A Meta–Analysis of Endoscopic Variceal Ligation for Primary Prophylaxis of Esophageal Variceal Bleeding

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Abstract
Despite publication of several randomized trials of prophylactic variceal ligation, the effect on bleeding–related outcomes is unclear. We performed a meta–analysis of the trials, as identified by electronic database searching and cross–referencing. Both investigators independently applied inclusion and exclusion criteria, and abstracted data from each trial. Standard meta–analytic techniques were used to compute relative risks and the number needed to treat (NNT) for first variceal bleed, bleed–related mortality, and all–cause mortality. Among 601 patients in 5 homogeneous trials comparing prophylactic ligation with untreated controls, relative risks of first variceal bleed, bleed–related mortality, and all–cause mortality were 0.36 (0.26–0.50), 0.20 (0.11–0.39), and 0.55 (0.43–0.71), with respective NNTs of 4.1, 6.7, and 5.3. Among 283 subjects from 4 trials comparing ligation with β–blocker therapy, the relative risk of first variceal bleed was 0.48 (0.24–0.96), with NNT of 13; however, there was no effect on either bleed–related mortality (relative risk [RR], 0.61; confidence interval [CI], 0.20–1.88) or all–cause mortality (RR, 0.95; CI, 0.56–1.62). In conclusion, compared with untreated controls, prophylactic ligation reduces the risks of variceal bleeding and mortality. Compared with β–blockers, ligation reduces the risk for first variceal bleed but has no effect on mortality. Prophylactic ligation should be considered for patients with large esophageal varices who cannot tolerate β–blockers. Subsequent research should further compare ligation and β–blockers to determine the effect on mortality, and measure ligation's cost–effectiveness.

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