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Self-expanding metal stents versus TIPS in treatment of refractory bleeding esophageal varices: a systematic review and meta-analysis.

ABSTRACT: Background and study aims ?Refractory and recurrent esophageal variceal (EV) bleeding can be life threatening. Self-expanding metal stents (SEMS) have been used as a "bridge" therapy. However, their role in the treatment protocol is not established due to paucity in data. Methods? We searched multiple databases from inception through May 2019 to identify studies that reported on SEMS and TIPS in refractory EV hemorrhage. Our primary goals were to analyze and compare the pooled all-cause mortality, immediate bleeding control and rebleeding rates. Results ?Five hundred forty-seven patients from 21 studies were analyzed (SEMS: 12 studies, 176 patients; TIPS: 9 studies, 398 patients). The pooled rate of all-cause mortality with SEMS was 43.6?% (95?% CI 28.6-59.8, I 2 ?=?38) and with TIPS was 27.9?% (95?% CI 16.3-43.6, I 2 ?=?91). The pooled rate of immediate bleeding control with SEMS was 84.5?% (95?% CI 74-91.2, I 2 ?=?40) and with TIPS was 97.9?% (95?% CI 87.7-99.7, I 2 ?=?0). The pooled rate of rebleeding with SEMS was 19.4?% (95?% CI 11.9-30.4, I 2 ?=?32) and with TIPS was 8.8?% (95?% CI 4.8-15.7, I 2 ?=?40). Conclusion ?Use of SEMS in refractory EV hemorrhage demonstrates acceptable immediate bleeding control with good technical success rate. Mortality and rebleeding rates were lesser with TIPS, however, its superiority and/ or inferiority cannot be validated due to limitations in the comparison methodology.

SUBMITTER: Mohan BP

PROVIDER: S-EPMC7035032 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Self-expanding metal stents versus TIPS in treatment of refractory bleeding esophageal varices: a systematic review and meta-analysis.

Mohan Babu P BP Chandan Saurabh S Khan Shahab R SR Kotagiri Rajesh R Kassab Lena L LL Olaiya Babatunde B Ponnada Suresh S Ofosu Andrew A Adler Douglas G DG

Endoscopy international open 20200221 3

<b>Background and study aims</b> Refractory and recurrent esophageal variceal (EV) bleeding can be life threatening. Self-expanding metal stents (SEMS) have been used as a "bridge" therapy. However, their role in the treatment protocol is not established due to paucity in data. <b>Methods </b> We searched multiple databases from inception through May 2019 to identify studies that reported on SEMS and TIPS in refractory EV hemorrhage. Our primary goals were to analyze and compare the pooled all- ...[more]

PMID: 32118103

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Project description:Background & aimsBleeding from gastric fundal varices (isolated gastric varices type 1/gastroesophageal varices type 2) represents a major problem because of a high incidence of rebleeding and death with standard-of-care therapy (endoscopic obliteration with tissue adhesives plus pharmacological therapy). Transjugular intrahepatic portosystemic shunts (TIPSs) are recommended as a rescue therapy. Pre-emptive 'early' TIPS (pTIPS) significantly improves control of bleeding and survival in patients at high-risk of dying or rebleeding from esophageal varices.MethodsThis randomised controlled trial investigate whether the use of pTIPS improves rebleeding-free survival in patients with gastric fundal varices (isolated gastric varices type 1 and/or gastroesophageal varices type 2) compared with standard therapy.ResultsThe study did not achieve the predefined sample size because of low recruitment. Nevertheless, pTIPS (n = 11) was more effective compared with combined endoscopic and pharmacological therapy (n = 10) in improving rebleeding-free survival (per protocol analysis: 100 vs. 28%; p = 0.017). This was mainly because of a better outcome in patients with Child-Pugh B or C scores. There were no differences in serious adverse events or in the incidence of hepatic encephalopathy among the different cohorts.ConclusionThe use of pTIPS should be considered in patients with Child-Pugh B or C scores bleeding from gastric fundal varices.Impact and implicationsThe first-line treatment of gastric fundal varices (GOV2 and/or IGV1) is the combination of pharmacological therapy and endoscopic obliteration with glue. TIPS is considered the main rescue therapy. Recent data suggest that, in patients at high-risk of dying or rebleeding (Child-Pugh C or B scores + active bleeding at endoscopy) from esophageal varices, the use of pTIPS, performed during the first 72 h from admission, results in an increased rate of control of bleeding and survival compared with combined endoscopic and pharmacological therapy. Herein, we present a randomised controlled trial comparing pTIPS with combined endoscopic (injection of glue) and pharmacological therapy (first, somatostatin or terlipressin; carvedilol after discharge) in the treatment of patients bleeding from GOV2 and/or IGV1. Although we were not able to include the calculated sample size because of the scarcity of these patients, our results show that the use of pTIPS is associated with a significantly higher actuarial rebleeding-free survival when analysed as per protocol. This is because of the greater efficacy of this treatment in patients with Child-Pugh B or C scores.

Dataset Information

Self-expanding metal stents versus TIPS in treatment of refractory bleeding esophageal varices: a systematic review and meta-analysis.

Publications

Self-expanding metal stents versus TIPS in treatment of refractory bleeding esophageal varices: a systematic review and meta-analysis.

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