Meta-analysis: endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding M. S. KHUROO*, N. S. KHUROO  , K. L. C. FARAHAT*, Y. S. KHUROO à , A. A. SOFI§ & S. T. DAHAB* Departments of *Medicine and  Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; àSri-Ramachandra Medical College and Research Institute, Porur, Chennai, India; §Riyadh Medical Complex, Riyadh, Saudi Arabia Accepted for publication 27 November 2004 SUMMARY Background: The treatment effects of primary prophy- lactic endoscopic variceal ligation are unclear. Aim: To compare the treatment effects of endoscopic variceal ligation and b-blockers for primary prophylaxis of oesophageal variceal bleeding. In addition, a sub- group analysis was done with the purpose to delineate differences in the effects of intervention that were biologically based. Methods: We performed a literature search for rand- omized controlled trials, which compared the treat- ment effects of endoscopic variceal ligation with b-blockers for primary prophylaxis of oesophageal variceal bleeding. Of the 955 articles screened, eight randomized-controlled trials including 596 subjects (285 with endoscopic variceal ligation and 311 with b-blockers) were analysed. Outcomes measures evalu- ated were first gastrointestinal bleed, first variceal bleed, all-cause deaths, bleed-related deaths and severe adverse events. The measure of association employed was relative risk; with heterogeneity and sensitivity analyses. Results: Variceal obliteration was obtained in 261 (91.6%) patients and target b-blockers therapy was achieved in 294 (94.5%) patients (P ¼ 0.19). Endo- scopic variceal ligation compared with b-blockers significantly reduced rates of first gastrointestinal bleed by 31% (RR, 0.69; 95% CI: 0.49–0.96; P ¼ 0.03; NNTB ¼ 15) and first variceal bleed by 43% (RR, 0.57; 95% CI: 0.38–0.85; P ¼ 0.0067; NNTB ¼ 11). All- cause deaths and bleed-related deaths were unaffected (RR, 1.03; 95% CI: 0.79–1.36; P ¼ 0.81 and RR, 0.84; 95% CI: 0.44–1.61; P ¼ 0.60 respectively). Severe adverse events were significantly less in endoscopic variceal ligation compared with b-blockers (RR, 0.34; 95% CI: 0.17–0.69; P ¼ 0.0024; NNTB ¼ 28). Sensi- tivity analysis of five trials published in peer review journals and four trials with high quality showed results similar to those seen in the primary analysis of all the eight trials, confirming stability of conclusions. Follow- ing variceal obliteration with endoscopic variceal liga- tion, oesophageal varices recurred in 83 (29.1%) patients. Seven (28.1%) patients bled with one fatal outcome. In subgroup analyses, endoscopic variceal ligation had significant advantage compared wtih b-blockers in trials including £ 30% patients with alcoholic cirrhosis, >30% patients with Child Class C cirrhosis and >50% patients with large varices. Conclusions: In patients with cirrhosis with moderate to large varices and who have not bled, endoscopic varices ligation compared with b-blockers significantly reduced bleeding episodes and severe adverse events, but had no effect on mortality. INTRODUCTION In patients with cirrhosis, the prevalence of oesopha- geal varices is 60% and the risk of gastrointestinal Correspondence to: Dr M. S. Khuroo, PO Box 3354, MBC 46, Riyadh 11211, Saudi Arabia. E-mail: khuroo@yahoo.com Aliment Pharmacol Ther 2005; 21: 347–361. doi: 10.1111/j.1365-2036.2005.02346.x Ó 2005 Blackwell Publishing Ltd 347