Banding Ligation Vs. Beta-Blockers in Esophageal Varices
Banding Ligation Vs. Beta-Blockers in Esophageal Varices
Objective: To compare banding ligation versus beta-blockers as primary prophylaxis in patients with esophageal varices and no previous bleeding.
Methods: 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.
Results: 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.
Conclusions: 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.
Development of esophageal varices is one of the most serious complications in portal hypertension. During a 5-yr period, about one in five patients with cirrhosis will die from variceal bleeding. The risk of bleeding depends on several factors including the variceal size, wall tension, and local irritation from alcohol. The development of esophageal varices and the risk of bleeding once the varices are present are closely related to the portal pressure. Esophageal varices develop once the hepatic venous pressure gradient exceeds 10 mmHg. A reduction in the hepatic venous pressure gradient with at least 20% of the baseline pressure or to less than 12 mmHg reduces the risk of bleeding. Interventions which decrease portal pressure may therefore help prevent bleeding.
Randomized trials and meta-analyses show that beta-blockers reduce the number of bleeding events when used as primary prevention in esophageal varices. Treatment with beta-blockers is recommended as the first-line treatment for primary prevention in medium-risk to high-risk varices. However, the effect on mortality is debated and many patients are unable to tolerate beta-blockers due to adverse events. Banding ligation may be considered as an alternative treatment option. A meta-analysis of 13 randomized trials found that banding ligation reduced the risk of bleeding compared with beta-blockers. No significant difference in mortality was found. Although these findings are promising, the results of individual trials are conflicting. Furthermore, the frequency of adverse events associated with banding ligation may be underestimated due to the inclusion of selected patient groups and the fact that only experienced operators participated in the trials. A meta-analysis of eight trials found that beta-blockers were associated with a significantly higher number of adverse events than banding ligation. If less experienced endoscopists had participated in the trials, the frequency of adverse events after banding ligation might have been higher. We therefore performed a systematic review on banding ligation versus beta-blockers for primary prevention in esophageal varices.
Abstract and Introduction
Abstract
Objective: To compare banding ligation versus beta-blockers as primary prophylaxis in patients with esophageal varices and no previous bleeding.
Methods: 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.
Results: 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.
Conclusions: 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.
Introduction
Development of esophageal varices is one of the most serious complications in portal hypertension. During a 5-yr period, about one in five patients with cirrhosis will die from variceal bleeding. The risk of bleeding depends on several factors including the variceal size, wall tension, and local irritation from alcohol. The development of esophageal varices and the risk of bleeding once the varices are present are closely related to the portal pressure. Esophageal varices develop once the hepatic venous pressure gradient exceeds 10 mmHg. A reduction in the hepatic venous pressure gradient with at least 20% of the baseline pressure or to less than 12 mmHg reduces the risk of bleeding. Interventions which decrease portal pressure may therefore help prevent bleeding.
Randomized trials and meta-analyses show that beta-blockers reduce the number of bleeding events when used as primary prevention in esophageal varices. Treatment with beta-blockers is recommended as the first-line treatment for primary prevention in medium-risk to high-risk varices. However, the effect on mortality is debated and many patients are unable to tolerate beta-blockers due to adverse events. Banding ligation may be considered as an alternative treatment option. A meta-analysis of 13 randomized trials found that banding ligation reduced the risk of bleeding compared with beta-blockers. No significant difference in mortality was found. Although these findings are promising, the results of individual trials are conflicting. Furthermore, the frequency of adverse events associated with banding ligation may be underestimated due to the inclusion of selected patient groups and the fact that only experienced operators participated in the trials. A meta-analysis of eight trials found that beta-blockers were associated with a significantly higher number of adverse events than banding ligation. If less experienced endoscopists had participated in the trials, the frequency of adverse events after banding ligation might have been higher. We therefore performed a systematic review on banding ligation versus beta-blockers for primary prevention in esophageal varices.
