Reply: Prophylactic Variceal Ligation Is Not Recommended for Patients Awaiting Live Donor Liver Transplant.

We thank Wai and colleagues1 for their comment on our article.2 Their experience is consistent with ours and different from that reported by Jutabha et al.3 In all 3 studies, the patients were liver transplant candidates and thus constituted a particular subgroup of patients with cirrhosis, as underlined also by Boyer.4 In our opinion, this favors the use of beta-blockers instead of banding for primary prophylaxis for at least 2 reasons. The first, as underlined by Wai et al., is the short follow-up before liver transplantation. In fact, as shown in Fig. 2 of our study, patients treated by ligation can bleed during treatment but not after variceal eradication unless varices recur. In contrast, patients taking beta-blockers present the same risk of bleeding over the same time period. As a result, a possible advantage of banding can be seen only after a long follow-up, which is unlikely in patients awaiting liver transplant as usually this occurs within 1 year. The other reason is that this group of patients is followed up intensively, and this may increase compliance to therapy. The use of beta-blockers does require dose adjustment and trying to maximize the dose tolerated by the patient. The 2 bleeding episodes from postbanding ulcers reported by Wai et al.1 are added to several others that have taken place during prophylactic treatment, including 2 events described in our study. Globally, the reported cases number at least 15, some of which have been fatal. In contrast, beta-blockers for primary prophylaxis of variceal bleeding have not caused fatalities thus far.5 It is difficult to predict which patients are at risk for postbanding ulcer bleeding. Our patients bled 9 and 11 days after the first banding session, respectively. One was Child B7, and the other was Child C14. The patients treated by Wai et al.1 bled 8 and 9 days after the second prophylactic ligation. Shepke et al.6 reported 5 (7%) bleeding episodes from postbanding ulcers, 2 of them fatal. The latter happened 3 and 12 days after the first banding session, respectively. Triantos et al.,7 treating patients unable to take beta-blockers, reported 3 cases of variceal bleeding, all between the first and second prophylactic banding sessions. As most bleeding occurs after the first banding session, we think that longer intervals between sessions, advocated by some authors to overcome this problem,5 would not reduce this risk. In addition and not to be discounted, we found that the costs are reduced to a third when beta-blockers are used with respect to banding for primary prophylaxis in these patients. Thus, nonselective beta-blockers remain the therapy of first choice for primary prophylaxis in liver transplant candidates.