title: Liver transplantation in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis.
abstract: BACKGROUND
  Bleeding esophageal varices (BEV) in cirrhosis has been considered an indication for liver transplantation (LT). This issue was examined in a randomized controlled trial (RCT) of unselected, consecutive patients with advanced cirrhosis and BEV that compared endoscopic sclerotherapy (EST; n = 106) to emergency direct portacaval shunt (EPCS; n = 105).
  
  
  METHODS
  Diagnostic work-up and treatment were initiated within 8 hours. Patients were evaluated for LT on admission and repeatedly thereafter; 96% underwent over 10 years of regular follow-up. The analysis was supplemented by 1300 unrandomized cirrhotic patients who previously underwent portacaval shunt (PCS) with 100% follow-up.
  
  
  RESULTS
  In the RCT long-term bleeding control was 100% following EPCS, only 20% following EST. Also, 3-, 5-, 10-, and 15-year survival rates were 75%, 73%, 46%, and 46%, respectively, following EPCS compared with 44%, 21%, 9%, and 9% following EST, respectively (P < .001). Only 13 RCT patients (6%) were ultimately referred for LT mainly because of progressive liver failure; only 7 (3%) were approved for LT and only 4 (2%) underwent LT. The 1- and 5-year LT survival rates were 0.68% and 0, respectively, compared with 81% and 73%, respectively, after EPCS. In the 1300 unrandomized PCS patients, 50 (3.8%) were referred and 19 (1.5%) underwent LT. The 5-year survival rate was 53% compared with 72% for all 1300 patients.
  
  
  CONCLUSIONS
  If bleeding is permanently controlled, as occurred invariably following EPCS, cirrhotic patients with BEV seldom require LT. PCS is effective first-line and long-term treatment. Should LT be required in patients with PCS, although technically more demanding, numerous studies have shown that PCS does not increase mortality or complications. EST is not effective emergency or long-term therapy.
authors.affiliation: Department of Surgery, University of California, San Diego Medical Center, San Diego, California 92103-8999, USA. morloff@ucsd.edu
authors.forename: M J
authors.initials: MJ
authors.lastname: Orloff
authors.forename: J I
authors.initials: JI
authors.lastname: Isenberg
authors.forename: H O
authors.initials: HO
authors.lastname: Wheeler
authors.forename: K S
authors.initials: KS
authors.lastname: Haynes
authors.forename: H
authors.initials: H
authors.lastname: Jinich-Brook
authors.forename: R
authors.initials: R
authors.lastname: Rapier
authors.forename: F
authors.initials: F
authors.lastname: Vaida
authors.forename: R J
authors.initials: RJ
authors.lastname: Hye
authors.forename: S L
authors.initials: SL
authors.lastname: Orloff
mesh_terms: D000208:Acute Disease; D004638:Emergency Treatment; D004932:Esophageal and Gastric Varices / Q000601:surgery*; D006801:Humans; D008103:Liver Cirrhosis / Q000601:surgery*; D016031:Liver Transplantation; D015996:Survival Rate; D016896:Treatment Outcome