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Long-term management of variceal bleeding: The place of varix injection and ligation

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Abstract

Injection sclerotherapy remains the most widely used long-term management for patients after an esophageal variceal bleed. Sclerotherapy treatments should be repeated weekly until the varices are eradicated. Follow-up endoscopy every 6 to 12 months is required for life. Whenever varices recur, further weekly injection treatments are administered until re-eradication is achieved. Failure of sclerotherapy must be diagnosed early and an alternative salvage procedure performed. We currently recommend the distal splenorenal shunt. Although the complications of sclerotherapy are not great, they are cumulative with time. Unlike most surgical procedures for portal hypertension, the technique of performing sclerotherapy is not standardized, making the comparison of controlled trials difficult. The current status of controlled trials comparing sclerotherapy with other treatments is evaluated. We conclude that repeated injection sclerotherapy is at present the initial treatment of choice for patients after an esophageal variceal bleed. The technique of the new procedure of esophageal variceal ligation is described. As with sclerotherapy, weekly treatment sessions are recommended until the esophageal varices are eradicated, followed by long-term endoscopic surveillance and repeat ligation treatment when varices recur. The four controlled trials that have compared variceal ligation with sclerotherapy favor ligation. Ligation eradicated esophageal varices with fewer treatment sessions and a lower complication rate. One trial demonstrated improved survival. Complications due to the overtube are being increasingly reported but were not a problem in the controlled trials. Although esophageal variceal ligation or ligation plus sclerotherapy may ultimately prove to be superior to sclerotherapy alone, more data are required before a final conclusion can be reached.

Résumé

La sclérothérapie reste le traitement de base pour les patients ayant saigné par rupture de varices oesophagiennes. Les injections de sclérothérapie doit être répétées chaque semaine jusqu'à ce que les varices soient éradiquées. Un suivi par endoscopie est nécessaire au moins une fois par an et à vie. Lorsque les varices réapparaissent, la sclérothérapie doit être recommencée jusqu'à obtenir de nouveau l'éadication. En cas d'échec, un procédé alternatif, le plus souvent une anastomose splénorénale distale, doit être choisi. Bien que le taux de complications de la sclérothérapie ne soit pas très élevé, celles-ci s'accumulent avec le temps. Au contraire des interventions chirurgicales, la technique de sclérothérapie n'est pas standardisée, ce qui rend la comparaison des essais contrôlés difficile. Les essais publiés jusqu'à présent comparant la sclérothérapie à d'autres modalités de traitement sont discutés. Nous concluons que la sclérothérapie répétée est le traitement initial de choix pour le patient ayant saigné de varices oesophagiennes. La technique de ligature des varices oesophagiennes est également décrite. Tout comme la sclérothérapie, les séances hebdomadaires sont nécessaires jusqu'à l'éradication des varices, suivies d'une surveillance endoscopique et éventuellement d'autres séances de ligature à la demande. Les quatre essais contrôlés comparant la ligature à la sclérothérapie sont tous en faveur de la ligature. De même, dans un des essais, la survie après ligature est améliorée. Les complications en rapport avec la gaine nécessaire à la ligature commencent à être publiées mais elles n'avaient pas été mentionnées auparavant dans les essais contrôlés. Il se peut que la ligature des varices ou la ligature combinée à la sclérothérapie soient supérieures à la sclérothérapie seule, mais il faut attendre les résultats d'autres études avant de pouvoir conclure formellement.

Resumen

La escleroterapia sigue siendo el método de mayor utilización en el manejo de los pacientes que han sufrido un episodio de hemorragia por várices esofágicas. La escleroterapia debe ser repetida semanalmente hasta cuando las várices sean erradicadas, y se requiere luego un seguimiento semestral o anual de por vida. En el momento en que se detecte recurrencia de las várices, se debe emprender de nuevo el régimen de inyecciones semanales hasta lograr su erradicación. La falla de la escleroterapia debe ser diagnosticada precozmente, para emprender una alternativa terapéutica de salvamento; nuestro grupo actualmente recomienda un “shunt” espleno-renal distal. Aunque las complicaciones de la escleroterapia no son mayores, sí son acumulativas. A diferencia de lo que ocurre con los procedimientos quirúrgicos, la técnica de la escleroterapia no ha sido estandarizada, lo cual hace difícil la comparación entre los diferentes ensayos clínicos controlados.

En el presente artículo se hace una evaluación del estado actual de los ensayos clínicos controlados, que comparan la escleroterapia con otras modalidades terapéuticas. Nuestra conclusión es que la escleroterapia, mediante inyecciones repetidas, es en el momento actual el tratamiento de elección para pacientes que han presentado hemorragia varicosa.

También se describe la técnica del nuevo procedimineto de ligadura endoscópica de las várices esofágicas. Al igual que con la escleroterapia, se recomiendan sesiones semanales hasta la erradicación de las várices, seguidas de vigilancia endoscópica a largo plazo, con repetición de la ligadura si hay recurrencia de las várices. Los cuatro ensayos clínicos controlados que comparan la ligadura con la escleroterapia, favorecen todos la ligadura.

La ligadura logró la erradicación de las várices con un número menor de sesiones y con inferior tasa de complicaciones, y uno de ellos demostró mejor supervivencia. A diferencia de la escleroterapia, la técnica de la ligadura sí está estandarizada. Se han venido informando complicaciones por el uso del tubo secundario, pero éstas no representaron problema en los ensayos clínicos controlados. Aunque la ligadura de las várices combinada con escleroterapia puede llegar a demostrar superioridad sobre la escleroterapia sola, todavía se requiere investigación adicional antes de llegar a conclusiones finales.

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Authors and Affiliations

  1. Department of Digestive Surgery, Regional Hospital, Pontchaillou, Rennes, France

    John Terblanche Ch.M.

  2. University of Rennes, Rennes, France

    John Terblanche Ch.M.

  3. Department of Surgery, University of Cape Town, J Floor, Old Main Building, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa

    John Terblanche Ch.M., Jake E. J. Krige M.B. & Philippus C. Bornman M.B.

  4. Medical Research Council Liver Research Center, University of Cape Town, Cape Town, South Africa

    John Terblanche Ch.M., Jake E. J. Krige M.B. & Philippus C. Bornman M.B.

  5. Department of Surgery, Gastrointestinal Surgery, University of Colorado Health Sciences Center, University of Colorado, Denver, Colorado, USA

    Greg V. Stiegmann M.D.

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  1. John Terblanche Ch.M.
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Terblanche, J., Stiegmann, G.V., Krige, J.E.J. et al. Long-term management of variceal bleeding: The place of varix injection and ligation. World J. Surg. 18, 185–192 (1994). https://doi.org/10.1007/BF00294399

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