Does Prophylactic Endoscopic Sclerotherapy Prevent Variceal Bleeding Or Not? A Question of Experimental Design

l/an Thiel, D. H., Dindzans, V. J., Schade, R. R., Rabinovitz, M. and Gavaler, J. S. (1993) Prophylactic versus emer#ency sclerotherapy of lar#e esopha#eal varices prior to liver transplantation. Di#estive Diseases and Sciences; 38 1505-1510 From January 1985 through July 1987, adult patients accepted for liver transplantation with large esophageal varices were enrolled in a study evaluating the use ofprophylactic vs emergency sclerotherapy. Six hundred forty-eight subjects received prophylactic sclerotherapy, and 172 received emergent sclerotherapy. Esophageal stricture formation was increased 12.9-fold (P < 0.001), esophageal perforation 6.4-fold (P < 0.005), and postsclerotherapy bleeding esophageal ulcers 3.7-fold (P < 0.001) in those receiving emergency sclerotherapy as opposed to prophylactic sclerotherapy. These differences were even greater if the number of sclerotherapy sessions rather than the number of patients was used as the denominator for the comparisons. In total, 19.6% of emergency sclerotherapy cases were associated with an untoward outcome of sclerotherapy; only 1.9% of cases receiving prophylactic sclerotherapy experienced an untoward outcome (P < 0.001). These data demonstrate that leinergency sclerotherapy is associated with a greater prevalence of complications and support earlier studies that show that sclerotherapy HPB INTERNATIONAL 155 prevents variceai bleeding over the short term. The data also suggest that when applied to patients with large varices awaiting orthotopic liver transplantation, it enhances the chance of a patient surviving to be transplanted by preventing a variceal bleed and the spiral of liver failure and death that frequently follows an episode of acute variceal bleeding.