Published online Jul 14, 2018. doi: 10.3748/wjg.v24.i26.2902
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
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.
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.
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.
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.
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.
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.
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.