Sclerotherapy versus ligation in hemorrhage caused by rupture of esophageal varices. Direct meta-analysis of randomized trials

OBJECTIVES: To compare the advantages of endoscopic ligation and endoscopic sclerotherapy for bleeding esophageal varices, published randomized clinical trials were critically reviewed by meta-analysis. Only ten clinical trials concerning a history of recent or active bleeding esophageal varices were included. METHODS: The methodology, population, treatment and outcomes of each relevant trial were evaluated by duplicate independent review. RESULTS: Endoscopic sclerotherapy compared to banding ligation significantly increased the rate of rebleeding (OR: 1.6; 95% IC: 1.1-2.3) without increasing early mortality compared to endoscopic banding ligation (OR: 1.3; 95% IC: 0.8-1.9). The rate of varice eradication associated with these two types of treatment was not different (OR: 0.9; 95% IC: 0.6-1.3) but was obtained more quickly with endoscopic banding ligation (3.8 +/- 1.6 versus 5.8 +/- 2.2; P < 0.05). The rate of complications was higher after sclerotherapy (OR: 2.5; 95% IC: 1.7-3.7), in those cases with a positive heterogeneity test. CONCLUSIONS: This meta-analysis shows a lower morbidity with endoscopic banding ligation in patients with variceal hemorrhage. The most important advantage of endoscopic banding ligation was the reduction of the rate of rebleeding.     

Endoscopic variceal ligation in prophylaxis of first variceal bleeding in cirrhotic patients with high-risk esophageal varices

To determine the efficacy of endoscopic variceal ligation (EVL) in prophylaxis on the rate of first esophageal variceal bleeding, we conducted a prospective, randomized trial in 126 cirrhotic patients with no history of previous upper gastrointestinal bleeding and with esophageal varices endoscopically judged to be at high risk of hemorrhage. The end-points of the study were bleeding and death. Life-table curves showed that prophylactic EVL significantly diminished the rate of variceal hemorrhage (12/62 [19%] vs. 38/64 [60%]; P = .0001) and overall mortality (17/62 [28%] vs. 37/64 [58%]; P = .0011). The 2-year cumulative bleeding rate was 19% (12/ 62) in the EVL group and 60% (38/64) in the control group. The 2-year cumulative mortality rate was 28% (17/62) in the EVL group and 58% (37/64) in the control group. Comparison of Kaplan-Meier estimates of the time to death of both groups showed significantly lower mortality in the ligation group (P = .001). Patients undergoing EVL had few treatment failures and died mainly of hepatic failure. The lower risk in the EVL group was attributed to a rapid reduction of variceal size. Prophylactic EVL was more efficient in preventing first bleeding in patients with good condition (Child A) than in those with decompensated disease (Child B and C). We conclude that prophylactic EVL can decrease the incidence of first variceal bleeding and death over a period of 2 years in cirrhotic patients with high-risk esophageal varices.     

Prospective study of bacteremia rate after elastic band ligation and sclerotherapy of esophageal varices in patients with hepatosplenic schistosomiasis

Bone scintigraphy was performed in a 69-year-old male patient with adult T-cell leukemia suffering from right lower limb pain. Numerous sites of increased uptake were seen in the skull, left clavicle, bilateral humeri, bilateral radii and right femur and tibia. Bone radiographs showed multiple osteolytic lesions, most of which corresponded to the abnormal deposits on the bone scans with 740 MBq of 99mTc-hydroxymethylene diphosphonate. This pattern is rarely reported, but bone involvement of adult T-cell leukemia is not uncommon. Bone involvement was remarkable on the appendicular skeleton when compared with common metastatic bone tumors. Bone scintigraphy may be useful in detecting bone involvement in adult T-cell leukemia.     

Management of esophageal varices in children by endoscopic variceal ligation

Endoscopic variceal sclerotherapy (EVS) has been considered the mainstay of therapy for bleeding esophageal varices in adults. However, recent data have shown that endoscopic variceal ligation (EVL) is just as efficacious and has fewer complications than EVS. Although there are many reports concerning EVL in adults, only a few studies have been done in children. This report describes experience with EVL in 22 children with esophageal variceal hemorrhage. Eighty-seven EVL procedures were performed during a 9-year period in 22 children. The causes of portal hypertension were biliary atresia (10), portal vein thrombosis (8), chronic active hepatitis (1), cirrhosis secondary to cystic fibrosis (2), and primary sclerosing cholangitis (1). The age range at the onset of variceal bleeding was 8 months to 19 years. Twelve patients had EVS before EVL treatment was begun. Distal esophageal varices (one to four per session) were mechanically ligated using an elastic band ligature device attached to a flexible endoscope. The aim of therapy was obliteration of distal esophageal varices by EVL, every 2 to 4 weeks, until eradication. Subsequent EVL was dictated by the status of the varices. Outcome was assessed with respect to survival, rebleeding, status of varices, and complications. The patients underwent a mean of four sessions of EVL (range, one to eight). Four patients subsequently underwent liver transplantation. Of the 18 patients remaining (average follow-up period, 5.3 years), 12 had their varices eradicated (average of four EVL sessions), four are still in treatment, one has not been evaluated in the past 4 years, and one died of liver failure. Complications included bleeding between sessions (6 patients), cervical esophageal perforation (1 patient), and transient fever (2 patients). No child has experienced symptoms of esophageal stenosis or gastroesophageal reflux. Two patients died of liver disease, unrelated to bleeding from portal hypertension. EVL is effective in controlling variceal hemorrhage in children with portal hypertension, regardless of etiology. The complication rate is low, and EVL is an acceptable and perhaps preferable alternative to EVS in children with esophageal varices.     

Endoscopic variceal ligation in the management of gastroesophageal varices in postoperative biliary atresia

BACKGROUND/PURPOSE: Gastroesophageal variceal bleeding is a serious and difficult problem in the long-term management of biliary atresia (BA). Recently, endoscopic approaches have been attempted to manage this problem. The authors have attempted endoscopic variceal ligation (EVL), a less invasive procedure than endoscopic sclerotherapy. METHODS: In the past 5 years, 66 EVL procedures using standard flexible endoscope with a diameter of 9 mm (type p-30, XQ200, or XQ240; Olympus, Tokyo, Japan) were performed in 30 separate sessions on 11 postoperative BA patients. The mean age of the children was 7.8 (range, 3 to 15) years. The EVL device was a small elastic O-ring or a loop ligator. RESULTS: EVL was performed for emergency hemostasis in two patients and prophylaxis for impending rupture in nine with large, blue varices, or with red spots on the variceal surface. During the initial procedure, all varices were ligated successfully, and reduction in size was noted. Of eight patients who were examined 7 to 14 days after treatment, seven (87.5%) had improved. Eight of 11 patients (72.7%) were finally cured or at least had improved after one to seven sessions of EVL. However, three patients did not show improvement after four to seven sessions because of the reappearance of the varices, development of distal lesions such as gastric varices, and acute gastric mucosal lesions. A technical complication encountered was a slippage of the O-ring in one patient. A technical difficulty was seen in ligating the giant gastric varix in one patient. There was no deterioration of liver function induced by EVL in this entire series. CONCLUSIONS: EVL is an effective and feasible treatment of gastroesophageal varices in postoperative BA patients. However, reappearance or reactivation of the varices or emergence of the more distal lesions is likely to occur even after repeated EVL.     

Disconnection as the last possible therapy of hemorrhage in esophageal varices

The authors draw attention to their favourable results of disconnection in haemorrhage of oesophageal varices. This favourable result applies to immediate results as well as long-term results. They emphasize in particular the fact that disconnection can be used also when other methods are not feasible for various reasons. This fact is demonstrated by the authors on three patients whose complicated history and general condition were such that disconnection was the only solution of the situation.     

Endoscopic variceal ligation. Experience in 78 patients

Endoscopic variceal ligation (EVL) is a new alternative to sclerotherapy in the treatment of esophageal variceal hemorrhage, which results in strangulation, necrosis and scar formation of varices without systemic or local adverse effect. From May 1, 1991 through July 1, 1992, EVL was performed in 78 consecutive patients, in 35 of them it was performed during active massive bleeding, and active bleeding was controlled by the initial session in 31 patients. With repeated EVL treatment, 32 patients had their varices obliterated. The varices had reduced in size in other patients. No ligation-related complications were observed. This procedure is a safe, effective and rather simple method to treat esophageal varices, especially in patients with poor liver function and recurrent bleeding after devascularization or shunt surgery.     

Emerging role of endoscopic variceal band ligation in the treatment of esophageal varices

Quantitative EEG techniques are becoming more available. Eventually, all EEG will be digital. Various digital utility programs can help even now with storage and viewing the polygraph EEG itself. Techniques of frequency analysis, topographic mapping and discriminant functions are also available but have limited clinical use. Applications as a monitoring tool and careful analysis of epileptic spikes have been shown some promise but need further study to identify their proper clinical roles.     

Recurrent source of bleeding in patients with esophageal varices]

During last 7 years were in Endoscopic Centre of Brno Traumatologic Hospital treated 824 patients (624 male, 200 female) with esophageal varices, indicated to endoscopic sclerotherapy, ligation, or tissue adhesive injection. For one or more episodes of bleeding were treated 659 patients and resting 165 received therapy prophylactically. Recurrent acute bleeding from upper GIT occurred from 1 January 1990 to 30 April 1997 in 212 of them. In patients with previously proved esophageal varices were investigated for repetitive acute bleeding in this period 212 of them. In 157 (74%) patients endoscopy confirmed expected repetitive bleeding from esophageal varices, but in 55 (26%) was found bleeding from other source of upper gastrointestinal tract. The bleeding from gastroduodenal ulcers in 18 (8%) patients, in 22 (10%) from apths, Mallory-Weiss syndrome was source of bleeding in 8 (4%) patients, and hemorrhagic gastropathy in 7 (3%) was found. The authors draw attention to the fact that, in their big group patients with esophageal varices, duplicity of source of bleeding occurred in 1/4 patients. They concluded, that in patients with previously proved esophageal varices in necessary to perform in case of recurrent bleeding emergency of urgent endoscopy not only of esophagus, but even of whole upper GIT. Therapeutic mistake can happen in 1/4 of patients, if repetitive bleeding from varices would be expected and automatically treated by balloon tube. The patients could be damaged by delay in the treatment of bleeding from other source.     

Transjugular intrahepatic portosystemic shunt. Treatment of patients with recurrent bleeding from esophageal varices

We report the results of transjugular intrahepatic portosystemic shunt (TIPS) procedure in six patients with liver cirrhosis and recurrent bleeding or acute intractable bleeding from oesophageal varices in spite of multiple sessions of sclerotherapy. Median follow-up was 15 months (range 1-24 months). The procedure was technically successful in all patients without procedure-related morbidity or mortality. Four of the procedures were performed electively and two as an emergency procedure. The portosystemic pressure gradient decreased to below 12 mmHg following TIPS implantation and the shunt bloodflow was one quarter to three-quarters of the portal bloodflow determined by Doppler ultrasound. Recurrent bleeding occurred in one patient but was amenable to endoscopic sclerotherapy. In this patient the shunt had developed a stenosis that was treated by balloondilatation and insertion of an additional stent six months following the initial procedure, and no further bleeding occurred. The remaining five patients had no rebleeding episodes. Repeated Doppler examinations in the followup period demonstrated patency of all shunts. None of the patients developed portosystemic encephalopathy. One patient died of cerebral haemorrhage, unrelated to TIPS, 16 months following implantation. Another patient died 14 months following TIPS due to acute mesenteric occlusion and septicaemia. We conclude that TIPS is feasible and effective in selected patients with liver cirrhosis and persistent or recurrent variceal bleeding following repeated endoscopic therapy.     

Endoscopic sclerotherapy versus variceal ligation in the long-term management of patients with cirrhosis after variceal bleeding. A prospective randomized study

BACKGROUND/AIMS: Long-term endoscopic injection sclerotherapy of oesophageal varices prevents rebleeding in patients with cirrhosis surviving an acute variceal bleeding episode. However, this treatment is associated with a substantial complication rate. Endoscopic band ligation is a newly developed technique in an attempt to provide a safer alternative. The aim of this study was to compare the efficacy and safety of injection sclerotherapy versus variceal ligation in the management of patients with cirrhosis after variceal haemorrhage. METHODS: Seventy-seven patients with cirrhosis who proved to have oesophageal variceal bleeding were studied. After initial control of haemorrhage by sclerotherapy, 40 of the patients were randomly assigned to sclerotherapy and 37 to ligation. Both procedures were performed under midazolam sedation at intervals of 7-14 days until all varices in the distal oesophagus were eradicated or were too small to receive further treatment. RESULTS: The eradication of varices required a lower mean number of sessions with ligation (3.7 +/- 1.9) than with sclerotherapy (5.8 +/- 2.7, p = 0.002). The mean duration of follow-up was similar in both groups (15.6 months +/- 7.3 and 15 +/- 7.4, respectively). The proportion of patients remaining free from recurrent bleeding against time was significantly higher in the ligation group as compared to the sclerotherapy group (chi 2 = 3.86, p = 0.05). Only 13 patients (35%) developed complications in the ligation group as compared to 24 (60%, p = 0.05) in the sclerotherapy group. The mortality rate was similar in both groups (20% and 21%, respectively). CONCLUSIONS: Variceal ligation is better than sclerotherapy in the long-term management of patients with cirrhosis after variceal haemorrhage which was initially controlled with sclerotherapy.     

Endoscopic ultrasonography for assessment of the response to combined radiation therapy and chemotherapy in patients with esophageal cancer

The current classification of cutaneous melanoma was developed in 1972 and revised in 1982. Since that time new concepts and terminology have evolved that require consideration of a further revision. This paper reviews some of the concepts that will form part of that process. Regional meetings of interested parties have been held to review the classification and there will be an open meeting on the topic at the 1997, 4th World Conference on Melanoma in Sydney, Australia. A questionnaire is included that will allow the interested reader to provide comments on the topic.     

Polyneuropathy caused by tuberculostatics. Study of motor nerve conduction in 29 patients

This paper presents the reconstruction of an unusual case of suicide. After raiding a branch-bank a robber fled shooting with his Sauer-Western revolver caliber .44 magnum at the pursuing policemen and succeeded in wrestling a pistol Walther caliber 7,65 mm from them. Under the fire of sub-machine guns he destroyed himself by a shot to the neck. Our investigations concerned a textile damage at the front of the sweater of the deceased surrounded by primer residue, showing characteristics of a close-up shot. The damage was identified as effect of explosion gases exhausting far-off the muzzle. The distance between this injury and the bullet hole corresponded with the length of the barrel of the Sauer-Western revolver and could be used for identification; it confirmed the diagnosis of a close-up shot at the neck, too. Collateral experiments with shots from distant ranges developed spadiceous melt figures of textile fibers around the bullet hole, the appearance of which is considered proof for a close-up shot commonly.     

Endoscopic ligation or diathermy of the sphenopalatine artery in persistent epistaxis

Conventional methods of arterial ligation in persistent epistaxis often involve significant surgical morbidity, as well as failure due to arterial anastomosis. We have performed endoscopic intranasal end ligation or diathermy of 11 sphenopalatine arteries in 10 patients with no complications and with no further episodes of epistaxis, with an average follow-up period of nine months.