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
Research background

Variceal bleeding is considered one of the most severe complications of portal hypertension and constitutes a life-threatening condition for cirrhosis patients. Recurrent variceal bleeding occurs in approximately 60% of patients within 2 years, with a six-week mortality rate of approximately 12%-16%. Available treatments for the secondary prophylaxis of variceal bleeding include pharmacotherapy, endoscopic treatment, transjugular intrahepatic portosystemic shunt (TIPS) placement and surgical shunting. The most recent guidelines suggest that the combination of non-selective β-blockers (propranolol or nadolol) and endoscopic band ligation constitutes the preferred treatment option for prevention of rebleeding in liver cirrhosis patients. Endoscopic band ligation should not be used alone unless the patient cannot tolerate β-blockers or there is a contraindication for non-selective β-blocker administration. Covered TIPS insertion is recommended for patients who do not respond to combination treatment.

Research motivation

Systematic reviews and meta-analyses have compared these interventions and highlighted differences in the efficacy of the different modalities. However, conflicting data are present in the existing literature.

Research objectives

The authors aimed to summarize and critically examine existing data focusing on the most updated randomized trials of the role of endoscopic band ligation in the secondary prophylaxis of variceal bleeding in liver cirrhosis patients.

Research methods

A systematic search of the MEDLINE and PubMed databases was performed. All manuscripts comparing the endoscopic band ligation intervention vs other interventions were studied. Data from the relevant meta-analyses and the most recent randomized studies t not included in these meta-analyses were analyzed.

Research results

The results demonstrated that band ligation was more effective than endoscopic sclerotherapy. The use of β-blockers in combination with band ligation increased the treatment efficacy, supporting the current guidelines regarding secondary prevention of variceal bleeding. TIPS placement was superior to combination therapy in terms of rebleeding prophylaxis, with no difference in the survival rates. However, the data concerning the incidence of hepatic encephalopathy were conflicting.

Research conclusions

This review demonstrated the most recent advances in the role of endoscopic band ligation for the treatment of esophageal variceal rebleeding. Endoscopic band ligation constitutes an effective treatment option for the prevention of recurrent variceal bleeding. However, the efficacy of band ligation is clearly increased by the addition of β-blocker therapy. Other treatment modalities could also be considered in selected clinical scenarios.

Research perspectives

Innovative endoscopic techniques and more effective treatment strategies or combinations of novel drugs should be developed in the future, with an aim of better clinical management of these patients.