The use of endoscopic band ligation in the primary prevention of bleeding in patients with ascites listed in the liver transplantation waiting list

Background. Saving lives and preventing patients from dropping out of the waiting list for liver transplantation due to the progression of portal hypertension and the development of complications is an urgent task of transplantology in conditions of a donor organ shortage, which causes long waiting times for this operation.
Aim. To study the efficacy of endoscopic band ligation versus no intervention in the primary prevention of upper gastrointestinal bleeding and assess the impact on survival of patients with ascites listed in the liver transplantation waiting list.
Material and methods. A retrospective comparative study was conducted in patients with decompensated liver diseases with severe ascites and varicose veins, without a history of bleeding, when included in the waiting list for liver transplantation. Primary prevention of bleeding from varices was carried out in patients by means of endoscopic ligation of varicose veins (n=92, group 1); this intervention was not performed in other patients (n=89, group 2).
Results. The compared groups were comparable in demographics, clinical parameters, MELD and Child-TurcottePugh scores, or the incidence of severe ascites. The study groups of patients did not have significant differences in the numbers of medium-size and large varices. The incidence of bleeding was significantly lower in the group of patients with endoscopic band ligation as a method of primary prevention than in the group of patients without this intervention (23.9% and 78.7%, respectively, p=0.0001). Patient survival was significantly higher in the group of patients who underwent endoscopic band ligation than in the group of patients without interventions, which was established using the Kaplan-Meier method (Log Rank=0.0001).
Conclusion. Primary prevention of bleeding from the upper digestive tract through endoscopic band ligation is an effective method of saving lives and preventing patients with ascites from dropping out of the liver transplantation waiting list in conditions of a donor organ shortageб which causes a long waiting period for surgery.

1. De Franchis R, Bosch J, GarciaTsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII – Renewing consensus in portal hypertension. J Hepatol. 2022;76(4):959–974. PMID: 35120736 https://doi.org/10.1016/j.jhep.2021.12.022

2. D'Amico G, Bernardi M, Angeli P. Towards a new definition of decompensated cirrhosis. J Hepatol. 2022;76(1):202–207. PMID: 34157322 https://doi.org/10.1016/j.jhep.2021.06.018

3. International report on organ donation and transplantation activities. Executive summary. 2018. October, 2020. Available at: https://www.transplant-observatory.org/wp-content/uploads/2020/10/glorep2018-2.pdf [Accessed March 30, 2023].

4. Toniutto P, Zanetto A, Ferrarese A, Burra P. Current challenges and future directions for liver transplantation. Liver Int. 2017;37(3):317–327. PMID: 27634369 https://doi.org/10.1111/liv.13255

5. Russo FP, Izzy M, Rammohan A, Kirchner VA, Di Maira T, Belli LS, et al. Global impact of the first wave of COVID-19 on liver transplant centers: a multi-society survey (EASL-ESOT/ELITA-ILTS). J Hepatol. 2022;76(2):364–370. PMID: 34653592 https://doi.org/10.1016/j.jhep.2021.09.041

6. Gautier SV, Khomyakov SM. Organ donation and transplantation in the Russian Federation in 2021. 14th Report from the Registry of the Russian Transplant Society. Russian Journal of Transplantology and Artificial Organs. 2022;24(3):8–31. (In Russ.). https://doi.org/10.15825/1995-1191-2022-3-8-31

7. Korobka VL, Pasechnikov VD, Korobka RV, Pak ES, Shapovalov AM. Use of endoscopic band ligation alone and in combination with nonselective beta blockers for prevention of variceal bleeding in ascites patients on the liver transplant waiting list. Russian Journal of Transplantology and Artificial Organs. 2022;24(3):42–50. (In Russ.). https://doi.org/10.15825/1995-1191-2022-3-42-50

8. De Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743–752. PMID: 26047908 https://doi.org/10.1016/j.jhep.2015.05.022

9. Esophageal Varices. World Gastroenterology Organisation Global Guidelines. January 2014. World Gastroenterology Organisation; 2013. Available at: https://www.worldgastroenterology.org/guidelines/esophageal-varices/esophagealvarices-english [Accessed March 30, 2023].

10. Moore KP, Wong F, Gines P, Bernardi M, Ochs A, Salerno F, et al. The management of ascites in cirrhosis: report on the consensus conference of the international Ascites club. Hepatology. 2003;38(1):258–266. PMID: 12830009 https://doi.org/10.1053/jhep.2003.50315

11. Leise MD, Kim WR, Kremers WK, Larson JJ, Larson JJ, Benson JT, et al. A revised model for end-stage liver disease optimizes prediction of mortality among patients awaiting liver transplantation. Gastroenterology. 2011;140(7):1952–1960. PMID: 21334338 https://doi.org/10.1053/j.gastro.2011.02.017

12. Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl Clin Surg. 1964;1:1–85. PMID: 4950264

13. Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60(8):646–649. PMID: 4541913 https://doi.org/10.1002/bjs.1800600817

14. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD. The Practice Guidelines Committee of the American Association of the Study of Liver Diseases, The Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology (Baltimore, Md.). 2007;46(3):922–938. PMID: 17879356 https://doi.org/10.1002/hep.21907

15. Carrion AF, Martin P. Keeping patients with end-stage liver disease alive while awaiting transplant: management of complications of portal hypertension. Clin Liver Dis. 2021;25(1):103–120. PMID: 33978573 https://doi.org/10.1016/j.cld.2020.08.007

16. Kovalak M, Lake J, Mattek N, Eisen G, Lieberman D, Zaman A. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc. 2007;65(1):82-88. PMID: 17185084 https://doi.org/10.1016/j.gie.2006.08.023

17. Vadera S, Yong CWK, Gluud LL, Morgan MY. Band ligation versus no intervention for primary prevention of upper gastrointestinal bleeding in adults with cirrhosis and oesophageal varices. Cochrane Database Syst Rev. 2019;6(6):CD012673. PMID: 31220333 https://doi.org/10.1002/14651858

18. Roccarina D, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, et al. Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network metaanalysis. Cochrane Database Syst Rev. 2021;4(4):CD013121. PMID: 33822357 https://doi.org/10.1002/14651858.CD013121.pub2