Observational Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Oct 16, 2020; 12(10): 365-377
Published online Oct 16, 2020. doi: 10.4253/wjge.v12.i10.365
Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication
Jake Krige, Eduard Jonas, Urda Kotze, Christo Kloppers, Karan Gandhi, Hisham Allam, Marc Bernon, Sean Burmeister, Mashiko Setshedi
Jake Krige, Eduard Jonas, Urda Kotze, Christo Kloppers, Karan Gandhi, Hisham Allam, Marc Bernon, Sean Burmeister, Mashiko Setshedi, Departments of Surgery and Medicine, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
Jake Krige, Department of Surgery, University of Cape Town Health Sciences Faculty, Cape Town 7925, South Africa
Author contributions: Krige J, Jonas E and Kotze U devised the study concept and design; Krige J, Kotze U were involved in acquisition of data; Krige J, Jonas E, Kotze U, Kloppers C, Gandhi K, Allam H, Bernon M and Burmeister S analyzed and interpreted the data; Krige J, Jonas E and Kotze U drafted the manuscript; Krige J, Jonas E, Kotze U, Kloppers C, Gandhi K, Allam H, Bernon M, Burmeister S and Setshedi M critically revised the manuscript for important intellectual content; Krige J, Kotze U and Setshedi M carried out the statistical analysis; Krige J and Jonas E provided final approval of the article.
Institutional review board statement: This study was approved by the Human Research Ethics Committee University of Cape Town Health Sciences Faculty.
Conflict-of-interest statement: They authors declare they have no conflict-of-interest.
Data sharing statement: No additional data.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Jake Krige, MBChB, MSc, PhD, FACS, FRCS (Ed), FCS (SA), Emeritus Professor, Department of Surgery, University of Cape Town Health Sciences Faculty, Anzio Road, Cape Town 7925, South Africa. jej.krige@uct.ac.za
Received: April 28, 2020
Peer-review started: April 28, 2020
First decision: May 24, 2020
Revised: June 29, 2020
Accepted: September 11, 2020
Article in press: September 11, 2020
Published online: October 16, 2020
Processing time: 168 Days and 16.6 Hours
Abstract
BACKGROUND

Bleeding esophageal varices (BEV) is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25% within six weeks of the index variceal bleed. After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selective β-blockers to prevent further bleeding and eradicate EV.

AIM

To assess the efficacy of endoscopic variceal ligation (EVL) in controlling acute variceal bleeding, preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices (EV) in patients who present with BEV.

METHODS

A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018. Control of acute bleeding, variceal recurrence, rebleeding, eradication and survival were analyzed using Baveno assessment criteria.

RESULTS

One hundred and forty patients (100 men, 40 women; mean age 50 years; range, 21–84 years; Child-Pugh grade A = 32; B = 48; C = 60) underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions. One hundred and fourteen (81%) of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV, while 26 (19%) patients had complicated and refractory variceal bleeding. EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients (95.7%). Six patients required balloon tamponade for control and 4 other patients rebled in hospital. Overall 5-d endoscopic failure to control variceal bleeding was 7.1% (n = 10) and four patients required a salvage transjugular intrahepatic portosystemic shunt. Index admission mortality was 14.2% (n = 20). EV were completely eradicated in 50 of 111 patients (45%) who survived > 3 mo of whom 31 recurred and 3 rebled. Sixteen (13.3%) of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital. Overall rebleeding from all sources after 2 years was 21.7% (n = 26). Sixty-nine (49.3%) of the 140 patients died, mainly due to liver failure (n = 46) during follow-up. Cumulative survival for the 140 patients was 71.4% at 1 year, 65% at 3 years, 60% at 5 years and 52.1% at 10 years.

CONCLUSION

EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%. Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV, of whom 62% recurred, there was a significant reduction in subsequent rebleeding.

Keywords: Endoscopy; Variceal ligation; Variceal bleeding; Secondary prophylaxis; Esophageal varices; Variceal recurrence

Core Tip: Control of acute bleeding is crucial in patients with portal hypertension and actively bleeding esophageal varices (BEV). The present study demonstrated that endoscopic variceal ligation (EVL) was highly effective in controlling acute variceal bleeding during the first endoscopic intervention in 95.7% of 140 patients with an overall 5-d failure to control bleeding of 7.1%. Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV, of which 62% recurred, there was a significant reduction in subsequent rebleeding. EVL was effective and safe with a low complication rate in treating BEV.