Propranolol versus endoscopic variceal ligation for primary prophylaxis of esophageal varices in cirrhosis: a systematic review and meta-analysis of randomized controlled trials.

Abstract

Background: Several studies have shown similar efficacy between nonselective beta-blockers (NSBBs) and endoscopic variceal ligation (EVL) in preventing esophageal variceal bleeding in cirrhosis. However, the comparative effectiveness between propranolol (PPL) and EVL remains uncertain. This meta-analysis evaluated both strategies.

Methods: PubMed, Embase, and Cochrane Central were searched for randomized-controlled trials (RCTs) comparing PPL and EVL for primary prophylaxis of esophageal variceal bleeding in cirrhotic patients. Outcomes were evaluated using risk ratios (RR) with 95% confidence intervals (CI), and heterogeneity was assessed by the I² statistic. Meta-regressions were conducted based on Child-Pugh classification and presence of ascites. All statistical analyses were performed using RStudio version 4.4.2.

Results: Fourteen RCTs were included, comprising 1345 patients: 664 (49.4%) received EVL and 681 (50.6%) PPL. EVL was more effective in preventing esophageal variceal hemorrhage (RR: 1.40; 95% CI: 1.02-1.91; p = 0.035; I² = 8.5%). No differences were found in variceal bleeding-related deaths (RR: 1.28; 95% CI: 0.76-2.15; p = 0.351; I² = 0%), all-cause mortality (RR: 0.93; 95% CI: 0.76-1.14; p = 0.503; I² = 0%), or in the incidence of adverse events (RR: 1.20; 95% CI: 0.59-2.46; p = 0.612; I² = 84.7%).

Conclusion: EVL was superior in preventing esophageal variceal bleeding. Such results suggest that not all NSBBs provide equivalent efficacy in primary prophylaxis, reinforcing the need for further studies to confirm these findings.