Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis.
BACKGROUND
The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage.


METHODS
A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death.


RESULTS
The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01).


CONCLUSIONS
EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027).
Orloff
Marshall J
MJ
Department of Surgery, University of California, San Diego Medical Center, San Diego, CA 92103-8999, USA.
Isenberg
Jon I
JI
Wheeler
Henry O
HO
Haynes
Kevin S
KS
Jinich-Brook
Horacio
H
Rapier
Roderick
R
Vaida
Florin
F
Hye
Robert J
RJ
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion / Q000706:statistics & numerical data; D004638:Emergency Treatment; D004724:Endoscopy / Q000379:methods*; D004932:Esophageal and Gastric Varices / Q000209:etiology / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000601:surgery*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D011167:Portacaval Shunt, Surgical / Q000379:methods*; D016016:Proportional Hazards Models; D012307:Risk Factors; D015911:Sclerotherapy / Q000379:methods*; D015996:Survival Rate; D016896:Treatment Outcome