Endoscopic Variceal Ligation Outperforms Injection Sclerotherapyin Controlling Actively Bleeding OesophagealVaricesin Decompensated Cirrhotic Patients: A Real World Comparative Cohort Analysis

Abstract

Acute variceal bleeding (AVB) is a severe and potentially life-threatening complication in patients with cirrhosis and portal hypertension with mortality rates as high as 20% for the index bleeding event and 10% for subsequent bleeding episodes [1][2][3]. Endoscopic intervention is the first-line treatment to control active bleeding, but around 60% of patients will rebleed after successful initial control if effective follow-up treatment is not provided [4]. Secondary prophylaxis to prevent further variceal bleeding is thus crucial and there is general consensus that patients surviving an initial bleeding episode should enter a longterm eradication and surveillance programme [4].Endoscopic variceal ligation (EVL) has replaced injection sclerotherapy (IST) in most centres as the endoscopic treatment of choice, supported by data from randomised controlled trials (RCTs) which show more rapid eradication of varices with lower rates of rebleeding and fewer oesophageal complications with EVL [5]. However, detailed data on the relative success of each method in controlling AVB with actively bleeding ("spurting") varices are limited. The cohorts analyzed in previous RCTs comparing EVL with IST included only small numbers of patients with active variceal bleeding with conflicting results [5]. In the present study the comparative efficacies of EVL and IST in controlling actively bleeding oesophageal varices in patients in a high volume academic endoscopy referral centre are reported in the largest matched patient cohort to date. Patients and MethodsAdult patients admitted to the Surgical Gastroenterology Unit in Groote Schuur Hospital, Cape Town with variceal bleeding between January 2000 and December 2018 were assessed. Only patients with actively bleeding ("spurting") oesophageal varices who received their first emergency and subsequent procedures in our unit were included in the study (Figure1). The outcome of endoscopic interventions, both emergency and sub-Background and aims: Although endoscopic variceal ligation (EVL) and injection sclerotherapy (IST) are both used to control acute bleeding, no detailed comparative data exist on the relative efficacy and outcome of each method in patients with actively bleeding ("spurting") oesophageal varices. This study compared the efficacy, safety and outcome of EVL with IST in controlling actively bleeding oesophageal varices. Methods:Forty cirrhotic patients with actively bleeding oesophageal varices (BOV) who received EVL were matched and compared with 40 who had IST. Control of variceal bleeding, rebleeding, variceal recurrence, endoscopic complications, eradication and survival were recorded using Baveno assessment criteria. Results: Primary endoscopic failure to control acute bleeding during the first endoscopic intervention occurred in 2.5% in the EVL group and 10% in the IST group. Secondary 5-day failure of bleeding control was 20% in the EVL group and 25% in the IST group. Overall successful endoscopic variceal bleeding during the index admission was similar (EVL 82.5%...