Systematic review with meta-analysis: self-expanding metal stents in patients with cirrhosis and severe or refractory oesophageal variceal bleeding.

Abstract

The prognosis of patients with cirrhosis and acute variceal bleeding is very poor when the standard-of-care fails to control bleeding. New treatment modalities are needed in these patients. To synthesise the available evidence on the efficacy of self-expanding metal stents (SEMS) in patients with cirrhosis and severe or refractory oesophageal variceal bleeding. Meta-analysis of trials evaluating SEMS in patients with cirrhosis and severe or refractory oesophageal variceal bleeding. Thirteen studies were included. The pooled estimate rates were 0.40 (95% confidence interval, CI=0.31-0.49) for death, 0.41 (95% CI=0.29-0.53) for liver-related death and 0.36 (95% CI=0.26-0.47) for death at day 30, with low heterogeneity between studies. The pooled estimate rates were 0.12 (95% CI=0.07-0.21) for mortality related to variceal bleeding, and 0.18 (95% CI=0.11-0.29) for failure to control bleeding with SEMS, with no or low heterogeneity between studies. The pooled estimate rate were 0.16 (95% CI=0.04-0.48) for rebleeding after stent removal and 0.28 (95% CI=0.17-0.43) for stent migration, with high heterogeneity. A significant proportion of patients had access to liver transplantation or to TIPSS [pooled estimate rate 0.10 (95% CI=0.04-0.21) and 0.26 (95% CI=0.18-0.36), respectively]. Fewer than 40% of patients treated with SEMS were dead at 1month. SEMS can be used as a bridge to TIPSS or to liver transplantation in a significant proportion of patients. Additional studies are required to identify potential risk factors leading to a poor prognosis in patients with acute variceal bleeding in whom the use of SEMS could be considered.