title: Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices.
abstract: BACKGROUND
  In patients with oesophageal varices, the combination of endoscopic variceal ligation (EVL) and medical therapy is recommended as standard of care for prevention of rebleeding. The results of previous meta-analyses on this topic are equivocal.
  
  
  OBJECTIVE
  To assess the effects of EVL plus medical therapy vs. monotherapy (EVL or medical therapy alone) for secondary prevention in oesophageal varices.
  
  
  METHODS
  Electronic and manual searches were combined. The primary outcome measures were overall rebleeding (variceal and nonvariceal) and mortality. Random-effects meta-analyses were performed with subgroup, sensitivity, regression and sequential analyses to identify sources of intertrial heterogeneity and the robustness of the results.
  
  
  RESULTS
  Nine randomised trials were included. In total, 442 patients were randomised to combination therapy and 513 to monotherapy. Combination therapy reduced rebleeding (RR = 0.68; 95% CI = 0.54-0.85; number needed to treat eight patients). The result was confirmed in sequential and regression analyses, but not when limiting the analysis to trials with adequate selection bias control. No effect on overall mortality was identified (RR = 0.89; 95% CI = 0.65-1.21). Combination therapy reduced bleeding-related mortality (RR = 0.52; 95% CI 0.27-0.99; number needed to treat 33 patients) and the risk of rebleeding from oesophageal varices. Combination therapy increased the risk of serious adverse events in fixed, but not in random-effects meta-analyses.
  
  
  CONCLUSIONS
  The combination of endoscopic variceal ligation and medical therapy reduce the risk of rebleeding, but not overall mortality. Additional research is needed to determine why reduced rebleeding rates do not lead to reduced mortality.
authors.affiliation: Department of Internal Medicine, Copenhagen University Hospital Gentofte, Hellerup, Denmark. majath@dadlnet.dk
authors.forename: M
authors.initials: M
authors.lastname: Thiele
authors.forename: A
authors.initials: A
authors.lastname: Krag
authors.forename: U
authors.initials: U
authors.lastname: Rohde
authors.forename: L L
authors.initials: LL
authors.lastname: Gluud
mesh_terms: D003131:Combined Modality Therapy / Q000379:methods; D004932:Esophageal and Gastric Varices / Q000401:mortality / Q000517:prevention & control*; D006471:Gastrointestinal Hemorrhage / Q000401:mortality / Q000517:prevention & control*; D006801:Humans; D008026:Ligation / Q000379:methods; D016032:Randomized Controlled Trials as Topic; D055502:Secondary Prevention