Transjugular intrahepatic portosystemic stent shunt (TIPS) vs. endoscopic banding in the prevention of variceal rebleeding: Final results of a randomized study

Sauer, Pieter J. J.; Benz, Christine; Theilmann, L; Richter, G. M.; Stremmel, Wolfgang; Stiehl, A.

doi:10.1016/s0016-5085(98)85416-4

Cited by 20 publications

(33 citation statements)

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“…The rebleeding rate of the TIPS group was notably low, similar to the ones reported in other controlled studies, [10][11][12][13] although there are several trials with higher rebleeding rates. 8,9,14,15 On the other hand, the rebleeding rate in our ES group is in accordance with the values reported by other investigators and similar to several comparative trials with TIPS. 8,[10][11][12]14,15 The benefit obtained in rebleeding prevention has been associated with a benefit in survival evaluated by the comparison of survival curves, and has been confirmed by multivariate analysis.…”

Section: Discussionsupporting

confidence: 92%

“…8,9,14,15 On the other hand, the rebleeding rate in our ES group is in accordance with the values reported by other investigators and similar to several comparative trials with TIPS. 8,[10][11][12]14,15 The benefit obtained in rebleeding prevention has been associated with a benefit in survival evaluated by the comparison of survival curves, and has been confirmed by multivariate analysis. The benefit has also been evident in the longer mean survival of patients assigned to TIPS and in the longer mean survival of the patients who died in each group (in the TIPS group, they could live for 21 months more than the patients in the ES group).…”

Section: Discussionsupporting

confidence: 92%

“…Actually, we observed recurrent spontaneous encephalopathy in 2 patients over age 65, a fact that should be considered when selecting future patients for TIPS (or proposing smaller stent diameter). Five of eight studies, 8,9,11,13,14 unlike our own, indicated a higher incidence of HE in the TIPS group, whereas the other three 10,[12][13][14][15] showed no difference. These differing results may be related to the diverse definitions for HE and the characteristics of the patients (e.g., age and severity of liver disease).…”

Section: Discussionmentioning

confidence: 44%

“…The noteworthy advances in pharmacological and endoscopic therapies have offered the patients better results in rebleeding and survival compared with placebo, although none of these procedures has shown to be clearly better than the others. The real possibility of the clinical application of TIPS has promoted the development of several controlled trials [8][9][10][11][12][13][14][15] aimed at evaluating the efficacy of this therapy.…”

Section: Discussionmentioning

confidence: 99%

“…Several initial series have suggested that it could be of great value for variceal bleeding, 6,7 but data from comparative studies with accepted therapies are scarce. [8][9][10][11][12][13][14][15] Our aim was to compare TIPS with a widely accepted therapy with low procedural mortality and morbidity and low inclusion limitations, like ES, for the prevention of variceal rebleeding (VB) in cirrhotic patients.…”

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confidence: 99%

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Transjugular Intrahepatic Portosystemic Shunt Versus Endoscopic Sclerotherapy for the Prevention of Variceal Rebleeding After Recent Variceal Hemorrhage

et al. 1999

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Variceal hemorrhage continues to be a major cause of morbidity and mortality in cirrhotic patients. Transjugular intrahepatic portosystemic shunt (TIPS) is gaining wide acceptance as a treatment for several complications of portal hypertension. The aim of the current randomized study was to compare the transjugular shunt and endoscopic sclerotherapy (ES) for the prevention of variceal rebleeding (VB) in cirrhotic patients. Forty-six consecutive cirrhotic patients with variceal bleeding were randomly allocated to receive either transjugular shunt (22 patients) or ES (24 patients) 24 hours after control of bleeding. VB (50% vs. 9%) and early (first 6 weeks) VB (33% vs. 5%) were significantly more frequent in sclerotherapy patients; the actuarial probability of being free of VB was higher in the shunt group (P F .002). Eight patients (33%) of the sclerotherapy group and 3 patients (15%) of the shunt group died; the actuarial probability of survival was higher for the shunted patients (P F .05); 6 patients in the sclerotherapy group and none in the shunt group died from VB (P F .05). No difference was found in the proportion of patients with clinically evident hepatic encephalopathy (HE). These results show that the transjugular shunt is more effective than sclerotherapy in the prevention of both early and long-term VB. Moreover, a significant improvement in survival was found in the shunt group. (HEPATOLOGY 1999;29:27-32.)Variceal bleeding in cirrhotic patients is the most important complication of portal hypertension for two main reasons: the high mortality of each episode of bleeding and the high proportion of patients that rebleed with the associated additional risk of death. 1,2 This second fact makes mandatory the application of therapeutic strategies to prevent recurrent hemorrhage. 3 The best results in terms of rebleeding prevention are obtained by surgical portal systemic shunts but are associated with high procedural mortality and high incidence of encephalopathy; this has limited its wide application and has encouraged investigations on other therapeutic options like endoscopic sclerotherapy (ES) and band ligation and drugs. 4 More recently, transjugular intrahepatic portosystemic shunt (TIPS) has been introduced in clinical use for several complications of portal hypertension 5 ; it enables the decompression of the portal venous system by means of a communication between the hepatic and the portal veins through the liver parenchyma with a percutaneous approach avoiding the risks and limitations of surgery. Several initial series have suggested that it could be of great value for variceal bleeding, 6,7 but data from comparative studies with accepted therapies are scarce. [8][9][10][11][12][13][14][15] Our aim was to compare TIPS with a widely accepted therapy with low procedural mortality and morbidity and low inclusion limitations, like ES, for the prevention of variceal rebleeding (VB) in cirrhotic patients. PATIENTS AND METHODSStudy Design. All patients presenting with a variceal hemorrhage were resus...

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Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 44%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Transjugular Intrahepatic Portosystemic Shunt Versus Endoscopic Sclerotherapy for the Prevention of Variceal Rebleeding After Recent Variceal Hemorrhage

et al. 1999

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A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices

et al. 1997

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The aim of this study was to compare transjugular intrahepatic portosystemic stent-shunt (TIPSS) with variceal band ligation (VBL) in the secondary prophylaxis of esophageal variceal hemorrhage in patients with cirrhosis. Fifty-eight patients with cirrhosis who presented with the first episode of esophageal variceal hemorrhage were randomized to TIPSS (31) or VBL (27), 24 hours after control of bleeding. Shunt function was assessed after 1 month and then at 6 monthly intervals thereafter. VBL was performed weekly until variceal eradication, and then at 3 months, 6 months, and yearly thereafter. Mean follow-up in the TIPSS group was 15.7 (+/-10.2) months; in the VBL group, it was 16.8 (+/-10.9) months. Results for rebleeding and mortality were analyzed on an intention-to-treat basis and using the Kaplan-Meier method. The frequency and the severity of variceal rebleeding was significantly lower in the TIPSS group (9.8%), compared with the VBL group (51.9%) (P < .0006). Although mortality rates were not significantly different, 8 of the patients who rebled in the VBL group required TIPSS therapy for uncontrolled bleeding. No significant differences were found in the frequency of other complications such as encephalopathy and sepsis. Patients in the VBL group required significantly greater time in the intensive care unit during the period of this study (<0.03). The total direct cost of treatment incurred was pound sterling 1,373 ($2,200) per patient, the cost being less in the patients treated with TIPSS compared with VBL. The results of this study show that TIPSS is superior to VBL for the secondary prophylaxis of variceal hemorrhage in patients with cirrhosis.

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Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta-analysis

et al. 1999

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Endoscopic treatment (ET) is frequently used to prevent variceal rebleeding but this still occurs in about 50% of patients. Recently, transjugular intrahepatic portosystemic shunt (TIPS) has been compared with ET in several trials. Using a meta-analysis, we evaluated randomized trials comparing TIPS to ET assessing prevention of rebleeding, survival, and the effects on resource use and the quality of patients' lives. Medical databases were searched between January 1988 and January 1999 as well as published citations and conference proceedings. Sensitivity analyses for type of publication, methodological quality score, mean duration of follow-up, type of ET, etiology, and severity of liver disease were performed. Eleven randomized trials involving 811 patients fulfilled the selection criteria. The median follow-up ranged from 10 to 32 months. Variceal bleeding is one of the most frequent and severe complications of portal hypertension. 1 It is associated with a high mortality during the acute episode and a high rate of recurrence in the patients who survive. 2 Thus, many studies have focused on therapeutic strategies to decrease the first occurrence of variceal bleeding, to increase survival from the acute episode, and to prevent rebleeding. There is a general consensus that all patients who have previously bled from varices should have secondary therapy to prevent further variceal bleeding. 3 Prevention of rebleeding was obtained initially by surgical portal systemic shunts and more recently by endoscopic treatments (ET) and drugs. 3 Surgical shunts are the most efficacious modality for prevention of rebleeding, but they are associated with an operative mortality, particularly in decompensated cirrhotics, and a high incidence of encephalopathy. 3 Endoscopic sclerotherapy has been shown to significantly reduce the rebleeding rate compared with controls or ␤-blockers and to improve survival compared with controls. 3 The combination of sclerotherapy and ␤-blockers seems to be superior to ␤-blockers alone, but not significantly different than sclerotherapy alone in both prevention of rebleeding and improvement of survival. 3 Results from a meta-analysis showed that surgical shunts were superior to sclerotherapy for prevention of rebleeding, but there was no difference in survival. 3 In the last decade, endoscopic band ligation was introduced and became the ET of choice for prevention of rebleeding in many centers. 4,5 However, rebleeding occurs in about 50% of cirrhotic patients despite ET. 4,6,7 Thus, new therapeutic options are needed.The transjugular intrahepatic portosystemic shunt (TIPS) is a recent therapeutic radiological procedure that involves the creation of a communication between the hepatic vein and an intrahepatic branch of the portal vein, thus decompressing the portal venous system. 8 TIPS is essentially a side-toside portacaval shunt, which does not require surgical intervention and thus has a lower mortality associated with the procedure. 9 Although TIPS was introduced into clinical practice only i...

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Transjugular intrahepatic portosystemic stent shunt (TIPS) vs. endoscopic banding in the prevention of variceal rebleeding: Final results of a randomized study

Cited by 20 publications

References 0 publications

Transjugular Intrahepatic Portosystemic Shunt Versus Endoscopic Sclerotherapy for the Prevention of Variceal Rebleeding After Recent Variceal Hemorrhage

Transjugular Intrahepatic Portosystemic Shunt Versus Endoscopic Sclerotherapy for the Prevention of Variceal Rebleeding After Recent Variceal Hemorrhage

A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices

Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta-analysis

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