Response:

Abstract

We appreciate the comments by Dr Gin-Ho Lo regarding the recommended intervals for endoscopy after endoscopic variceal ligation (EVL) for both primary and secondary prophylaxis of variceal bleeding recently published in Gastrointestinal Endoscopy by the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy.1Standards of Practice CommitteeThe role of endoscopy in the management of variceal hemorrhage.Gastrointest Endosc. 2014; 80: 221-227Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar As we state in our document, the optimal intervals for EVL for both primary and secondary prophylaxis have not been clearly defined by clinical studies. We recommended a wide range for the interval between endoscopies based on a review of the published data and the understanding that various practice settings may not allow for shorter intervals. Other consensus guidelines actually recommend EVL every 1 to 2 weeks until obliteration of varices is achieved.2Garcia-Tsao G. Sanyal A.J. Grace N.D. et al.Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.Hepatology. 2007; 46: 922-938Crossref PubMed Scopus (1333) Google Scholar However, as mentioned in the letter, other studies have demonstrated that an interval of 3 weeks or longer was associated with a lower risk of rebleeding.3Harewood G.C. Baron T.H. Song L.M. Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleeding.J Gastroenterol Hepatol. 2006; 21: 237-241Crossref PubMed Scopus (31) Google Scholar Because there is a lack of data to demonstrate significant benefits in mortality between intervals of 1 to 8 weeks, the Standards of Practice Committee of the ASGE has recommended that the interval between endoscopies be 1 to 8 weeks to allow individual practitioners to determine the optimal interval for their specific patient populations. The recommendation was based on low-quality evidence (GRADE score of 2), which means that further research is very likely to change the recommended interval. However, at this time, the committee believes that the published data do not support recommending a narrower interval. We appreciate the comments by Dr Gin-Ho Lo regarding the recommended intervals for endoscopy after endoscopic variceal ligation (EVL) for both primary and secondary prophylaxis of variceal bleeding recently published in Gastrointestinal Endoscopy by the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy.1Standards of Practice CommitteeThe role of endoscopy in the management of variceal hemorrhage.Gastrointest Endosc. 2014; 80: 221-227Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar As we state in our document, the optimal intervals for EVL for both primary and secondary prophylaxis have not been clearly defined by clinical studies. We recommended a wide range for the interval between endoscopies based on a review of the published data and the understanding that various practice settings may not allow for shorter intervals. Other consensus guidelines actually recommend EVL every 1 to 2 weeks until obliteration of varices is achieved.2Garcia-Tsao G. Sanyal A.J. Grace N.D. et al.Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.Hepatology. 2007; 46: 922-938Crossref PubMed Scopus (1333) Google Scholar However, as mentioned in the letter, other studies have demonstrated that an interval of 3 weeks or longer was associated with a lower risk of rebleeding.3Harewood G.C. Baron T.H. Song L.M. Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleeding.J Gastroenterol Hepatol. 2006; 21: 237-241Crossref PubMed Scopus (31) Google Scholar Because there is a lack of data to demonstrate significant benefits in mortality between intervals of 1 to 8 weeks, the Standards of Practice Committee of the ASGE has recommended that the interval between endoscopies be 1 to 8 weeks to allow individual practitioners to determine the optimal interval for their specific patient populations. The recommendation was based on low-quality evidence (GRADE score of 2), which means that further research is very likely to change the recommended interval. However, at this time, the committee believes that the published data do not support recommending a narrower interval. The optimal interval of endoscopic variceal ligation: an issue of controversyGastrointestinal EndoscopyVol. 81Issue 3PreviewI read with interest the article regarding the role of endoscopy in the management of variceal hemorrhage.1 The statements suggested that endoscopic variceal ligation (EVL) be performed at intervals of 1 to 8 weeks for both primary prophylaxis and secondary prevention of rebleeding. The wide range of intervals may elicit confusion for endoscopists. A recent randomized controlled study from our colleagues demonstrated that patients receiving EVL monthly had rates of rebleeding and mortality similar to those receiving EVL biweekly for secondary prophylaxis. Full-Text PDF