Combination therapy versus pharmacotherapy, endoscopic variceal ligation, or the transjugular intrahepatic portosystemic shunt alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized controlled trials.

Lu-Lu Lin,Lei Wang,Chao Zhang,Shi-Ming Du,Hui-Yun Gu,Xian-Feng Shen,Jie Luo,Zhi-Yuan Jian,Yan Fu

doi:10.18632/oncotarget.18143

Lu-Lu Lin, Lei Wang + Show 7 more

Open Access

https://doi.org/10.18632/oncotarget.18143

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Journal: Oncotarget	Publication Date: May 24, 2017
Citations: 16	License type: cc-by

Affiliation: Taihe Hospital, Hubei University of Medicine

Abstract

Patients with liver cirrhosis and variceal hemorrhage are at increased risk of rebleeding. We performed a meta-analysis toassess the clinical efficacy of combination therapy (pharmacotherapy and endoscopic variceal ligation (EVL)) compared with pharmacotherapy, EVL, or transjugular intrahepatic portosystemic shunt (TIPS) alone in the prevention of rebleeding and mortality. A literature search of MEDLINE, EMBASE, and the Cochrane Controlled Trials Register, up until November 2016, identified relevant randomized controlled trials. Data analysis was performed using Stata 12.0. Regarding overall mortality, combination therapy was as effective as EVL, pharmacotherapy, and TIPS (relative risk (RR) = 0.62, 95% confidence interval (CI): 0.36-1.08, RR=1.05, 95% CI: 0.68-1.63, and RR=1.39, 95% CI: 0.92-2.09, respectively). Combination therapy was as effective as EVL and pharmacotherapy alone in reducing blood-related mortality (RR=0.43, 95% CI: 0.15-1.25, and RR=0.42, 95% CI: 0.17-1.06), whereas TIPS was more effective than combination therapy (RR=5.66, 95% CI: 1.02-31.40). This was also the case for rebleeding; combination therapy was more effective than EVL and pharmacotherapy alone (RR=0.57, 95% CI: 0.41-0.79, and RR=0.65, 95% CI: 0.48-0.88), whereas TIPS was more effective than combination therapy (RR=9.42, 95% CI: 2.99-29.65). Finally, regarding rebleeding from esophageal varices, combination therapy was as effective as EVL alone (RR=0.59, 95% CI: 0.33-1.06) and was more effective than pharmacotherapy alone (RR=0.58, 95% CI: 0.40-0.85), although was less effective than TIPS (RR=2.20, 95% CI: 1.22-3.99). TIPS was recommended as the first choice of therapy in the secondary prevention of esophageal variceal bleeding.

Highlights

Variceal rebleeding is a frequent and severe complication in cirrhotic patients
Combination therapy was as effective as endoscopic variceal ligation (EVL), pharmacotherapy, and transjugular intrahepatic portosystemic shunt (TIPS) (relative risk (RR) = 0.62, 95% confidence interval (CI): 0.36-1.08, RR=1.05, 95% CI: 0.68-1.63, and RR=1.39, 95% CI: 0.92-2.09, respectively)
Combination therapy was as effective as EVL and pharmacotherapy alone in reducing blood-related mortality (RR=0.43, 95% CI: 0.15-1.25, and RR=0.42, 95% CI: 0.17-1.06), whereas TIPS was more effective than combination therapy (RR=5.66, 95% CI: 1.02-31.40)

Summary

Introduction

Variceal rebleeding is a frequent and severe complication in cirrhotic patients. Patients who survive an episode of acute variceal hemorrhage are at increased risk of rebleeding and death. Pharmacotherapy, endoscopic variceal ligation (EVL), and the transjugular intrahepatic portosystemic shunt (TIPS) are the recommended interventions for the prevention of variceal bleeding. Ligation is reported to be more effective at reducing patient mortality than sclerotherapy [6]. EVL achieves variceal obliteration with fewer endoscopic sessions and has been found to be effective in controlling active variceal bleeding [7,8,9,10]. The TIPS procedure is a minimally invasive, image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute bleeding [11]. TIPS were created with Wallstents (Schneider, Inc., Plymouth, Minnesota) using standard techniques described elsewhere, and effectively control bleeding in patients with refractory variceal hemorrhage [12, 13]

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