Documento de consenso de la Sociedad Española de Endoscopia Digestiva sobre SpyGlass-DS / SEED Consensus Document on SpyGlass-DS

La colangiopancreatografía retrógrada endoscópica (CPRE) es la técnica de elección para el tratamiento de la patología biliopancreática. Sin embargo, las imágenes fluoroscópicas no siempre permiten un diagnóstico adecuado. Por otra parte, algunos cálculos de gran tamaño no se pueden extraer con los métodos habituales. En estas situaciones, la colangioscopia ha mostrado ser una herramienta fundamental para el diagnóstico de las estenosis biliares y el tratamiento de los cálculos de gran tamaño. Además, su papel en la patología pancreática está en creciente aumento. El desarrollo de un colangioscopio de un único operador y desechable ha permitido expandir la técnica entre buena parte de los hospitales que realizan CPRE. Por este motivo, la Sociedad Española de Endoscopia Digestiva ha desarrollado este documento de consenso sobre la utilización del colangioscopio Spyglass-DS. El documento ha sido elaborado por un grupo de endoscopistas expertos en colangioscopia, revisando la evidencia científica de las principales indicaciones actuales de la colangiopancreatoscopia.(AU)

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.(AU)

SEED Consensus Document on SpyGlass-DS. / Documento de consenso de la Sociedad Española de Endoscopia Digestiva sobre SpyGlass-DS.

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.

CHOLANGIOPANCREATOSCOPY. WORKING PROTOCOL. SEED Recommendations.

Direct endoscopic visualization of biliary and pancreatic ducts represents one step further in the journey of digestive endoscopy. It allows the identification of lesions that were previously attainable through indirect means. Directed biopsy taking has permitted a better characterization of the lesions. The use of power sources through the cholangiopancreatoscope means that it is now possible to fragment and remove refractory lithiases using traditional endoscopic systems. This document aims to define the advisable workflow when using a single-use, flexible cholangiopancreatoscope with the commercial name of SpyGlass®. Penning a set of guidelines to provide instructions on the technique, as well as tips and tricks related with the operation of these endoscopes will be a useful resource.

Dexmedetomidina subcutánea. ¿Es útil en el perioperatorio del paciente pediátrico? / Subcutaneous dexmedetomidine. Is it useful in the perioperative of the pediatric patient?

Resumen: Introducción: La dexmedetomidina es un alfa 2 agonista, al cual se le han atribuido diversos efectos clínicos (antinociceptivos, hipnótico-sedantes, anestésicos, cardiovasculares, ventilatorios, renales, endocrinos y oculares), variados mecanismos de acción, y versatilidad en sus vías de administración, por lo que ha sido utilizada como adyuvante durante el período perioperatorio, ya que proporciona sedación, ansiólisis, prevención de delirio y analgesia. En este estudio, se evaluó exclusivamente la administración subcutánea como adyuvante, sus implicaciones sobre el dolor y la comodidad en el postoperatorio. Material y métodos: Se realizó una serie de casos de forma prospectiva, observacional, descriptiva, en donde se estudiaron pacientes de 3-15 años de edad, de ambos géneros, programados para cirugía de abdomen bajo, ASA I-II. Se dividieron en cuatro grupos: grupo I recibió placebo; II, III y IV clorhidrato de dexmedetomidina de 1, 1.5 y 2 μg/kg, respectivamente. El placebo o clorhidrato de dexmedetomidina se administraron vía subcutánea en región deltoidea. En el postoperatorio inmediato se tomaron en cuenta, por única vez, la escala de sedación, delirio y confort, para valorar durante la emersión el impacto de la dosis de dexmedetomidina. Después se realizó la medición y registro en tres tiempos distintos de los parámetros hemodinámicos (TA, FC, SpO2), así como la intensidad del dolor; la primera al finalizar el procedimiento quirúrgico, a las 12 y a las 24 horas. Conclusiones: La administración subcutánea de dexmedetomidina en el paciente pediátrico es una alternativa segura y eficaz, que preserva la función respiratoria, con adecuado grado de sedación, y estabilidad hemodinámica, mejorando la analgesia (hasta 24 horas) posterior al evento quirúrgico, menor agitación y delirio en el postoperatorio, lo que resulta en mayor comodidad.

Abstract. Introduction: Dexmedetomidine is an alpha 2 agonist, several clinical effects has been attributed (antinociceptive, hypnotic-sedative, anesthetic, cardiovascular, ventilatory, renal, endocrine and ocular), varied mechanisms of action, and versatility in its administration pathways. It has been used as adjuvant during the perioperative period providing sedation, anxiolysis, delirium prevention and analgesia. In this study we evaluated exclusively subcutaneous administration as an adjuvant, its implications on pain and postoperative comfort (PO). Material and methods: A prospective, observational, descriptive series of cases was performed. Patients 3-15 years of age, scheduled for low abdominal surgery, both genders, ASA I, II. They were divided into four groups: Group I. placebo, group II, III and IV received dexmedetomidine hydrochloride 1, 1.5 and 2 μg/kg respectively. The placebo or dexmedetomidine hydrochloride was administered subcutaneously in the deltoid region. The sedation, delirium and comfort scale were titrated in the immediate postoperative PO to assess the impact of the dose of dexmedetomidine during the emersion. Subsequently, three evaluations of the hemodynamic parameters (TA, FC, SpO2) were performed, as well as the intensity of the pain, the first one at the end of the surgical procedure, 12 and at 24 hours later. Conclusions: Subcutaneous administration of dexmedetomidine in the pediatric patient is a safe and effective alternative, preserving respiratory function, with adequate sedation, hemodynamic stability, improving analgesia (up to 24 hours) after the surgical event, less agitation and delirium in the postoperative resulting in greater comfort.

Sedoanalgesia en neonato a base de remifentanyl. En relación con un caso para epiglotopexia / Sedoanalgesia in neonate based on remifentanyl. In relation to a case for epiglottopexy

Resumen: La etapa neonatal comprende del primer día hasta el día 28 de vida. Se caracteriza por ser una etapa de inmadurez anatómica, fisiológica y metabólica. Por estas características del neonato, los fármacos anestésicos impactan de manera importante en su fisiología respiratoria y cardiovascular; además la farmacocinética se ve modificada por esta inmadurez. La laringomalacia es una de las principales causas de estridor en esta etapa, misma que, dependiendo de la severidad puede requerir manejo quirúrgico, siendo una opción la epiglotopexia. Dicho procedimiento requiere analgesia potente y a su vez la posibilidad de mantener la ventilación espontánea para su adecuada evaluación, mismas que pueden ser alcanzadas con el uso de remifentanyl. Presentamos el caso clínico de un neonato de término de 22 días de vida a quien se le administró remifentanyl como base de la sedoanalgesia para realización de epiglotopexia de manera exitosa. Su potencia analgésica, capacidad de mantener el automatismo ventilatorio y la farmacocinética predecible en el neonato, convierten al remifentanyl en un agente ideal para proporcionar adecuada sedoanalgesia para diferentes procedimientos con un perfil de fácil titulación y de recuperación rápida en el neonato.

Abstract. The neonatal stage comprises from the first day of birth until day 28 of life. It is characterized by being a stage of anatomical, physiological and metabolic immaturity. Due to these characteristics of neonates, anesthetic drugs have an important impact on their respiratory and cardiovascular physiology, and their immaturity on pharmacokinetics. Laryngomalacia is one of the main causes of stridor in this stage, which depending on its severity could require surgical treatment, such as an epiglotopexy. This procedure requires potent analgesia and at the same time the possibility of maintaining spontaneous ventilation for its appropriate evaluation. This can be achieved with the use of remifentanyl. We present the clinical case of a term neonate of 22 days of age who we administered Remifentanyl as the basis of sedoanalgesia for the successful completion of an epiglotopexy. Its analgesic potency, ability to maintain ventilatory automatism and predictable pharmacokinetics in the neonate, makes it an ideal agent to provide adecuate sedoanalgesia for different procedures with an easy titration profile and rapid recovery in the neonate.

Experimental study of hybrid-knife endoscopic submucosal dissection (ESD) versus standard ESD in a Western country.

BACKGROUND: Endoscopic submucosal dissection (ESD) is an effective but time-consuming treatment for early neoplasia that requires a high level of expertise. OBJECTIVE: The objective of this study was to assess the efficacy and learning curve of gastric ESD with a hybrid knife with high pressure water jet and to compare with standard ESD. MATERIAL AND METHODS: We performed a prospective non survival animal study comparing hybrid-knife and standard gastric ESD. Variables recorded were: Number of en-bloc ESD, number of ESD with all marks included (R0), size of specimens, time and speed of dissection and adverse events. Ten endoscopists performed a total of 50 gastric ESD (30 hybrid-knife and 20 standard). RESULTS: Forty-six (92 %) ESD were en-bloc and 25 (50 %) R0 (hybrid-knife: n = 13, 44 %; standard: n = 16, 80 %; p = 0.04). Hybrid-knife ESD was faster than standard (time: 44.6 +/- 21.4 minutes vs. 68.7 +/- 33.5 minutes; p = 0.009 and velocity: 20.8 +/- 9.2 mm(2)/min vs. 14.3 +/- 9.3 mm(2)/min (p = 0.079). Adverse events were not different. There was no change in speed with any of two techniques (hybrid-knife: From 20.33 +/- 15.68 to 28.18 +/- 20.07 mm(2)/min; p = 0.615 and standard: From 6.4 +/- 0.3 to 19.48 +/- 19.21 mm(2)/min; p = 0.607). The learning curve showed a significant improvement in R0 rate in the hybrid-knife group (from 30 % to 100 %). CONCLUSION: despite the initial performance of hybrid-knife ESD is worse than standard ESD, the learning curve with hybrid knife ESD is short and is associated with a rapid improvement. The introduction of new tools to facilitate ESD should be implemented with caution in order to avoid a negative impact on the results.

Experimental study of hybrid-knife endoscopic submucosal dissection (ESD) versus standard ESD in a Western country / Estudio experimental sobre disección submucosa endoscópica con bisturí híbrido frente a la ESD estándar en un país occidental

Background: Endoscopic submucosal dissection (ESD) is an effective but time-consuming treatment for early neoplasia that requires a high level of expertise. Objective: The objective of this study was to assess the efficacy and learning curve of gastric ESD with a hybrid knife with highpressure water jet and to compare with standard ESD. Material and methods: We performed a prospective nonsurvival animal study comparing hybrid-knife and standard gastric ESD. Variables recorded were: Number of en-bloc ESD, number of ESD with all marks included (R0), size of specimens, time and speed of dissection and adverse events. Ten endoscopists performed atotal of 50 gastric ESD (30 hybrid-knife and 20 standard). Results: Forty-six (92 %) ESD were en-bloc and 25 (50 %) R0 (hybrid-knife: n = 13, 44 %; standard: n = 16, 80 %; p = 0.04).Hybrid-knife ESD was faster than standard (time: 44.6 ± 21.4 minutes vs. 68.7 ± 33.5 minutes; p = 0.009 and velocity: 20.8 ± 9.2 mm2/ min vs. 14.3 ± 9.3 mm2/min (p = 0.079). Adverse events were not different. There was no change in speed with any of two techniques (hybrid-knife: From 20.33 ± 15.68 to 28.18 ± 20.07 mm2/min; p= 0.615 and standard: From 6.4 ± 0.3 to 19.48 ± 19.21 mm2/min; p = 0.607). The learning curve showed a significant improvement in R0 rate in the hybrid-knife group (from 30 % to 100 %). Conclusion: despite the initial performance of hybrid-knife ESD is worse than standard ESD, the learning curve with hybridknife ESD is short and is associated with a rapid improvement. The introduction of new tools to facilitate ESD should be implemented with caution in order to avoid a negative impact on the results (AU)

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Disección submucosa endoscópica. Guía de práctica clínica de la SEED / Endoscopic submucosal dissection. Sociedad Española de Endoscopia Digestiva (SEED) clinical guideline

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Evaluación de la implantación de las indicaciones y niveles de prioridad del Servizo Galego de Saude para la colonoscopia en pacientes sintomáticos: estudio prospectivo y transversal / Evaluation of the implementation of Galician Health Service indications and priority levels for colonoscopy in symptomatic patients: prospective, cross-sectional study

Introducción: el Servizo Galego de Saúde estableció indicaciones y niveles de prioridad de la colonoscopia (I-vía rápida, II-preferente, III-normal) acorde al riesgo de detectar cáncer colorrectal y lesiones colónicas significativas con acceso desde atención primaria. Nuestro objetivo es analizar los resultados de la implantación. Métodos: estudio prospectivo transversal y observacional. Se incluyeron las colonoscopias solicitadas entre julio y octubre de 2012 en pacientes sintomáticos. Se recogió el nivel asistencial solicitante (especializada o primaria), nivel de prioridad, adecuación a los criterios establecidos, tiempos de demora (solicitud y consulta inicial) y rendimiento diagnóstico para cáncer colorrectal y/o lesión colónica significativa. Se compararon los niveles asistenciales en las prioridades I y II. Resultados: se incluyeron 425 colonoscopias (I = 221, II = 141, III = 63) con una adecuación al protocolo del 67.5 %. Los niveles de prioridad se relacionaron significativamente con los tiempos de demora (días) desde la solicitud (I = 8,7 ± 8,9, II = 50 ± 20,3, III = 80,2 ± 32,2; p < 0,001) y la consulta inicial (I = 32,2 ± 38, II = 74,5 ± 44,2, III = 128,5 ± 47,4; p > 0,001); y con la tasa detección de cáncer colorrectal (I = 20,1 %, II = 19,1 %, III = 4,8 %; p < 0,001) y lesión colónica significativa (I = 35,3 %, II = 34 %, III = 19 %; p = 0,002). En las colonoscopias solicitadas con prioridad I y II desde primaria (21,8 %), la demora desde la consulta inicial fue inferior (primaria = 29,3 ± 26, especializada = 55,2 ± 48,6; p < 0,001) y se detectó más cáncer colorrectal (OR 2,41, IC 95 % 1,31-4,42) y lesión colónica significativa (OR 1,88, IC 95 % 1,13-3,15). Conclusiones: los niveles de prioridad se asocian significativamente con la detección de cáncer colorrectal y lesión colónica significativa. El acceso a la colonoscopia desde primaria reduce los tiempos de demora e incrementa el rendimiento diagnóstico (AU)

Background: the Galician Health Service established indications and priority levels (I = fast track, II = preferential, III = normal) for colonoscopy, according to the risk of colorectal cancer and significant colonic lesions detection with access from primary health care. Our aim is to show the results of the implementation. Methods: we included colonoscopies requested in symptomatic patients from June to October 2012 in a prospective observational cross sectional study. We collected health care level (primary, secondary),priority, appropriateness to the established criteria, wait times (from colonoscopy application and initial consultation) and diagnostic yield for colorectal cancer and/or significant colonic lesion. We compared health care levels in priorities I and II. Results: 425 colonoscopies were included (I = 221, II = 141, III = 63). The appropriateness rate to the protocol was 67.5 %. Priority levels were significantly associated to wait times (days) from application (I = 8.7 ± 8.9, II = 50 ± 20.3, III = 80.2 ± 32.2; p <0.001) and initial consultation (I = 32.2 ± 38, II = 74.5 ± 44.2, III = 128.5 ± 47.4; p < 0.001), and with colorectal cancer (I = 20.1 %, II = 19.1 %, III = 4.8 %, p < 0.001) and significant colonic lesion (I = 35.3 %, II = 34 %, III = 19 %, p = 0.002) detection rates. In priority I and II, 21.8 % of colonoscopies were requested from primary health care. Referral form primary health care reduced wait times from initial consultation to colonoscopy (primary = 29.3 ± 26, secondary = 55.2 ± 48.6, p < 0.001). Instead, colorectal cancer (OR 2.41, 95 % CI 1.31-4.42) and significant colonic lesion (OR 1.88, 95 % CI 1.13-3.15) detection rate was increased. Conclusions: Galician Health Service priority levels are significantly associated with colorectal cancer and significant colonic lesion detection. Referrals to colonoscopy from primary health care reduce waiting times and increase diagnostic yield (AU)

Evaluation of the implementation of Galician Health Service indications and priority levels for colonoscopy in symptomatic patients: prospective, cross-sectional study.

BACKGROUND: the Galician Health Service established indications and priority levels (I = fast track, II = preferential, III = normal) for colonoscopy, according to the risk of colorectal cancer and significant colonic lesions detection with access from primary health care. Our aim is to show the results of the implementation. METHODS: we included colonoscopies requested in symptomatic patients from June to October 2012 in a prospective observational cross sectional study. We collected health care level (primary, secondary), priority, appropriateness to the established criteria, wait times (from colonoscopy application and initial consultation) and diagnostic yield for colorectal cancer and/or significant colonic lesion. We compared health care levels in priorities I and II. RESULTS: 425 colonoscopies were included (I = 221, II = 141, III = 63). The appropriateness rate to the protocol was 67.5 %. Priority levels were significantly associated to wait times (days) from application (I = 8.7 ± 8.9, II = 50 + or - 20.3, III = 80.2 + or - 32.2; p < 0.001) and initial consultation (I = 32.2 + or - 38, II = 74.5 + or - 44.2, III = 128.5 + or - 47.4; p < 0.001), and with colorectal cancer (I = 20.1 %, II = 19.1 %, III = 4.8 %, p < 0.001) and significant colonic lesion (I = 35.3 %, II = 34 %, III = 19 %, p = 0.002) detection rates. In priority I and II, 21.8 % of colonoscopies were requested from primary health care. Referral form primary health care reduced wait times from initial consultation to colonoscopy (primary = 29.3 + or - 26, secondary = 55.2 + or - 48.6, p < 0.001). Instead, colorectal cancer (OR 2.41, 95 % CI 1.31-4.42) and significant colonic lesion (OR 1.88, 95 % CI 1.13- 3.15) detection rate was increased. CONCLUSIONS: Galician Health Service priority levels are significantly associated with colorectal cancer and significant colonic lesion detection. Referrals to colonoscopy from primary health care reduce waiting times and increase diagnostic yield.

Situación actual del manejo de la hemorragia digestiva alta no varicosa en España / Current management of nonvariceal upper gastrointestinal bleeding in Spain

Introducción La mortalidad en la hemorragia digestiva alta no varicosa (HDA-NV) no ha variado. Se necesita conocer más información para mejorar las estrategias de tratamiento. Los objetivos de este estudio fueron: a) describir el perfil de presentación de los episodios de HDA-NV; b) el manejo clínico según práctica clínica habitual, y c) establecer cuáles son los resultados clínicos asociados a los tratamientos endoscópicos y médicos en España. Métodos ENERGIB fue un estudio retrospectivo de cohortes que recogió información del manejo y forma de presentación de HDA-NV en Europa. Presentamos los datos relativos a España. Los pacientes se trataron según la práctica clínica habitual. Para las variables cuantitativas se calculó la media y la desviación estándar y para las categóricas se calcularon frecuencias absolutas y relativas. Resultados Los pacientes (n = 403) fueron hombres (71%), con edad media 65 años, asociaron comorbilidad (62,5%). Los equipos encargados de su manejo fueron gastroenterólogos (57,1%) o médicos internistas (25,1%). Los inhibidores de la bomba de protones se usaron de forma empírica preendoscopia en un 80% de los casos. El 6,4% presentó persistencia y el 6,7% resangrado después de la endoscopia. La tasa de mortalidad en los 30 días posteriores fue del 3,5%.ConclusionesEste estudio permite conocer el perfil de presentación de los episodios de HDA-NV en España y el manejo en práctica clínica habitual. Este se ajusta a los estándares propuestos por las recientes guías de práctica clínica. Entre otros datos destaca que los pacientes con hemorragia son cada vez de edad más avanzada y presentan un mayor número de enfermedades asociadas, lo que podría explicar que la mortalidad se haya mantenido estable a pesar de los evidentes avances en el manejo de esta entidad (AU)

Background Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain. Methods The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables. Results Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%.ConclusionsThis study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity (AU)

[Current management of nonvariceal upper gastrointestinal bleeding in Spain]. / Situación actual del manejo de la hemorragia digestiva alta no varicosa en España.

BACKGROUND: Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain. METHODS: The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables. RESULTS: Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%. CONCLUSIONS: This study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity.

Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: a multicenter trial.

beta-Blockers and endoscopic variceal ligation (EVL) have proven to be valuable methods in the prevention of variceal rebleeding. The aim of this study was to compare the efficacy of EVL combined with nadolol versus EVL alone as secondary prophylaxis for variceal bleeding. Patients admitted for acute variceal bleeding were treated during emergency endoscopy with EVL or sclerotherapy and received somatostatin for 5 days. At that point, patients were randomized to receive EVL plus nadolol or EVL alone. EVL sessions were repeated every 10 to 12 days until the varices were eradicated. Eighty patients with cirrhosis (alcoholic origin in 66%) were included (Child-Turcotte-Pugh A, 15%; B, 56%; C, 29%). The median follow-up period was 16 months (range, 1-24 months). The variceal bleeding recurrence rate was 14% in the EVL plus nadolol group and 38% in the EVL group (P = .006). Mortality was similar in both groups: five patients (11.6%) died in the combined therapy group and four patients (10.8%) died in the EVL group. There were no significant differences in the number of EVL sessions to eradicate varices: 3.2 +/- 1.3 in the combined therapy group versus 3.5 +/- 1.3 in the EVL alone group. The actuarial probability of variceal recurrence at 1 year was lower in the EVL plus nadolol group (54%) than in the EVL group (77%; P = .06). Adverse effects resulting from nadolol were observed in 11% of the patients. In conclusion, nadolol plus EVL reduces the incidence of variceal rebleeding compared with EVL alone. A combined treatment could lower the probability of variceal recurrence after eradication.