Endoscopic variceal ligation bests propranolol in preventing oesophageal variceal bleeding in HCC patients

This randomised trial aimed to address whether endoscopic variceal ligation (EVL) or propranolol (PPL) is more effective at preventing initial oesophageal variceal bleeding (EVB) in patients with hepatocellular carcinoma (HCC). Patients with hepatocellular carcinoma and medium-to-large oesophageal varices (EVs) but without previous oesophageal variceal bleeding were randomised to receive EVL (every 3-4 weeks until variceal eradication) or propranolol (up to 320 mg daily) at a 1:1 ratio. Long-term follow-up data on oesophageal variceal bleeding, other upper gastrointestinal bleeding (UGIB), non-bleeding liver decompensation, overall survival (OS) and adverse events (AEs) were analysed using competing risk regression. Results: Between June 2011 and April 2021, 144 patients were randomised to receive EVL (n=72) or propranolol (n=72). In the endoscopic variceal ligation group, 7 patients experienced oesophageal variceal bleeding, and 30 died; in the propranolol group, 19 patients had oesophageal variceal bleeding, and 40 died. The endoscopic variceal ligation group had a lower cumulative incidence of EVB (Gray's test, p=0.009) than its counterpart, with no mortality difference (Gray's test, p=0.085). For patients with Barcelona Clinic Liver Cancer (BCLC) stage A/B, endoscopic variceal ligation was better than PPL in reducing oesophageal variceal bleeding (p<0.001) and mortality (p=0.003).

For patients beyond Barcelona Clinic Liver Cancer stage B, between-group outcomes were similar. Other upper gastrointestinal bleeding, non-bleeding liver decompensation and AEs did not differ between groups. A competing risk regression model confirmed the prognostic value of endoscopic variceal ligation. Endoscopic variceal ligation is superior to propranolol in preventing initial oesophageal variceal bleeding in patients with hepatocellular carcinoma. The benefits of endoscopic variceal ligation on oesophageal variceal bleeding and OS may be limited to patients with Barcelona Clinic Liver Cancer stage A/B and not to those with Barcelona Clinic Liver Cancer stage C/D.

Reference:

Yang TC, Chen WC, Hou MC, Chen PH, Lee PC, Chang CY, Lu HS, Chen YJ, Hsu SJ, Huang HC, Luo JC, Huang YH, Lee FY. Endoscopic variceal ligation versus propranolol for the primary prevention of oesophageal variceal bleeding in patients with hepatocellular carcinoma: an open-label, two-centre, randomised controlled trial. Gut. 2023 Dec 14:gutjnl-2023-330419. doi: 10.1136/gutjnl-2023-330419. Epub ahead of print. PMID: 38123994.

Keywords:

Endoscopic variceal ligation, propranolol, oesophagus, variceal bleeding, HCC patients, Yang TC, Chen WC, Hou MC, Chen PH, Lee PC, Chang CY, Lu HS, Chen YJ, Hsu SJ, Huang HC, Luo JC, Huang YH, Lee FY, hepatocellular carcinoma; oesophageal varices; portal hypertension