Randomised controlled trial of long term portographic follow up versus variceal band ligation following transjugular intrahepatic portosystemic stent shunt for preventing oesophageal variceal rebleeding

Efficacy of TIPS plus extrahepatic collateral embolisation in real-world data: a validation study

OBJECTIVES

The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) plus extrahepatic collateral embolisation (TIPS+E) in reducing rebleeding and hepatic encephalopathy (HE) post-TIPS was recently reported in a meta-analysis, but further validation is essential. This study aims to confirm the effectiveness of TIPS+E using real-world data.

METHODS

The multicentre retrospective cohort included 2077 patients with cirrhosis who underwent TIPS±E (TIPS: 631, TIPS+E: 1446) between January 2010 and December 2022. Regression and propensity score matching (PSM) were used to adjust for baseline characteristic differences. After PSM, clinical outcomes, including rebleeding, HE, survival and further decompensation (FDC), were analysed. Baseline data from all patients contributed to the construction of prognostic models.

RESULTS

After PSM, 1136 matched patients (TIPS+E: TIPS=568:568) were included. TIPS+E demonstrated a significant reduction in rebleeding (HR 0.77; 95% CI 0.59 to 0.99; p=0.04), HE (HR 0.82; 95% CI 0.68 to 0.99; p=0.04) and FDC (HR 0.85; 95% CI 0.73 to 0.99; p=0.04), comparing to TIPS. Significantly, TIPS+E also reduced rebleeding, HE and FDC in subgroup of using 8 mm diameter stents and embolising of gastric varices+spontaneous portosystemic shunts (GV+SPSS). However, there were no differences in overall or subgroup survival analysis. Additionally, the random forest models showed higher accuracy and AUROC comparing to other models. Controlling post-TIPS portal pressure gradient (pPPG) within 7 mm Hg

CONCLUSION

Our real-world data validation confirms the high efficacy of TIPS+E in reducing rebleeding and HE, particularly when using 8 mm diameter stents, embolising GV+SPSS and maintaining an optimal pPPG.

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Key Words

• GASTROINTESTINAL BLEEDING
• HEPATIC ENCEPHALOPATHY
• INTERVENTIONAL RADIOLOGY
• LIVER CIRRHOSIS
• PORTAL HYPERTENSION

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MESH Headings

• Humans
• Portasystemic Shunt, Transjugular Intrahepatic
• Retrospective Studies
• Gastrointestinal Hemorrhage/surgery
• Esophageal and Gastric Varices/surgery
• Liver Cirrhosis/complications
• Liver Cirrhosis/surgery
• Hepatic Encephalopathy

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Grants

• National Natural Science Foundation of China
• Department of Health of Shandong Province

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Affiliation(s)

Lianhui Zhao Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
Jun Tie Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, Shaanxi, People's Republic of China
Guangchuan Wang Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China Department of Biostatistics, School of Public Health, Shandong University, Jinan, Shandong Province, People's Republic of China
Zhengjie Li School of Automation, Qingdao University, Qingdao, Shandong Province, People's Republic of China
Jiao Xu Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Centre for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, Shaanxi, People's Republic of China
Yuzheng Zhuge Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsun Province, People's Republic of China
Feng Zhang Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsun Province, People's Republic of China
Hao Wu Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
Bo Wei Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
Hui Xue Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
Peijie Li Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
Wei Wu Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
Chao Chen Gastroenterology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China
Qiong Wu Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China
Yifu Xia Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China
Xiubin Sun Department of Biostatistics, School of Public Health, Shandong University, Jinan, Shandong Province, People's Republic of China
Chunqing Zhang Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong Province, People's Republic of China Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, People's Republic of China

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Secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta-analysis

BACKGROUND

Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years of diagnosis. Several different treatments are available, which include endoscopic sclerotherapy, variceal band ligation, beta-blockers, transjugular intrahepatic portosystemic shunt (TIPS), and surgical portocaval shunts, among others. However, there is uncertainty surrounding their individual and relative benefits and harms.

OBJECTIVES

To compare the benefits and harms of different initial treatments for secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for secondary prevention according to their safety and efficacy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until December 2019 to identify randomised clinical trials in people with cirrhosis and a previous history of bleeding from oesophageal varices.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and previous history of bleeding from oesophageal varices. We excluded randomised clinical trials in which participants had no previous history of bleeding from oesophageal varices, previous history of bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those who had acute bleeding at the time of treatment, and those who had previously undergone liver transplantation.

DATA COLLECTION AND ANALYSIS

We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.

MAIN RESULTS

We included a total of 48 randomised clinical trials (3526 participants) in the review. Forty-six trials (3442 participants) were included in one or more comparisons. The trials that provided the information included people with cirrhosis due to varied aetiologies. The follow-up ranged from two months to 61 months. All the trials were at high risk of bias. A total of 12 interventions were compared in these trials (sclerotherapy, beta-blockers, variceal band ligation, beta-blockers plus sclerotherapy, no active intervention, TIPS (transjugular intrahepatic portosystemic shunt), beta-blockers plus nitrates, portocaval shunt, sclerotherapy plus variceal band ligation, beta-blockers plus nitrates plus variceal band ligation, beta-blockers plus variceal band ligation, sclerotherapy plus nitrates). Overall, 22.5% of the trial participants who received the reference treatment (chosen because this was the commonest treatment compared in the trials) of sclerotherapy died during the follow-up period ranging from two months to 61 months. There was considerable uncertainty in the effects of interventions on mortality. Accordingly, none of the interventions showed superiority over another. None of the trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation may result in fewer serious adverse events (number of people) than sclerotherapy (OR 0.19; 95% CrI 0.06 to 0.54; 1 trial; 100 participants). Based on low or very low-certainty evidence, the adverse events (number of participants) and adverse events (number of events) may be different across many comparisons; however, these differences are due to very small trials at high risk of bias showing large differences in some comparisons leading to many differences despite absence of direct evidence. Based on low-certainty evidence, TIPS may result in large decrease in symptomatic rebleed than variceal band ligation (HR 0.12; 95% CrI 0.03 to 0.41; 1 trial; 58 participants). Based on moderate-certainty evidence, any variceal rebleed was probably lower in sclerotherapy than in no active intervention (HR 0.62; 95% CrI 0.35 to 0.99, direct comparison HR 0.66; 95% CrI 0.11 to 3.13; 3 trials; 296 participants), beta-blockers plus sclerotherapy than sclerotherapy alone (HR 0.60; 95% CrI 0.37 to 0.95; direct comparison HR 0.50; 95% CrI 0.07 to 2.96; 4 trials; 231 participants); TIPS than sclerotherapy (HR 0.18; 95% CrI 0.08 to 0.38; direct comparison HR 0.22; 95% CrI 0.01 to 7.51; 2 trials; 109 participants), and in portocaval shunt than sclerotherapy (HR 0.21; 95% CrI 0.05 to 0.77; no direct comparison) groups. Based on low-certainty evidence, beta-blockers alone and TIPS might result in more, other compensation, events than sclerotherapy (rate ratio 2.37; 95% CrI 1.35 to 4.67; 1 trial; 65 participants and rate ratio 2.30; 95% CrI 1.20 to 4.65; 2 trials; 109 participants; low-certainty evidence). The evidence indicates considerable uncertainty about the effect of the interventions including those related to beta-blockers plus variceal band ligation in the remaining comparisons.

AUTHORS' CONCLUSIONS

The evidence indicates considerable uncertainty about the effect of the interventions on mortality. Variceal band ligation might result in fewer serious adverse events than sclerotherapy. TIPS might result in a large decrease in symptomatic rebleed than variceal band ligation. Sclerotherapy probably results in fewer 'any' variceal rebleeding than no active intervention. Beta-blockers plus sclerotherapy and TIPS probably result in fewer 'any' variceal rebleeding than sclerotherapy. Beta-blockers alone and TIPS might result in more other compensation events than sclerotherapy. The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. Accordingly, high-quality randomised comparative clinical trials are needed.

Transjugular intrahepatic portal shunt in the treatment of portal hypertension due to cirrhosis: single center experience

Aim

To investigate clinical efficacy of transjugular intrahepatic portal shunt (TIPS) for the treatment of cirrhotic portal hypertension.

Methods

71 cases of patients with cirrhotic portal hypertension and esophageal and gastric variceal bleeding hospitalized from January 2014 to June 2017 were enrolled and treated with TIPS. The change of portal pressure and serum biochemical indexes before and after TIPS were compared, and re-hemorrhage rate, ascites incidence, complications, and survival rate were calculated.

Results

71 patients (male/female 47/24, aged 29–77 years, average 48.9 ± 9.8 years) with cirrhotic portal hypertension received TIPS. The success rate of TIPS was 93% (66/71). During 1–24 months (mean 12.5 ± 7 months) follow-up of 66 patients, 61 cases survived and 5 cases died. The portal pressure decreased significantly from 40.48 ± 3.15 cmH2O to 23.59 ± 4.41 cmH2O after TIPS (P < 0.05). During the follow-up, the incidence of hepatic encephalopathy was 12.1%, the incidence of re-hemorrhage was 18.2%, and there were 4 cases of stent dysfunction, with 1 case of bare stent and 3 cases of dual stent.

Conclusion

TIPS is an effective procedure for the treatment of cirrhotic portal hypertension complications, since it can reduce portal pressure and significantly alleviate ascites. Liver function is impaired in short-term after TIPS, but TIPS has no significant effect on liver function in middle-term.

Advanced Cirrhosis Combined with Portal Vein Thrombosis: A Randomized Trial of TIPS versus Endoscopic Band Ligation Plus Propranolol for the Prevention of Recurrent Esophageal Variceal Bleeding

PURPOSE

To compare transjugular intrahepatic portosystemic shunt (TIPS) placement with or without variceal embolization with endoscopic band ligation (EBL) plus propranolol in preventing recurrent esophageal variceal bleeding in patients with advanced cirrhosis and portal vein thrombosis.

MATERIALS AND METHODS

The present randomized controlled trial was approved by the ethics committee board of West China Hospital. Written informed consent was obtained from each patient. Between January 2010 and December 2012, 73 patients were randomly allocated to receive TIPS (n = 37) or EBL plus propranolol (n = 36). The comparisons of recurrent variceal bleeding, hepatic encephalopathy, and survival rates were based on the Kaplan-Meier method and were compared using the log-rank test.

RESULTS

The mean follow-up time was 22.8 months ± 7.7(standard deviation) in the TIPS group and 20.9 months ± 8.9 in the EBL group. The 2-year probability of remaining free of recurrent variceal bleeding was higher in the TIPS group (77.8%) than in the EBL group (42.9%) (P = .002). Overall recanalization was achieved in 24 (64.9%) patients from the TIPS group and seven (19.4%) patients from the EBL group. The hepatic encephalopathy rates exhibited no significant differences between the two groups (P = .53). The 1- and 2-year probability of survival was 86.5% and 72.9%, respectively, in the TIPS group and 83.3% and 57.2%, respectively, in the EBL group, with no significant difference (P = .23).

CONCLUSION

TIPS was more effective than EBL plus propranolol in preventing recurrent esophageal variceal bleeding in patients with advanced cirrhosis and portal vein thrombosis and did not increase the incidence of hepatic encephalopathy. Survival was similar in both groups.

Antibiotic prophylaxis in the prevention of rebleeding in acute variceal hemorrhage: A randomized trial

Objective:

To assess the role of antibiotic prophylaxis in the prevention of rebleeding in acute variceal hemorrhage.

Materials and Methods:

A total of 60 patients who underwent endoscopic therapy for bleeding esophageal varices were randomized into the prophylaxis group and the on-demand group. Patients in the prophylaxis group received antibiotic prophylaxis using intravenous ofloxacin till the patient resumed oral fluids, followed by oral ofloxacin tablet for a total of 7 days. In the on-demand group, antibiotics were used only when infection was evident. Patients were monitored for rebleeding and infection during the hospital stay.

Results:

A total of 30 patients in the prophylaxis group and 26 patients in the on-demand group were analyzed. The clinical characteristics in both the groups were similar. The Child–Pugh score was around 7 in both the groups. The incidence of infection was 5/30 (16.7%) in the prophylaxis group and 7/26 (26.9%) in the on-demand group (P = 0.52). The incidence of early rebleeding in the prophylaxis vs. the on-demand group was 3 vs. 5 (P = 0.69), and the incidence of late rebleeding was 6 vs. 8 (P = 0.48). The differences were not significant.

Conclusion:

The present study shows a trend toward lower rate of early and late rebleeding, infection rate and mortality in the prophylaxis group; hence, routine use of antibiotics in all such patients may not be necessary. Further studies with a larger sample size and a longer follow-up period are required to validate the usefulness of antibiotics in these patients.

Transjugular intrahepatic portosystemic shunt in combination with or without variceal embolization for the prevention of variceal rebleeding: a meta-analysis

BACKGROUND AND AIM

Transjugular intrahepatic portosystemic shunt (TIPS) is the mainstay treatment option for the complications of portal hypertension. Whether or not variceal embolization should be performed during TIPS procedures remains controversial. A meta-analysis to compare the incidence of shunt dysfunction, variceal rebleeding, encephalopathy, and death between patients treated with TIPS alone and those treated with TIPS combined with variceal embolization was conducted.

METHODS

All relevant studies were searched via PubMed, EMBASE, and Cochrane Library databases. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled. Heterogeneity among studies and publication bias were assessed.

RESULTS

Six articles were included in our study. Type of stents was covered (n = 2), bare (n = 2), mixed (n = 1), and unknown (n = 1). Varices were angiographically embolized by coils in six studies. Additional liquids agents were employed in three studies. Compared with TIPS alone group, TIPS combined with variceal embolization group had a significantly lower incidence of variceal rebleeding (OR 2.02, 95% CI 1.29-3.17, P = 0.002), but a similar incidence of shunt dysfunction (OR 1.26, 95% CI 0.76-2.08, P = 0.38), encephalopathy (OR 0.81, 95% CI 0.46-1.43, P = 0.47), and death (OR 0.90, 95% CI 0.55-1.47, P = 0.68). Neither any significant heterogeneity nor proof of publication bias among studies was found in all meta-analyses.

CONCLUSIONS

Adjunctive variceal embolization during TIPS procedures might be beneficial in the prevention of variceal rebleeding. However, given the heterogeneity of type of stents, embolic agents, type of varices, and indications of variceal embolization among studies, additional well-designed randomized, controlled trials with larger sample size and use of covered stents should be warranted to confirm these findings.

The transjugular intrahepatic portosystemic shunt (TIPS)

The creation of an intrahepatic portosystemic shunt via a transjugular approach (TIPS) is an interventional radiological procedure used to treat the complications of portal hypertension. TIPS insertion is principally indicated to prevent or arrest variceal bleeding when medical or endoscopic treatments fail, and in the management refractory ascites. This review discusses the development and execution of the technique, with focus on its clinical efficacy. Patient selection, imaging surveillance, revision techniques, and complications are also discussed.

Transjugular intrahepatic portosystemic stent shunt (TIPSS) modification in the management of post-TIPSS refractory hepatic encephalopathy

BACKGROUND

Post-transjugular intrahepatic portosystemic stent shunt (TIPSS) hepatic encephalopathy (HE) can occur in up to one third of patients. In 5%, this can be refractory to optimal medical treatment and may require shunt modification. The efficacy of shunt modification has been poorly studied.

AIMS

To evaluate the efficacy of and natural history following TIPSS modification for treatment of refractory HE.

METHODS

From a dedicated database, we selected and further studied patients who had TIPSS modification for refractory HE.

RESULTS

Over a 14 year period, of 733 TIPSS insertions, 211(29%) patients developed HE post-TIPSS. In 38 patients, shunt modification (reduction (n = 9) and occlusion (n = 29)) was performed for refractory HE. Indications for TIPSS were: variceal bleeding (n = 32), refractory ascites (n = 5), and other (n = 1). Child's grades A, B, and C were noted in 11%, 47%, and 42% of cases, respectively. HE improved in 58% of patients and remained unchanged or worsened in 42%, with similar results for occlusions and reductions. Following shunt modification, variceal bleeding recurred in three patients and ascites in three. Twenty five patients have died (liver related in 15) at a median duration of 10.2 months. Three patients died due to procedure related complications following shunt occlusions (mesenteric infarction (n = 2) and septicaemia (n = 1)). Median survival of patients whose HE did not improve following shunt modification was 79 days compared with 278 days in patients whose did (p<0.05). No variables independently predicted response to shunt modification.

CONCLUSIONS

TIPSS modification is a useful option for patients with refractory HE following TIPSS insertion. Due to the significant risk of iatrogenic complications with shunt occlusions, shunt reduction is a safer and preferred option.

The natural history of parallel transjugular intrahepatic portosystemic stent shunts using uncovered stent: the role of host-related factors

OBJECTIVES

Parallel shunts (PS) are used in the management of transjugular intrahepatic portosystemic stent-shunt (TIPS) insufficiency, a major limitation of the technique. This study describes the natural history of PS, and uses them as a model to assess the role of host factors in the development of primary shunt insufficiency.

METHODS

Out of 338 patients with TIPS, 40 (11.8%) patients required insertion of a PS. Baseline and follow-up data of these patients were collected. Regular shunt surveillance involved biannual clinic visits and transjugular portography.

RESULTS

The non-PS group (group 1; n = 298) and the PS group (group 2; n = 40) had similar baseline demographic and disease characteristics. Index shunts of both groups and the PS produced a significant portal pressure gradient drop (P < 0.001), which was less in the index shunts of Group 2 (P < 0.02 for both). PS had similar cumulative shunt patency rates to those of the index shunts of Group 1, and both were greater than those of index shunts in Group 2 (P < 0.001 for both). The intervention rate (number of interventions/number of check portograms x 100) was similar for PS and the index shunts of Group 1 (38.7% and 43% respectively), but was significantly higher in the index shunts of Group 2 (85.6%; P < 0.01 for both). In Group 1 and Group 2, 144 patients (48.3%) and 21 patients (52.5%) died during follow-up after a median period of 23.4 and 8.9 months respectively.

CONCLUSIONS

These findings do not support the hypothesis that shunt insufficiency is related to host factors.

Portal hypertension

PURPOSE OF REVIEW

Report on significant advances in the pathophysiology, diagnosis, and management of the complications of portal hypertension that have occurred in the last year.

RECENT FINDINGS

The specific areas reviewed refer to experimental studies aimed at modifying the factors that lead to portal hypertension (increased intrahepatic vascular resistance and splanchnic vasodilatation) and recent advances in the diagnosis and management of the complications of portal hypertension. The specific complications reviewed in this paper are varices and variceal bleeding (primary prophylaxis, treatment of the acute episode, and secondary prophylaxis), ascites and some of its complications (hyponatremia, hepatic hydrothorax), hepatorenal syndrome, spontaneous bacterial peritonitis, and hepatic encephalopathy.

SUMMARY

Important studies, mostly prospective, regarding the management of the complications of portal hypertension are reviewed, including trials that demonstrate the value of the hepatic venous pressure gradient in predicting these complications, a trial of beta-blockers in patients with small varices, a randomized trial of transjugular intrahepatic portosystemic shunt using covered stents and another pilot study using this shunt in the treatment of hepatorenal syndrome, a trial of antibiotic prophylaxis in preventing early variceal rebleeding, and a trial of synbiotic therapy in hepatic encephalopathy. These trials will contribute to advancing the practice of hepatology and defining future research areas.

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