title: A new "sandwich" method of combined endoscopic variceal ligation and sclerotherapy versus ligation alone in the treatment of esophageal variceal bleeding: a randomized trial.
abstract: 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.
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei-Veterans General Hospital, and National Yang-Ming University School of Medicine, Taipei, Taiwan, Republic of China.
authors.forename: M C
authors.initials: MC
authors.lastname: Hou
authors.forename: W C
authors.initials: WC
authors.lastname: Chen
authors.forename: H C
authors.initials: HC
authors.lastname: Lin
authors.forename: F Y
authors.initials: FY
authors.lastname: Lee
authors.forename: F Y
authors.initials: FY
authors.lastname: Chang
authors.forename: S D
authors.initials: SD
authors.lastname: Lee
mesh_terms: D003131:Combined Modality Therapy; D004932:Esophageal and Gastric Varices / Q000401:mortality / Q000628:therapy*; D005260:Female; D006801:Humans; D008026:Ligation / Q000379:methods; D008134:Long-Term Care; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012008:Recurrence; D015911:Sclerotherapy / Q000379:methods; D015996:Survival Rate