A new sandwich method of combined endoscopic variceal ligation and sclerotherapy versus ligation alone in the treatment of esophageal variceal bleeding: A randomized trial

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May 2001 . Volume 53 . Number 6

Original Articles

A new " sandwich " method of combined endoscopic variceal ligation and

sclerotherapy versus ligation alone in the treatment of esophageal variceal

bleeding: A randomized trial

Ming-Chih Hou, MD [MEDLINE LOOKUP]

Wen-Chih Chen, MD [MEDLINE LOOKUP]

Han-Chieh Lin, MD [MEDLINE LOOKUP]

Fa-Yauh Lee, MD [MEDLINE LOOKUP]

Full-Young Chang, MD [MEDLINE LOOKUP]

Shou-Dong Lee, MD [MEDLINE LOOKUP]

Taipei, Taiwan, Republic of China

Background: Variceal ligation is the optimum endoscopic method for treating

esophageal variceal bleeding. However, both early and multiple recurrences

of esophageal varices frequently follow ligation. The aim of this randomized

study was to determine whether a new, combined endoscopic " sandwich " method

(i.e., ligation-sclerotherapy-ligation) could achieve better results than

ligation alone.

Methods: Ninety-four patients with cirrhosis and acute or recent esophageal

variceal bleeding were randomized to undergo either the " sandwich " method or

ligation alone (47 patients in each group).

Results: The sclerosant was retained in the varices for more than 30 minutes

in 7 of 8 patients undergoing the " sandwich " method plus radiographic

contrast medium. Active bleeding was controlled with this new method (9/9)

as efficiently as ligation (12/12). The rate of recurrent bleeding was

similar for both methods. Multivariate analysis showed the necessity for the

use of antibiotics (odds ratio 3.95: 95% CI [1.60, 9.76]) to be an

independent factor for recurrent bleeding. Two patients in the " sandwich "

group developed strictures, but the frequency of other complications did not

differ between the 2 groups. Kaplan-Meier analysis showed the cumulative

probability of variceal recurrence was lower with the " sandwich " method (p =

0.0391). The survival rate and causes of death were similar in both groups.

Conclusions: The " sandwich " method leads to longer retention of sclerosant

in varices. This method is superior to ligation alone in terms of lower

variceal recurrence rate and comparable to ligation with respect to

hemostasis. However, it is unknown whether the lower recurrence rate of

varices will persist long-term. (Gastrointest Endosc 2001;53:572-8.)

a.. Received May 15, 2000.

b.. For revision July 27, 2000.

c.. Accepted January 5, 2001.

d.. From the Division of Gastroenterology, Department of Medicine,

Taipei-Veterans General Hospital, and National Yang-Ming University School

of Medicine, Taipei, Taiwan.

e.. Supported in part by a grant (VGH-89-C-271) from Taipei-Veterans

General Hospital and in part by a grant (NSC 89-2314-b-075-072) from

National Science Council, Republic of China.

f.. Reprint requests: Ming-Chih Hou, MD, Division of Gasteroenterology,

Department of Medicine, Taipei-Veterans General Hospital, No. 201, Sec 2,

Shih-Pai Rd., Taipei, Taiwan 11217.

g.. Gastrointest Endosc 2001;53:572-8

h.. Copyright © 2001 by the American Society for Gastrointestinal

Endoscopy

i.. 0016-5107/2001/$35.00 + 0 37/1/114058

j.. doi:10.1067/mge.2001.114058