Comparison of characteristics of recurrent esophageal varices after endoscopic ligation versus endoscopic ligation plus sclerotherapy

BACKGROUND/AIMS: The characteristics of recurrent esophageal varices after endoscopic variceal ligation (EVL) plus endoscopic injection sclerotherapy (EIS) versus EVL alone, including the number of additional treatments and patterns of recurrence have been compared. METHODOLOGY: Thirty-four patients with cirrhosis and esophageal varices were treated by EVL alone (EVL group), and 46 patients were treated by EVL followed by extravariceal injection sclerotherapy (EVL+extraEIS group). RESULTS: Fewer treatment sessions were needed (p<0.005), and more O-rings were required (p<0.0001) in the EVL group than in the EVL+extraEIS group. The 1- and 3-year cumulative recurrence rates were higher in the EVL group (81.3% and 93.8%) than in the EVL+extraEIS group (62.8% and 91.5%) (p<0.05). Endoscopic examination at first recurrence showed varices of a more severe form (p<0.001), but less frequently having the red color sign (p<0.0001), and intramucosal venous dilatation (p<0.0001) in the EVL group than in the EVL+extraEIS group. The number of rehospitalizations for additional treatment was lower (p<0.0001) and more patients could be managed with only endoscopic treatment for recurrent varices in the EVL group than in the EVL+extraEIS group (p<0.05). CONCLUSIONS: Even if the overall rate of variceal recurrence was higher, fewer treatment sessions were needed, and the number of rehospitalizations for these additional treatments was lower in the EVL group than in the EVL+extraEIS group. Multiple sessions of EVL are an effective strategy for the treatment of esophageal varices.     

Prophylactic endoscopic sclerotherapy of oesophageal varices in liver cirrhosis. A multicentre prospective controlled randomised trial in Vienna.

The effect of prophylactic treatment of oesophageal varices by endoscopic injection sclerotherapy before the first episode of variceal haemorrhage was studied in patients with cirrhosis in a prospective, randomised and controlled multicentre trial. From February 1984 to March 1987 patients with liver cirrhosis and large varices (stage III-IV according to Paquet) were treated and followed up. The sample comprised 87 patients: 45 in the prophylactic treatment and 42 in the control group. After excluding drop outs, 41 patients were treated in each group. Twenty nine per cent of patients in the sclerotherapy group and 34% in the control group had a variceal haemorrhage during the period of observation. There was no significant difference in the distributions of the bleeding free intervals between the sclerotherapy and the control groups. During the follow up period 24% of patients in the sclerotherapy group and 46% in the control group died. The distribution of survival times indicates a tendency towards longer survival of patients with prophylactic sclerotherapy, particularly in those with alcoholic cirrhosis.     

Endoscopic injection sclerotherapy for esophageal varices in cirrhotic patients without hepatocellular carcinoma: a comparison of longterm survival between prophylactic therapy and emergency therapy

BACKGROUND: This study aimed to determine whether prophylactic endoscopic injection sclerotherapy prolonged survival in patients with esophageal varices complicated by liver cirrhosis in the absence of hepatocellular carcinoma, compared with emergency sclerotherapy. METHODS: The subjects included 160 patients suffering from esophageal varices complicated by liver cirrhosis without hepatocellular carcinoma. Sixty-eight patients underwent emergency therapy for bleeding varices and the remaining 92 patients underwent prophylactic sclerotherapy. All subjects continued to receive therapy until the varices disappeared. RESULTS: Five-year survival was significantly better in the prophylactic group compared with the emergency group. During the 5-year observation period, 20 of the 68 patients in the emergency group experienced rebleeding and 5 patients died as a result of rebleeding. These rates were significantly higher than those in the prophylactic group (1 of 9 patients with bleeding died among the 92 prophylactic sclerotherapy patients). Multivariate analysis showed that prophylactic therapy and Child's C hepatic function were significant factors for 5-year survival. CONCLUSIONS: Prophylactic sclerotherapy for esophageal varices might be more effective in prolonging longterm survival of patients complicated by liver cirrhosis in the absence of hepatocellular carcinoma, compared with emergency sclerotherapy.     

Therapeutic results of endoscopic variceal ligation for acute bleeding of oesophageal and gastric varices

Endoscopic variceal ligation (EVL) using 'O' rings is widely accepted as a treatment of oesophageal varices that is at least as effective as endoscopic injection sclerotherapy but which produces fewer complications. Endoscopic variceal ligation using detachable snares has attracted attention as a safe and easy method of endoscopic treatment for gastric varices. Nineteen patients with acute bleeding from oesophageal or gastric varices were treated in the present study. Of these, 14 patients were treated with EVL using 'O' rings and five patients were treated with EVL using detachable snares and the treatment results were evaluated. Haemostasis was achieved in all patients. No serious complications of the procedures were observed. However, recurrences and rebleeding were observed in some patients during the maximum follow-up period of 24 months. Endoscopic variceal ligation using 'O' rings and detachable snares is useful for achieving haemostasis in cases of acute bleeding from oesophageal or gastric varices. However, additional endoscopic sclerotherapy may be needed to eliminate the variceal feeding vessels to further improve the long-term prognosis of these patients.     

Endoscopic ligation of oesophageal varices compared with injection sclerotherapy in primary biliary cirrhosis

BACKGROUND AND AIMS: Oesophageal varices are an important complication in primary biliary cirrhosis (PBC). However, there have yet to be any studies made on treatment of oesophageal varices in PBC. We therefore studied the efficacy and related complications of endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS) as an initial treatment in primary biliary cirrhotic patients. METHODS: From December 1985 to March 1999, 29 biliary cirrhotic Japanese patients with portal hypertension and oesophageal varices were treated in our clinics. Eleven patients were treated with EVL and EIS, and 18 patients underwent EIS only. The liver function, renal function and respiratory function were studied before and after endoscopic treatment and any complications were also examined. RESULTS: In stages III and IV, significant differences were observed in the serum levels for total bilirubin and gamma-glutamic pyruvic transaminase only in the EIS group. Significant differences were observed in the rate of appearance of pyrexia, retrosternal pain and pleural effusion between the EIS and EVL groups. CONCLUSION: EVL significantly reduced the adverse effects associated with EIS at the initial session in primary biliary cirrhotic patients.     

心得安单纯或联合使用在二级预防食管静脉曲张出血中的疗效比较

目的比较单纯心得安、套扎＋心得安、硬化剂＋心得安二级预防食管静脉曲张出血的疗效,探寻心得安二级预防食管静脉曲张出血的最佳组合。方法78例食管静脉曲张出血患者随机分成3组,每组26例,止血后分别给予心得安（心得安组）、套扎＋心得安（套扎组）、硬化剂＋心得安（硬化剂组）,比较各组12个月内再出血率、死亡率,以及各组门脉高压性胃病、胃底静脉曲张发生率、食管曲张静脉复发率。结果12个月内再出血率套扎组为30．77％,明显低于心得安组（53．85％）及硬化组（42．31％）（P均〈0．05）;套扎组和心得安组门脉高压性胃病及胃底静脉曲张发生率相似,都明显低于硬化组（P均〈0．05）;而食管静脉曲张再发率高于硬化组（P〈0．05）。结论在应用心得安的基础上进行套扎治疗可能是目前食管静脉曲张出血最有效的二级预防方法。     

Study of oesophageal motility in Egyptian cirrhotic patients before and after prophylactic endoscopic variceal ligation

Background and aimThe aim of this work is to study oesophageal motility in non bleeding cirrhotic patients before and after endoscopic ligation of oesophageal varices.Patients and methodsThis study was conducted on 90 subjects as follows:Group (I): 50 patients with liver cirrhosis and large oesophageal varices (i.e. grade III, IV).Group (II): 20 patients diagnosed with liver cirrhosis but without oesophageal varices.Group (III): 20 healthy volunteers.Written informed consent was obtained from all subjects.Complete laboratory investigations were done as well as abdominal ultrasonography, upper endoscopy and oesophageal motility was done by stationary and rapid pull through manometery using a low compliance pneumohydraulic perfusion system. EVL was done in 50 patients (Group I).ResultsOesophageal motility before EVL revealed that there was a significant decrease in the amplitude of the contractive wave at the middle and the distal oesophagus and there was an increase in the wave velocity in the distal oesophagus with significant increase in the abnormal waves with no effect on wave duration. Ascites had no effect on the oesophageal motility and the LES pressure; also there was no significant difference in patients in terms of Child Pugh grading.Oesophageal motility after EVL revealed no significant decrease in the amplitude of the contractive wave at the middle oesophagus, and the decreased amplitude in the distal oesophagus before EVL was returned to the level of normal healthy control. Also, there was increase in the velocity of wave after EVL in the distal oesophagus with no effect on wave duration.ConclusionProphylactic EVL is an effective method for primary prophylaxis of oesophageal varices with no serious complications. EVL normalized oesophageal motility and if it induced abnormal oesophageal motility, it was of little clinical significance and reversible.     

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.     

A prospective trial of endoscopic sclerotherapy v oesophageal transection and gastric devascularisation in the long term management of bleeding oesophageal varices.

In a prospective three centre study oesophageal transection and gastric devascularisation have been compared with endoscopic sclerotherapy in the long term management of bleeding oesophageal varices. Cirrhotic patients (Child's A or B grade) with documented bleeding oesophageal varices were treated initially with emergency sclerotherapy, and after five days stability, were allocated to one of the two treatment regimes. The endoscopic sclerotherapy group underwent regular sclerotherapy until variceal obliteration while those undergoing surgery were not endoscoped unless bleeding recurred, when they were treated by sclerotherapy if appropriate. Ninety two patients were eligible for analysis (68% alcoholic cirrhosis; mean age 50.1 years) and follow up was achieved for a mean of 52.5 months (range 17-83). Mortality in the first three months was greater in the oesophageal transection and gastric devascularisation group (20% v 1%) but by two years the survival curves were the same and thereafter there was no difference in mortality. Rebleeding occurred in 13/41 (31%) patients, undergoing oesophageal transection and gastric devascularisation. The costs incurred during the first year of oesophageal transection and gastric devascularisation treatment were significantly greater than with endoscopic sclerotherapy (4369 pounds v 1067 pounds, p < 0.0001) and the high rate of rebleeding in the surgical group meant that no cost savings occurred in subsequent years. It is concluded that oesophageal transection and gastric devascularisation confers no benefit over endoscopic sclerotherapy in terms of long term survival and that it is not cost effective as judged by the current health care costs in the United Kingdom.     

Endoscopic injection sclerotherapy for esophageal varices in cirrhotic patients with hepatocellular carcinoma: risk factors for survival

GOALS: We previously showed that endoscopic injection sclerotherapy (EIS) prolonged survival in patients with esophageal varices complicated by hepatocellular carcinoma (HCC) and liver cirrhosis. Here, we evaluated risk factors that affect EIS outcomes. Among factors, the difference between prophylactic and emergency EIS was of interest, and we analyzed precisely. STUDY: Subjects were 134 patients with esophageal varices complicated by HCC and liver cirrhosis: 38 underwent emergent therapy for bleeding varices and 96 underwent prophylactic sclerotherapy. RESULTS: During 2-year observation, 22 of the 38 (57.9%) and 38 of the 96 (39.6%) died. Analysis by univariate Cox's proportional hazard model indicated that prognosis of patients receiving emergency EIS was inferior to those with prophylactic EIS. However, multivariate Cox's analysis showed that emergency EIS itself extended survivals of those with esophageal varices complicated by HCC and liver cirrhosis. Patients' hepatic function (Child-Pugh classes) and tumor sizes were also statistically significant factors for survival. Neither prophylactic nor emergency EIS prolonged survival of patients with Child C hepatic function or those with HCCs larger than 5 cm. CONCLUSIONS: The prophylactic sclerotherapy for esophageal varices prolongs long-term survival of patients with liver cirrhosis and HCC, better than emergency therapy. However, EIS itself had no beneficial effect on patients with poor disease status.     

内镜套扎术在治疗食管静脉曲张破裂出血中的临床应用价值

目的探讨内镜下食管静脉曲张套扎术（EVL）治疗和预防肝硬化患者食管静脉曲张破裂出血的临床应用价值。方法回顾性分析2008-01～2012-01该院142例肝硬化食管静脉曲张破裂出血患者,其中行EVL治疗74例（治疗组）,内科保守治疗68例（对照组）,并对其临床疗效进行随访观察。结果所有患者随访6个月以上,治疗组的早期再出血率、迟发出血率、曲张静脉好转率、复发率、手术率及病死率均低于对照组（P〈0.05或〈0.01）。结论 EVL能有效地降低肝硬化门脉高压患者食管静脉曲张的程度,降低再出血率、复发率、手术率和病死率,是一种有效的内镜治疗手段。     

内镜疗法后续应用粉防己碱预防食管静脉曲张破裂再出血的研究

目的:研究内镜套扎术和(或)硬化剂治疗后续用粉防己碱预防肝硬化食管静脉破裂出血患者再出血的作用.方法:90例肝硬化并发食管胃底静脉曲张破裂出血患者,分成治疗组及对照组,2组均接受内镜治疗,继而都予以一般对症、保肝治疗,而治疗组加用粉防己碱(20 mg,3次/d),疗程12个月,随访治疗期间出血复发率及静脉曲张复发率,同时实验前及实验结束时2组患者均行血流动力学检测及内镜检查.结果:治疗组患者出血复发率及静脉曲张复发率均明显低于对照组(P＜0.05),治疗组患者血流动力明显改善(P＜0.05),而对照组血流动力学无明显变化.结论:内镜套扎术和(或)硬化剂治疗后续用粉防己碱可明显降低肝硬化并食管静脉曲张出血患者的再出血率及静脉曲张复发率,其作用机制可能与抑制钙离子通道、提高一氧化氮合酶活性及抑制胶原纤维合成有关.     

Endoscopic variceal ligation is a sufficient procedure for the treatment of oesophageal varices in patients with hepatitis C liver cirrhosis: comparison with injection sclerotherapy

AIMS: Endoscopic variceal ligation (EVL) is a recently developed alternative to endoscopic injection sclerotherapy (EIS) for the treatment of oesophageal varices. Endoscopic variceal ligation and EIS were compared in an attempt to clarify the efficacy and safety of EVL for patients with cirrhosis due to hepatitis C. METHODS: Endoscopic variceal ligation was performed in 60 patients and EIS in 30. Varices were eradicated in all patients by EVL and 87% (26 out of 30) by EIS. RESULTS: There was no significant difference between EVL and EIS in relation to the incidence of bleeding and the 5 year survival rate after treatment. There were no severe complications except mild substernal pain after EVL, while pulmonary embolism occurred in one patient receiving EIS. CONCLUSIONS: Endoscopic variceal ligation is a safe and effective technique for eradicating oesophageal varices in patients with hepatitis C cirrhosis.     

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.     

Influence of endoscopic variceal ligation on oesophageal motility

BACKGROUND: To determine the change of oesophageal manometry in patients with oesophageal varices before and after oesophageal variceal ligation (EVL). METHODS: Forty-five patients who had liver cirrhosis and oesophageal varices with high risk of bleeding were managed by EVL. Oesophageal manometry was performed just prior to the ligation and 4-6 weeks after obliteration of varices. Another 45 age- and sex-matched patients without hepatic, oesophageal or systemic disease served as the control group. RESULTS: At 5 cm above the lower oesophageal sphincter (LES), the amplitude of the contractive wave was significantly lower in patients before EVL (56.9 +/- 31.8 vs 80.1 +/- 30.1, P< 1.05) and returned to the level of control subjects after EVL (76.5 +/- 37.0 vs 80.1 +/- 30.1, P> 0.05). At 10 cm above LES, the amplitude of the contractive wave was significantly lower in patients before and after EVL than the control group (54.3 +/- 29.2 vs 68.1 +/- 29.5, 54.2 +/- 26.0 vs 68.1 +/- 29.5, respectively, P< 0.05). The percentage of tertiary waves was significantly higher in patients before and after EVL than in the control group (31.4 +/- 36.6 vs 5.8 +/- 15.1, 26.9 +/- 32.9 vs 5.8 +/- 15.1, respectively, P< 0.05). However, no significant swallowing disturbance was noted in patients after EVL. There was significantly greater LES length in patients before EVL (4.0 +/- 0.9 vs 3.4 +/- 0.7, P<0.05) but there was no significant difference in the LES length after EVL as compared with the control group. Eighty-six per cent (39/45) of patients developed paraoesophageal varices and 31% (14/45) developed new varices 6 months after variceal obliteration. However, there was no significant difference in manometry at the time of variceal obliteration between patients with variceal recurrence and those without. CONCLUSIONS: The presence of varices affected oesophageal motility. However, such abnormality had little clinical significance. Endoscopic variceal ligation normalized oesophageal motility and may not induce abnormal oesophageal motility. The manometric change can not be used to predict the recurrence of varices in cirrhotic patients after variceal obliteration.     

内镜下套扎术预防肝硬化食管静脉曲张破裂出血的远期随访观察

目的 观察肝硬化食管静脉曲张患者分别行食管静脉曲张套扎术(endoscopic variceal ligation,EVL)和口服普萘洛尔后的再出血发生率、死亡率、治疗前后静脉曲张程度以及肝功能分级变化.方法 共纳入患者118例,其中66例采用EVL治疗,52例采用药物预防治疗.EVL 治疗组给予多次套扎,直到曲张静脉消失;药物治疗组给予普萘洛尔,起始剂量10 mg,每日2次,逐渐增至最大耐受剂量.对所有患者随访20个月,观察比较两组出血发生率和死亡率、治疗前后静脉曲张程度以及肝功能分级变化.结果 EVL治疗组有效随访58例,其问发生出血7例(12.1%),死亡2例(3.4%);药物治疗组有效随访46例,期间发生出血14例(30.4%),死亡6例(13.0%),两组间差异有统计学意义(P<0.05).EVL治疗组总静脉消失率为41.3%(24/58),药物治疗组46例曲张静脉均未消失;比较两组治疗前后肝功能未见明显变化(P>0.05).结论 与服用普萘洛尔相比,EVL能显著降低出血率、死亡率和静脉曲张程度,且对肝功能无明显损害作用.     

内镜下套扎治疗肝硬化食管静脉曲张出血108例

目的　探讨内镜下套扎治疗肝硬化食管静脉曲张 (EV)破裂出血的止血效果及安全性。方法　对 14 3例肝硬化EV破裂出血患者分别进行内镜下食管静脉曲张套扎 (EVL) 10 8例和药物治疗 3 5例 ,比较两组止血效果。结果　EVL组急诊止血率 98.1% ,明显高于药物治疗组 42 .1% (P <0 .0 5 ) ,两组在住院期间病死率 ( 18.5 %对 42 .9% ,P <0 .0 5 )及半年存活率 ( 80 .6%对 40 .0 % ,P <0 .0 5 )有显著差异。结论　EVL是肝硬化EV破裂出血近期止血的可靠治疗手段之一 ,但其长期疗效尚有待进一步研究     

Endoscopic variceal ligation of patients with liver cirrhosis and cirrhosis accompanied by hepatocellular carcinoma

Background: Rupture of esophageal varices with severe gastrointestinal hemorrhage is one of the most serious complications of liver cirrhosis (LC) and hepatocellular carcinoma (HCC) complicating LC. The present study looks at the success of hemostasis in LC and LC accompanied by HCC, the success of breaking the varices cluster and the rate of rebleeding in patients of LC subject to emergency ligation and prophylactic ligation. Methods: Seventy‐five patients were divided into three groups. Group 1: 30 patients with LC accompanied by HCC with digestive bleeding; group 2: 30 patients with LC with digestive bleeding; and group 3: 15 patients with LC with high risk of digestive bleeding from esophageal varices (with no medical history of digestive bleeding). Success of hemostasis 72 h after endoscopic variceal ligation (EVL) was that patients did not vomit blood nor produce black feces. The effectiveness of EVL for iradication of the variceal cluster was classified into three levels: good, fairly good and poor. Results: The hemostasis success in group 1 (LC accompanied by HCC) and group 2 (LC with digestive bleeding due to esophageal varices) was 73.3% and 93.4%, respectively. The success of breaking the varix cluster in group 2 (LC) and group 3 (LC with high risk of digestive bleeding and treated by prophylactic ligation) was 73.3% and 80%, respectively. The rate of rebleeding in group 2 and group 3 after 1 year was 20% and 13.3%, respectively. Conclusion: Endoscopic variceal ligation is a good technique for variceal hemostasis and eradication of the esophageal varices cluster.     

Sclerotherapy versus sclerotherapy and propranolol in the prevention of rebleeding from oesophageal varices: a randomised study.

BACKGROUND--This trial was carried out to assess the value of propranolol in the prevention of recurrent variceal bleeding when combined with longterm endoscopic sclerotherapy. PATIENTS AND METHODS--Two hundred patients (161 male, 39 female, age range 20-68 years) with portal hypertension resulting mainly from schistosomal periportal fibrosis or posthepatitic cirrhosis presenting with their first episode of haematemesis or melena, or both were included. This was confirmed endoscopically to result from ruptured oesophageal varices. After initial control of bleeding, patients were randomised into two groups: group 1 treated with endoscopic sclerotherapy alone and group 2 treated with sclerotherapy plus propranolol. They were followed up for two years. RESULTS--Group (2) had a lower rebleeding rate (14.3% v 38.6% in group 1), lower variceal recurrence after obliteration (17% v 34% in group 1), longer period between variceal obliteration and recurrence (36 weeks v 21 weeks in group 1); but no change in mortality (12% in both groups). CONCLUSIONS--Patients treated with sclerotherapy should be given propranolol for longterm management.     

Adjuvant sclerotherapy after ligation for the treatment of esophageal varices: a prospective, randomized long-term study

BACKGROUND: To assess the efficacy of adjuvant sclerotherapy after banding for the treatment of esophageal varices, a randomized trial was carried out of endoscopic variceal ligation (EVL) alone with sequential sclerotherapy versus sequential ligation-sclerotherapy (SLS) after banding with respect to variceal eradication, associated complications, and recurrence of varices. METHODS: One hundred patients qualified for this study. Fourteen patients were not included for the following reasons: 6 chose not to participate, 4 had fundal varices, and 4 had some form of cancer. Of the remaining 86 patients in the study, 42 underwent EVL alone and the other 44 SLS. Variceal ligation was begun in the region of the gastroesophageal junction, with subsequent ligatures applied cephalad 3 to 5 cm; ligation was repeated every 2 weeks until variceal obliteration. For SLS, ligation was also begun in the region of the gastroesophageal junction and repeated until varices were reduced to F1 size. Subsequently, these patients underwent sclerotherapy with between 6 and 8 mL of sodium tetradecyl sulfate (free hand technique). RESULTS: No significant differences were found between EVL alone and SLS with regard to variceal eradication, development of associated complications, and recurrent bleeding during a follow-up of 2 years. The probability of variceal recurrence requiring further treatment after 1 year was 14% for the SLS group and 26% for EVL group patients. Another year later, the probability of variceal recurrence was 24% and 45%, respectively, for the SLS and EVL groups. CONCLUSIONS: Because a significantly lower rate of variceal recurrence was found for SLS patients, sequential sclerotherapy followed by ligation to eradicate those varices too small to easily band may be a better procedure.