The quality of evidence is downgraded by study limitations (unclear allocation concealment).
A Cochrane review [Abstract] 1 included 19 trials with a total of 1508 patients to compare the benefits and harms of banding ligation (averagely 2 - 3 procedures per patient) versus non-selective beta-blockers as primary prevention in adult patients with endoscopically verified oesophageal varices that have never bled, irrespective of the underlying liver disease (cirrhosis or other cause; the majority of the patients had non-alcoholic liver disease). In most trials only patients with large or high-risk oesophageal varices were included. In 17 trials propranolol was used and in 1 trial each nadolol or carvedilol.
731 patients were randomized to banding ligation and 773 to non selective beta-blockers. The summary of main outcomes is presented in table 1.
| Outcome | Number of participants (trials) | Intervention(Banding ligation) | Control(Beta-blockers) | Effect size (95 % CI) |
|---|---|---|---|---|
| Mortality | 1508(19) | 176/731(24%) | 177/773(23%) | RR 1.09(0.92 to 1.30) |
| Variceal bleeding | 1201 (15) | 75/590(13%) | 112/611(19%) | RR 0.67(0.46 to 0.98) |
| Upper gastrointestinal bleeding | 1508(19) | 103/731(14%) | 158/773(20%) | RR 0.69(0.52 to 0.91) |
| Bleeding-related mortality | 1152 (13) | 29/567(5.1%) | 37/585(6.3%) | RR 0.85(0.53 to 1.39) |
For mortality, there was no difference between banding ligation and non-selective beta-blockers In trials with a low risk of selection bias (RR 1.18; 95% CI 0.95 to 1.47, 3 trials) or an unclear risk of selection bias (RR 0.96; 95% CI 0.72 to 1.28). The beneficial effect of banding ligation on bleeding was not confirmed in subgroup analyses of trials with adequate randomisation or full paper articles (RR 0.84; 95% CI 0.53 to 1.33). The results of trials with less than 20 months of follow-up found a better effect of banding ligation compared to trials with longer follow-up.
Beta-blockers may have other than bleeding-related beneficial effects on mortality.
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