Therapeutic face-off: Band ligation versus beta blockage for variceal binding

Sarin et al. prospectively compared propranolol treatment and endoscopic ligation for primary prevention of esophageal variceal bleeding. The patients were randomized to receive either beta-blocker therapy with an aim to decrease heart rate by 25% or weekly variceal ligation until obliteration was achieved. The study population of 89 patients were at high risk for bleeding as determined by the presence of large varices, defined as >5 mm in diameter. Eighty-two of these patients were cirrhotic. Forty-four were treated with propranolol, and 45 underwent variceal ligation. The mean duration of post- treatment follow-up for the medical arm was 14 months compared to 13 months for the endoscopic group. The mean time required to achieve the desired heart rate reduction was approximately 2.5 days, and an average of 3.2 ligation sessions were necessary to achieve variceal obliteration. At 18 months after initiation of treatment, the statistical probability of bleeding was 43% in the propranolol group compared to 15% in the ligation group. Twelve patients in the propranolol group and four in the ligation group exhibited bleeding; however, three of the four in the ligation group bled before complete variceal obliteration. No serious complications occurred in the ligation group, whereas beta-blocker therapy was discontinued in two patients because of side effects (hypotension, altered mental status). Five deaths occurred in each group; variceal bleeding was the cause in four propranolol and three ligation patients. The authors concluded that endoscopic ligation appears to be a safe and more effective treatment than propranolol for patients with high-risk esophageal varices. (C) 2000 by Am. Coll. of Gastroenterology.