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Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + β‐blocker for prevention of variceal rebleeding
Author(s) -
Holster I. Lisanne,
Tjwa Eric T.T.L.,
Moelker Adriaan,
Wils Alexandra,
Hansen Bettina E.,
Vermeijden J. Reinoud,
Scholten Pieter,
van Hoek Bart,
Nicolai Jan J.,
Kuipers Ernst J.,
Pattynama Peter M.T.,
van Buuren Henk R.
Publication year - 2016
Publication title -
hepatology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 5.488
H-Index - 361
eISSN - 1527-3350
pISSN - 0270-9139
DOI - 10.1002/hep.28318
Subject(s) - medicine , transjugular intrahepatic portosystemic shunt , hepatic encephalopathy , cirrhosis , portal hypertension , gastroenterology , portal hypertensive gastropathy , randomization , varix , model for end stage liver disease , hepatology , gastric varices , endoscopy , surgery , encephalopathy , esophageal varices , randomized controlled trial , liver transplantation , transplantation
Gastroesophageal variceal bleeding in patients with cirrhosis is associated with significant morbidity and mortality, as well as a high rebleeding risk. Limited data are available on the role of transjugular intrahepatic portosystemic shunt (TIPS) with covered stents in patients receiving standard endoscopic, vasoactive, and antibiotic treatment. In this multicenter randomized trial, long‐term endoscopic variceal ligation (EVL) or glue injection + β‐blocker treatment was compared with TIPS placement in 72 patients with a first or second episode of gastric and/or esophageal variceal bleeding, after hemodynamic stabilization upon endoscopic, vasoactive, and antibiotic treatment. Randomization was stratified according to Child‐Pugh score. Kaplan‐Meier (event‐free) survival estimates were used for the endpoints rebleeding, death, treatment failure, and hepatic encephalopathy. During a median follow‐up of 23 months, 10 (29%) of 35 patients in the endoscopy + β‐blocker group, as compared to 0 of 37 (0%) patients in the TIPS group, developed variceal rebleeding ( P = 0.001). Mortality (TIPS 32% vs. endoscopy 26%; P = 0.418) and treatment failure (TIPS 38% vs. endoscopy 34%; P = 0.685) did not differ between groups. Early hepatic encephalopathy (within 1 year) was significantly more frequent in the TIPS group (35% vs. 14%; P = 0.035), but during long‐term follow‐up this difference diminished (38% vs. 23%; P = 0.121). Conclusions : In unselected patients with cirrhosis, who underwent successful endoscopic hemostasis for variceal bleeding, covered TIPS was superior to EVL + β‐blocker for reduction of variceal rebleeding, but did not improve survival. TIPS was associated with higher rates of early hepatic encephalopathy. (H epatology 2016;63:581–589)