Endoscopic ligation compared with sclerotherapy for bleeding esophageal varices in children with extrahepatic portal venous obstruction

Endoscopic sclerotherapy is an effective treatment for bleeding esophageal varices, but it is associated with significant complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, has been shown to be superior to sclerotherapy in adult patients with cirrhosis. To determine the efficacy and safety of endoscopic sclerotherapy and ligation, the 2 methods were compared in a randomized control trial in 49 children with extrahepatic portal venous obstruction who had proven bleeding from esophageal varices. Twenty-four patients were treated with sclerotherapy and 25 with band ligation. No significant differences were found between the sclerotherapy and ligation groups in arresting active index bleeding (100% each) and achieving variceal eradication (91.7% vs. 96%, P =.61). Band ligation eradicated varices in fewer endoscopic sessions than did sclerotherapy (3.9 +/- 1.1 vs. 6.1 +/- 1.7, respectively, P <.0001). The rebleeding rate was significantly higher in the sclerotherapy group (25% vs. 4%, P =.049), as was the rate of major complications (25% vs. 4%, P =.049). After eradication, esophageal variceal recurrence was not significantly different in patients treated by ligation than by sclerotherapy (17.4% vs. 10%, P =.67). In conclusion, variceal band ligation in children is a safe and effective technique that achieves variceal eradication more quickly, with a lower rebleeding rate and fewer complications compared with sclerotherapy.     

Combined ligation and sclerotherapy versus ligation alone for secondary prophylaxis of esophageal variceal bleeding: a meta-analysis

OBJECTIVES: Variceal ligation has been shown to be superior to sclerotherapy in prevention of rebleeding and improving survival in patients with cirrhosis. However, 25% of patients will rebleed before completion of treatment. A number of trials have compared the combination of ligation and sclerotherapy to ligation alone in achieving rapid and complete eradication of esophageal varices, with conflicting results. METHODS: Two reviewers independently identified seven randomized, controlled trials that compared endoscopic variceal ligation with the combination of sclerotherapy and ligation for the treatment of esophageal varices. Studies were identified by searching MEDLINE, reviewing references from retrieved articles, and scanning abstracts from conference proceedings. For each outcome, odds ratios (ORs) were calculated using fixed-effects and random-effects models. The Mantel-Haenszel test for statistical heterogeneity was used to assess the validity of combining results from individual studies. RESULTS: No significant difference was seen in cessation of actively bleeding varices (OR = 1.01, 95% CI = 0.43-2.36), variceal rebleeding (OR = 1.12, CI = 0.69-1.81), and mortality (OR = 1.1, CI = 0.70-1.74) in patients with variceal ligation versus patients receiving the combination treatment of ligation and sclerotherapy. Treatment sessions required to achieve complete variceal eradication were similar in the two treatment arms. A significantly higher incidence of esophageal stricture was seen in combination therapy (p < 0.001). CONCLUSIONS: The combination of ligation and sclerotherapy offers no advantage over ligation alone in prevention of rebleeding and in reduction of mortality. It is also associated with a higher complication rate of esophageal stricture.     

Endoscopic management for bleeding esophageal varices: sclerotherapy versus sclerotherapy plus band ligation versus band ligation alone. One year experience at a main hospital in Saudi Arabia.

BACKGROUND/AIMS: This study was done retrospectively to compare the outcome of sclerotherapy alone, band ligation alone and band ligation alternating with sclerotherapy in treatment of esophageal varices. METHODOLOGY: During 1 year 30 patients were admitted with variceal bleeding. They received either injection sclerotherapy (8 patients) or band ligation (11 patients), and 11 patients had a combination of both either during first bleed or during follow-up therapy, which is more than 2 sessions in each group. RESULTS: The success rate for stopping first bleeding was 100% in the band ligation and sclerotherapy alone group. The rebleeding rate was 27% in the combination group, 9% in the band ligation group, and none had rebleeding in the sclerotherapy group during follow-up. Eradication of varices was observed in 33% of patients after a second set of sclerotherapy and band ligation. CONCLUSIONS: Our study showed no significant difference between sclerotherapy versus band ligation in stopping initial bleeding or eradication of varices during the follow-up period, but there was a difference in re-bleeding rates among the three groups.     

小剂量硬化剂加固对食管静脉曲张术后的影响

目的探讨在密集套扎疗法的基础上进行硬化加固治疗对于食管静脉曲张复发的防治作用。方法对食管静脉曲张套扎治疗后食管曲张静脉消失或基本消失的患者进行硬化剂加固治疗,从齿状线开始依次向上在残存小曲张静脉内与血管旁粘膜下层注射5％鱼肝油酸钠,每点注射1—2ml,每次共注射10—14ml。观察其对静脉曲张消失后复发的预防作用。结果加固治疗组49例共行硬化治疗132次,平均2．7次,最多治疗4次。随访12～25个月,平均18个月。结果40例（81．9％）患者未发现食管静脉曲张再出现,原有细小静脉明显减轻或消失,9例复发。加固组与单纯套扎组再出血率有明显差异（10．2％对23．4％,P〈0．05）;超声内镜检查显示加固治疗组食管曲张静脉发现率明显低于单纯套扎组（42．9％对76．6％,P〈0．01）;加固治疗组与单纯套扎组穿通支血管检出率无明显差异（42．8％对57．4％,P〉0．05）。治疗后未发现严重并发症。结论套扎治疗后小剂量硬化剂加固治疗可显著减少套扎术后残留的食管曲张静脉、防止闭塞消失的静脉再通、预防再出血,有助于提高结扎术的长期疗效,延缓静脉曲张的复发。     

Randomized trial of ligation versus combined ligation and sclerotherapy for bleeding esophageal varices.

BACKGROUND: Endoscopic band ligation combined with sclerotherapy has been postulated to be superior to ligation alone for the treatment of esophageal variceal bleeding. METHODS: A randomized trial of ligation versus combined ligation and sclerotherapy was designed to determine whether combined therapy results in faster eradication of varices compared to ligation alone. Sixty patients were randomized to undergo band ligation or ligation combined with injection of 1 to 2 mL of polidocanol (1%) into each variceal column immediately proximal to the previously placed bands. Therapy was repeated at 1- or 2-week intervals until variceal eradication was achieved. Follow-up endoscopy was performed at 3 months and then at 6-month intervals. RESULTS: The demographic and clinical characteristics of the 31 patients who underwent ligation were similar to those of the 29 who received combined treatment. Sixty percent of the patients had cirrhosis due to viral hepatitis. No significant differences were found between the combined and ligation alone groups in arresting active bleeding [9 of 9 (100%) vs. 6 of 7 (86%)], units of blood transfusion (3 +/- 0.8 vs. 2 +/- 0.6), number of sessions required to eradicate varices (3.8 +/- 0.5 vs. 3.6 +/- 0.4), treatment failure [2 (17%) vs. 4 (14%)], esophageal varix recurrence [6 (21.%) vs. 2 (6%)], gastric varices formation [4 (14%) vs. 1 (3%)], stricture [1 (3%) vs. 0 (0%)], recurrent bleeding [5 (17%) vs. 7 (23%)], other complications [10 (34%) vs. 9 (29%)], or death [3 (10%) vs. 7 (23%)] during a follow-up period of up to 36 months. CONCLUSIONS: Combined ligation and sclerotherapy does not reduce the number of endoscopic treatment sessions required for variceal eradication and offers no benefit over ligation alone. Because of the lack of benefit, the added procedure time, and the cost, we do not advocate combination therapy, and ligation alone remains the best endoscopic treatment.     

Efficacy of absolute alcohol injection compared with band ligation in the eradication of esophageal varices

BACKGROUND: Endoscopic sclerotherapy is an absolute indication for treating esophageal varices. Re-bleeding is common during the treatment period, before all varices become eradicated. AIM: To compare two techniques of endoscopic esophageal varices eradication: sclerotherapy with absolute alcohol and banding ligation. PATIENTS AND METHOD: Forty-six patients with liver cirrhosis and esophageal varices were prospectively randomized into two treatment groups: endoscopic sclerotherapy with absolute alcohol and banding ligation. Patients were included if they had large varices with signs of high bleeding risk. Informed writing consent was obtained from every patient and the Ethics Committee of Federal University of S?o Paulo, SP, Brazil, approved the study. After eradication, all patients were followed up to 1 year to look for re-bleeding episodes and variceal recurrence. RESULTS: Both groups were similar except that male gender was more common in the sclerotherapy group. There was no statistical difference regarding variceal eradication (78.3% in sclerotherapy group vs 73.9% in the ligation group), recurrence (26.7% vs 42.9%, respectively) and death related to any cause (21.7% vs 13.9%). In the sclerotherapy group more sessions were need to obtain complete variceal eradication. In this group we did observe a high re-bleeding rate (34.8%) and more ulcers associated with retrosternal pain right after the procedure. There was no difference regarding overall morbidity and mortality. CONCLUSIONS: Banding ligation requires fewer sessions than sclerotherapy with absolute alcohol to eradicate esophageal varices. Both methods are equally efficient regarding variceal eradication and recurrence during a short follow-up period.     

Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: a multicenter trial

beta-Blockers and endoscopic variceal ligation (EVL) have proven to be valuable methods in the prevention of variceal rebleeding. The aim of this study was to compare the efficacy of EVL combined with nadolol versus EVL alone as secondary prophylaxis for variceal bleeding. Patients admitted for acute variceal bleeding were treated during emergency endoscopy with EVL or sclerotherapy and received somatostatin for 5 days. At that point, patients were randomized to receive EVL plus nadolol or EVL alone. EVL sessions were repeated every 10 to 12 days until the varices were eradicated. Eighty patients with cirrhosis (alcoholic origin in 66%) were included (Child-Turcotte-Pugh A, 15%; B, 56%; C, 29%). The median follow-up period was 16 months (range, 1-24 months). The variceal bleeding recurrence rate was 14% in the EVL plus nadolol group and 38% in the EVL group (P = .006). Mortality was similar in both groups: five patients (11.6%) died in the combined therapy group and four patients (10.8%) died in the EVL group. There were no significant differences in the number of EVL sessions to eradicate varices: 3.2 +/- 1.3 in the combined therapy group versus 3.5 +/- 1.3 in the EVL alone group. The actuarial probability of variceal recurrence at 1 year was lower in the EVL plus nadolol group (54%) than in the EVL group (77%; P = .06). Adverse effects resulting from nadolol were observed in 11% of the patients. In conclusion, nadolol plus EVL reduces the incidence of variceal rebleeding compared with EVL alone. A combined treatment could lower the probability of variceal recurrence after eradication.     

Recurrence of esophageal varices following endoscopic treatment and its impact on rebleeding: comparison of sclerotherapy and ligation

BACKGROUND/AIMS: Endoscopic variceal ligation is superior to sclerotherapy because of its lower rebleeding and complication rates. However, ligation is not without drawbacks due to a higher tendency to variceal recurrence. We conducted a randomized cohort study to delineate the long-term history of variceal recurrence following ligation and sclerotherapy, and to clarify the impact of recurrence on rebleeding and on the consumption of endoscopic treatment resources. METHODS: Two hundred cirrhotic patients with esophageal variceal bleeding were randomized to undergo maintenance endoscopic variceal sclerotherapy or ligation. RESULTS: One hundred and forty-one patients achieved variceal eradication and were regularly followed up for 2.2 to 6.7 (mean: 5.1 +/- 1.2) years. The demographic data, hepatic reserve, bleeding severity, and endoscopic features of both sclerotherapy (n=70) and ligation (n=71) showed no difference. Forty (57.1%) patients who underwent sclerotherapy experienced 58 recurrences of esophageal varices, in contrast to the 46 (64.8%) patients who underwent ligation and experienced 81 episodes of recurrence. Kaplan-Meier analysis showed that within 2 years variceal recurrence was more frequent for ligation than sclerotherapy, and the difference decreased thereafter. Multiple recurrence appeared more common with ligation (1/2/3/4/5 episodes of recurrence: 46/23/8/3/1 vs. 40/14/3/1/0, p=0.08). On multifactorial analysis, the endoscopic treatment method and red wale markings were the two factors determining variceal recurrence. Rebleeding from recurrent esophageal varices was unusual and showed no difference between the two groups (7/58 vs. 6/81, p>0.05). Rebleeding from gastric varices was more common after eradication by sclerotherapy (7/19 vs. 1/16, p=0.085) than by ligation. The number of sessions required for eradication of recurrent varices was no different between the two groups. CONCLUSIONS: Early recurrence and multiple recurrence of esophageal varices are more likely in patients undergoing endoscopic ligation, compared to sclerotherapy; however, the recurrence did not lead to a higher risk of rebleeding or require more endoscopic treatment.     

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

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.     

密集多点结扎术治疗食管静脉曲张出血的临床疗效观察

目的探讨内镜下密集多点结扎术(DEVL)治疗食管静脉曲张出血的近远期疗效。方法对贲门口齿状线及以上5～6cm范围的曲张静脉密集多点结扎，每隔2～3周重复治疗，直至曲张静脉全部根治。术后3、6、12个月定期随访及胃镜复查，术后3个月结果作为近期疗效判断依据，6个月以后作为远期疗效判断依据。结果126例患者共完成403次、3641点结扎，平均每例结扎3．2次．28．9点。急诊止血率为100．0％；近期食管静脉曲张根治率为94．4％、总有效率为100．0％、复发出血率为3．9％；经过平均22．3个月随访，远期食管静脉曲张复发率为11．9％、复发出血率为3．2％、未见复发出血死亡。术后多数患者有一过性门静脉高压性胃病加重。结论DEVL治疗能有效急诊止血、根治食管静脉曲张和预防再出血，远期疗效较好。治疗不受肝功能状态的影响，并发症少。     

Endoscopic band ligation plus argon plasma coagulation versus scleroligation for eradication of esophageal varices

Background and Aim: The aim of this study was to evaluate endoscopic band ligation plus argon plasma coagulation versus scleroligation. Methods: Patients were randomized to: Group I, 50 patients subjected to endoscopic injection sclerotherapy; Group II, 50 patients subjected to variceal band ligation; Group III, 50 patients subjected to combined endoscopic sclerotherapy and band ligation; and Group IV, 50 patients subjected to endoscopic band ligation plus argon plasma coagulation. Results: A comparison of the number of therapeutic sessions showed that group III underwent significantly fewer sessions. As regards post‐treatment complications, Group I showed a high incidence of transient pyrexia, transient dysphagia and/or retrosternal pain and ulceration, while in group II a higher incidence of rebleeding was demonstrated, as well as a higher incidence of esophageal varix recurrence after eradication during the follow‐up period. A higher mortality incidence was detected in groups I and II. The follow‐up incidence did not significantly differ between the different study groups. Conclusion: Scleroligation allows very rapid eradication of varices, has a low recurrence rate, avoids the disadvantage of high recurrence of band ligation alone, and does not require special skills over sclerotherapy or band ligation. Also, band ligation plus argon plasma coagulation allows for very rapid eradication of varices, and a low recurrence rate, with no obvious recorded complications, but it has the disadvantage of being the most expensive technique and requires special equipment that is only available in a few endoscopic centers.     

Endoscopic ligation vs. sclerotherapy in adults with extrahepatic portal venous obstruction: a prospective randomized study

BACKGROUND: Endoscopic sclerotherapy is a well-established treatment for bleeding esophageal varices, although it has a substantial complication rate. A prospective randomized trial was conducted to determine whether endoscopic variceal ligation is safer and more effective than sclerotherapy in adults with bleeding esophageal varices because of extrahepatic portal venous obstruction. METHODS: Thirty-six patients underwent sclerotherapy and 37 had band ligation. RESULTS: Ligation and sclerotherapy were equally effective for achieving variceal eradication (94.6% vs. 91.7%, respectively; p=0.67). However, ligation achieved eradication with fewer endoscopic sessions (3.7 [1.2] vs. 7.7 [3.3]; p <0.0001) and within a shorter time interval (50.1 [17.7] days vs. 99 [54.8] days; p <0.0001). In the ligation group, recurrent bleeding was less frequent (2.7% vs. 19.4%; p=0.028; however, Bonferroni correction for multiple testing removes this significance) and the rate of major complications was lower (2.7% vs. 22.2%; p=0.014). Total cost per patient was significantly higher in the sclerotherapy vs. the ligation group ($216.6 [71.8] vs. $182.6 [63.4]; p=0.035). During the follow-up period after variceal eradication, no significant differences were found between the sclerotherapy and the ligation groups with respect to recurrent bleeding (3% vs. 2.9%; p=1.0), esophageal variceal recurrence (9.1% vs. 11.4%; p=1.0), and formation of new gastric varices (9.1% vs. 14.3%; p=0.51). CONCLUSIONS: Variceal band ligation is superior to sclerotherapy, because it is less costly and achieves variceal eradication more quickly, with lower relative frequencies of recurrent variceal bleeding and complications.     

A new technique of combined endoscopic sclerotherapy and ligation for variceal bleeding

AIM: To develop a technique of combined endoscopic sclerotherapy and ligation (ESL) in which both techniques of endoscopic sclerotherapy (ES) and endoscopic variceal ligation (EVL) can be optimally used. METHODS: ESL was performed in 10 patients (age 46.4+/-7.9; 9 males, 1 female) with cirrhosis of liver using sclerotherapy needle and Speedband, Superview multiple band ligater (Boston Scientific, Microvasive, Watertown, MA). A single band was placed 5-10 cm proximal to the gastro-esophageal junction over each varix from proximal to distal margin, followed by intravariceal injection of 1.5 % ethoxysclerol (4 ml each) 2 to 3 cm proximal to the gastroesophageal junction on the ligated varices distal to deployed band. EVL was then performed at the injection site. Similarly other varices were also injected and ligated from distal to proximally. In the subsequent sessions, ES alone was performed to sclerose small varices at the gastroesophageal junction. RESULTS: ESL was successfully performed in all patients. A median of 3 (ESL 1, ES 2) sessions (ranged 1-4) were required to eradicate the varices in 9 (90 %) of 10 patients. Recurrence of varices without bleed was seen in 1 patient during a mean follow-up of 10.3 months (ranged 6-15). Two patients died of liver failure. None died of variceal bleeding. None of the patients had procedure related complications. CONCLUSION: ESL may be useful in the fast eradication of esophageal varices. However, randomised controlled trials are required to find out its relative efficacy and impact on variceal recurrence in comparison to ES or EVL.     

Detachable endoloop vs. elastic band ligation for bleeding esophageal varices

BACKGROUND: Variceal bleeding is a serious complication with a mortality rate that ranges from 20% to 50%. Patients who have variceal hemorrhage usually are treated by endoscopic injection sclerotherapy or elastic band ligation to eradicate the varices. Endoloop ligation is a newly developed technique for achieving hemostasis and variceal eradication. This study compared endoloop ligation with elastic band ligation in patients with acute esophageal variceal bleeding. METHODS: Fifty patients with acute esophageal variceal bleeding were recruited: 25 were treated by elastic band ligation and 25 by endoloop ligation. RESULTS: Although the number of patients in whom bleeding recurred during a follow-up period of 6 months was smaller in the endoloop group (12%) vs. the band group (28%), this difference was not statistically significant. Furthermore, no statistically significant difference was found between the two groups with respect to the number of patients in whom variceal eradication was achieved, the number of treatment sessions required for variceal eradication, or the frequency of variceal recurrence. The total cost for variceal obliteration by endoloop ligation was 342 dollars per patient, whereas, the total cost of variceal eradication by elastic band ligation was 356 dollars per patient. The endoloop had certain technical advantages over band application: a better field of vision, tighter application, good results with junctional varices, and a lack of strain exerted by the device on the endoscope. CONCLUSIONS: Endoloop ligation is a promising new technique for management of patients with bleeding esophageal varices.     

Propranolol reduces the rebleeding rate during endoscopic sclerotherapy before variceal obliteration.

In patients treated with sclerotherapy, most rebleeding episodes are observed before variceal obliteration. This prospective randomized study aimed to assess if propranolol together with sclerotherapy could reduce the rebleeding rate before variceal obliteration. Seventy-five patients (59 male, 16 female; mean age, 54 +/- 15 years) with cirrhosis (from alcohol abuse in 91%) admitted with upper gastrointestinal bleeding, which was endoscopically proven to originate from ruptured esophageal varices, were included. After initial control of bleeding, the patients were randomized into the following two groups: group 1 treated with sclerotherapy alone (36 patients) and group 2 treated with sclerotherapy plus propranolol (39 patients). They were followed up to variceal obliteration. In group 2, 7 patients rebled as compared with 14 patients treated with sclerotherapy alone (P less than 0.005). When considering only rebleedings from esophageal varices, 4 patients rebled in group 2 vs. 10 in group 1 (P less than 0.10). The total number of rebleeding episodes was lower in group 2 than in group 1 whether considering all causes (8 vs. 17; P less than 0.07) or variceal rebleedings alone (4 vs. 13; P less than 0.01). Mean total blood requirement per patient was lower in group 2 than in group 1 (1.4 +/- 3.4 vs. 2.79 +/- 6.4 units of blood, respectively; P less than 0.01). Mortality was similar in both groups of patients (14% vs. 13% in groups 1 and 2, respectively, NS). It is concluded that patients treated with sclerotherapy should be given propranolol before variceal obliteration.     

Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomized trial

Both beta-blockers and endoscopic variceal ligation (EVL) have proven to be valuable alternatives to sclerotherapy in the prevention of variceal rebleeding. Sucralfate is a mucosal protector. The effects of combinations of beta-blocker, band ligation, and sucralfate (triple therapy) remain unknown. A total of 122 patients with a history of esophageal variceal bleeding were randomized to receive EVL only (group A, 62 patients) or triple therapy (group B, 60 patients). The procedure for the triple therapy included ligation with the addition of sucralfate granules until variceal obliteration. In addition, nadolol was administered during the course of the study or until death. After a median follow-up of 21 months, recurrent upper gastrointestinal bleeding developed in 29 patients (47%) in group A and 14 patients (23%) in group B (P =.005). Recurrent bleeding from esophagogastric varices occurred in 18 patients in group A and 7 patients in group B (P =.001). Twenty-one patients in group A (50%) and 12 patients (26%) in group B experienced variceal recurrence after variceal obliteration (P <.05). Treatment failure occurred in 11 patients (18%) in group A and in 4 patients (7%) in group B (P =.05). Twenty patients from group A and 10 patients from group B died (P =.08); 9 and 4 of these deaths, respectively, were attributed to variceal hemorrhage (P =.26). The combination of ligation, nadolol, and sucralfate (triple therapy) proved more effective than banding ligation alone in terms of prevention of variceal recurrence and upper gastrointestinal rebleeding as well as variceal rebleeding.     

Band ligation plus sclerotherapy versus sclerotherapy alone in children with extrahepatic portal venous obstruction

Although endoscopic band ligation (EVL) plus sclerotherapy (EST) has shown to be superior to any individual method, there is no study in children. We therefore analyzed our experience of EST and EVL + EST in children with extrahepatic portal venous obstruction (EHPVO). Over a period of 8 years, 136 children who presented with a history of recent variceal bleeding due to EHPVO were studied; 30 of them received EVL + EST and 106 received EST alone. In the EVL + EST group, after the first session of EVL, EST was done three times weekly until variceal eradication was achieved. The mean age of these children was 7 +/- 3.6 years with a male-to-female ratio of 2.6:1. The rate of eradication was comparable in both groups (100% in EVL + EST and 96% in EST). However, EVL + EST group required a significantly fewer sessions and lower volume of sclerosant (2 +/- 1 vs. 4.4 +/- 2 sessions, P < 0.001 and 3.1 +/- 2 mL versus 7.5 +/- 4 mL, P < 0.001 respectively). There were significantly less complications in EVL + EST group (10% vs. 36%, P < 0.01). Over a mean follow-up of 27 months, varices recurred in 6.6% and 10% cases, respectively. EVL + EST is a better method in the treatment of esophageal varices in children with EHPVO than EST alone, as it required fewer session and had fewer complication.     

Improved long-term survival following complete eradication of esophageal varices by sclerotherapy

BACKGROUND/AIMS: Conflicting results have been reported concerning the effect of endoscopic injection sclerotherapy upon the long-term survival of cirrhotic patients with esophageal varix. The recurrence and rebleeding of esophageal varices seems to be an important factor influencing long-term survival. We investigated the long-term survival of patients after complete eradication of esophageal varices. METHODOLOGY: Forty patients treated by endoscopic injection sclerotherapy for acute esophageal variceal bleeding were studied. The recurrence rate of varices and the long-term survival of patients in whom complete eradication of esophageal varices was obtained were compared with those of patients in whom the eradication of varices was incomplete. RESULTS: The frequency of the recurrence/deterioration rate of varices and rebleeding in the complete eradication group was significantly lower than that in the incomplete eradication group (10.7% vs. 100%, 0% vs. 58.3%, respectively, p < 0.01). Accumulated 5-year survival rate of the complete eradication group was significantly higher than that of the incomplete eradication group (68.2% vs. 43.2%, p < 0.05). CONCLUSIONS: Complete eradication of esophageal varices by endoscopic injection sclerotherapy is effective both in preventing variceal re-bleeding and in improving the survival of cirrhotic patients with esophageal varices.     

Variceal band ligation and variceal band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding in cirrhotic patients: a randomized, prospective and controlled trial

BACKGROUND: The combination treatment of band ligation plus sclerotherapy has been proposed to hasten variceal eradication. The aim of this study was to assess the efficacy of band ligation alone versus band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding. METHODS: Eighty cirrhotic patients were randomized to group I (band ligation) with 41 patients or to group II (band ligation plus sclerotherapy) with 39 patients in whom polidocanol (2%) was injected 1 to 2 cm proximal to each band. RESULTS: At baseline, both groups were similar with regard to clinical, demographic and laboratory data. Mean follow-up time (standard error) for group I was 336.5 +/- 43.4 days and for group II 386.1 +/- 40.1 days (p = 0.4). No statistical differences were observed between group I and group II in relation to recurrence of bleeding (31.7% vs. 23%, p = 0.38), treatment failure (24.4% vs. 12. 8%, p = 0.18), death (39% vs. 30.8%, p = 0.44) and variceal eradication (65.8% vs. 74.4%, p = 0.40). Group II had a significantly higher number of complications than group I, 30.8% versus 7.3%, respectively (p = 0.05). The number of bleeding related deaths was higher in group I than in group II (22% vs. 10.3%, respectively; p = 0.15). CONCLUSIONS: No significant difference was observed between band ligation and band ligation plus sclerotherapy in prevention of recurrent variceal bleeding. Furthermore, there was a higher incidence of complications in the latter group.     

A randomized, controlled trial of banding ligation plus drug therapy versus drug therapy alone in the prevention of esophageal variceal rebleeding

Background & Aims:  Both medications with beta-blockers and isosorbide-5-mononitrate and endoscopic variceal ligation have been proven plausible in the prevention of variceal rebleeding. However, the relative efficacy and safety of the combined treatment for preventing rebleeding remains unresolved.
Methods:  Patients with history of esophageal variceal bleeding were enrolled. Emergency ligation was performed in patients with acute variceal bleeding. After hemodynamic stability, eligible patients were randomized to either the Medication group, using nadolol plus isorsorbide-5-mononitrate, or the Combined group, receiving banding ligation in addition to medications. Patients in the two groups with rebleeding from esophageal varices were treated with band ligation. The end points were rebleeding from varices or death.
Results:  After a median follow up of 23 months, recurrent upper gastrointestinal bleeding developed in 51% in the Medication group and 38% in the Combined group ( P  = 0.21). Recurrent bleeding from esophageal varices occurred in 26 patients (43%) in the Medication group and in 16 patients (26%) in the Combined group ( P  = 0.07). Recurrent bleeding from gastroesophageal varices occurred in 48% of Medication group and 28% of Combined group ( P  = 0.05). The frequency of adverse effects and mortality rates were similar between both groups ( P  = 0.28).
Conclusions:  Combined ligation with medications was marginally more effective than medication alone in the prevention of gastroesophageal variceal rebleeding with similar adverse effects and mortality.