Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal rebleeding after recent variceal hemorrhage

Abstract

Variceal hemorrhage continues to be a major cause of morbidity and mortality in cirrhotic patients. Transjugular intrahepatic portosystemic shunt (TIPS) is gaining wide acceptance as a treatment for several complications of portal hypertension. The aim of the current randomized study was to compare the transjugular shunt and endoscopic sclerotherapy (ES) for the prevention of variceal rebleeding (VB) in cirrhotic patients. Forty-six consecutive cirrhotic patients with variceal bleeding were randomly allocated to receive either transjugular shunt (22 patients) or ES (24 patients) 24 hours after control of bleeding. VB (50% vs. 9%) and early (first 6 weeks) VB (33% vs. 5%) were significantly more frequent in sclerotherapy patients; the actuarial probability of being free of VB was higher in the shunt group (P F .002). Eight patients (33%) of the sclerotherapy group and 3 patients (15%) of the shunt group died; the actuarial probability of survival was higher for the shunted patients (P F .05); 6 patients in the sclerotherapy group and none in the shunt group died from VB (P F .05). No difference was found in the proportion of patients with clinically evident hepatic encephalopathy (HE). These results show that the transjugular shunt is more effective than sclerotherapy in the prevention of both early and long-term VB. Moreover, a significant improvement in survival was found in the shunt group. (HEPATOLOGY 1999;29:27-32.)Variceal bleeding in cirrhotic patients is the most important complication of portal hypertension for two main reasons: the high mortality of each episode of bleeding and the high proportion of patients that rebleed with the associated additional risk of death. 1,2 This second fact makes mandatory the application of therapeutic strategies to prevent recurrent hemorrhage. 3 The best results in terms of rebleeding prevention are obtained by surgical portal systemic shunts but are associated with high procedural mortality and high incidence of encephalopathy; this has limited its wide application and has encouraged investigations on other therapeutic options like endoscopic sclerotherapy (ES) and band ligation and drugs. 4 More recently, transjugular intrahepatic portosystemic shunt (TIPS) has been introduced in clinical use for several complications of portal hypertension 5 ; it enables the decompression of the portal venous system by means of a communication between the hepatic and the portal veins through the liver parenchyma with a percutaneous approach avoiding the risks and limitations of surgery. Several initial series have suggested that it could be of great value for variceal bleeding, 6,7 but data from comparative studies with accepted therapies are scarce. [8][9][10][11][12][13][14][15] Our aim was to compare TIPS with a widely accepted therapy with low procedural mortality and morbidity and low inclusion limitations, like ES, for the prevention of variceal rebleeding (VB) in cirrhotic patients. PATIENTS AND METHODSStudy Design. All patients presenting with a variceal hemorrhage were resusc...

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

“…Overall, 11 randomized trials involving 811 patients [13][14][15][16][23][24][25][26][27][28][29] met the inclusion criteria. Eight were published as full articles in peer-reviewed journals, [13][14][15][16][23][24][25][26] and 3 were published only as abstracts [27][28][29] (Table 2). Agreement between reviewers for the selection of relevant articles was 100%.…”

“…TIPS was compared with sclerotherapy alone in 5 studies, [13][14][15][16]26 with sclerotherapy plus propranolol in 3 studies 23,24,27 (sclerotherapy or ligation plus propranolol in one 23 ), and with ligation alone in 3 studies 25,28,29 (Table 2).…”

“…Moreover, there were 7 (2.2%) of 322 patients randomized to TIPS who were crossed over to ET (Table 5) mainly when TIPS placement was technically unsuccessful 23,25 or even when there was a TIPS failure. 16 Mean or median follow-up was less than 16 months in 6, 14,23,25,[27][28][29] 18 months in 2, 24,26 between 19 and 21 months in 2, 15,16 and 32 months in 1 study 13 (Table 5).…”

“…Thus, several randomized controlled studies were conducted to evaluate objectively the efficacy of TIPS in this setting. TIPS has been compared with sclerotherapy (with or without the addition of propanolol) and with ligation and has been found to be superior for prevention of rebleeding in most, but not all, 13 studies and equal 14,15 or inferior 13 or superior 16 in terms of survival. To critically appraise and bring together the current evidence on TIPS for prevention of rebleeding, we performed a meta-analysis of the results of randomized trials comparing TIPS with ET.…”

TIPS versus drug therapy in preventing variceal rebleeding in advanced cirrhosis: A randomized controlled trial

“…2 TIPS is relatively easy to perform, quite safe, and causes a portal decompression similar to that achieved by surgical shunts. 3,4 Randomized controlled trials (RCTs) [5][6][7][8][9][10][11][12][13][14][15] and meta-analyses [16][17][18][19] have shown that TIPS is more effective than endoscopic therapy in preventing variceal rebleeding. However, some studies reported an increased in-cidence of encephalopathy following TIPS.…”