Endoscopic variceal ligation for primary prophylaxis of esophageal variceal hemorrhage in pre-liver transplant patients

Abstract

Endoscopic variceal ligation (EVL) is widely used to prevent esophageal variceal bleeding in patients with advanced cirrhosis. However, the safety and efficacy of EVL in this setting have not been clearly established. This study included 300 adult patients with cirrhosis on our liver transplant waitlist who underwent upper gastrointestinal endoscopy. Esophageal varices deemed to be at high risk of bleeding were banded until eradication or transplantation. A retrospective review of patient notes and endoscopy databases was undertaken, and the number of banding episodes, complications, and patient outcomes were recorded. Forty-two of 300 patients presented with or had previous variceal bleeding prior to referral and were excluded from the analysis. Of the remaining 258 patients, 101 underwent a total of 259 banding episodes (2.6 per patient) with a median follow-up post-banding of 18.4 months per patient (a total of 150 patient years). Failed prophylaxis occurred in 2 patients (2%), and there were 3 episodes (1.2%) of acute hematemesis from band-induced ulceration. One patient (1%) had mild esophageal stricturing post-banding without dysphagia. Four of 36 patients (11%) previously found to have moderately sized or larger varices that were not banded presented with hematemesis due to variceal bleeding and were subsequently banded. None of the patients that received banding died because of bleeding or failed to receive a transplant as a result of banding complications. This study shows that in liver transplant candidates, EVL is highly effective in preventing first variceal bleed. Although banding carries a small risk of band-induced bleeding, this rate is low in comparison with the predicted rate of variceal bleeding in this population.