Transjugular Intrahepatic Portosystemic Shunt Group Research Articles

Prevention of Recurrent Esophageal Variceal Hemorrhage

Variceal rebleeding is a very frequent and severe complication in cirrhotic patients; therefore, its prevention should be mandatory. Lately several studies demonstrated that the rate of rebleeding was decreased by 40% and overall survival is improved by 20% with beta-blockers. However, this treatment presents some problems, such as the number of nonresponders and contraindications for its use. Recent trials found that the combination of beta-blockers with mononitrate of isosorbide to be superior to beta-blockade alone. Furthermore, endoscopic band ligation also shown to decrease the frequency of rebleeding, complications, and death compared with sclerotherapy and should be the preferred endoscopic treatment. In addition, the comparison between combined pharmacologic treatment with endoscopic treatment present similar rebleeding and mortality rates. More recently, the addition of nadolol to endoscopic band ligation increased the efficacy of endoscopy alone in the prevention of variceal rebleeding. These studies suggest that banding plus drugs could be the treatment of choice for the prophylaxis of rebleeding. When these treatments fail, the recommendation is to use transjugular intrahepatic portosystemic shunt (TIPS) or surgical shunts. Both treatments are effective in preventing rebleeding; however, they are associated with a greater risk of encephalopathy. The comparison of portacaval shunts with TIPS demonstrated that TIPS patients presented higher rebleeding, treatment failure, and transplantation. Another randomized controlled trial comparing distal splenorenal shunt with TIPS shows that variceal rebleeding was similar in both groups without differences in encephalopathy and mortality. The only difference observed was the higher rate of reintervention observed in the TIPS group to maintain his patency.

A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding

Both endoscopic obturation and transjugular intrahepatic portosystemic shunts (TIPSs) have proven to be effective in preventing rebleeding from gastric varices. This study compared the efficacy and complications of these modalities. Cirrhotic patients with acute bleeding from gastric varices were considered for inclusion. After initial control, eligible patients were randomly allocated to two groups: TIPS (n = 35) and obturation using cyanoacrylate (n = 37). In the cyanoacrylate group, treatment was repeated regularly until gastric varices were obliterated. Patients of both groups received regular follow-up. The end points were gastric variceal rebleeding or death. Stent shunt insertion was successful in all TIPS patients, and mean portal pressure gradient decreased from 21.4 +/- 7.5 mm Hg to 7.5 +/- 3.5 mm Hg ( P < 0.001). Variceal obliteration was achieved in 19 patients in the cyanoacrylate group (51 %) compared with seven TIPS patients (20 %) ( P < 0.02). After a median follow up of 33 months, upper gastrointestinal bleeding occurred in 15 TIPS patients (43 %) and 22 cyanoacrylate patients (59 %) ( P = 0.12). Rebleeding from gastric varices was encountered in four TIPS patients (11 %) and 14 cyanoacrylate patients (38 %) ( P = 0.014; odds ratio 3.6, 95 %CI 1.2 - 11.1). Blood transfusion requirements were lower in the TIPS group than in the cyanoacrylate group ( P < 0.01). Survival and frequency of complications were similar in both groups. TIPS proved more effective than glue injection in preventing rebleeding from gastric varices, with similar survival and frequency of complications.

Transjugular Intrahepatic Portosystemic Shunt for Refractory Ascites: A Meta-analysis of Individual Patient Data

Several randomized controlled trials have compared a transjugular intrahepatic portosystemic shunt (TIPS) with large-volume paracentesis in cirrhotic patients with refractory ascites. Although all agree that TIPS reduces the recurrence rate of ascites, survival is controversial. The aim of this study was to compare the effects of TIPS and large-volume paracentesis in cirrhotic patients with refractory ascites by means of meta-analysis of individual patient data from 4 randomized controlled trials. The study population consisted of 305 patients: 149 allocated to TIPS and 156 to paracentesis. Cumulative probabilities of transplant-free survival and of hepatic encephalopathy (HE) were estimated by the Kaplan-Meier method and differences assessed by log-rank test. The total number of HE episodes per patient was also compared between TIPS and paracentesis. Tense ascites recurred in 42% of patients allocated to TIPS and 89% allocated to paracentesis (P < .0001). Sixty-five patients in the TIPS group and 78 in the paracentesis group died. The actuarial probability of transplant-free survival was significantly better in the TIPS group (P = .035). Cox regression analysis performed in a subgroup of 235 patients (114 allocated to TIPS and 121 to paracentesis) showed that age, serum bilirubin level, plasma sodium level, and treatment allocation were independently associated with transplant-free survival. The average number of HE episodes was significantly higher in the TIPS group (1.13 +/- 1.93 vs 0.63 +/- 1.18; P = .006), although the cumulative probability of developing the first episode of HE was similar between the groups (P = .19). The present meta-analysis of individual patient data provides further evidence to the previous meta-analyses of literature data showing that TIPS significantly improves transplant-free survival of cirrhotic patients with refractory ascites.

Transjugular Intrahepatic Portosystemic Shunt for Portal Vein Thrombosis with and Without Underlying Cirrhosis

Van Ha et al. have recently described their experience regarding the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in patients with liver cirrhosis and portal vein thrombosis (PVT) [1]. Amongst 15 patients, including 4 with acute PVT, the overall success rate was 87%, but was less than 75% in 4 patients with long-standing PVT and cavernous transformation. The 30 day mortality was 13%. No patients with non-cirrhotic PVT were included. We have recently reported on 28 patients referred for TIPS who had PVT, which is the largest series in the literature. The overall success rate was 73%, but among 9 patients with cavernous transformation of the portal vein the success rate was similar (6/9; Table 1) [2]. In our series the overall mortality was 10%, but only 4% in the successful TIPS group. At first we thought that the age of the thrombus, the presence of cavernous transformation, or the extension of thrombus into the superior mesenteric vein would be predictive of failure of the procedure, but this was not the case. The only factor which was predictive of failure was the presence of a visible intrahepatic portal vein branch at ultrasound before and during the procedure. Our series included 12 patients with non-cirrhotic PVT for whom the indication for TIPS was recurrent bleeding in 80%. In this group, the success rate was similar to that in the cirrhotic group (9/12, 75%). We agree with Van Ha et al. that the indication for a TIPS procedure for non-cirrhotic PVT remains controversial, but we believe that PVT per se could be an indication. TIPS might not modify survival in patients with non-cirrhotic PVT as they have a limited life expectancy, but it could improve their quality of life. Moreover TIPS should be the preferred therapeutic option in patients with PVT in association with Budd-Chiari syndrome, because it restores blood flow in the sinusoids and improves survival in this group of patients that are characterized by a dreadful prognosis [3]. Van Ha et al. correctly did not reach a firm conclusion on the indication for anticoagulation in this group of patients. In our group we anticoagulated 53% of patients, without complications. We believe that when not contraindicated anticoagulation should be used, especially in non-cirrhotic PVT, given that at least 30% of patients have prothrombotic defects and remembering that not all thrombophilic conditions can be diagnosed [4]. Patients with liver cirrhosis may benefit from anticoagulation in terms of stent patency, when PVT is present before TIPS placement, but this has not been demonstrated conclusively. In our opinion, if no contraindications are present, anticoagulation should be commenced in all patients with PVT. PVT can be an indication for TIPS regardless of the presence of cirrhosis. Cavernous transformation is not a contraindication, even if it increases the technical challenge and possibility of failure, and we believe TIPS should be attempted.

Elective Transjugular Intrahepatic Portosystemic Shunt Creation for Portal Decompression in the Immediate Pretransplantation Period in Adult Living Related Liver Transplant Recipient Candidates: Preliminary Results

To evaluate (i) the efficacy of purposeful creation of transjugular intrahepatic portosystemic shunts (TIPS) before transplantation to optimize potential living related liver transplantation (LRLTx) and (ii) the efficacy of TIPS creation in this setting in reducing perioperative resource utilization. Retrospective review was performed of the records of patients who underwent adult LRLTx with or without preoperative TIPS creation from October 2003 through April 2005. Patients were evaluated for preoperative parameters (Child-Pugh class, Model for End-stage Liver Disease score, Acute Physiology and Chronic Health Evaluation [APACHE] II score, and coagulation parameters), intraoperative parameters (blood transfusion requirements and operative time), and postoperative parameters (intensive care unit stay, hospital stay, and 30-day repeat operation and mortality rates). Comparison between the two treatment groups was made with the Mann-Whitney U test. Within the TIPS group, comparison of blood transfusion requirements was performed by one-way analysis of variance based on the degree of portosystemic gradient reduction after TIPS creation. Sixteen patients were included in the TIPS group, and 12 patients were included in the group without TIPS. Median time between TIPS and transplantation was 2 days. There was no statistical difference in the preoperative, intraoperative, and postoperative parameters between groups except for the APACHE II score (P<.002), which was higher in the TIPS group. Despite this, the outcome and postoperative hospital resource utilization were similar between groups. Intraoperative blood transfusion based on the degree of portosystemic gradient reduction after TIPS creation was not significantly different between groups. Newly created TIPS do not interfere with the intraoperative technical and perioperative clinical aspects of adult LRLTx. Preoperative TIPS creation before transplantation may reduce the postoperative morbidity and mortality seen in liver transplant recipients who have a greater APACHE II score at the outset of treatment.

Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with and without cavernous transformation

Treatment options for patients with portal vein thrombosis are limited. To evaluate the feasibility and efficacy of transjugular intrahepatic portosystemic shunt for portal vein thrombosis with/without cavernomatous transformation. A survey of such patients, referred for transjugular intrahepatic portosystemic shunt between 1994 and 2005, was performed. Success rates, complications, transjugular intrahepatic portosystemic shunt patency and clinical progression were examined. Transjugular intrahepatic portosystemic shunt was attempted in 28 patients (13 cirrhotics). Indications were: presurgery/transplantation (2), worsening of ascites (2), variceal bleeding (15 - 8 elective), refractory ascites (3), portal biliopathy (3) and portal vein thrombosis complicating Budd-Chiari syndrome (2). Transjugular intrahepatic portosystemic shunt was placed successfully in 19 of 28 (73%); 23 of 28 had complete portal vein thrombosis and 9 of 23 had cavernous transformation and transjugular intrahepatic portosystemic shunt was successfully placed in six of these. In the 19 patients with transjugular intrahepatic portosystemic shunt, the mean follow-up was 18.1 months (range 5-70): six patients had stent revisions; three had liver transplantation, one died of bleeding. Most cirrhotic patients had an improvement in the Child-Pugh score. In the failed transjugular intrahepatic portosystemic shunt group, two of nine died, and three had further bleeding. Transjugular intrahepatic portosystemic shunt should be considered for selected patients with symptomatic complete portal vein thrombosis with/without cavernous transformation, as clinical improvement and less rebleeding occur when transjugular intrahepatic portosystemic shunt placement is successful.

Transjugular Intrahepatic Portosystemic Shunt before Abdominal Surgery in Cirrhotic Patients: A Retrospective, Comparative Study

Surgery in cirrhotic patients is associated with high morbidity and mortality related to portal hypertension and liver insufficiency. Therefore, preoperative portal decompression is a logical approach to facilitate abdominal surgery and hopefully to improve postoperative survival. The present study evaluated the clinical outcomes of 18 patients (mean age 58 years) with cirrhosis (seven alcoholics and 11 nonalcoholics) who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement before antrectomy (n=5), colectomy (n=10), small-bowel resection (n=1), pancreatectomy (n=1) and nephrectomy (n=1). TIPS was performed a mean (+/-SD) of 72+/-21 days before surgery and induced a marked mean decrease in portohepatic gradient from 21.4+/-3.9 mmHg to 8.4+/-3.4 mmHg. Cirrhotic patients (n=17) who underwent elective abdominal surgery without preoperative TIPS placement were used as the control group. Both groups were matched for age, etiology of cirrhosis, indications for surgery, type of surgery and coagulation parameters. The mean Pugh score was significantly higher in the TIPS group (7.7 versus 6.2). No significant differences were observed for operative blood loss, postoperative complications, duration of hospitalization and one-month (83% versus 88%) or one-year (54% versus 63%) cumulative survival rate. Analysis using the Cox proportional hazards model showed that neither TIPS placement nor preoperative Pugh score were independent predictors for survival. The present study suggests that preoperative TIPS placement does not improve postoperative evolution after abdominal surgery in cirrhotic patients with good or moderately impaired liver function.

Early HVPG measurement and TIPS for acute variceal hemorrhage: Is sooner really better?

Early HVPG measurement and TIPS for acute variceal hemorrhage: Is sooner really better?

Transjugular intrahepatic portosystemic shunt in refractory ascites: a meta‐analysis

Transjugular intrahepatic portosystemic shunt (TIPS) is a more effective treatment for refractory ascites than large volume paracentesis (LVP), but the magnitude of its effect in terms of control of ascites, encephalopathy and survival has not been established. This meta-analysis compare TIPS to LVP in terms of control of ascites at 4 and 12 months, encephalopathy and survival at 1 and 2 years. Five randomized controlled trials involving 330 patients were included. In the TIPS group, control of ascites was more frequently achieved at 4 months (66% vs 23.8%, mean difference: 41.4%, 95% confidence interval (CI): 29.5-53.2%, P < 0.001) and 12 months (54.8% vs 18.9%, mean difference: 35%, 95% CI: 24.9-45.1%, P < 0.001), whereas encephalopathy was higher (54.9% vs 38.1%, mean difference: 17%, 95% CI: 7.3-26.6%, P < 0.001). Survival at 1 year (61.7% vs 56.5%, mean difference: 3.2%, 95% CI: -14.7 to 21.9%) and 2 years (50% vs 42.8%, mean difference: 6.8%, 95% CI: -10 to 23.6%) were not significantly different. TIPS is a more effective treatment for refractory ascites than LVP. However, TIPS increase encephalopathy and does not improve survival.

Trial for treatment of refractory ascites TIPS the scales

Trial for treatment of refractory ascites TIPS the scales

Cost-effectiveness of N-butyl-2-cyanoacrylate (histoacryl) glue injections versus transjugular intrahepatic portosystemic shunt in the management of acute gastric variceal bleeding

The management of bleeding gastric varices has not been standardized. Although transjugular intrahepatic portosystemic shunt (TIPS) is used in most centers, endoscopic treatment with N-butyl-2-cyanoacrylate (cyanoacrylate) glue has recently been shown to be effective. Cost-effectiveness analyses of these methods are lacking. Methods We performed a retrospective review of patients with bleeding gastric varices treated either by TIPS or cyanoacrylate glue injection. Economic analysis was based on direct costs for a fixed financial year. The two groups were compared for a period of 6 months follow-up, to liver transplantation, or death for each patient. Results Between January, 1995 and December, 1999, 20 patients with bleeding gastric varices had TIPS; 23 patients had cyanoacrylate glue injection from January, 2000 to October, 2001. There were no significant differences between the two groups in patient characteristics, transfusion requirement, and gastric variceal anatomy. In the TIPS group, 15/20 patients had the procedure performed within 24 h of hemorrhage, and 90% of stent insertions were successful. Complications consisted of two cases of pulmonary edema, two cases of severe encephalopathy, and a 15% stenosis rate at 6 months. In the glue group, there were 3 ± 1.5 endoscopies and 2 ± 1 injections per patient, with a 96% initial hemostasis. There was one case of (glue) pulmonary embolism and one blocked front endoscope lens, which required repair. The initial rebleed rate was significantly lower in patients who had TIPS (15% vs 30%, p = 0.005). The inpatient stay was shorter in the glue group (13 ± 1 vs 18 ± 2 days, p = 0.05), but there was no difference in the overall mortality rate. The median cost within 6 months of initial gastric variceal bleeding was $4,138 ($3,009–$8,290) for glue versus $11,906 ($8,200–$16,770) for TIPS ( p < 0.0001). Conclusion In this comparable group of patients, cyanoacrylate glue injection was more cost effective than TIPS in the management of acute gastric variceal bleeding. A prospective, randomized trial would be required to confirm our analysis.

Liver transplantation and transjugular intrahepatic portosystemic shunt

Objective Describe the results of liver transplantation after installing Transjugular Intrahepatic Portosystemic Shunt (TIPS) and compare them with those of a control group in a comparative, longitudinal, retrospective study. Materials and methods Between April 1986 and October 2002, we performed 875 liver transplantations. Between January 1996 and October 2002, 26 transplantations were performed on TIPS carriers. This group was compared with a control cohort of 50 randomly selected patients who underwent transplantation in this period (non-TIPS carriers). Both groups were homogeneous with no significant differences between age, sex United Network for Organ Sharing (UNOS) score, Child stage, or etiology. Results Actuarial survival rates at 1 and 3 years: TIPS group 96.15% and 89.29% versus control cohort 87.8% and 81%, respectively. In 73.9%, the TIPS was clearly effective; in 88.9%, a postoperative Doppler revealed normal flow. There were no statistically significant differences compared with time on the waiting list for transplant, duration of the operation, ischemia times, intraoperative consumption of hemoderivates, vascular or nonvascular postoperative complications, duration of stay in the intensive care unit, hospital stay, or retransplantation rate. Conclusions In our experience, TIPS insertion does not affect either the intraoperative or postoperative evolution and is not associated with an increased time on the liver transplant waiting list.

The North American Study for the Treatment of Refractory Ascites

Background & Aims: The clinical utility of transjugular intrahepatic portosystemic shunts (TIPS) vis-à-vis total paracentesis in the management of refractory ascites is unclear. Methods: A multicenter, prospective, randomized clinical trial was performed in which 109 subjects with refractory ascites were randomized to either medical therapy (sodium restriction, diuretics, and total paracentesis) (n = 57) or medical therapy plus TIPS (n = 52). The principal end points were recurrence of tense symptomatic ascites and mortality. Results: A technically adequate shunt was created in 49 of 52 subjects. TIPS plus medical therapy was significantly superior to medical therapy alone in preventing recurrence of ascites (P < 0.001). The total number of deaths in the 2 groups was identical (TIPS vs. medical therapy alone: 21 vs. 21). There were no significant differences in the 2 arms with respect to overall and transplant-free survival. There was a higher incidence of moderate to severe encephalopathy in the TIPS group (20 of 52 vs. 12 of 57; P = 0.058). There were no significant differences in the number of subjects who developed liver failure (7 vs. 3), variceal hemorrhage (5 vs. 8), or acute renal failure (3 vs. 2). There were also no significant differences between the 2 groups in the frequency of emergency-department visits, medically indicated hospitalizations, or quality of life. Conclusions: Although TIPS plus medical therapy is superior to medical therapy alone for the control of ascites, it does not improve survival, affect hospitalization rates, or improve quality of life.GASTROENTEROLOGY 2003;124:634-641

Transjugular intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis

Background & Aims: The transjugular intrahepatic portosystemic shunt (TIPS) has been shown to be more effective than repeated paracentesis plus albumin in the control of refractory ascites. However, its effect on survival and healthcare costs is still uncertain. Methods: Seventy patients with cirrhosis and refractory ascites were randomly assigned to TIPS (35 patients) or repeated paracentesis plus intravenous albumin (35 patients). The primary endpoint was survival without liver transplantation. Secondary endpoints were complications of cirrhosis and costs. Results: Twenty patients treated with TIPS and 18 treated with paracentesis died during the study period, whereas 7 patients in each group underwent liver transplantation (mean follow-up 282 ± 43 vs. 325 ± 61 days, respectively). The probability of survival without liver transplantation was 41% at 1 year and 26% at 2 years in the TIPS group, as compared with 35% and 30% in the paracentesis group (P = 0.51). In a multivariate analysis, only baseline blood urea nitrogen levels and Child-Pugh score were independently associated with survival. Recurrence of ascites and development of hepatorenal syndrome were lower in the TIPS group compared with the paracentesis group, whereas the frequency of severe hepatic encephalopathy was greater in the TIPS group. The calculated costs were higher in the TIPS group than in the paracentesis group. Conclusions: In patients with refractory ascites, TIPS lowers the rate of ascites recurrence and the risk of developing hepatorenal syndrome. However, TIPS does not improve survival and is associated with an increased frequency of severe encephalopathy and higher costs compared with repeated paracentesis plus albumin.GASTROENTEROLOGY 2002;123:1839-1847

TIPS versus drug therapy in preventing variceal rebleeding in advanced cirrhosis: A randomized controlled trial

Prevention of variceal rebleeding is mandatory in cirrhotic patients. We compared the efficacy, safety, and cost of transjugular intrahepatic portosystemic shunt (TIPS) versus pharmacologic therapy in preventing variceal rebleeding in patients with advanced cirrhosis. A total of 91 Child-Pugh class B/C cirrhotic patients surviving their first episode of variceal bleeding were randomized to receive TIPS (n = 47) or drug therapy (propranolol + isosorbide-5-mononitrate) (n = 44) to prevent variceal rebleeding. Mean follow-up was 15 months. Rebleeding occurred in 6 (13%) TIPS-treated patients versus 17 (39%) drug-treated patients (P = .007). The 2-year rebleeding probability was 13% versus 49% (P = .01). A similar number of reinterventions were required in the 2 groups; these were mainly angioplasty ± restenting in the TIPS group (90 of 98) and endoscopic therapy for rebleeding in the medical group (45 of 62) (not significant). Encephalopathy was more frequent in TIPS than in drug-treated patients (38% vs. 14%, P = .007). Child-Pugh class improved more frequently in drug-treated than in TIPS-treated patients (72% vs. 45%; P = .04). The 2-year survival probability was identical (72%). The identified cost of therapy was double for TIPS-treated patients. In summary, medical therapy was less effective than TIPS in preventing rebleeding. However, it caused less encephalopathy, identical survival, and more frequent improvement in Child-Pugh class with lower costs than TIPS in high-risk cirrhotic patients. This suggests that TIPS should not be used as a first-line treatment, but as a rescue for failures of medical/endoscopic treatments (first-option therapies). (HEPATOLOGY .)

Transjugular Intrahepatic Portosystemic Shunting is not Superior to Endoscopic Variceal Band Ligation for Prevention of Variceal Rebleeding in Cirrhotic Patients: a Randomized, Controlled Trial

Background: The aim of the present study was to compare the transjugular intrahepatic portosystemic shunt (TIPS) with variceal band ligation (VBL) in the prophylaxis of variceal rebleeding in patients with cirrhosis of the liver. Methods: Fifty-four cirrhotic patients (21 Child-Pugh class A, 27 class B, 6 class C) were randomized to TIPS ( n = 28) or VBL ( n = 26) within 2 months after control of esophageal variceal hemorrhage. Statistical analysis was performed on the intention-to-treat principle. Results: Mean follow-up was 2 years. Mortality risk at 1 and 2 years of follow-up was 7.8% ± 5.3% and 19.9% ± 8.8% in the TIPS group and 16.5% ± 7.6% and 16.5% ± 7.6% in the VBL group, respectively (n.s.); actuarial probability of remaining free from rebleeding was 83.7% ± 7.4% and 71.4% ± 10.4% in the TIPS group and 83.9% ± 7.3% and 78.1% ± 8.8% in the VBL group at 1 and 2 years, respectively (n.s.). Hepatic encephalopathy within 1 month after randomization was observed in 2 patients in the TIPS group and in 1 in the VBL group. Conclusion: TIPS is not superior to VBL in the prevention of variceal rebleeding. Furthermore, similar mortality rates in patients treated with TIPS or VBL negate TIPS as the preferred strategy for prevention of variceal rebleeding.

Esophageal Varices: TIPS or Ligation. What Is Your Final Answer?

ARTICLE SUMMARY A randomized study was conducted comparing two-year survival and rebleeding rates in patients with liver cirrhosis (Child-Pugh score 12 or less) receiving either transjugular intrahepatic portosystemic shunt (TIPS) (n=41) or serial endoscopic variceal ligation (EVL) (n=39) after initial control of bleeding. Patients with fundal varices were excluded. There was no difference in the two-year rates of survival between the groups (57% in the TIPS group compared with 56% in the EVL group), whereas the two-year rebleeding rates were 18.5% in the TIPS group and 66% in the EVL group (P<0.001). No patient who received TIPS suffered uncontrolled bleeding, whereas 11 banded patients had uncontrolled bleeding – of whom eight underwent emergency TIPS and the remaining three died. There was no difference in the rates of encephalopathy at two years between the two groups (44% in the TIPS group, 47% in the EVL group). Likewise, the numbers of days spent in hospital were similar between the two groups, both during the index bleed and over two years. The probability of shunt dysfunction in the TIPS group was 73% at two years.

A randomized clinical trial comparing transjugular intrahepatic portosystemic shunt with endoscopic sclerotherapy in the long-term management of patients with cirrhosis after recent variceal hemorrhage

The aim of this study was to compare the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) with that of endoscopic sclerotherapy (ES) in the long-term management of patients with cirrhosis after variceal bleeding. Seventy-eight consecutive cirrhotic patients with recent variceal bleeding were randomly allocated to either TIPS ( n=38) or ES ( n=40). All patients were in good condition at randomization. The mean follow-up was 1116±92 days in the TIPS group and 1047±102 days in the ES group. Differences in rebleeding from any source (18.4% vs. 32.5%) and esophageal variceal rebleeding (15.7% vs. 27.5%) were not significantly different between the two groups ( P>0.05). The mortality rates were similar in both treatment groups. Shunt dysfunction was noted in 27 patients (71%) in the TIPS group. There were more numbers of rehospitalization during follow-up in the TIPS group than in the ES group (2.6±0.4 vs. 1.1±0.2) ( P<0.01). TIPS and ES are equally effective in the prevention of variceal rebleeding. However, TIPS is associated with high incidence of shunt dysfunction, which lead to more rehospitalization. Therefore, TIPS may not be a first-line treatment for the prevention of variceal rebleeding in cirrhotic patients who are in stable condition.

Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomised trial

BACKGROUND AND AIMS The transjugular intrahepatic portosystemic shunt (TIPS) is a new therapeutic modality for variceal bleeding. In this study we compared the two year survival and rebleeding rates in...

3573 Endoscopic variceal banding compared with transjugular intrahepatic portosystemic shunt in the prevention of esophageal variceal rebleeding. a randomized trial.

Introduction: Variceal hemorrhage in cirrhotic patients persists to be a major complication of portal hypertension. This is due to the high mortality after a bleeding event and the eminent risk of death following an episode of rebleeding. First line endoscopic treatment to prevent variceal rebleeding is variceal banding (VB) instead of endoscopic sclerotherapy. In a randomized trial, we compared endoscopic variceal band ligation with transjugular intrahepatic portosystemic shunt (TIPS) for the prevention of esophageal variceal rebleeding. Patients and Methods: Thirty-seven cirrhotic patients with a first episode of variceal hemorrhage were included in our study (TIPS: n=18; VB: n=19). Results of rebleeding and survival were analyzed on an intention-to-treat basis employing the Kaplan-Meier method. Results: This study showed that TIPS reduced variceal rebleeding in trend but not significantly (TIPS vs. ligation: 2/18 patients [11 %] vs. 4/19 patients [21%], p>0.05). We found no significant difference between TIPS and VB regarding mortality. Encephalopathy was documented in six patients of the TIPS group [33%] and in five patients of the band ligation group [26%]. Duration of hospitalization did not differ significantly for patients treated with either TIPS or variceal banding (p=0.43). However, cost of material totaled for TIPS-placement and follow-up interventions exceeded that of VB (TIPS-group: US $ 4370/patient; VB-group: US $ 214/patient). Conclusion: In summary, there was no significant difference between TIPS and VB in prevention of variceal rebleeding. To prevent rebleeding from esophageal varices endoscopic band ligation is as effective as TIPS. Regarding the costs of material and hospitalization time, endoscopic variceal banding seems to be the reasonable therapeutic alternative compared to TIPS.We, therefore, recommend band ligation as the first line treatment for the prevention of esophageal variceal bleeding. To our experience, however, second line treatment could be TIPS in patients with recurrent episodes of variceal bleeding despite band ligation.