Early TIPS versus Endoscopic Treatment in Cirrhotics with Variceal Bleeding: A Meta-Analysis: Presidential Poster

Abstract

Purpose: In cirrhotics, acute variceal hemorrhage is associated with high morbidity and mortality. The most recent (2007) practice guideline co-developed by the American College of Gastroenterology and the American Association for the Study of Liver Disease recommends endoscopic/pharmacologic treatment for prevention of recurrent hemorrhage. Transjugular intrahepatic portosystemic shunt (TIPS) is not advocated, except for endoscopic/pharmacologic failures. Several small studies suggest higher success in prevention of re-bleeding, as well as improved survival without excess hepatic encephalopathy in patients who receive TIPS within the first week after bleeding. We report a meta-analysis of randomized controlled trials (RCTs) of early TIPS vs. endoscopic/pharmacologic treatment. Methods: We searched Pubmed, Medline, Embase, and Cochrane database for studies that compared endoscopic therapy to TIPS within the first week after acute variceal bleeding. We only included randomized control trials (RCTs). Studies selection and data extraction were done by two reviewers. The quality of trials was assessed using methodology obtained from The Cochrane Reviewers' Handbook. Heterogeneity of the studies was analyzed by Cochran's Q statistics. Mantel Haenszel relative risk was calculated with fixed effect model to combine studies. Results: Thirty-five studies were evaluated; 26 were rejected because of different study end-points, no control group, non-randomization, or TIPS performed more than a week post-variceal bleeding. This left nine trials, which included 563 cirrhotic patients with Child-Pugh class A, B, and C. Early TIPS was associated with a significant risk reduction in the one-year incidence of variceal re-bleeding (Relative risk [RR] 0.28; 95% confidence interval [CI] 0.20-0.39; P <0.001). Significantly lower one-year mortality was observed in patients who underwent early TIPS, compared to endoscopic therapy (RR, 0.70; 95% CI 0.50-1.00; P= 0.05). No significant difference in the incidence of hepatic encephalopathy was observed between the two treatment groups. (RR 1.06; 95% CI 0.63; 1.76; P= 0.83). However, there was moderate heterogeneity among the hepatic encephalopathy results reported in the studies (I2= 60%). Conclusion: TIPS performed within a week of major esophageal variceal hemorrhage is superior to pharmacologic/endoscopic treatment in reducing subsequent bleeding. It is associated with superior one-year survival, and does not result in higher degrees of encephalopathy. Clinical practice guideline recommendations may need to be modified to reflect clear and compelling new data, reflecting the value of early TIPS in appropriately selected patients.