Upper GI bleed: varices: staple transection of the oesophagus controlled bleeding better than sclerotherapy

Clinical bottom line (level 1b)

  1. Patients with bleeding varices that were not controlled by drugs and transfusions and who had staple transection of the oesophagus compared with sclerotherapy were less likely to rebleed (NNT = 4 at 6 weeks) .
  2. There was no clear difference in mortality or complications.
Burroughs et al: The New England Journal of Medicine 1989; 321: 857-862
Expires October 2002

The study

Unblinded ?concealed randomised trial with intention-to-treat
Setting: university hospital, UK

101 patients (aged 17 to 83, mean 50, 62% male) with haematemesis or melaena from oesophageal varices (confirmed on endoscopy), and the bleeding could not be controlled by drugs and transfusions (>6 units of blood required, further bleeding with a change in vital signs or a fall in Hb > 20 g/l) medical mea

Excluded if
  • aged < 16
  • non-cirrhotic portal hypertension
  • previous oesophageal transection
  • decision made to avoid invasive treatment (e.g. patients in terminal phase of liver disease or cancer)

Note:
  • Patients were stratified for Child's grading system before randomisation.


    • Control Group: (n = 50, 50 analysed): sclerotherapy using ethanolamine
    Experimental Group: (n = 51, 51 analysed): staple transection of the oesophagus

    100% followed for 6 weeks

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    death weeks 22
    (44.0%)    		 19
    (37.3%)    		 15%
    (-36% to 47%)    		 6.75%
    (-12.37% to 25.86%)    		 15
    (NNT = 4 to infinity;
    NNH = 8 to infinity)
    rebleeding 5 days 19
    (38%)    		 6
    (11.76%)    		 69%
    (29% to 87%)    		 26.24%
    (10.14% to 42.34%)    		 4
    (2 to 10)
    complications leading to death weeks 5
    (10.0%)    		 5
    (10.0%)    		 2%
    (-220% to 70%)    		 0.20%
    (-11.5% to 11.9%)    		 510
    (NNT = 8 to infinity;
    NNH = 9 to infinity)

    Comments

    1. The study is too small to show any clear effect on mortality or complications.
    2. Staple transection required surgery and the use of an operating theatre, so may be more costly than sclerotherapy (although the trial data suggest comparable costs, it was not formally evaluating this aspect).
    3. Transection is no longer a first line treatment but something like ultima ratio if more advanced drug therapies and TIPS have failed to control bleeding

    Citation

    1. Burroughs AK, Hamilton G, Phillips A, et al: Comparison of sclerotherapy with staple transection of the esophagus for the emergency control of bleeding from esophageal varices. The New England Journal of Medicine 1989; 321: 857-862
    Contributor: Chris Ball and Musab Hayatli, October 1999
    Reviewer: Horand Meier

    Clinical Question.
    Patient bleeding oesophageal varices uncontrolled by drugs and transfusion
    Intervention or Exposure staple transection of the oesophagus
    Comparison sclerotherapy
    Outcome rebleeding, death, complications