Comparison of endoscopic variceal injection sclerotherapy and ligation for the treatment of esophageal variceal hemorrhage: A prospective randomized trial

Abstract

To determine the efficacy of endoscopic variceal sclerotherapy (EVS) and ligation (EVL) in the management of esophageal variceal bleeding, 134 cirrhotic patients were randomized to receive either treatment. The clinical and endoscopic characteristics were similar in both groups. Active bleeding was controlled with ligation (20 of 20) as efficiently as with sclerotherapy (14 of 16). Elective sclerotherapy consumed less time than ligation (7.9 +/- 1.8 minutes vs. 11.5 +/- 2.7 minutes, P < .001), but there was no difference between emergent sclerotherapy (14.5 +/- 5.8 minutes) and ligation (14.9 +/- 4.1 minutes). Ligation reduced one grade of variceal size more quickly than sclerotherapy (1.1 +/- 0.4 vs. 2.0 +/- 1.7 session, P < .001). The rebleeding rate was lower with ligation (13 of 67 vs. 28 of 67, P < .01). Esophageal ulcer was the most common source of rebleeding. Recurrence of varices appears more probable with ligation (P = .079). The complication rate was higher with sclerotherapy (15 of 67 vs. 3 of 67, P < .01), with esophageal stricture being the most common cause. Survival rate was the same in both groups even after stratifying patients into good and poor hepatic reserve groups. Hepatic failure was the major cause of death, followed by exsanguination. In summary, EVL was superior to EVS regarding rebleeding and complications but not in other aspects such as time consumption in elective treatment and recurrence of varices. Substantial results for long-term follow-up are required before conclusion of the treatment of choice.

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

“…Theoretically, variceal recurrence would be more frequent in patients treated with EVL than in patients treated with EIS. Indeed, according to our observation and the study by Hou et al, 10,11 variceal recurrence is truly more frequent in patients managed with EVL. Conversely, variceal recurrence was more frequent in patients managed with EIS in the study by Stiegmann et al 7 It is difficult to explain the contradictory results, but they may be related to the different criteria of variceal obliteration and variceal recurrence that have been used.…”

“…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.…”

“…[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. [9][10][11] Therefore, it seems appropriate to recommend EVL over EIS as the first choice in the management of bleeding esophageal varices.…”

“…The primary end-point was variceal recurrence, and the secondary end-point was variceal rebleeding. Anticipation of a recurrent rate of varices was 40% in patients receiving only EVL 7,11 and, expecting a 75% decrease in patients receiving additive EIS, with an ␣ error of 0.05 and a ␤ error of 0.10, a minimum sample size of 66 patients was required for analysis. To detect predictive factors for variceal recurrence, rebleeding, or treatment failure, univariate analysis was performed by the log rank test with inclusion of the following parameters: age, gender, etiology of liver disease, acute bleeding, ascites, albumin and bilirubin values, prothrombin time, ChildPugh classification, size of varices, and treatment modality.…”

Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding

“…[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.…”