Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Surgery had higher short-term mortality than sclerotherapy for cirrhosis and variceal hemorrhage

ACP J Club. 1993 July-Aug;119:18. doi:10.7326/ACPJC-1993-119-1-018


Source Citation

Triger DR, Johnson AG, Brazier JE, et al. A prospective trial of endoscopic sclerotherapy v oesophageal transection and gastric devascularisation in the long term management of bleeding oesophageal varices. Gut. 1992 Nov:33:1553-8.


Abstract

Objective

To compare repeated sclerotherapy with modified transection and devascularization for long-term mortality, morbidity, and cost in patients with cirrhosis and variceal hemorrhage.

Design

Randomized controlled trial with mean follow-up of 53 months.

Setting

3 hospitals in the United Kingdom.

Patients

97 adults (mean age 50 y, 68% with alcoholic cirrhosis, 59 men) hospitalized with biopsy-proven cirrhosis of Child grade A or B and endoscopically proven first esophageal hemorrhage. Exclusion criteria were high risk or unsuitability for surgery, taking β-blockers, waiting for liver transplant, or positivity for hepatitis B surface antigen. Follow-up was complete.

Intervention

Patients were resuscitated from their qualifying esophageal hemorrhage and treated with urgent endoscopic sclerotherapy. After 5 days with no bleeding, patients were eligible for randomization. 46 patients were randomized to surgery (esophageal devascularization with transection) and received sclerotherapy only as needed. 51 patients were randomized to sclerotherapy (regular intravariceal injections of all patent varices with ethanolamine oleate at 1- to 4-week intervals until obliteration). Routine endoscopies were done every 3 to 12 months.

Main outcome measures

Variceal hemorrhage and all-cause mortality, surgical failure (endoscopically proven hemorrhage requiring hospitalization), sclerotherapy failure (> 10 units of blood needed on a single admission), and 5-year cost analysis for a subset of patients.

Main results

In the surgery group, 9 patients died in the first 3 months compared with none in the sclerotherapy group (20% vs 0%, { P < 0.001}*) (Table). At study end the surgery group showed a trend toward a decreased failure rate (32% vs 49%, { P = 0.09}*) but spent more days in the hospital (27 vs 10 d, P < 0.001). The surgery group also had higher mean first-year costs (£4369 vs £1094 {$8432 vs $2111}*, P < 0.001).

Conclusions

Short-term mortality for patients with cirrhosis and first variceal hemorrhage was higher for esophageal transection plus devascularization than for endoscopic sclerotherapy. Patients receiving surgery had longer hospital stays and higher initial costs.

Source of funding: Not stated.

For article reprint: Dr. D.R. Triger, University of Sheffield Medical School, Beech Hill Road, Sheffield S10 2RX, United Kingdom. FAX 44-742-725-962.

*Numbers calculated from data in article and exchange rate for January 1991 [1 £ = U.S. $1.93].


Table. Sclerotherapy vs surgery for cirrhosis and variceal hemorrhage at 3 months

Outcome Sclerotherapy Surgery RRR (95% CI) NNT (CI)
Mortality 0% 19.6% 100% (64 to 100) 5 (3 to 9)

*Abbreviations defined in Glossary; RRR, NNT, and CI calculated from data in article.


Commentary

The first goal in all episodes of gastrointestinal bleeding is resuscitation. The second goal in management of variceal hemorrhage is to stop the bleeding. More than 50% of those with variceal hemorrhage stop bleeding spontaneously, but patients who do not stop are at high risk for death. Sclerotherapy, portacaval shunting, and esophageal transection are all effective in stopping acute variceal bleeding, although results are extraordinarily operator dependent. The third goal of management is to reduce the nearly 70% risk for rebleeding; each episode is accompanied by significant mortality.

Triger and colleagues address this third goal by comparing repeated injection sclerotherapy with esophageal transection and devascularization in a population that was largely made up of patients with alcoholic cirrhosis of Child grade A and B. With mean follow-up of more than 4 years, no difference was found in overall mortality, but there was a greater early mortality and cost with surgery. Although a greater number of recurrences of variceal bleeding were reported in the sclerotherapy group, only 1 of these patients required surgery, and the groups did not differ in risk for hemorrhage from all causes. Rebleeding in the sclerotherapy group may have been exaggerated by the suboptimal timing of repeated sclerotherapy sessions. These findings cannot be extrapolated to Child C patients, nor do they address the question of optimal "salvage" therapy for those whose initial sclerotherapy is unsuccessful (1). Also, as for any abdominal surgery procedure, esophageal transection and devascularization may make subsequent liver transplantation more difficult. Long-term management of variceal hemorrhage continues to depend on local endoscopic or surgical expertise modified by the patient's candidacy for eventual transplantation.

Joseph M. Alcorn, MD
University of New MexicoAlbuquerque, New Mexico, USA


Reference

1. McCormick PA, Kaye GL, Greenslade L, et al. Esophageal staple transection as a salvage procedure after failure of acute injection sclerotherapy. Hepatology. 1992;15:403-6.