Self-expanding metal stents versus TIPS in treatment of refractory bleeding esophageal varices: a systematic review and meta-analysis

Abstract

Background and study aims Refractory and recurrent esophageal variceal (EV) bleeding can be life threatening. Self-expanding metal stents (SEMS) have been used as a “bridge” therapy. However, their role in the treatment protocol is not established due to paucity in data. Methods We searched multiple databases from inception through May 2019 to identify studies that reported on SEMS and TIPS in refractory EV hemorrhage. Our primary goals were to analyze and compare the pooled all-cause mortality, immediate bleeding control and rebleeding rates. Results Five hundred forty-seven patients from 21 studies were analyzed (SEMS: 12 studies, 176 patients; TIPS: 9 studies, 398 patients). The pooled rate of all-cause mortality with SEMS was 43.6 % (95 % CI 28.6–59.8, I2 = 38) and with TIPS was 27.9 % (95 % CI 16.3–43.6, I2 = 91). The pooled rate of immediate bleeding control with SEMS was 84.5 % (95 % CI 74–91.2, I2 = 40) and with TIPS was 97.9 % (95 % CI 87.7–99.7, I2 = 0). The pooled rate of rebleeding with SEMS was 19.4 % (95 % CI 11.9–30.4, I2 = 32) and with TIPS was 8.8 % (95 % CI 4.8–15.7, I2 = 40). Conclusion Use of SEMS in refractory EV hemorrhage demonstrates acceptable immediate bleeding control with good technical success rate. Mortality and rebleeding rates were lesser with TIPS, however, its superiority and/ or inferiority cannot be validated due to limitations in the comparison methodology.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

“…Esophageal stent placement for acute variceal bleeding has mainly been investigated in small retrospective studies using a dedicated stent design (SX-ELLA stent DANIS) for the treatment of refractory bleeding (Table 6s). Stent duration is reported to range from 1-30 days [126]. Pooled data analysis shows that SEMS placement leads to control of bleeding in > 80 % of patients, without severe stent-related adverse events [126,127].…”

“…Stent duration is reported to range from 1-30 days [126]. Pooled data analysis shows that SEMS placement leads to control of bleeding in > 80 % of patients, without severe stent-related adverse events [126,127]. In 21 % of patients, bleeding reoccurs within 6 weeks after SEMS placement [128].…”

Pipeline Esophagogastric Varices Secondary to Extrahepatic Portal Vein Obstruction Treated Endoscopically with the Assistance of Transileocolic Obliteration

“…A randomized control study showed that SEMSs have greater efficacy with less-severe adverse events than balloon tamponade in the control of esophageal variceal hemorrhaging ( 11 ). Although the use of SEMSs for refractory variceal bleeding has shown good immediate bleeding control with an acceptable technical success rate, the mortality and rebleeding rates were reported to be higher than those of TIPS in a meta-analysis ( 12 ). Thus, according to the European Society of Gastrointestinal Endoscopy (ESGE) Guideline, the use of SEMSs is considered as a temporal bridge therapy to TIPS ( 13 ), and we did not consider the use of SEMSs to be a positive option.…”

Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting

“…In the setting of refractory acute variceal bleeding, several systematic reviews and meta-analyses [ 89 , 90 , 91 ] support use of SEMS in successful control of severe or refractory acute variceal bleeding, without significant device-related AEs (Fig. 5 ).…”