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

Abstract

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...

Rates of recurrent variceal bleeding are low with modern esophageal banding strategies: a retrospective cohort study

“…Our study demonstrated an overall re-bleeding rate in a real-world clinical practice over a 2-year period of 4.6%, which is markedly lower than previous reports with standard clinical practice [4,15,16,[23][24][25][26][27][28][29]. Other studies suggest a re-bleeding rate of 17.2% during the first 12 months following sentinel bleed among patients undergoing band ligation in conjunction with b-blockers for secondary prevention [30], although Includes one patient who suffered a fatal re-bleeding event.…”

Variceal bleeding

“…If the initial bleeding episode is controlled with sclerotherapy, follow-up endoscopic banding can still be performed. The combination of endoscopic banding and sclerotherapy is not more effective than banding alone [15]. Contraindications Inability to visualize the esophagus.…”

Color Doppler endoscopic ultrasonography in identifying groups at a high-risk of recurrence of esophageal varices after endoscopic treatment

“…[1][2][3][4][5][6][7][8] However, the time from treatment to the recurrence of esophageal varices varies markedly between patients, even when the same procedure is performed. Factors affecting the time to recurrence in individuals remain unknown, although this variation may be due partly to differences in the venous structure connected with esophageal varices, and the associated hemodynamics.…”