The role of sclerotherapy in the treatment of esophageal varices: personal experience and a review of randomized trials.

Although many more randomized trials will be required to define the role of prophylactic EVS and other therapies (95-99) in the treatment of varices, EVS appears to have a place in the management of varices before they bleed. However, in view of studies recently presented in abstract form (98, 99), it must be stressed that at least in the United States, prophylactic EVS should be restricted to patients in randomized trials. Results from a VA cooperative study (98) led to the conclusion that prophylactic EVS should not be done in male patients with alcoholic cirrhosis and esophageal varices due to excess mortality in the active EVS group (p = 0.009). Although a large number of patients (n = 282) were included into this trial, on the average each of the 12 VA centers treated only 12 patients with EVS. Thus, although investigators were experienced with EVS, a single unforseen problem occurring at each VA center only once could dramatically alter the results of the study. For example, a relatively potent sclerosant solution (45) used in this study may be effective in treating variceal bleeders, but be too toxic and damaging to the esophagus for prophylactic EVS. Also, even though to enter the VA cooperative study, patients were required to have at least three variceal channels, and 89% in the study actually had "large" varices, these "large" varices may not be the same as the "ominous-looking" varices required of the patients in Paquet's study (88, 89, 99). Exactly which subgroups will benefit from each of the various treatments available will be defined as further studies of patients with a high risk of variceal bleeding are completed (95, 99).