of variceal bleeding, liver function remains the determining factor of patient survival. Liver transplantation is the only definitive treatment that can alter the course of the disease.

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A Prospective, Randomized Controlled Trial of Chronic Esophageal Variceal Sclerotherapy

Cited by 236 publications

References 18 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

Endoscopic Variceal Ligation Is Superior to Combined Ligation and Sclerotherapy for Esophageal Varices: A Multicenter Prospective Randomized Trial

Update on Treatment of Variceal Hemorrhage

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