PREDICTIVE FACTORS OF ESOPHAGEAL VARICES RECURRENCE AFTER PROPHYLACTIC ENDOSCOPIC BAND LIGATION

Aims:

Eradication of esophageal varices (EV) by endoscopic band ligation (EBL) is an effective variceal bleeding prophylactic therapy. However variceal recurrence following EBL is common. We aimed to determine the outcome of prophylactic EBL and understand factors related to EV recurrence.

Methods:

We included all cirrhotic patients who entered a protocol of EBL between 2010 – 2015, for primary or secondary variceal bleeding prophylaxis. EBL was regularly performed until EV eradication, then at 3 and 9 months and thereafter annually. Eradication was defined as absence of EV or identification of small EV with no EBL indication. Recurrence corresponded to large EV with additional EBL need or variceal bleeding, in patients with previous successful variceal eradication.

Results:

101 patients were selected, 75.2% (n = 76) male, mean age = 57.2 ± 10.9 years. MELD ranged between 6 – 27 (mean 12.3 ± 4.2). Mean follow-up was 45.8 ± 21.5 months. Mortality rate was 50.5% (n = 51), 38.6% (n = 39) directly related to cirrhosis complications.

Successful eradication of EV was achieved in 89.1% (n = 90) of patients, with 2.8 ± 1.6 endoscopic sessions and 13.7 ± 8.6 total bands applied over 17.0 ± 14.5 weeks. Recurrence rate was 61.1% (n = 55), including 5.6% (n = 5) variceal rebleeding episodes. Concomitant non-selective beta-blocker therapy (≥40 mg propranolol or carvedilol) reduced recurrence rate (p = 0.017). Variceal bleeding stigmata (p = 0.023), portal hypertensive gastropathy (p = 0.031), interbanding interval ≥6 weeks (p = 0.023) and higher total number of bands used (p = 0.017) were associated with recurrence. On multivariate analysis adjusted for age, gender, MELD, primary/secondary prophylaxis and cirrhosis etiology, beta-blocker therapy was independently associated with less recurrence (OR = 3.72; 95% CI: 1.09 – 15.54). Variceal bleeding stigmata (OR = 9.94; 95% CI: 1.74 – 56.93) and a higher number of bands necessary for eradication (OR = 1.13; 95% CI: 1.02 – 1-25) were associated with recurrence (r²= 0.45).

Conclusions:

EBL was an effective therapy for EV eradication however recurrence was high (61.1%). Concomitant beta-blocker therapy diminished recurrence rate. Variceal bleeding stigmata at index endoscopy and a higher need of bands for eradication predicted higher recurrence.