3573 Endoscopic variceal banding compared with transjugular intrahepatic portosystemic shunt in the prevention of esophageal variceal rebleeding. a randomized trial.

Abstract

Introduction: Variceal hemorrhage in cirrhotic patients persists to be a major complication of portal hypertension. This is due to the high mortality after a bleeding event and the eminent risk of death following an episode of rebleeding. First line endoscopic treatment to prevent variceal rebleeding is variceal banding (VB) instead of endoscopic sclerotherapy. In a randomized trial, we compared endoscopic variceal band ligation with transjugular intrahepatic portosystemic shunt (TIPS) for the prevention of esophageal variceal rebleeding. Patients and Methods: Thirty-seven cirrhotic patients with a first episode of variceal hemorrhage were included in our study (TIPS: n=18; VB: n=19). Results of rebleeding and survival were analyzed on an intention-to-treat basis employing the Kaplan-Meier method. Results: This study showed that TIPS reduced variceal rebleeding in trend but not significantly (TIPS vs. ligation: 2/18 patients [11 %] vs. 4/19 patients [21%], p>0.05). We found no significant difference between TIPS and VB regarding mortality. Encephalopathy was documented in six patients of the TIPS group [33%] and in five patients of the band ligation group [26%]. Duration of hospitalization did not differ significantly for patients treated with either TIPS or variceal banding (p=0.43). However, cost of material totaled for TIPS-placement and follow-up interventions exceeded that of VB (TIPS-group: US $ 4370/patient; VB-group: US $ 214/patient). Conclusion: In summary, there was no significant difference between TIPS and VB in prevention of variceal rebleeding. To prevent rebleeding from esophageal varices endoscopic band ligation is as effective as TIPS. Regarding the costs of material and hospitalization time, endoscopic variceal banding seems to be the reasonable therapeutic alternative compared to TIPS.We, therefore, recommend band ligation as the first line treatment for the prevention of esophageal variceal bleeding. To our experience, however, second line treatment could be TIPS in patients with recurrent episodes of variceal bleeding despite band ligation.