Comparison of endoscopic variceal sclerotherapy with sequential endoscopic band ligation plus low-dose sclerotherapy for secondary prophylaxis of variceal hemorrhage: a prospective randomized study

doi:10.1053/ge.1999.v50.98594

Gastrointestinal Endoscopy

Volume 50, Issue 3, September 1999, Pages 369-373

https://doi.org/10.1053/ge.1999.v50.98594 Get rights and content

Abstract

Background: Endoscopic variceal sclerotherapy and band ligation both have certain limitations such as, respectively, esophageal complications and early recurrence of varices. Methods: From February 1994 to March 1996, all consecutive patients with portal hypertension due to either cirrhosis or noncirrhotic portal fibrosis and a history of variceal bleeding were included in a prospective study and randomly assigned to receive either endoscopic variceal sclerotherapy alone or endoscopic variceal band ligation plus low-dose endoscopic variceal sclerotherapy. Results: Of 69 patients, 34 were randomly assigned to receive endoscopic variceal sclerotherapy alone; 35 received endoscopic variceal band ligation plus endoscopic variceal sclerotherapy. Complete variceal eradication rates (85% vs. 80%) and the number of endoscopic sessions required for eradication (6.61 ± 2.94 vs. 7.85 ± 3.31) were similar in the endoscopic variceal sclerotherapy and endoscopic variceal band ligation plus endoscopic variceal sclerotherapy groups, respectively. The mean volume of sclerosant required in the combined group (54.94 ± 33.74 mL) was significantly less than that in the endoscopic variceal sclerotherapy group (81.91 ± 34.80 mL). The complication and recurrent bleeding rates were significantly higher in the endoscopic variceal sclerotherapy group than those in the combined group (20% and 16% vs. 3% and 3%, respectively). Conclusions: Both endoscopic variceal sclerotherapy and endoscopic variceal band ligation plus endoscopic variceal sclerotherapy were comparable in eradicating varices but the combined technique was associated with significantly lower complication and recurrent bleeding rates. (Gastrointest Endosc 1999;50:369-73.)

Section snippets

PATIENTS AND METHODS

From February 1994 to March 1996, 69 consecutive patients with portal hypertension due to either cirrhosis of the liver or noncirrhotic portal fibrosis (NCPF) and a history of upper GI bleeding (hematemesis and/or melena) were included in the study. Bleeding was considered to be from the esophageal varices if it was documented endoscopically or if there was no potential source of bleeding other than large esophageal varices (grade 3 or 4). Variceal size was graded according to the

RESULTS

A total of 69 patients were enrolled in the study: 34 in the EST group and 35 in the EVL plus EST group. The two groups were similar with respect to age, gender, cause of portal hypertension, and Child-Pugh grade (Table 1).

. Demographic data of patients at inclusion in the study

Empty Cell	EST alone group (n = 34)	EVL + EST group (n = 35)
Age (mean, range) (yr)	40.76 (20-70)	39.52 (20-61)
Gender	24 men, 10 women	31 men, 4 women
Cause of portal hypertension
Cirrhosis	30	29
Child-Pugh class
A	9	11
B	19	17
C	2	1
NCPF	4	6
Initial

DISCUSSION

The major problem associated with EST is a high rate of complications such as deep and large esophageal ulcers, esophageal strictures, mediastinitis, and pleural effusion.12, 13 Various factors have been identified that are related to the development of complications after EST such as the type of sclerosant used, intravariceal or paravariceal injection, amount and concentration of the sclerosant, and the time interval between two EST sessions. Of these, the volume of sclerosant used in a

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Cited by (32)

Randomized controlled trial of scleroligation versus band ligation alone for eradication of gastroesophageal varices
2017, Gastrointestinal Endoscopy
Citation Excerpt :
The band ligation and scleroligation groups had a similar good outcome regarding pyrexia, ulceration, pain, and development of portal hypertensive gastropathy. This is different than the statement of Garg et al,26 who performed secondary prophylaxis of variceal hemorrhage by combined variceal band ligation and sclerotherapy, with the conclusion that although they were equivalent in variceal eradication, the combination produced significantly lower adverse events. The most common esophageal adverse event of sclerotherapy is mucosal ulceration that happens within 24 hours of the procedure, in up to 90% of cases.
Gastric varices develop in 5% to 33% of patients with portal hypertension. Their most common form is concomitant gastroesophageal varices. Scleroligation (combined sclerotherapy and band ligation) has been used successfully in management of esophageal varices but has not been evaluated previously in the management of gastroesophageal varices. The aim of this work was evaluation of a new scleroligation technique for management of bleeding gastroesophageal varices regarding efficacy, adverse events, variceal recurrence, and survival.
This study was conducted on 120 cirrhotic patients with bleeding gastroesophageal varices, whom we divided randomly into 2 groups of 60 patients each—a band ligation group and a scleroligation group.
The mean number of sessions was lower in the scleroligation group than in the band ligation group (2.22 ± 0.92 and 3.43 ± 0.67, respectively) (P < .001), as were the duration of treatment and total number of bands used. Cost and survival were comparable in the 2 groups. There was no significant difference between the 2 maneuvers regarding adverse events, recurrence rates, or rebleeding rates after obliteration. Recurrence was significantly higher in patients with larger varices, ulceration, and postprocedure pyrexia. Rebleeding was significantly higher among those who experienced postprocedure pyrexia and developed or had worsening of gastric antral vascular ectasia.
Scleroligation appears to achieve a faster rate of eradication with fewer treatment sessions and total number of bands deployed to achieve variceal obliteration than band ligation and is comparable in cost and in adverse event and recurrence rates. (Clinical trial registration number: NCT02646202.)
The Role of Endoscopy in Secondary Prophylaxis of Esophageal Varices
2010, Clinics in Liver Disease
Citation Excerpt :
Thus, EIS with low-dose sclerosants following repeated EVL was developed to reduce variceal recurrence. Several trials have shown that metachronous combination therapy with EIS and EVL could reduce the variceal recurrence or even reduce incidence of variceal rebleeding as compared with that treated with EVL or EIS alone.76–78 Thus, metachronous combination therapy with EIS and EVL is more favored than the synchronous combination.
Injection therapies for variceal bleeding disorders of the GI tract
2008, Gastrointestinal Endoscopy
Citation Excerpt :
However, in a meta-analysis by Laine and Cook,9 endoscopic variceal ligation therapy significantly reduced rebleeding (odds ratio [OR] 0.52, 95% CI, 0.37-0.74), mortality (OR 0.67, 95% CI, 0.46-0.98), the frequency of esophageal strictures (OR 0.10, 95% CI, 0.03-0.29), and the number of sessions (2.2 fewer sessions, 95% CI, 0.9-3.5) required to achieve variceal obliteration when compared with injection sclerotherapy. The combination of variceal ligation and injection sclerotherapy confers significant advantages when compared with sclerotherapy alone, by decreasing complications, rebleeding, the number of sessions to achieve eradication, and variceal recurrence rates.43-46 Studies that compared combination therapy with variceal ligation alone did not find similar advantages.47-52
Endoscopic Therapy in the Management of Esophageal Varices: Injection Sclerotherapy and Variceal Ligation
2006, Surgery of the Liver, Biliary Tract and Pancreas: Volumes 1-2, Fourth Edition
Injection sclerotherapy for the management of esophageal and gastric varices
2005, Techniques in Gastrointestinal Endoscopy
The development of esophageal and gastric varices is an important complication of portal hypertension with significant morbidity and mortality. Endoscopic variceal sclerotherapy (EVS) was the first and, for many years, the only successful endoscopic method available for the treatment of bleeding varices. Endoscopic variceal ligation (EVL) has since replaced EVS, except in certain situations where EVL is unavailable or not technically feasible. In these instances, EVS, when performed correctly, is a proven and effective method of controlling acute hemorrhage. Endoscopists performing sclerotherapy should be well aware of the multitude of common and potentially serious complications of EVS, so that the risks of these complications can be minimized.
Improvement of collateral vessels in the vicinity of gastric cardia after endoscopic variceal ligation therapy for esophageal varices
2004, Clinical Gastroenterology and Hepatology
$Background & Aims:$ Endoscopic variceal ligation (EVL) therapy has been performed widely to treat or prevent variceal bleeding. We sought to examine the influence of EVL for esophageal varices on collateral vessels in the vicinity of gastric cardia. $Methods:$ In 42 patients with esophagogastric varices, conventional endoscopy and endoscopic ultrasonography with a 20-MHz probe (CUP-EUS) were performed before and at every 3 months after EVL for esophageal varices. By using conventional endoscopy, cardial variceal sizes were divided into 3 grades: F0, F1, and F2. The sizes of submucosal, perforating, and paracardial vessels at the cardia also were classified into 3 grades according to CUP-EUS findings. $Results:$ Conventional endoscopy showed cardial varices in 33 (79%) patients before and 23 (55%) patients at 3 months after the treatment (P < 0.05). CUP EUS showed that 29 (69%) patients had severe grade cardial submucosal vessels before EVL, but only 13 (31%) patients did after the treatment (P < 0.01). Nineteen (45%) patients had severe grade cardial perforating vessels before EVL, but only 4 (10%) patients did after the treatment (P < 0.001). Furthermore, patients with severe grade residual submucosal or perforating vessels at the cardia had shorter recurrence-free times of esophageal varices (P < 0.01, 0.05, respectively). $Conclusions:$ Collateral vessels in the vicinity of gastric cardia were improved significantly after EVL, indicating that esophageal varices can be treated by EVL even though they connect with cardial varices. Furthermore, eradication of such collateral vessels by EVL may lead to longer recurrence-free status of esophageal varices.

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^☆: From the Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.

^☆☆: Reprint requests: Rakesh Tandon, MD, PhD, Department of Gastroenterology, A.I.I.M.S., New Delhi 110 029, India.

^★: 37/1/98594

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Comparison of endoscopic variceal sclerotherapy with sequential endoscopic band ligation plus low-dose sclerotherapy for secondary prophylaxis of variceal hemorrhage: a prospective randomized study☆,☆☆,★

Abstract

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

Hepatology

Gastrointest Endosc

Hepatology

Gastroenterology

Gastroenterology

Lancet

Gastroenterology

Gastrointest Endosc

A 20 year prospective study of cirrhosis

Br J Med

Liver study group of V Carvello Hospital: survival and prognostic indications in compensated and decompensated cirrhosis

Dig Dis Sci

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Hepatology

A prospective randomized controlled trial of chronic esophageal variceal sclerotherapy

Hepatology