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Endoscopic Ligation Compared with Sclerotherapy for the Treatment of Bleeding Esophageal Varices

Loren Laine, MD; Hussein M. El-Newihi, MD; Barry Migikovsky, MD; Robin Sloane, MD; and Francisco Garcia, LVN
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From the University of Southern California School of Medicine, Los Angeles, California. Requests for Reprints: Loren Laine, MD, GI Division (LAC 12-137), Department of Medicine, U.S.C. School of Medicine, 2025 Zonal Avenue, Los Angeles, CA 90033. Acknowledgments: The authors thank Maria Trujillo and the nursing staff and fellows of the Gastrointestinal Endoscopy Unit at Los Angeles County + University of Southern California Medical Center for their assistance in this study.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(1):1-7. doi:10.7326/0003-4819-119-1-199307010-00001
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Objective: Comparison of the safety and efficacy of endoscopic sclerotherapy and ligation for the treatment of bleeding esophageal varices.

Design: Randomized, controlled trial.

Setting: An urban county hospital.

Patients: Patients with clinically severe bleeding from esophageal varices.

Intervention: A total of 77 patients were randomly assigned to receive sclerotherapy or ligation at the initial endoscopic examination. Treatment was repeated weekly until variceal obliteration was achieved. After eradication, patients had endoscopic examinations every 3 months or for any episode of rebleeding. Recurrent varices were treated with the originally assigned form of endoscopic therapy.

Measurements: Patients were assessed for further bleeding, for transfusion requirements, for time in hospital, for variceal eradication, for number of treatment sessions required, for complications, for treatment failure, and for risk of death.

Results: Rebleeding tended to be less frequent with ligation than with sclerotherapy: 10 of 38 (26%) compared with 17 of 39 (44%) (difference, 17% [95% CI, 4% to 38%]), but results in the two groups were comparable for blood transfusions, for length of hospital stay, and for risk of death. Comparison of Kaplan-Meier estimates of time to rebleeding and death showed no statistical differences between treatments. Complications were less common in the ligation group: fewer patients in the ligation group had esophageal strictures (0 of 38 compared with 13 of 39 [33%]; P < 0.001) and had complicated esophageal ulcers (1 of 38 [2.6%] compared with 6 of 39 [15%]; P = 0.11). In addition, fewer ligation treatments were required to achieve variceal eradication (4.1 0.3 compared with 6.2 0.4; P < 0.001).

Conclusion: Endoscopic ligation causes statistically fewer local complications than sclerotherapy and achieves variceal eradication more rapidly. Ligation is a viable alternative to sclerotherapy and may have some advantages as a treatment for bleeding esophageal varices.


Grahic Jump Location
Figure 1.
Kaplan-Meier estimation of time to first rebleeding episode due to esophageal varices or esophageal ulcers in the ligation and sclerotherapy groups.P

The number of patients still under observation (without rebleeding or reaching an end point of follow-up) at 200-day intervals is shown at the bottom of the figure. > 0.2 for comparison of ligation and sclerotherapy groups.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Kaplan-Meier estimation of survival curves in the ligation and sclerotherapy groups.P

The number of patients still under observation (without reaching an end point of follow-up) at 200-day intervals is shown at the bottom of the figure. > 0.2 for comparison of ligation and sclerotherapy groups.

Grahic Jump Location




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