title: Covered transjugular intrahepatic portosystemic shunt versus endoscopic therapy + β-blocker for prevention of variceal rebleeding.
abstract: Gastroesophageal variceal bleeding in patients with cirrhosis is associated with significant morbidity and mortality, as well as a high rebleeding risk. Limited data are available on the role of transjugular intrahepatic portosystemic shunt (TIPS) with covered stents in patients receiving standard endoscopic, vasoactive, and antibiotic treatment. In this multicenter randomized trial, long-term endoscopic variceal ligation (EVL) or glue injection + β-blocker treatment was compared with TIPS placement in 72 patients with a first or second episode of gastric and/or esophageal variceal bleeding, after hemodynamic stabilization upon endoscopic, vasoactive, and antibiotic treatment. Randomization was stratified according to Child-Pugh score. Kaplan-Meier (event-free) survival estimates were used for the endpoints rebleeding, death, treatment failure, and hepatic encephalopathy. During a median follow-up of 23 months, 10 (29%) of 35 patients in the endoscopy + β-blocker group, as compared to 0 of 37 (0%) patients in the TIPS group, developed variceal rebleeding (P = 0.001). Mortality (TIPS 32% vs. endoscopy 26%; P = 0.418) and treatment failure (TIPS 38% vs. endoscopy 34%; P = 0.685) did not differ between groups. Early hepatic encephalopathy (within 1 year) was significantly more frequent in the TIPS group (35% vs. 14%; P = 0.035), but during long-term follow-up this difference diminished (38% vs. 23%; P = 0.121).
  
  
  CONCLUSIONS
  In unselected patients with cirrhosis, who underwent successful endoscopic hemostasis for variceal bleeding, covered TIPS was superior to EVL + β-blocker for reduction of variceal rebleeding, but did not improve survival. TIPS was associated with higher rates of early hepatic encephalopathy.
authors.affiliation: Departments of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: I Lisanne
authors.initials: IL
authors.lastname: Holster
authors.affiliation: Departments of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: Eric T T L
authors.initials: ET
authors.lastname: Tjwa
authors.affiliation: Departments of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: Adriaan
authors.initials: A
authors.lastname: Moelker
authors.affiliation: Departments of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Wils
authors.affiliation: Departments of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: Bettina E
authors.initials: BE
authors.lastname: Hansen
authors.affiliation: Department of Gastroenterology and Hepatology, and Meander MC, Amersfoort, The Netherlands.
authors.forename: J Reinoud
authors.initials: JR
authors.lastname: Vermeijden
authors.affiliation: Sint Lucas Andreas Hospital, Amsterdam, The Netherlands.
authors.forename: Pieter
authors.initials: P
authors.lastname: Scholten
authors.affiliation: LUMC, Leiden, the Netherlands.
authors.forename: Bart
authors.initials: B
authors.lastname: van Hoek
authors.affiliation: HagaHospital, Den Haag, The Netherlands.
authors.forename: Jan J
authors.initials: JJ
authors.lastname: Nicolai
authors.affiliation: Departments of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.|Departments of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: Ernst J
authors.initials: EJ
authors.lastname: Kuipers
authors.affiliation: Departments of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: Peter M T
authors.initials: PM
authors.lastname: Pattynama
authors.affiliation: Departments of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: Henk R
authors.initials: HR
authors.lastname: van Buuren
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D003131:Combined Modality Therapy; D016099:Endoscopy, Gastrointestinal; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000401:mortality / Q000517:prevention & control*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011138:Polytetrafluoroethylene; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000295:instrumentation / Q000379:methods*; D011474:Prosthesis Design; D012008:Recurrence; D015607:Stents; D017211:Treatment Failure
chemical_list: D000319:Adrenergic beta-Antagonists; D011138:Polytetrafluoroethylene