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Prevention of the recurrence of bleeding from oesophageal varices in cirrhosis : Propranolol versus oesophageal clip, a randomized trial
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PREVENTION OF THE RECURRENCE OF BLEEDING FROM OESOPHAGEAL VARICES IN CIRRHOSIS VERSUS OESOPHAGEAL CLIP, A RANDOMIZED TRIAL
: PROPRANOLOL
P.Bories~ M.Ampelas~ B.Feneyrou~ P.Guiry~ J.P.Daures I P.Bauret~ J.B.Prioton~ H.Michel Cllnique des Maladies de l'Appareil Dlgestlf, Chirurgie, D.I.M,, CHR Montpellier (France) In cirrhotic patients in groups A and B of Child's classi~icatlon, a recurrence of oesophageal bleeding has be~n significantly reduced by (a) treatment with propranolol and (b) portal disconnection by an oesophageal clip . The object of the present trial was to compare the efficacy of the two forms of treatment. Patients and methods : The patients included in the trial were randomly selected cirrhotic patients with bleeding from oesophageal varlces confirmed by endoscopy. Patients over 80 years of age or with a contraindication to beta-blocklng agents, were omitted. When oesophageal bleeding had ceased and had been haemodynamically stable for at least 72 hours, the patients were randomly assigned to one of the two treatment groups (propranolol or oesophageal cllp). Child's scoring system was used to estimate the degree of severity of the cirrhosis. The dosage of propranolol, was adjusted to reduce the basal cardiac frequency by 25%. The numerical results were analysed by the Kaplan-Mayer system. Results : 50 cirrhotic patients were included in the trial : 26 in the medical group and 24 in the surgical group, i.e., 39% of the patients admitted to hospital for oesophageal bleeding. No significant differences between the two groups were observed in respect of age, sex, aetiology, size of the varlces, previous bleeding, number of blood transfusions, or waiting time to be included in the trial. After 18 + 14 months, 19 patients in the medical group and 4 patients in the surgical group had a recurrence of oesophageal bleeding. There was a significant difference in the cumulative figures for the two groups for patients having no recurrence of oesophageal bleeding (28% + 9 for the medical group and 77% + for surgical group (p < 0.001). Of the 19 patients in the medical group who had a recurrence of bleeding, 8 died; of the 4 patients in the surgical group who had a recurrence of bleeding, 2 died. There were also four deaths among the patients in the surgical group from post-operatlve causes. Conclusions : i) The use of an oesophageal clip proved to be superior to propranolol in preventing a recurrence of bleeding from oesophageal varices. 2) Neither form of treatment significantly reduced the overall death rate. i . D . Lebrec et coll. NEJM, 1981. 2. J.8. Prioton et coll. SGO, 1986
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MEASUREMENTS OF PORTAL PRESSUREBY HEPATIC VEIN CATHETERISATION ACCURATELY REFLECT THE EFFECTS OF VASOPRESSINON VARICEAL PRESSURE IN CIRRHOSIS. J.Bosch, J.M. Bordas, D.Kravetz, R.Mastai, M.Navasa, G.Silva, J.Chesta, J.C.Garc~a-PagSn, J.Rod~s. Liver Unit. Hospital Cl~nic i P r o v i n c i a l . Barcelona
The b e n e f i c i a l effects of vasopressin in portal hypertension have been usually assessed by i n d i r e c t measurements of portal pressure by hepatic vein c a t h e t e r i s a t i o n . However, i t is uncertain to what extent measurements of wedged and free hepatic venous pressures (WHVP and FHVP) adequately r e f l e c t the changes occurring at the oesophageal varices. The present study addressed t h i s question in a series of I I alcoholic c i r r h o t i c s undergoing therapeutic sclerotherapy by measuring simultaneously WHVP, i n t r a v a r i c e a l pressure (IVP, variceal puncture), FHVP, superior vena cava pressure (SVCP), and the intravascular pressure gradients WHVP-FHVP and IVP-SVCP p r i o r and a f t e r the i n j e c t i o n of vasopressin (I U i v ) . Vasopressln caused a s i g n i f i c a n t reduction in portal and variceal pressures, as shown by the f a l l in WHVP (from 28.6+2.7 to 24.0+2.3 mmHg, p
S13
PREVENTION OF THE RECURRENCE OF BLEEDING FROM OESOPHAGEAL VARICES IN CIRRHOSIS VERSUS OESOPHAGEAL CLIP, A RANDOMIZED TRIAL
: PROPRANOLOL
P.Bories~ M.Ampelas~ B.Feneyrou~ P.Guiry~ J.P.Daures I P.Bauret~ J.B.Prioton~ H.Michel Cllnique des Maladies de l'Appareil Dlgestlf, Chirurgie, D.I.M,, CHR Montpellier (France) In cirrhotic patients in groups A and B of Child's classi~icatlon, a recurrence of oesophageal bleeding has be~n significantly reduced by (a) treatment with propranolol and (b) portal disconnection by an oesophageal clip . The object of the present trial was to compare the efficacy of the two forms of treatment. Patients and methods : The patients included in the trial were randomly selected cirrhotic patients with bleeding from oesophageal varlces confirmed by endoscopy. Patients over 80 years of age or with a contraindication to beta-blocklng agents, were omitted. When oesophageal bleeding had ceased and had been haemodynamically stable for at least 72 hours, the patients were randomly assigned to one of the two treatment groups (propranolol or oesophageal cllp). Child's scoring system was used to estimate the degree of severity of the cirrhosis. The dosage of propranolol, was adjusted to reduce the basal cardiac frequency by 25%. The numerical results were analysed by the Kaplan-Mayer system. Results : 50 cirrhotic patients were included in the trial : 26 in the medical group and 24 in the surgical group, i.e., 39% of the patients admitted to hospital for oesophageal bleeding. No significant differences between the two groups were observed in respect of age, sex, aetiology, size of the varlces, previous bleeding, number of blood transfusions, or waiting time to be included in the trial. After 18 + 14 months, 19 patients in the medical group and 4 patients in the surgical group had a recurrence of oesophageal bleeding. There was a significant difference in the cumulative figures for the two groups for patients having no recurrence of oesophageal bleeding (28% + 9 for the medical group and 77% + for surgical group (p < 0.001). Of the 19 patients in the medical group who had a recurrence of bleeding, 8 died; of the 4 patients in the surgical group who had a recurrence of bleeding, 2 died. There were also four deaths among the patients in the surgical group from post-operatlve causes. Conclusions : i) The use of an oesophageal clip proved to be superior to propranolol in preventing a recurrence of bleeding from oesophageal varices. 2) Neither form of treatment significantly reduced the overall death rate. i . D . Lebrec et coll. NEJM, 1981. 2. J.8. Prioton et coll. SGO, 1986
22
MEASUREMENTS OF PORTAL PRESSUREBY HEPATIC VEIN CATHETERISATION ACCURATELY REFLECT THE EFFECTS OF VASOPRESSINON VARICEAL PRESSURE IN CIRRHOSIS. J.Bosch, J.M. Bordas, D.Kravetz, R.Mastai, M.Navasa, G.Silva, J.Chesta, J.C.Garc~a-PagSn, J.Rod~s. Liver Unit. Hospital Cl~nic i P r o v i n c i a l . Barcelona
The b e n e f i c i a l effects of vasopressin in portal hypertension have been usually assessed by i n d i r e c t measurements of portal pressure by hepatic vein c a t h e t e r i s a t i o n . However, i t is uncertain to what extent measurements of wedged and free hepatic venous pressures (WHVP and FHVP) adequately r e f l e c t the changes occurring at the oesophageal varices. The present study addressed t h i s question in a series of I I alcoholic c i r r h o t i c s undergoing therapeutic sclerotherapy by measuring simultaneously WHVP, i n t r a v a r i c e a l pressure (IVP, variceal puncture), FHVP, superior vena cava pressure (SVCP), and the intravascular pressure gradients WHVP-FHVP and IVP-SVCP p r i o r and a f t e r the i n j e c t i o n of vasopressin (I U i v ) . Vasopressln caused a s i g n i f i c a n t reduction in portal and variceal pressures, as shown by the f a l l in WHVP (from 28.6+2.7 to 24.0+2.3 mmHg, p
S13