Reuters Health Information (2005-04-18): Ligation may outperform beta blockade for esophageal varices
Ligation may outperform beta blockade for esophageal varices
Last Updated: 2005-04-18 16:19:43 -0400 (Reuters Health)
NEW YORK (Reuters Health) - In patients with hepatic
cirrhosis and high-risk esophageal varices, endoscopic variceal band
ligation may be more effective than treatment with the beta-blocker
propranolol in preventing variceal hemorrhage, the results of a small
study suggest. Overall costs appear to be similar for the two treatment
There are no randomized controlled trials comparing beta-blockade
with banding using a multishot-banding device with translucent tips,
Dr. Dennis M. Jensen of the David Geffen School of Medicine at UCLA and
colleagues note in the April issue of Gastroenterology.
Beta-blockers reduce the risk of variceal bleeding by decreasing
portal pressure and variceal blood flow, the authors explain, and are
considered the standard of care for preventing a first esophageal
variceal hemorrhage. The researchers suggest that recent improvements
to banding devices may make them a better alternative.
For their prospective study, Dr. Jensen's group enrolled subjects
with cirrhosis of the liver who were candidates for liver transplant
and had large or high-risk nonbleeding esophageal varices. Thirty-one
patients were randomly assigned to propranolol 80 mg to 160 mg b.i.d.
to achieve heart rate reduction of 25% while maintaining a heart rate
greater than 50 beats/minute and systolic blood pressure of 90 mm Hg.
The remaining 31 patients were randomly assigned to variceal
ligation performed monthly with a multishot-banding device with
translucent tips until varices were eradicated.
Enrollment was stopped early because an interim analysis showed a
significant difference in treatment failure rates, the authors report.
During mean follow-up of 15 months, there were four cases of
variceal bleeding and two other severe adverse events, and four deaths
in the propranolol group, compared with no adverse events or deaths in
the banding group (p = 0.0098 and 0.0443, respectively).
Overall costs were not significantly different when including
treatment costs and costs of hospitalization ($3300 in the propranolol
group and $2228 in the banding group, p = 0.44).
"Prophylactic banding seems to be a more promising treatment than
propranolol for preventing initial variceal bleeding for compliant
patients who are at high risk of initial variceal hemorrhage and who
are candidates for liver transplantation," Dr. Jensen's group concludes.
However, Dr. Thomas D. Boyer, at the University of Arizona in
Tucson, disagrees with this conclusion. He notes in an editorial that
the study by Dr. Jensen's group was too small and follow-up too short
to conclusively state that banding is preferable to treatment with
propranolol. He believes that the two treatments are equivalent.
"Nonselective beta-blockers remain the treatment of choice for the
primary prevention of variceal bleeding," he writes. "Variceal band
ligation should be considered in patients who are intolerant of
beta-blockers or in whom beta-blocker therapy is contraindicated."