Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults

Banding ligation as primary prevention appears not to reduce total mortality but it may reduce bleeding in patients with oesophageal varices that have never bled, compared to non-selective beta-blockers.

The quality of evidence is downgraded by study limitations (unclear allocation concealment).

Summary

A Cochrane review included 19 trials with a total of 1508 patients to compare the benefits and harms of banding ligation (averagely 2 – 3 procedures per patient) versus non-selective beta-blockers as primary prevention in adult patients with endoscopically verified oesophageal varices that have never bled, irrespective of the underlying liver disease (cirrhosis or other cause; the majority of the patients had non-alcoholic liver disease). In most trials only patients with large or high-risk oesophageal varices were included. In 17 trials propranolol was used and in 1 trial each nadolol or carvedilol.

731 patients were randomized to banding ligation and 773 to non selective beta-blockers. The summary of main outcomes is presented in table 1.

For mortality, there was no difference between banding ligation and non-selective beta-blockers In trials with a low risk of selection bias (RR 1.18; 95% CI 0.95 to 1.47, 3 trials) or an unclear risk of selection bias (RR 0.96; 95% CI 0.72 to 1.28). The beneficial effect of banding ligation on bleeding was not confirmed in subgroup analyses of trials with adequate randomisation or full paper articles (RR 0.84; 95% CI 0.53 to 1.33). The results of trials with less than 20 months of follow-up found a better effect of banding ligation compared to trials with longer follow-up.

Clinical comments

Beta-blockers may have other than bleeding-related beneficial effects on mortality.

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Ədəbiyyat

1. Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev 2012;8:CD004544.