Systematic Reviews
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 14, 2018; 24(26): 2902-2914
Published online Jul 14, 2018. doi: 10.3748/wjg.v24.i26.2902
Role of band ligation for secondary prophylaxis of variceal bleeding
Ioanna Aggeletopoulou, Christos Konstantakis, Spilios Manolakopoulos, Christos Triantos
Ioanna Aggeletopoulou, Christos Konstantakis, Christos Triantos, Department of Gastroenterology, University Hospital of Patras, Patras 26504, Greece
Spilios Manolakopoulos, 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens 11527, Greece
Author contributions: Aggeletopoulou I and Konstantakis C were responsible for the literature review and analysis; Aggeletopoulou I, Manolakopoulos S and Triantos C were responsible for drafting the manuscript and interpretation of the data; Manolakopoulos S and Triantos C were responsible for revision of the manuscript for important intellectual content; all authors issued final approval for the version to be submitted.
Conflict-of-interest statement: Spilios Manolakopoulos has received research grants from Gilead Sciences, Regulus and Bristol-Myers Squibb and fees for lectures and advisory board from Gilead Sciences, Roche, Bristol-Myers Squibb, GSK, AbbVie and MSD; Christos Triantos has received fees as a speaker/advisory board member and research/travel grants from MSD, Roche, AbbVie, Janssen, Bristol-Myers Squibb, Bayer and Gilead Sciences.
PRISMA 2009 Checklist statement: The authors read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Christos Triantos, PhD, Assistant Professor in Internal Medicine and Gastroenterology, Department of Gastroenterology, University Hospital of Patras, D. Stamatopoulou 4, Rio, Patras 26504, Greece.
Telephone: +30-69-72894651 Fax: +30-26-10625382
Received: March 29, 2018
Peer-review started: March 30, 2018
First decision: May 17, 2018
Revised: June 5, 2018
Accepted: June 25, 2018
Article in press: June 25, 2018
Published online: July 14, 2018

To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis.


A literature review was performed using the MEDLINE and PubMed databases. The search terms consisted of the words “endoscopic band ligation” OR “variceal band ligation” OR “ligation” AND “secondary prophylaxis” OR “secondary prevention” AND “variceal bleeding” OR “variceal hemorrhage” AND “liver cirrhosis”. The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices.


This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.


This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.

Keywords: Band ligation, Variceal bleeding, Rebleeding, Liver cirrhosis, Endoscopic therapy, Variceal eradication, Secondary prophylaxis, Esophageal varices

Core tip: Variceal bleeding is a life-threatening complication of liver cirrhosis. The current guidelines recommend the use of band ligation together with β-blockers in the setting of secondary prophylaxis for variceal bleeding in patients with cirrhosis. This review summarizes data from meta-analyses and randomized trials to demonstrate the most recent advances in the management of variceal rebleeding. The current evidence suggests that the efficacy of band ligation is increased by adding β-blockers in accordance with the current guidelines. However, combination therapy does not procure a survival advantage. Innovative interventions and more effective novel strategies aiming to improve clinical outcomes should be developed.