Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta-analysis

Abstract

Endoscopic treatment (ET) is frequently used to prevent variceal rebleeding but this still occurs in about 50% of patients. Recently, transjugular intrahepatic portosystemic shunt (TIPS) has been compared with ET in several trials. Using a meta-analysis, we evaluated randomized trials comparing TIPS to ET assessing prevention of rebleeding, survival, and the effects on resource use and the quality of patients' lives. Medical databases were searched between January 1988 and January 1999 as well as published citations and conference proceedings. Sensitivity analyses for type of publication, methodological quality score, mean duration of follow-up, type of ET, etiology, and severity of liver disease were performed. Eleven randomized trials involving 811 patients fulfilled the selection criteria. The median follow-up ranged from 10 to 32 months. Variceal bleeding is one of the most frequent and severe complications of portal hypertension. 1 It is associated with a high mortality during the acute episode and a high rate of recurrence in the patients who survive. 2 Thus, many studies have focused on therapeutic strategies to decrease the first occurrence of variceal bleeding, to increase survival from the acute episode, and to prevent rebleeding. There is a general consensus that all patients who have previously bled from varices should have secondary therapy to prevent further variceal bleeding. 3 Prevention of rebleeding was obtained initially by surgical portal systemic shunts and more recently by endoscopic treatments (ET) and drugs. 3 Surgical shunts are the most efficacious modality for prevention of rebleeding, but they are associated with an operative mortality, particularly in decompensated cirrhotics, and a high incidence of encephalopathy. 3 Endoscopic sclerotherapy has been shown to significantly reduce the rebleeding rate compared with controls or ␤-blockers and to improve survival compared with controls. 3 The combination of sclerotherapy and ␤-blockers seems to be superior to ␤-blockers alone, but not significantly different than sclerotherapy alone in both prevention of rebleeding and improvement of survival. 3 Results from a meta-analysis showed that surgical shunts were superior to sclerotherapy for prevention of rebleeding, but there was no difference in survival. 3 In the last decade, endoscopic band ligation was introduced and became the ET of choice for prevention of rebleeding in many centers. 4,5 However, rebleeding occurs in about 50% of cirrhotic patients despite ET. 4,6,7 Thus, new therapeutic options are needed.The transjugular intrahepatic portosystemic shunt (TIPS) is a recent therapeutic radiological procedure that involves the creation of a communication between the hepatic vein and an intrahepatic branch of the portal vein, thus decompressing the portal venous system. 8 TIPS is essentially a side-toside portacaval shunt, which does not require surgical intervention and thus has a lower mortality associated with the procedure. 9 Although TIPS was introduced into clinical practice only i...

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

“…82,127,128 Not surprisingly, recent meta-analyses of 11 trials that compared TIPS to endoscopic therapy as first-line therapy show similar results. 129,130 That is, even though rebleeding is significantly less frequent with TIPS, post-treatment encephalopathy occurs significantly more often after TIPS, and there is no difference in mortality between groups. Furthermore, a recent trial showed that, even though pharmacological (propranolol plus nitrates) therapy was less effective than TIPS in preventing rebleeding, it was associated with less encephalopathy, identical survival, and more frequent improvement in Child-Pugh class with lower costs than TIPS.…”

Transjugular intrahepatic portosystemic shunt for palliative treatment of portal hypertension secondary to portal vein tumor thrombosis

“…It was reported that the rate of stenosis of shunt was 33-66% within 1 year and that of encephalopathy was 10-30% [1][2]19,22] . In recent years some scholars applied TIPS to portal hypertension secondary to portal thromblization to ensure the patients to have time for further treatments including liver transplanation [26][27][28][29] .…”

“…TIPS is effective in treating patients with hemorrhage, intractable ascites and portal hypertensive gastropathy, and many favorable results and experiences have been obtained as well [1][2][3][4][5][6][7] . TIPS has been widely used for portal hypertension with portal vein thrombosis (PVT), type-III Budd-Chiari syndrome, even bile duct occlusive diseases, and other portal hypertension [8][9][10][11][12][13][14][15][16][17] .…”

Splenic Artery Embolization as an Adjunctive Procedure for Portal Hypertension

“…A rough estimate of mortality rate in this population from splenic embolization is 1% (compared with a reported 2.8% mortality from transjugular intrahepatic portosystemic shunt). 39,52 Conclusion Splenic embolization is a technique that can be used alone or in conjunction with other treatments for the mitigation of portal hypertension and associated physiological effects of portal hypertension. This technique can be used safely when total embolization volume is 50% and the procedural and periprocedural time periods are covered with antibiotics.…”