035 - Early Transjugular Intrahepatic Portosystemic Shunt To Prevent Variceal Rebleeding In Cirrhosis: A Meta-Analysis
Zaeem Billah, MD – Physician, Department of Interventional Radiology, Kaiser Permanente Southern California; Austin Shinagawa, MD – Physician, Department of Interventional Radiology, Kaiser Permanente Southern California; Geogy Vatakencherry, MD – Physician, Department of Interventional Radiology, Kaiser Permanente Southern California
Purpose: Current guidelines recommend the use of endoscopic therapy for acute variceal bleed whereas Transjugular intrahepatic portosystemic shunt (TIPS) is used as a secondary prophylaxis to prevent variceal rebleeding. Several studies have suggested that early TIPS, placed within 5 days of a variceal bleed, is associated with improved prevention of rebleeding without significant increase in mortality. However, there are still discrepancies regarding the rate of hepatic encephalopathy as a complication of TIPS. We conducted an up-to-date systematic review with meta-analysis to evaluate the safety and efficacy of early TIPS versus endoscopic therapy in preventing variceal rebleeding in cirrhotic patients.
Material and Methods: Pubmed, Ovid, and Medline were used to search for randomized controlled trials that evaluated the use of early TIPS versus endoscopic therapy for secondary prevention of variceal rebleeding in cirrhotic patients. The inclusion criteria were: randomized controlled trials, cirrhotic patients with prior episode of esophageal variceal bleed, and patients who underwent early TIPS versus endoscopic therapy. The study was excluded if TIPS placement occurred more than 5 days after the variceal bleed. The primary outcome was mortality at 1 year. Secondary outcomes were variceal rebleeding and hepatic encephalopathy at 1 year.
Results: Eleven randomized controlled trials were identified that included 864 patients with cirrhosis. All studies initially utilized endoscopic therapy to control the acute variceal bleed. The average follow-up time was 21 months. No significant difference in mortality at 1 year was noted between early TIPS group and the endoscopic therapy group (p = 0.46). However, there were significantly lower rates of variceal rebleeding in the early TIPS group compared to the endoscopic therapy group (p < 0.001). No significant difference in the incidence of hepatic encephalopathy at 1 year was noted between the two groups (p=0.08).
Conclusions: Early TIPS is superior to endoscopic therapy in preventing variceal rebleed in cirrhotic patients without significantly increasing the rate of mortality or hepatic encephalopathy.