TIPS vs. cyanoacrylate injection in the prevention of gastric variceal rebleeding

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I would like to thank Drs. Spahr et al. for their comments on our article regarding the prevention of gastric variceal rebleeding [1]. All of our patients received cyanoacrylate injection at index bleed. The numbers of patients with actively bleeding varices at index endoscopy were shown in Table 1: 13 patients (37 %) in the transjugular intrahepatic portosystemic shunt (TIPS) group and 14 patients (38 %) in the cyanoacrylate group. The mean time from enrollment to initial session of elective treatment was 14 days (range: 7 - 25 days) in the cyanoacrylate group and 4 days (range: 1 - 7 days) in the TIPS group. The mean time from enrollment to first session of elective treatment was thus longer in the cyanoacrylate group than in the TIPS group. This may be partly responsible for the striking difference in rebleeding rates between the two groups. Since all patients had already received cyanoacrylate injection at index bleed, we delayed the initial session of elective treatment in our cyanoacrylate group in order to avoid the occurrence of gastric ulcers induced by repeat cyanoacrylate injection after a short interval [2]. I agree that secondary prophylaxis of variceal bleeding should be started as soon as possible after control of acute hemorrhage. However, the appropriate interval between cyanoacrylate injections for acute treatment and for first elective therapy of gastric varices awaits further investigation. Our results showed the TIPS was more effective than cyanoacrylate injection in reducing variceal rebleeding, with smaller amounts of blood required and similar complication and survival rates. It is for this reason that we suggested that TIPS could be the choice of modality in the prevention of rebleeding from gastric varices. The following interpretation is also possible that although TIPS is more effective than cyanoacrylate injection in reducing gastric variceal bleeding, TIPS is an invasive procedure with the potential to induce hepatic encephalopathy, and hence TIPS should be reserved for patients in whom endoscopic treatment has failed - as in the recommendations in the policy statement by the American Association for the Study of Liver Diseases [3]. Whether TIPS should be the first choice for the prevention of gastric variceal rebleeding depends on the availability of local expertise, the complexity of the patient’s varices, (e. g., concomitant severe esophageal varices and gastric varices), and the patient’s preference. Since hepatic encephalopathy can usually be improved by administration of lactulose, and rebleeding from gastric varices is generally formidable with a high risk of mortality, the choice of TIPS instead of cyanoacrylate injection to prevent gastric variceal rebleeding appears to be the more logical choice. It is indeed the case that more controlled trials are required to verify the role of TIPS in the reduction of variceal rebleeding.