Sarin S K, Lamba G S, Kumar M, Misra A, Murthy N S
Department of Gastroenterology, G.B. Pant Hospital, New Delhi, India.
N Engl J Med. 1999 Apr 1;340(13):988-93. doi: 10.1056/NEJM199904013401302.
We compared propranolol therapy and endoscopic ligation for the primary prevention of bleeding from esophageal varices. This prospective, controlled trial included consecutive eligible patients who had large varices (>5 mm in diameter) that were at high risk for bleeding. The patients were assigned to either propranolol therapy, at a dose sufficient to decrease the base-line heart rate by 25 percent, or variceal ligation, to be performed weekly until the varices were obliterated or so reduced in size that it was not possible to continue treatment.
Of the 89 patients, 82 of whom had cirrhosis of the liver, 44 received propranolol and 45 underwent variceal ligation. The mean (+/-SD) duration of follow-up in each group was 14+/-9 and 13+/-10 months, respectively. The mean time required to achieve an adequate reduction in the heart rate was 2.5+/-1.7 days; the mean number of sessions needed to complete variceal ligation was 3.2+/-1.1. After 18 months, the actuarial probability of bleeding was 43 percent in the propranolol group and 15 percent in the ligation group (P=0.04). Twelve patients in the propranolol group and four in the ligation group had bleeding. Three of the four in the ligation group had bleeding before their varices had been obliterated. Nine patients in the ligation group had recurrent varices, a mean of 3.7 months after the initial treatment. Five patients in each group died; bleeding from the varices was the cause of death of four patients in the propranolol group and of three in the ligation group. There were no serious complications of variceal ligation; in the propranolol group, treatment was stopped in two patients because of side effects.
In patients with high-risk esophageal varices, endoscopic ligation of the varices is safe and more effective than propranolol for the primary prevention of variceal bleeding.
我们比较了普萘洛尔治疗与内镜下套扎术对食管静脉曲张出血的一级预防效果。这项前瞻性对照试验纳入了连续符合条件的患者，这些患者有直径大于5毫米的大静脉曲张且出血风险高。患者被分配接受普萘洛尔治疗，剂量要足以使基础心率降低25%，或者接受静脉曲张套扎术，每周进行一次，直到静脉曲张消失或缩小到无法继续治疗。
89例患者中，82例有肝硬化，44例接受普萘洛尔治疗，45例接受静脉曲张套扎术。每组的平均（±标准差）随访时间分别为14±9个月和13±10个月。使心率充分降低所需的平均时间为2.5±1.7天；完成静脉曲张套扎术所需的平均次数为3.2±1.1次。18个月后，普萘洛尔组出血的精算概率为43%，套扎术组为15%（P = 0.04）。普萘洛尔组有12例患者出血，套扎术组有4例患者出血。套扎术组的4例患者中有3例在静脉曲张未消失前就发生了出血。套扎术组有9例患者静脉曲张复发，平均在初始治疗后3.7个月。每组有5例患者死亡；普萘洛尔组有4例患者因静脉曲张出血死亡，套扎术组有3例患者因静脉曲张出血死亡。静脉曲张套扎术没有严重并发症；在普萘洛尔组，有2例患者因副作用而停止治疗。
对于高危食管静脉曲张患者，内镜下静脉曲张套扎术对于静脉曲张出血的一级预防是安全的，且比普萘洛尔更有效。
