596 Efficacy of Self Expanding Metal Stent (SEMS) in Refractory Bleeding Esophageal Varices, Is There a Mortality Benefit? An Indirect-Comparison Meta-Analysis to Trans-Jugular Intra-Hepatic Porto-Systemic Shunt (TIPS)

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INTRODUCTION: Acute esophageal variceal hemorrhage (eVH) is a life threatening complication of portal hypertension and current guidelines recommend endoscopy with variceal band ligation within 12 hours of presentation. Up to 20% of these episodes can be refractory to standard treatment and in these cases, a “bridge” therapy is often necessary to control hemorrhage. Self-expanding metal stents (SEMS) have been used in this setting, however their role in the treatment protocol is unknown due to paucity in data. Aim of this study was to evaluate the clinical performance of SEMS and indirectly compare it to transjugular intrahepatic portosystemic shunt (TIPS) in refractory eVH, by meta-analysis methods. METHODS: We searched multiple databases from inception to May2019 to identify studies that reported on the clinical outcomes of SEMS and TIPS in refractory eVH. Outcomes assessed were all-cause mortality, technical success, immediate bleeding control, rebleeding, and adverse events. I2 statistics was used to assess heterogeneity. RESULTS: 574 patients from 21 studies were analyzed (SEMS: 12 studies, 176 patients; TIPS: 9 studies, 398 patients). The pooled rate of technical success with SEMS and TIPS were comparable (88.3%, 81.7-92.7 vs 91%, 86.2-94.2, P = 0.42). The pooled rate of immediate bleeding control with SEMS was 84.5% (74-91.2) and with TIPS was 97.9% (87.7-99.7), with statistical significance P = 0.03. The pooled rate of rebleeding with SEMS was 19.4% (11.9-30.4) and with TIPS was 8.8% (4.8-15.7), with statistical significance P = 0.04. The pooled rate of all adverse events were comparable (36.9%, 26-49.2 vs 41.4%, 26.5-58.1, P = 0.66). Pooled rate of stent migration in SEMS cohort was 31.8% (22-43.5). The pooled rate of all-cause mortality with SEMS was 43.6% (28.6-59.8) and with TIPS was 27.9% (16.3-43.6). There was no statistical significance (P = 0.16). I2 heterogeneity of 91% was observed in mortality with TIPS. All results are summarized in Table 1. CONCLUSION: SEMS did not demonstrate mortality benefit when compared to TIPS in the management of refractory eVH. The overall clinical outcomes with SEMS seemed to be inferior to TIPS with higher rebleeding rate and lesser immediate bleeding control rate. In addition, a stent migration rate of 32% was noted with SEMS despite the comparable overall adverse events between the modalities. Based on our analysis, an emergent TIPS should be the standard of care in refractory eVH.