A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding

Lo, Gin‐Ho; Liang, Huihong; Chen, W.-C.; Chen, M.-H.; Lai, K.-H.; Hsu, Pin‐I; Lin, Ching-Chung; Chan, H.-H.; Pan, Hong-Tao

doi:10.1055/s-2007-966591

Cited by 285 publications

(232 citation statements)

References 20 publications

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“…18 Costeffective analyses comparing NBC injection with TIPS have suggested that NBC is a safe and effective treatment for gastric variceal bleeding that can be provided at a significantly lower cost compared with TIPS placement. 19,20 The usefulness of TIPS is also limited by its availability only in major centers. 17 Balloon occluded retrograde transvenous obliteration has been used successfully for GV obliteration, primarily in Japan, as an elective procedure, but is unsuitable for acute gastric variceal bleeding and requires the presence of a spontaneous gastro-renal shunt.…”

Section: Discussionmentioning

confidence: 99%

“…21 The preferred first line treatment for acute gastric variceal bleeding is endoscopic obliteration with NBC. 20,22 Endoscopic injection of tissue glue for gastric variceal bleeding was first reported in 1986 by Soehendra et al 12 Since then, this method has been adopted widely and proved to be effective in the hemostasis of gastric variceal bleeding. [23][24][25][26][27][28]30 NBC, a liquid monomer, undergoes rapid exothermic polymerization on contact with living tissues, and this property of the compound has been used to eradicate and treat GV.…”

Section: Discussionmentioning

confidence: 99%

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Gastric Varices in Cirrhosis versus Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-Butyl-2-cyanoacrylate Injection

Sharma

Banka

Rawat

et al. 2013

Journal of Clinical and Experimental Hepatology

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Background: Gastric varices are found in patients with portal hypertension. Incidence of bleeding from gastric varices is relatively low, but tends to be more severe, and is associated with higher mortality than esophageal variceal bleeding. Aims and objectives: To compare the prevalence and types of gastric varices in cirrhosis versus extrahepatic portal venous obstruction (EHPVO) and the results of endoscopic N-butyl-2-cyanoacrylate (NBC, glue) injection. Methods: Eighty six patients presenting with bleeding from gastric varices between August 2010 and August 2011 were retrospectively analyzed. Results: Of 86 patients, 65% (n = 56) were cirrhotics and 35% (n = 30) had EHPVO. Distribution of types of gastric varices showed GOV1 in 14% (n = 8) of cirrhotics vs. 7% (n = 2) of EHPVO, GOV2 in 80% (n = 45) of cirrhotics vs. 53% (n = 16) of EHPVO, IGV1 in 40% (n = 12) of patients with EHPVO vs. 4% (n = 2) cirrhotics. The patients were treated with NBC injections. The mean volume of glue injected was 3.7 ± 2.58 ml over a median of 1 session (range: 1-8). The total volume of glue required was lower in cirrhotics (3.2 ± 2 ml vs. 4.7 ± 3.1 ml, p < 0.05) than in EHPVO patients. Twenty (36%) of cirrhotics required >1 sessions of glue injection as compared to 17 (57%) of EHPVO patients. Over mean follow up of 12 months, rebleeding (9% vs. 10%) and mortality (11% vs. 3%) were similar in patients with cirrhosis and EHPVO. Conclusions: In patients with bleeding from gastric varices, GOV2 is more common in cirrhotics and IGV1 in patients with EHPVO. Patients with EHPVO required higher total volume of glue and more glue sessions for gastric varix obturation. ( J CLIN EXP HEPATOL 2013;3:19-23)

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Gastric Varices in Cirrhosis versus Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-Butyl-2-cyanoacrylate Injection

Sharma

Banka

Rawat

et al. 2013

Journal of Clinical and Experimental Hepatology

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“…Bleeding was controlled in most patients, comparable to the success rate for bleeding esophageal varices 45 . In another small series with 32 patients with refractory bleeding gastric varices, TIPS placement achieved homeostasis in 90% in those with active bleeding, and re-bleeding rates were 14%, 26%, and 31%, respectively at 1 month, 6 months, and 1 year 48 . In addition, TIPS has also been compared to glue therapy for bleeding gastric varices 4849 .…”

Section: Refractory Bleeding From Gastric Varices and Portal Hypertenmentioning

confidence: 93%

Transjugular Intrahepatic Portosystemic Shunt

Preedy¹,

Watson²

2010

Handbook of Disease Burdens and Quality of Life Measures

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Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the complications of portal hypertension. The largest body of evidence for its use has been supported for recurrent or refractory variceal bleeding and refractory ascites. Its use has also been advocated for acute variceal bleed, hepatic hydrothorax, and hepatorenal syndrome. With the replacement of bare metal stents with polytetrafluoroethylen (PTFE) covered stents, shunt patency has improved dramatically thus improving outcomes. Therefore, reassessment of its utility, management of its complications, and understanding of various TIPS techniques is important.

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“…It is recommended that TIPS be used in acute bleeding from fundal varices when EVO is unavailable or if rebleeding occurs after EVO; however, this has not been evaluated prospectively. A small single-center study comparing EVO versus TIPS in the prevention of recurrent hemorrhage in patients in whom acute gastric variceal hemorrhage was controlled with EVO showed similar rebleeding rates, but again fewer than 50% of the patients were bleeding from fundal varices [46]. …”

Section: Diagnosis and Treatment Of Acute Gastric Variceal Bleedingmentioning

confidence: 98%

Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations

et al. 2011

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Background Acute variceal bleeding (AVB) is a medical emergency and associated with a mortality of 20% at 6 weeks. Significant advances have occurred in the recent past and hence there is a need to update the existing consensus guidelines. There is also a need to include the literature from the Eastern and Asian countries where majority of patients with portal hypertension (PHT) live. MethodsThe expert working party, predominantly from the Asia-Pacific region, reviewed the existing literature and deliberated to develop consensus guidelines. The working party adopted the Oxford system for developing an evidence-based approach. Only those statements that were unanimously approved by the experts were accepted. Results AVB is defined as a bleed in a known or suspected case of PHT, with the presence of hematemesis within 24 h of presentation, and/or ongoing melena, with last melanic stool within last 24 h. The time frame for the 123Hepatol Int (2011( ) 5:607-624 DOI 10.1007 AVB episode is 48 h. AVB is further classified as active or inactive at the time of endoscopy. Combination therapy with vasoactive drugs (\30 min of hospitalization) and endoscopic variceal ligation (door to scope time \6 h) is accepted as first-line therapy. Rebleeding (48 h of T 0 ) is further sub-classified as very early rebleeding (48 to 120 h from T 0 ), early rebleeding (6 to 42 days from T 0 ) and late rebleeding (after 42 days from T 0 ) to maintain uniformity in clinical trials. Emphasis should be to evaluate the role of adjusted blood requirement index (ABRI), assessment of associated comorbid conditions and poor predictors of nonresponse to combination therapy, and proposed APASL (Asian Pacific Association for Study of the Liver) Severity Score in assessing these patients. Role of hepatic venous pressure gradient in AVB is considered useful. Antibiotic (cephalosporins) prophylaxis is recommended and search for acute ischemic hepatic injury should be done. New guidelines have been developed for management of variceal bleed in patients with non-cirrhotic PHT and variceal bleed in pediatric patients. Conclusion Management of acute variceal bleeding in Asia-Pacific region needs special attention for uniformity of treatment and future clinical trials.

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A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding

Abstract: TIPS proved more effective than glue injection in preventing rebleeding from gastric varices, with similar survival and frequency of complications.

Cited by 285 publications

References 20 publications

Gastric Varices in Cirrhosis versus Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-Butyl-2-cyanoacrylate Injection

Gastric Varices in Cirrhosis versus Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-Butyl-2-cyanoacrylate Injection

Transjugular Intrahepatic Portosystemic Shunt

Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations

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