Endoscopic treatment of bleeding esophageal varices

 

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We read with great interest the meta-analysis by Triantos et al. [1] on the role of sclerotherapy in the treatment of acute variceal bleeding in relation to vasoactive drugs and ligation. Regarding vasoactive drugs, the analysis confirmed the findings of other meta-analyses [2] [3]. However, regarding the role of ligation, the authors concluded, ”Sclerotherapy can remain a gold standard in variceal bleeding,” despite their having shown a significant difference in favor of ligation with respect to the control of bleeding. We believe that the conclusions contradict the results of their own and of previous meta-analyses [4] [5]. According to the Baveno IV consensus, ligation can be considered to be the first-choice or ”gold standard” treatment [6].

The meta-analysis does not take the complications associated with sclerotherapy into account. It is stated, but not supported by evidence, that the double intubation necessary for ligation increases the risk of complications and lengthens the procedure. Current evidence based on the use of vasoactive drugs at admission [2] [3] or even before admission [7] has shown that massive spurting bleeding or oozing is seldom seen at the time of endoscopy, and therefore the suggested problem of double intubation and visibility through the ligation cap is rarely a problem in clinical practice. Therefore, contrasting this undocumented problem with the scientific evidence that the complication rate is significantly less with ligation compared with sclerotherapy, we question the plausibility of the conclusion, which also conflicts with other guidelines and recommendations [6] [8] [9].

Among the eight published studies selected for the meta-analysis, seven studies with 684 patients [10] [11] [12] [13] [14] [15] [16] reported significantly fewer complications in the ligation group, while only one study with 103 patients [17] reported comparable complication rates for the two treatment methods. The complications of sclerotherapy were mainly esophageal strictures and/or ulcers, pneumonia, and other infections. Other studies that were not included in the meta-analysis, including a recent randomized study with 179 patients, also found ligation to be significantly superior to sclerotherapy with regard to side effects [18] [19].

In conclusion, we do not find evidence or new data in the literature to support modification of the Baveno IV recommendations [6]: ”Ligation is the recommended form of endoscopic therapy for acute variceal bleeding although sclerotherapy may be used in the acute setting if ligation is technically difficult.” Furthermore, it is noteworthy that ligation is already an integral part of the treatment of esophageal varices, because ligation is the endoscopic treatment of choice for secondary prophylaxis and in cases where there are contraindications to or intolerance of beta-blockers for primary prophylaxis, due to its efficacy and safety [5] [20] [21] [22].

Competing interests: None

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A. Krag,MD 

Department of Medical Gastroenterology 439
Hvidovre University Hospital

Kettegaard Alle 30
2650 Hvidovre
Copenhagen
Denmark

Fax: +45-36473311

Email: aleksander.krag@hh.hosp.dk