Introduction Secondary prevention of oesophageal variceal bleeding traditionally relies on combination therapy with non-selective beta-blockers and endoscopic band ligation in patients with cirrhosis. However, patients with hepatocellular carcinoma (HCC) represent a distinct high-risk population with advanced portal hypertension, impaired liver reserve and competing oncologic mortality, raising uncertainty about whether standard variceal prophylaxis strategies provide similar benefit in this setting.
Introduction
Secondary prevention of oesophageal variceal bleeding traditionally relies on combination therapy with non-selective beta-blockers and endoscopic band ligation in patients with cirrhosis. However, patients with hepatocellular carcinoma (HCC) represent a distinct high-risk population with advanced portal hypertension, impaired liver reserve and competing oncologic mortality, raising uncertainty about whether standard variceal prophylaxis strategies provide similar benefit in this setting.
Problem Statement
Although propranolol combined with endoscopic band ligation is widely accepted for secondary prophylaxis of variceal bleeding in cirrhosis, evidence specifically supporting this approach in patients with HCC has been limited. The balance between efficacy, tolerability and survival benefit in patients with advanced liver cancer and portal hypertension remains unclear.
Summary
This randomized trial demonstrates that adding propranolol to endoscopic band ligation does not improve outcomes in patients with HCC undergoing secondary prevention of oesophageal variceal bleeding. Rates of early re bleeding, cumulative recurrent bleeding and overall survival were similar between patients treated with combination therapy and those receiving band ligation alone. Importantly, the study population largely consisted of patients with advanced disease and impaired hepatic reserve, reflecting a clinically relevant real-world HCC cohort. Large varices emerged as the primary predictor of recurrent bleeding, emphasizing the dominant role of portal hypertensive severity rather than beta-blocker therapy in determining outcomes. These findings challenge the routine extrapolation of cirrhosis-based secondary prophylaxis strategies to patients with HCC and suggest that the additional use of propranolol may not provide meaningful clinical benefit in this population. The study supports a more individualized approach to variceal management in HCC, particularly in patients with advanced tumor burden and decompensated liver disease.
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