Banding Ligation Versus Beta-Blockers as Primary Prophylaxis in Esophageal Varices: Systematic Review of Randomized Trials

Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Center for Clinical Intervention Research, Rigshospitalet, Copenhagen, Denmark.
The American Journal of Gastroenterology (Impact Factor: 10.76). 01/2008; 102(12):2842-8; quiz 2841, 2849. DOI: 10.1111/j.1572-0241.2007.01564.x
Source: PubMed


To compare banding ligation versus beta-blockers as primary prophylaxis in patients with esophageal varices and no previous bleeding.
Randomized trials were identified through electronic databases, reference lists in relevant articles, and correspondence with experts. Three authors extracted data. Random effects meta-analysis and metaregression were performed. The reported allocation sequence generation and concealment were extracted as measures of bias control.
The initial searches identified 1,174 references. Sixteen trials were included. In 15 trials, patients had high-risk varices. Three trials reported adequate bias control. All trials reported mortality for banding ligation (116/573 patients) and beta-blockers (115/594 patients). Mortality in the two treatment groups was not significantly different in the trials with adequate bias control (relative risk 1.22, 95% CI 0.84-1.78) or unclear bias control (RR 1.02, 95% CI 0.75-1.39). Trials with adequate bias control found no significant difference in bleeding rates (RR 0.86, 95% CI 0.55-1.35). Trials with unclear bias control found that banding ligation significantly reduced bleeding (RR 0.56, 95% CI 0.41-0.77). Both treatments were associated with adverse events. In metaregression analyses, the estimated effect of ligation was significantly more positive if trials were published as abstracts. Likewise, the shorter the follow-up, the more positive the estimated effect of ligation.
Banding ligation and beta-blockers may be used as primary prophylaxis in high-risk esophageal varices. The estimated effect of banding ligation in some trials may be biased and was associated with the duration of follow-up. Further high-quality trials are still needed.

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Available from: Christian Gluud, Mar 12, 2014
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    • "In recent years, EVL has replaced endoscopic sclerotherapy. In patients with medium or large varices, either nonselective β-blockers or EVL can be used, since a meta-analysis of high-quality, randomized, controlled trials has shown equivalent efficacy and no differences in survival [25]. However, EVL should be preferred for patients at high-risk for variceal bleeding who have medium or large varices with red wale marks or advanced liver cirrhosis. "
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    ABSTRACT: Variceal hemorrhage is a common and devastating complication of portal hypertension and is a leading cause of death in patients with cirrhosis. The management of gastroesophageal varices has evolved over the last decade resulting in improved mortality and morbidity rates. Regarding the primary prevention of variceal hemorrhaging, nonselective β -blockers should be the first-line therapy in all patients with medium to large varices and in patients with small varices associated with high-risk features such as red wale marks and/or advanced cirrhosis. EVL should be offered in cases of intolerance or side effects to β -blockers, or for patients at high-risk for variceal bleeding who have medium or large varices with red wale marks or advanced liver cirrhosis. In acute bleeding, vasoactive agents should be initiated along with antibiotics followed by EVL or endoscopic sclerotherapy (if EVL is technically difficult) within the first 12 hours of presentation. Where available, terlipressin is the preferred agent because of its safety profile and it represents the only drug with a proven efficacy in improving survival. All patients surviving an episode of bleeding should undergo further prophylaxis to prevent rebleeding with EVL and nonselective β -blockers.
    03/2013; 2013(3):434609. DOI:10.1155/2013/434609
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    • "A meta-analysis [103] of 16 trials with over 1,000 patients indicates that β-blockers and endoscopic variceal ligation may be equivalent in survival benefit. β-blockers may have a wider spectrum of applicability in non-variceal bleeding, including portal congestive gastropathy where the utility of therapeutic endoscopy is limited [104]. "
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    ABSTRACT: Mortality in cirrhosis is consequent of decompensation, only treatment being timely liver transplantation. Organ allocation is prioritized for the sickest patients based on Model for End Stage Liver Disease (MELD) score. In order to improve survival in patients with high MELD score it is imperative to preserve them in suitable condition till transplantation. Here we examine means to prolong life in high MELD score patients till a suitable liver is available. We specially emphasize protection of airways by avoidance of sedatives, avoidance of Bilevel Positive Airway Pressure, elective intubation in grade III or higher encephalopathy, maintaining a low threshold for intubation with lesser grades of encephalopathy when undergoing upper endoscopy or colonoscopy as pre transplant evaluation or transferring patient to a transplant center. Consider post-pyloric tube feeding in encephalopathy to maintain muscle mass and minimize risk of aspiration. In non intubated and well controlled encephalopathy, frequent physical mobility by active and passive exercises are recommended. When renal replacement therapy is needed, night-time Continuous Veno-Venous Hemodialysis may be useful in keeping the daytime free for mobility. Sparing and judicious use of steroids needs to be borne in mind in treatment of ARDS and acute hepatitis from alcohol or autoimmune process.
    07/2012; 2012(1):318627. DOI:10.1155/2012/318627
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    • "A large meta-analysis looking at propranolol/nadolol versus placebo, in patients with cirrhosis and medium to large varices, found a significantly lower incidence of first variceal bleeding in the treatment group: 14% compared to 30% [4]. Also, these nonselective beta-blockers may be equivalent to endoscopic variceal band ligation (EVBL) in terms of primary prevention and mortality rate [15, 16]. In addition, they are inexpensive and can potentially prevent other complications of cirrhosis such as spontaneous bacterial peritonitis and bleeding from portal hypertensive gastropathy [17, 18]. "
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    ABSTRACT: Variceal hemorrhage is one of the major complications of liver cirrhosis associated with significant mortality and morbidity. Its management has evolved over the past decade and has substantially reduced the rate of first and recurrent bleeding while decreasing mortality. In general, treatment of esophageal varices can be divided into three categories: primary prophylaxis (prevention of first episode of bleeding), management of acute bleeding, and secondary prophylaxis (prevention of recurrent hemorrhage). The goal of this paper is to describe the current evidence behind the management of esophageal varices. We will discuss indications for primary prophylaxis and the different modes of therapy, pharmacological and interventional treatment in acute bleeding, and therapeutic options in preventing recurrent bleeding. The indications for TIPS will also be reviewed including its possible benefits in acute variceal hemorrhage.
    04/2012; 2012(1):750150. DOI:10.1155/2012/750150
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