World Journal of Surgery

, Volume 18, Issue 2, pp 176–184

Prophylactic treatment of patients with esophageal varices: Is it ever indicated?

  • James D. Greig
  • O. James Garden
  • David C. Carter
Article

Abstract

The prognosis of patients who bleed from esophageal varices is dismal. Prophylactic treatment of the varix or the elevated portal venous pressure offers a possibility of improving the outlook for these patients. However, as only approximately one-third of patients with varices bleed during their lifetime, correct identification of high-risk patients is vital before embarking on prophylaxis. At present, neither European or Japanese selection criteria are perfect in this respect. The documented incidence of initial variceal bleeding varies between 27% and 48%, and most bleeding episodes occur within the first year after varices are diagnosed. Data from six randomized controlled trials comparing prophylactic β-blockers with placebo demonstrated a decreased incidence of bleeding in propranolol-treated patients, which in large measure may depend on patient compliance and did not significantly affect survival in all but one study. Early randomized studies of prophylactic sclerotherapy have shown significant reductions in both the incidence of bleeding and mortality, but this promise has not been sustained by subsequent trials, and indeed sclerotherapy was detrimental in two studies. The impressive results in highly selected patients treated in Japan by prophylactic surgery are unlikely to be repeated in a Western setting, involving patient populations that consist predominantly of alcoholic cirrhotics. At present prophylaxis with β-blockade seems to offer the best therapeutic option, but the future may lie in the development of new interventional techniques such as tranjugular intrahepatic portosystemic stent shunting (TIPS) or variceal banding, and ultimately with hepatic transplantation.

Résumé

Le pronostic des patients ayant saigné de varices oesophagiennes est médiocre. Le traitement prophylactique des varices ou d'une hypertension portale permet une amélioration potentielle du pronostic de ces patients. Cependant, comme seulement un tiers des patients avec des varices saignent pendant leur vie, l'identification correcte des patients à risque élevé est capitale avant d'envisager une politique prophylactique généralisée. Actuellement, ni les critères européens ni les critères japonais ne sont suffisants pour déterminer cette population à risque. L'incidence d'hémorragie par rupture des varices initiale va de 27% à 48% dans la littérature et la plupart des hémorragies se produisent pendant la première année après le diagnostic de varices oesophagiennes. Les résultats provenant de six études comparant les béta bloqueurs à un placebo ont démontré une baisse de l'incidence de l'hémorragie chez les patients traités par le propranol. Ce résultat peut certes être attribué à une différence de coopération parmi les patients: la survie n'est pas différente d'une étude à l'autre sauf une. Les études randomisées de sclérothérapie prophylactique ont démontré une réduction significative dans l'incidence d'hémorragie et de la mortalité, mais cet espoir n'a pas été retrouvé par les essais suivants et la sclérothérapie a été néfaste dans deux de ces essais. Il est peu probable que les résultats impressionnants recueillis au Japon puissent être reproduits en Occident où la population est composée en grand majorité par des cirrhotiques d'origine alcoolique. Actuellement, la prophylaxie par béta-bloqueurs semble être le meilleur des traitements mais à l'avenir, la meilleure option thérapeutique pourrait être le shunt intrahépatique transjugulaire ou le wrapping périoesophagien et ultérieurement la transplantation hépatique.

Resumen

El pronóstico de los pacientes que sangran como consecuencia de várices esofágicas es sombró. El tratamiento profiláctico de las várices o de la elevada presión portal ofrece una posibilidad de mejorar el futuro de estos pacientes.

Sin embargo, como apenas aproximadamente un tercio de los pacientes con várices sangran en el curso de su vida, la correcta identificación de los casos de “alto riesgo” es de vital importancia antes de embarcarse en tratamiento profiláctico.

En la actualidad ni los criterios de selección europeos ni los japoneses pueden considerarse como perfectos a este respecto. La frecuencia del sangrado varicoso inicial oscila entre 27% y 48%, y la mayoría de los episodios hemorrágicos ocurren dentro del primer año después de establecido el diagnóstico de las várices. Los resultados de seis (6) ensayos clinicos randomizados en que compararon los beta-bloqueadores con placebeo demuestran una disminución en la incidencia de sangrado en los pacientes tratados con propranolol, lo cual en gran parte depende de la obediencia del paciente, pero afectó en forma significativa la sobrevida, excepto en uno de los estudios.

Anteriores estudios randomizados sobre escleroterapia profiláctica han demostrado reducciones significativas tanto en la incidencia de sangrado como en la mortalidad, pero ésto no ha sido reproducido en ensayos clínicos subsiguientes, y en realidad la escleroterapia pareció ser nociva en dos estudios. Los impresionantes resultados en pacientes altamente seleccionados logrados en el Japón con la cirugía profiláctica muy probablemente no lograrán ser reproducidos en Occidente, donde las poblaciones de pacientes están conformadas predominantemente por cirróticos alcohólicos. En el momento actual la profilaxis con beta-bloqueadores parece ser la mejor opción terapéutica, pero el futuro puede bien ser el desarrollo de nuevas técnicas intervencionistas tales como “shunts” transyugulares intrahepáticos (TIPS) o la ligadura endoscópica de las várices y, por último, el trasplante de hígado.

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Copyright information

© Société Internationale de Chirurgie 1994

Authors and Affiliations

  • James D. Greig
    • 1
  • O. James Garden
    • 1
  • David C. Carter
    • 1
  1. 1.University Department of SurgeryRoyal Infirmary of EdinburghEdinburghScotland

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