title: Combined ligation and sclerotherapy versus ligation alone for secondary prophylaxis of esophageal variceal bleeding: a meta-analysis.
abstract: OBJECTIVE
  Variceal ligation has been shown to be superior to sclerotherapy in prevention of rebleeding and improving survival in patients with cirrhosis. However, 25% of patients will rebleed before completion of treatment. A number of trials have compared the combination of ligation and sclerotherapy to ligation alone in achieving rapid and complete eradication of esophageal varices, with conflicting results.
  
  
  METHODS
  Two reviewers independently identified seven randomized, controlled trials that compared endoscopic variceal ligation with the combination of sclerotherapy and ligation for the treatment of esophageal varices. Studies were identified by searching MEDLINE, reviewing references from retrieved articles, and scanning abstracts from conference proceedings. For each outcome, odds ratios (ORs) were calculated using fixed-effects and random-effects models. The Mantel-Haenszel test for statistical heterogeneity was used to assess the validity of combining results from individual studies.
  
  
  RESULTS
  No significant difference was seen in cessation of actively bleeding varices (OR = 1.01, 95% CI = 0.43-2.36), variceal rebleeding (OR = 1.12, CI = 0.69-1.81), and mortality (OR = 1.1, CI = 0.70-1.74) in patients with variceal ligation versus patients receiving the combination treatment of ligation and sclerotherapy. Treatment sessions required to achieve complete variceal eradication were similar in the two treatment arms. A significantly higher incidence of esophageal stricture was seen in combination therapy (p < 0.001).
  
  
  CONCLUSIONS
  The combination of ligation and sclerotherapy offers no advantage over ligation alone in prevention of rebleeding and in reduction of mortality. It is also associated with a higher complication rate of esophageal stricture.
authors.affiliation: Division of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA.
authors.forename: Pankaj
authors.initials: P
authors.lastname: Singh
authors.forename: Nakechand
authors.initials: N
authors.lastname: Pooran
authors.forename: Anant
authors.initials: A
authors.lastname: Indaram
authors.forename: Simmy
authors.initials: S
authors.lastname: Bank
mesh_terms: D000328:Adult; D000368:Aged; D003131:Combined Modality Therapy; D004932:Esophageal and Gastric Varices / Q000401:mortality / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000401:mortality / Q000517:prevention & control* / Q000628:therapy*; D006801:Humans; D008026:Ligation; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D015911:Sclerotherapy; D055502:Secondary Prevention; D016896:Treatment Outcome