Recurrence of Upper Gastrointestinal Hemorrhage in Sclerotherapy X Elastic Ligature: Systematic Review

Upper gastrointestinal bleeding is an important medical emergency, with a high rate of morbidity and lethality [1]. Over the past few years, a significant evolution in the methods and techniques available has been observed. Endoscopic therapy, whether with elastic ligation or sclerotherapy, is the most indicated for the management of upper gastrointestinal bleeding and for post-bleeding treatment [2]. However, both techniques have advantages and disadvantages, as well as different statistics about the likelihood of recurrences and rebleeds. This complication is conceptualized as gastrointestinal bleeding proximal to the Treitz angle, which has an increasing incidence due to the aging of the population and its comorbidities [3]. In addition, the causes of upper gastrointestinal bleeding may be due to non-varicose factors, or bleeding from esophageal varices, with a total of 80% of cases resulting from the first type mentioned [3].

Although the mortality rate from upper gastrointestinal bleeding has declined over the years, as a result of the implementation of several more effective treatment and care modalities, its mortality rates still reach the 20% range in up to 6 weeks [2]. The rate of a first episode of bleeding from varicose veins is 5-15% in 1 year and its risk is defined by the size of the varicose veins, presence of red signs, severity of liver disease and continuous alcohol intake. Among the prognostic factors, the size of the varicose vein is the most important, and the larger the caliber, the greater the risk of bleeding [2]. In view of these previous considerations, the objective of the present study was to compare, through a systematic review, the recurrence of upper digestive hemorrhage in the sclerotherapy and elastic ligation techniques.

The most relevant studies originally published in the English language were analyzed, from 2003 to 2018, using the MEDLINE, Lilacs, SciELO databases as a reference. In order to select the studies with the greatest scientific evidence, only controlled and randomized controlled trials (ECCR) were identified, identified by previous reviews, and whose scope was updated and revised, in addition to systematic reviews with or without meta-analysis. The search strategy used the following keywords: sclerotherapy; elastic bandage and upper gastrointestinal bleeding. The inclusion and exclusion criteria were applied based on the types of studies, language, type of therapy and date of publication from the points raised in each item exposed (Chart 1). For the selection of studies, the inclusion and exclusion criteria presented in Table 1 were applied.

Table 1:Inclusion and exclusion criteria applied in the selection of studies.

Table 2:Summary of studies and their main results.

By crossing the keywords sclerotherapy, elastic ligation and upper gastrointestinal bleeding, it was possible to obtain an initial sample of 9 articles. However, after applying the Randomized Controlled Trial and Clinical Trials filters and after reading the articles found, 6 articles were selected involving the theme and which were then part of the final sample. In Table 1 we will present a summary of the works selected and reviewed in the present study.

Through this study, we sought to compare the recurrence of upper gastrointestinal bleeding in the sclerotherapy and elastic ligation techniques, pointing out the consensus that exists on this topic in national and international literature. What are the risks of each of these techniques? Which is more prone to recurrences and what are the advantages and limitations of each one in particular? Analyzing the results obtained through the bibliographic survey, it was possible to observe that both techniques have important advantages and are perfectly indicated. However, in short, the literature allows us to conclude that the technique considered the gold standard for these cases is the technique of elastic ligation, which is the one with the lowest risk of recurrences in comparison to the sclerotherapy technique, although many professionals still choose to use the technique of sclerotherapy, especially in surgical intervention in pediatric patients. This finding was evident in several of the most recent studies that highlighted the fact that sclerotherapy is a pioneering technique in this type of intervention, and although it is still widely used, its usefulness has fallen a lot since the appearance and improvement of the technique of elastic ligation. Sclerotherapy was the first option available, in terms of technique, to be used in these cases. However, over the years and with the evolution of available techniques and materials, the technique of elastic ligation started to gain its space and is currently recommended as being the gold standard in these cases [2, 3].

Guidoux, et al. [7] who added that, after the advent of elastic ligation, the preference for sclerotherapy has been revised, since, in the authors’ view, elastic ligation has lower rates of morbidity. Also, according to Guidoux, et al. [7] over the years, the elastic bandage has been replaced, representing, in the survey carried out in a hospital unit by these authors, a total of 76% of the cases in which surgical intervention related to upper gastrointestinal bleeding was required. However, in many situations, the use of sclerotherapy is still highly recommended, considering the advantages attributed by many to this technique. Specifically analyzing the issue of the occurrence of recurrences, it was possible to observe that most of the studies listed here presented data on this topic, a topic of great importance when talking about rehabilitation in these cases. Thus, the analyzed literature presented several studies comparing the occurrence of recurrences between both techniques. It was possible to observe that, in general, the results showed that the technique of elastic ligation is the most used and considered the one of choice when it comes to prevention of cases of variceal bleeding. However, there was no consensus on which technique can be considered the most effective when the theme is the prevention of the occurrence of recurrences.

In the study by Zanette, et al. [6], the authors stated that elastic ligation of esophageal varices is as effective as sclerotherapy itself, but also highlighted that the technique of elastic ligation is the one that most presented, according to the literature review, a higher frequency of recurrences. than the sclerotherapy technique. Among the studies that pointed to a higher risk of recurrence in the elastic ligation technique is Santos8, which obtained a rate of recurrence and greater complications in the elastic ligation technique compared to the cyanoacrylate injection technique. Also, in the study by Leal, et al, [19] in their study they observed that the rate of rebleeding after elastic ligation was common in 18.2%. It was also possible to observe that the patients who had recurrences were also the ones who had a high mortality rate. Otherwise, some authors have pointed out that there are no differences between the results obtained, in terms of recurrence, in the use of the technique of elastic ligation and sclerotherapy. This was evident in the study by Luz [9] who found similar results, which suggest that sclerosis and elastic ligation are equally effective in controlling acute variceal hemorrhage.

Now analyzing the results obtained with the sclerotherapy technique in terms of recurrences, it was possible to observe that some authors defended this technique as the safest and with the lowest risk of recurrences. This was observed in the study by Santos, et al. [13] who stated that this technique is the most used in children due to its safety and effectiveness, and that the risk of new episodes of upper gastrointestinal bleeding is low (0 to 11.9%), being the most cases from gastric varices or duodenal ulcer. Another advantage of this technique is the fact that it presents a low risk of serious complications, although mild reactions have been frequently reported. Also, in the study by Batista-Neto, et al. [14], sclerotherapy was performed on 30 patients, with a recurrence rate of 16.7%. To our understanding, analyzing the recurrence rates of the studies by Batista-Neto, et al. [14], who evaluated the relapse in sclerotherapy, and the study by Leal, et al. [19] who evaluated the rate in cases of elastic ligation, were very similar, reaching 16.7 % and 18.2% respectively. In the study by Pimenta, et al. [23], which was carried out with 85 patients, the authors observed that rebleeding was more frequent in patients undergoing sclerotherapy, reaching 42.3% in relation to the group submitted to elastic ligation, which reached 26.5%.

It is also noteworthy that the occurrence of upper gastrointestinal bleeding represents an important medical emergency, which requires immediate hospitalization and specialized intervention, in view of the risk of death. Initially analyzing the mortality rate of this type of pathology, according to the vision of Luz, et al. [2], this complication can present a rate of up to 20% of mortality, with a period of up to 6 weeks after the occurrence of the event. The occurrence of these cases has been associated with population aging in agreement with the comorbidities associated with it [3]. Studies have pointed out that the risks will depend on the severity and size of the varicose vein and the size of the varicose vein is still a factor considered essential in order to have a definition of the prognosis of each case [2]. In view of its risks, it is known that the therapeutic options in these cases are quite restricted. Therefore, in these situations, surgical intervention is recommended especially in those cases where treatment and endoscopic retreatment are not effective, according to Lourenço and Oliveira [5].

Therefore, in view of all the results obtained, we consider that it is not possible to present a definitive position as to which technique - sclerotherapy or elastic ligation - is the most effective in preventing recurrences in upper gastrointestinal bleeding. We also consisder that the evidence indicates that the sclerotherapy technique has been advocated as safer for pediatric patients, but that the technique of elastic ligation is considered the gold standard for cases of upper gastrointestinal bleeding in general, being preferred by a wide variety of professionals trained to carry out such intervention.

In view of the results found, there is no definitive consensus on which technique - sclerotherapy or elastic ligation - could be associated with a lower risk of recurrences in cases involving upper gastrointestinal bleeding. The literature points out advantages both in the sclerotherapy technique and in the technique of elastic ligation, and, in general, it is currently observed that the technique considered the gold standard for these cases is the technique of elastic ligation, although many professionals still opt for the use of sclerotherapy, especially in surgical intervention in pediatric patients.

None.

No conflict of interest.

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