Endoscopic Sclerotherapy as Compared with Endoscopic Ligation for Bleeding Esophageal Varices

Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival. Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (±SD) number of treatments with ligation (4±2 vs. 5±2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041 ), as was the rate of complications (22 percent vs. 2 percent, P<0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections. Patients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy. (N Engl J Med 1992;326:1527–32.), ENDOSCOPIC sclerotherapy is an accepted treatment for both acute and definitive management of bleeding esophageal varices. Most studies indicate that sclerotherapy is superior to medical management when results are measured by the control of active bleeding and the prevention of recurrences,^{1 2 3 4 5 6 7} and a meta-analysis of seven trials showed that overall survival was improved by this treatment.⁸ Sclerotherapy also appears to be equal or superior to the insertion of a portacaval or selective splenorenal shunt in terms of both survival and the preservation of hepatic function.^{9 10 11} Despite these results, this treatment is associated with adverse pulmonary and renal effects, esophageal ulceration,…