Endoscopic variceal ligation bests propranolol in preventing oesophageal variceal bleeding in HCC patients

This randomised trial aimed to address whether endoscopic variceal ligation (EVL) or propranolol (PPL) is more effective at preventing initial oesophageal variceal bleeding (EVB) in patients with hepatocellular carcinoma (HCC). Patients with hepatocellular carcinoma and medium-to-large oesophageal varices (EVs) but without previous oesophageal variceal bleeding were randomised to receive EVL (every 3-4 weeks until variceal eradication) or propranolol (up to 320 mg daily) at a 1:1 ratio. Long-term follow-up data on oesophageal variceal bleeding, other upper gastrointestinal bleeding (UGIB), non-bleeding liver decompensation, overall survival (OS) and adverse events (AEs) were analysed using competing risk regression. Results: Between June 2011 and April 2021, 144 patients were randomised to receive EVL (n=72) or propranolol (n=72). In the endoscopic variceal ligation group, 7 patients experienced oesophageal variceal bleeding, and 30 died; in the propranolol group, 19 patients had oesophageal variceal bleeding, and 40 died. The endoscopic variceal ligation group had a lower cumulative incidence of EVB (Gray's test, p=0.009) than its counterpart, with no mortality difference (Gray's test, p=0.085). For patients with Barcelona Clinic Liver Cancer (BCLC) stage A/B, endoscopic variceal ligation was better than PPL in reducing oesophageal variceal bleeding (p<0.001) and mortality (p=0.003).