Upper GI bleed: varices: oesophageal transection compared with sclerotherapy increased early mortality without reducing rebleeding

Clinical bottom line (level 1b)

  1. Patients following a first bleed from oesophageal varices who had oesophageal transection and gastric devascularisation compared with sclerotherapy were at increased risk of dying in the next 3 months (NNH = 6 at 3 months) , but not at 5 years.
  2. There was no clear difference in the rate of rebleeding.
Triger et al: Gut 1992; 33: 1553-1558
Expires October 2002

The study

Unblinded ?concealed randomised trial without intention-to-treat
Setting: 3 acute hospitals, UK

100 patients (aged 23 to 65; mean 50, 59% male) recent oesophageal variceal bleed (confirmed on endoscopy)

Excluded if
  • waiting for liver transplantation
  • HBsAg positive
  • patients at high risk for elective surgery, or unsuitable for surgery
  • previous major GI surgery
  • previous therapy for oesophageal varices
  • on beta-blockers
  • Child's grading C or D
  • further bleeding within five days of bleed
  • evidence of septicaemia or renal failure
  • aged <16 or >65

Control Group: (n = 51, 51 analysed): endoscopic sclerotherapy using ethanolamine every 1 to 4 weeks until obliteration
Experimental Group: (n = 49, 46 analysed): oesophagogastric devascularisation with oesophageal transection

97% followed for 4.5 years 17 to 83 months

The evidence

Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
death 3 months 1
(1.96%)		 9
(19.6%)		 -898%
(-7467% to -31%)		 -17.6%
(-29.7% to -5.53%)		 -6
(-18 to -3)
death 4.5 years 18
(35.3%)		 15
(32.6%)		 8%
(-61% to 47%)		 2.69%
(-16.2% to 21.5%)		 37
(NNT = 6 to infinity;
NNH = 5 to infinity)
rebleeding weeks 25
(49.0%)		 17
(37.0%)		 25%
(-21% to 53%)		 12.1%
(-7.50% to 31.6%)		 8
(NNT = 13 to infinity;
NNH = 3 to infinity)

Comments

  1. Patients were randomised in blocks of four.

Citation

  1. Triger DR, Johnson AG, Brazier JE, et al: A prospective trial of endoscopic sclerotherapy versus oesophageal transection and gastric devascularisation in the long term management of bleeding oesophageal varices. Gut 1992; 33: 1553-1558
Contributor: Chris Ball and Musab Hayatli, October 1999
Reviewer:

Clinical Question.
Patient first bleed from oesophageal varices
Intervention or Exposure oesophageal transection and gastric devascularisation
Comparison sclerotherapy
Outcome rebleeding, death