Update of Endoscopic Band Ligation Therapy for Treatment of Esophageal Varices

Treatment of Acutely Bleeding Varices

Endoscopic band ligation is generally acknowledged to be equal or superior to sclerotherapy for treatment of acute bleeding although some believe it is more difficult to perform during active hemorrhage. Drug therapy is increasingly accepted as a valuable adjunct to acute endoscopic therapy. It is unclear; however, which drug regimen is optimal. Accurate interpretation of results from studies of acute bleeding is hampered by differences in definitions and end-points. It is important to distinguish, when possible, treatments conducted in patients who are actively bleeding at the time of endoscopic therapy from those in patients in whom bleeding has stopped by the time endoscopy is performed. The latter usually have better outcomes.

Endoscopic Sclerotherapy vs. Drug Therapy

Two meta-analyses examined studies that compared endoscopic sclerotherapy with a variety of drug therapies (vasopressin, terlipressin, somatostatin, octreotide). The study by Goulis & Burroughs (n = 921) showed improved control of bleeding with endoscopic sclerotherapy (OR = 1.6, 95 % CI 1.08 – 2.39) and a trend toward reduced mortality in the endoscopic cohort (OR = 1.35, CI 0.99 – 1.9) [1]. In a larger (n = 1146) meta-analysis by D’Amico, the two treatments were found equal in terms of bleeding control, the incidence of recurrent hemorrhage and survival; however, sclerotherapy was associated with a significantly greater frequency of adverse and serious adverse events. The authors concluded: ”there was no convincing evidence to support the use of sclerotherapy as the first single treatment when compared with modern vasoactive drugs” [2].

Endoscopic Sclerotherapy Plus Vasoactive Drugs vs. Endoscopic Sclerotherapy

Seven of nine randomized trials that examined vasoactive drugs used in combination with endoscopic sclerotherapy for control of acute bleeding demonstrated benefit for patients treated with the combination. Benefits generally consisted of a reduction in the incidence of recurrent hemorrhage, lower transfusion requirements or less consumption of hospital resources. A recent meta-analysis confirmed that endoscopic sclerotherapy treatment of acute variceal bleeding is optimized by the combination of a vasoactive drug with endoscopic sclerotherapy as compared with treatment by endoscopic sclerotherapy alone [3]. Unfortunately, there was no survival advantage associated with the combination therapy.

Endoscopic Sclerotherapy vs Endoscopic Ligation

Analysis of the subgroups of actively bleeding patients from multiple randomized trials which compared the two treatments confirmed that endoscopic sclerotherapy and endoscopic ligation are both effective for control of acutely bleeding esophageal varices [4]. Lo et. al. randomized 120 patients with acute variceal bleeding [5]. Control in patients who were actively bleeding was 80 % and 94 % in sclerotherapy and band ligation patients respectively (P = 0.23). The authors found band ligation superior to sclerotherapy for control of spurting varices and equal to sclerotherapy for control of oozing varices. Patients treated with endoscopic ligation in this trial experienced significantly fewer complications than those treated with sclerotherapy.

Endoscopic Ligation Plus Octreotide vs. Endoscopic Ligation

Sung et. al. randomized 100 consecutive patients with acutely bleeding esophageal varices to receive band ligation and octreotide (5 days) or band ligation alone [6]. Initial control of bleeding was equal; however, there was less recurrent bleeding in the combined group (OR = 0.22, CI 0.08 – 0.6) and lower 30-day mortality (OR = 0.45, CI 0.17 – 1.2).

Control of Actively Bleeding Esophageal Varices

Distinction between patients with stigmata of recent hemorrhage at endoscopy and those with ongoing active bleeding at endoscopy is blurred in many trials. Gross et. al. performed a meta-analysis of 13 trials in which precise information about patients with active hemorrhage (n = 513) was given (Table [1]) [7].

Table 1 Treatment of actively bleeding esophageal varices: meta-analysis by Gross et al. 7 Treatment Patients Control, % 95 % Cl Vasoconstrictive** 195 *68.7 % 62 – 75 % Vasoactive*** 145 *75.9 % 68 – 83 % Sclerotherapy 95 81.1 % 71 – 88 % Band ligation 78 *91.0 % 82 – 96 % * vasoconstrictive vs. ligation: p < 0.002, vasoactive vs. ligation: p < 0.02, all other differences in comparisons of treatments (e.g. sclerotherapy vs. ligation) were not statistically significant; ** vasopressin, terlipressin, glypressin; *** octreotide, somatostatin.

There was no difference in effectiveness of controlling active bleeding when sclerotherapy was compared with either group of drugs nor was there a significant difference when sclerotherapy was compared with band ligation. When band ligation was compared with either of the drug groups it was significantly (P < 0.002 and P < 0.02, respectively) more effective for controlling active bleeding.

Consensus is emerging that patients with acute bleeding from esophageal varices are best treated with a combination of pharmacological and endoscopic methods. Drug therapy should probably be started as soon as possible (prior to endoscopy) in order to maximize its value. What must be identified is the best drug and the optimal endoscopic treatment. There appears to be little difference in short-term control of bleeding between any drug and endoscopic sclerotherapy when these methods are compared. There is, however, a higher incidence of complications with the latter if patients are followed for more than a few days. Endoscopic band ligation is now widely available and appears to have advantages over sclerotherapy both in efficacy for controlling acute bleeding and in safety. Old arguments that endoscopic ligation is more difficult to perform in the actively bleeding patient are heard less often now as experience and comfort levels with use of the technique have increased.

References

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