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TIPS versus endoscopic therapy for variceal rebleeding in cirrhosis: A meta-analysis update

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Summary

Endoscopic therapy (ET) is most common method for preventing variceal bleeding in cirrhosis, but the outcomes are not perfect. Recently, transjugular intrahepatic portosystemic shunt (TIPS) is introduced into clinical practice. However, the beneficial effects of TIPS compared to ET on cirrhotic patients is unknown. The aim of this study was to evaluate and compare the effects of TIPS with those of the most frequently used ET for prevention of variceal rebleeding (VRB) in liver cirrhosis. The Pub-Med, EMBASE, and Cochrane Library databases were searched from inception to February 2017. The primary study outcomes included the incidence of VRB, all-cause mortality, bleeding-related death, and the incidence of post-treatment hepatic encephalopathy (PTE). The odds ratios (ORs) with 95% confidence intervals (CI) were pooled for dichotomous variables. Subgroup analyses were performed. Twenty-four studies were eligible and they included 1120 subjects treated with TIPS and 1065 subjects treated with ET. Although there was no significant difference in survival and PTE, TIPS was superior to ET in decreasing the incidence of VRB (OR=0.27; 95% CI, 0.19–0.39, P<0.00001), and decreasing the incidence of bleeding-related death (OR=0.21; 95% CI, 0.13–0.32, P<0.00001). Subgroup analysis found a lower mortality (OR=0.48; 95% CI, 0.23–0.97; P=0.04) without any increased incidence of PTE (OR=1.37; 95% CI, 0.75–2.50; P=0.31) in the studies of a greater proportion (≥40%) of patients with Child-Pugh class C cirrhosis receiving TIPS, and TIPS with covered stent did not increase the risk of PTE compared to ET (OR=1.52, 95% CI =0.82–2.80, P=0.18). It was concluded that TIPS with covered stent might be considered the preferred choice of therapy in patients with severe liver disease for secondary prophylaxis.

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References

  1. de Franchis R, Baveno VF. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol, 2010,53(4):762–768

    Article  PubMed  Google Scholar 

  2. Rossle M. TIPS: 25 years later. J Hepatol, 2013,59(5):1081–1093

    Article  PubMed  Google Scholar 

  3. Boyer TD, Haskal ZJ; American Association for the Study of Liver D. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology, 2005,41(2):386–400

    Article  PubMed  Google Scholar 

  4. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology, 2007,46(3):922–938

    Article  CAS  PubMed  Google Scholar 

  5. Banares R, Albillos A, Rincon D, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology, 2002,35(3):609–615

    Article  PubMed  Google Scholar 

  6. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2013. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.

    Google Scholar 

  7. Cabrera J, Maynar M, Granados R, et al. Transjugular intrahepatic portosystemic shunt versus sclerotherapy in the elective treatment of variceal hemorrhage. Gastroenterology, 1996,110(3):832–839

    Article  CAS  PubMed  Google Scholar 

  8. Cello JP, Ring EJ, Olcott EW, et al. Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage. A randomized, controlled trial. Ann Intern Med, 1997,126(11):858–865

    CAS  PubMed  Google Scholar 

  9. Jalan R, Forrest EH, Stanley AJ, et al. A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices. Hepatology, 1997,26(5):1115–1122

    CAS  PubMed  Google Scholar 

  10. Rossle M, Deibert P, Haag K, et al. Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding. Lancet, 1997,349(9058):1043–1049

    Article  CAS  PubMed  Google Scholar 

  11. Sanyal AJ, Freedman AM, Luketic VA, et al. Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage. A randomized, controlled trial. Ann Intern Med, 1997,126(11):849–857

    CAS  PubMed  Google Scholar 

  12. Sauer P, Theilmann L, Stremmel W, et al. Transjugular intrahepatic portosystemic stent shunt versus sclerotherapy plus propranolol for variceal rebleeding. Gastroenterology, 1997,113(5):1623–1631

    Article  CAS  PubMed  Google Scholar 

  13. Merli M, Salerno F, Riggio O, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal bleeding in cirrhosis: a randomized multicenter trial. Gruppo Italiano Studio TIPS (G.I.S.T.). Hepatology, 1998,27(1):48–53

    CAS  PubMed  Google Scholar 

  14. Garcia-Villarreal L, Martinez-Lagares F, Sierra A, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal rebleeding after recent variceal hemorrhage. Hepatology, 1999,29(1):27–32

    Article  CAS  PubMed  Google Scholar 

  15. Narahara Y, Kanazawa H, Kawamata H, et al. 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. Hepatol Res, 2001,21(3):189–198

    Article  PubMed  Google Scholar 

  16. Pomier-Layrargues G, Villeneuve JP, Deschenes M, et al. Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomised trial. Gut, 2001,48(3):390–396

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Gülberg V, Schepke M, Geigenberger G, et al. Transjugular intrahepatic portosystemic shunting is not superior to endoscopic variceal band ligation for prevention of variceal rebleeding in cirrhotic patients: a randomized, controlledtrial. Scand J Gastroenterol, 2002,37(3):338–343

    Article  PubMed  Google Scholar 

  18. Sauer P, Hansmann J, Richter GM, et al. Endoscopic variceal ligation plus propranolol vs. transjugular intrahepatic portosystemic stent shunt: a long-term randomized trial. Endoscopy, 2002,34(9):690–697

    CAS  PubMed  Google Scholar 

  19. Lo GH, Liang HL, Chen WC, et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy, 2007,39(8):679–685

    Article  PubMed  Google Scholar 

  20. Procaccini NJ, Al-Osaimi AM, Northup P, et al. Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: a single-center U.S. analysis. GastroIntest Endosc, 2009,70(5):881–887

    Article  PubMed  Google Scholar 

  21. Garcia-Pagan JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med, 2010,362(25):2370–2379

    Article  CAS  PubMed  Google Scholar 

  22. Popovic P, Stabuc B, Skok P, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy in the elective treatment of recurrent variceal bleeding. J Int Med Res, 2010,38(3):1121–1133

    Article  CAS  PubMed  Google Scholar 

  23. Xue H, Zhang M, Pang JX, et al. Transjugular intrahepatic portosystemic shunt vs endoscopic therapy in preventing variceal rebleeding. World J Gastroenterol, 2012,18(48):7341–7347

    Article  PubMed  PubMed Central  Google Scholar 

  24. Garcia-Pagan JC, Di Pascoli M, Caca K, et al. Use of early-TIPS for high-risk variceal bleeding: results of a post-RCT surveillance study. J Hepatol, 2013,58(1):45–50

    Article  PubMed  Google Scholar 

  25. Holster IL, Tjwa ETTL, Moelker A, et al. Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + beta-blocker for prevention of variceal rebleeding. Hepatology, 2016,63(2):581–589

    Article  CAS  PubMed  Google Scholar 

  26. Kochhar GS, Navaneethan U, Hartman J, et al. Comparative study of endoscopy vs. transjugular intrahepatic portosystemic shunt in the management of gastric variceal bleeding. Gastroenterol Rep (Oxf), 2015,3(1):75–82

    Google Scholar 

  27. Rudler M, Cluzel P, Corvec TL, et al. Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival. Aliment Pharmacol Ther, 2014,40(9):1074–1080

    Article  CAS  PubMed  Google Scholar 

  28. Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology, 2004,40(4):793–801

    Article  PubMed  Google Scholar 

  29. Sauerbruch T, Mengel M, Dollinger M, et al. Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents versus hemodynamically controlled medical therapy. Gastroenterology, 2015,149(3):660–668

    Article  PubMed  Google Scholar 

  30. Jalan R, Bzeizi KI, Tripathi D, et al. Impact of transjugular intrahepatic portosystemic stent-shunt for secondary prophylaxis of oesophageal variceal haemorrhage: a single-centre study over an 11-year period. Eur J Gastroenterol Hepatol, 2002,14(6):615–626

    Article  PubMed  Google Scholar 

  31. Zheng M, Chen Y, Bai J, et al. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy in the secondary prophylaxis of variceal rebleeding in cirrhotic patients: meta-analysis update. J Clin Gastroenterol, 2008,42(5):507–516

    Article  PubMed  Google Scholar 

  32. Salerno F, Camma C, Enea M, et al. Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data. Gastroenterology, 2007,133(3):825–834

    Article  CAS  PubMed  Google Scholar 

  33. Casadaban LC, Parvinian A, Minocha J, et al. Clearing the confusion over hepatic encephalopathy after TIPS creation: Incidence, prognostic factors, and clinical outcomes. Dig Dis Sci, 2015,60(4):1059–1066

    Article  PubMed  Google Scholar 

  34. Perarnau JM, Le Guge A, Nicolas C, et al. Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial. J Hepatol, 2014,60(5):962–968

    PubMed  Google Scholar 

  35. Yang Z, Han G, Wu Q, et al. Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents versus bare stents: a meta-analysis. J Gastroenterol Hepatol, 2010,25(11):1718–1725

    Article  PubMed  Google Scholar 

  36. Lindor RA, Lindor KD. The value of observational research in liver diseases. Hepatology, 2011,53(1):1–3

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Gastroenterology, the Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430014, China

    Hu Zhang  (张 虎), Hui Li  (李 晖), Heng Zhang  (张 姮), Dan Zheng  (郑 丹), Chen-ming Sun  (孙琛明) & Jie Wu  (吴 杰)

  2. Department of Cardiology, the Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430014, China

    Hui Zhang  (张 辉)

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  1. Hu Zhang  (张 虎)
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  3. Hui Li  (李 晖)
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Correspondence to Jie Wu  (吴 杰).

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This project was supported by the Natural Science Foundation of Central Hospital of Wuhan (No. YQ16B01).

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Zhang, H., Zhang, H., Li, H. et al. TIPS versus endoscopic therapy for variceal rebleeding in cirrhosis: A meta-analysis update. J. Huazhong Univ. Sci. Technol. [Med. Sci.] 37, 475–485 (2017). https://doi.org/10.1007/s11596-017-1760-6

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  • DOI: https://doi.org/10.1007/s11596-017-1760-6

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