Rosario Gonzalez, MD; Javier Zamora, MD, PhD; Judith Gomez-Camarero, MD; Luis-Miguel Molinero, PhD; Rafael Bañares, MD, PhD; Agustín Albillos, MD, PhD
Acknowledgment: The authors thank Ana Burton and Kimiyo Nishimura for their assistance with English and Japanese translations, respectively.
Grant Support: From the Spanish Ministry of Health, Instituto de Salud Carlos III, CM04/00132 (Dr. González) and PI051871, Ciberehd (Drs. Bañares and Albillos); Fundación para la Investigación Biomédica, Hospital General Universitario Gregorio Marañón (Dr. Gomez-Camarero); the Fundación Mutua Madrileña (Drs. Bañares and Albillos [FundacionMM-2006-001 for Dr. Albillos]); and the Spanish Ministry of Education, BFU 2006-09280/BFI (Dr. Albillos). Ciberesp and Ciberehd are funded by the Instituto de Salud Carlos III.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Agustín Albillos, MD, PhD, Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Carretera de Colmenar km 9.100, 28034 Madrid, Spain; e-mail, email@example.com.
Current Author Addresses: Drs. González and Albillos: Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Carretera De Colmenar km 9.100, 28034 Madrid, Spain.
Dr. Zamora: Servicio de Bioestadística, Hospital Universitario Ramón y Cajal, Carretera de Colmenar km 9.100, 28034 Madrid, Spain.
Drs. Gomez-Camarero and Bañares: Servicio de Gastroenterología, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007 Madrid, Spain.
Dr. Molinero: Alce Ingeniería, Calle Fray Luis de León, Bajo D, 28230 Madrid, Spain.
Combining endoscopic therapy and β-blockers may improve outcomes in patients with cirrhosis and bleeding esophageal varices.
To assess whether a combination of endoscopic and drug therapy prevents overall and variceal rebleeding and improves survival better than either therapy alone.
MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and conference proceedings through 30 December 2007.
Randomized trials comparing endoscopic plus β-blocker therapy with either therapy alone, without language restrictions.
Two reviewers independently extracted data on interventions and the primary study outcomes of overall rebleeding and mortality. Metaregression and stratified analysis were used to explore heterogeneity.
23 trials (1860 patients) met inclusion criteria. Combination therapy reduced overall rebleeding more than endoscopic therapy alone (pooled relative risk, 0.68 [95% CI, 0.52 to 0.89]; I2 = 61%) or β-blocker therapy alone (pooled relative risk, 0.71 [CI, 0.59 to 0.86]; I2 = 0%). Combination therapy also reduced variceal rebleeding and variceal recurrence. Reduction in mortality from combination therapy did not statistically significantly differ from that from endoscopic (Peto odds ratio, 0.78 [CI, 0.58 to 1.07) or drug therapy (Peto odds ratio, 0.70 [CI, 0.46 to 1.06]). Effects were independent of the endoscopic procedure (injection sclerotherapy or banding). No trial-level variable associated with the effect was identified through metaregression or stratified analysis.
Statistically significant heterogeneity in trial quality and evidence for selective reporting and publication bias were found.
A combination of endoscopic and drug therapy reduces overall and variceal rebleeding in cirrhosis more than either therapy alone.
Gonzalez R, Zamora J, Gomez-Camarero J, Molinero L, Bañares R, Albillos A. Meta-analysis: Combination Endoscopic and Drug Therapy to Prevent Variceal Rebleeding in Cirrhosis. Ann Intern Med. 2008;149:109–122. doi: 10.7326/0003-4819-149-2-200807150-00007
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Published: Ann Intern Med. 2008;149(2):109-122.
Gastroenterology/Hepatology, Liver Disease.
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