title: Early TIPS versus endoscopic therapy for secondary prophylaxis after management of acute esophageal variceal bleeding in cirrhotic patients: a meta-analysis of randomized controlled trials.
abstract: OBJECTIVE
  American College of Gastroenterology and American Association for the Study of Liver Disease guidelines recommend endoscopic and pharmacologic treatment for esophageal variceal bleed. Transjugular intrahepatic portosystemic shunt (TIPS) placement is reserved for cases of therapeutic failure. Several studies have suggested improved prevention of rebleeding and improved survival without excess hepatic encephalopathy in patients who receive TIPS within the first 5 days after bleeding (early TIPS). In this meta-analysis, we evaluated the safety and efficacy of early TIPS versus endoscopic therapy for secondary prophylaxis after acute esophageal variceal bleeding in cirrhotic patients.
  
  
  METHODS
  Pubmed, Medline, Embase, ClinicalTrials.gov, and ISI Web of Science were searched for randomized controlled trials that compared early TIPS to endoscopic therapy. The primary outcome was mortality at 1 year; secondary outcomes were rebleeding and hepatic encephalopathy at 1 year.
  
  
  RESULTS
  Nine randomized controlled trials involving 608 cirrhotic patients were identified. Early TIPS was associated with a significant risk reduction in 1-year mortality (RR, 0.68; 95% CI, 0.49-0.96; P = 0.03) and 1-year incidence of variceal rebleeding (RR, 0.28; 95% CI, 0.20-0.40; P < 0.001) without significant heterogeneity among studies (I(2)  = 30% and 47%, respectively). No significant difference in the incidence of hepatic encephalopathy at 1 year was observed (RR, 1.36; 95% CI, 0.72-2.56; P = 0.34); however, there was significant heterogeneity among studies (I(2)  = 68%).
  
  
  CONCLUSIONS
  TIPS placed within 5 days after a major esophageal variceal hemorrhage is superior to endoscopic treatment in reducing subsequent bleeding. Early TIPS placement is also associated with superior 1-year survival without significantly increasing the incidence of hepatic encephalopathy.
authors: Internal Medicine Department, Cleveland Clinic, Cleveland, Ohio, USA.
authors: Shadi Al
authors: SA
authors: Halabi
authors: Department of Medicine, Michigan State School of Medicine, East Lansing, Michigan, USA. tareksawas@yahoo.com.
authors: Tarek
authors: T
authors: Sawas
authors: Morsani College of Medicine, University of South Florida, Tampa, Florida, USA.
authors: Besher
authors: B
authors: Sadat
authors: Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors: Aiyah
authors: A
authors: Jandali
authors: Internal Medicine Department, Cleveland Clinic, Cleveland, Ohio, USA.
authors: Hadi Al
authors: HA
authors: Halabi
authors: Internal Medicine Department, Cleveland Clinic, Cleveland, Ohio, USA.
authors: Fadi Al
authors: FA
authors: Halabi
authors: Department of Gastroenterology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors: Baljendra
authors: B
authors: Kapoor
authors: Internal Medicine Department, Cleveland Clinic, Cleveland, Ohio, USA. careyw@ccf.org.
authors: William D
authors: WD
authors: Carey
mesh_terms: D000208:Acute Disease; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D004932:Esophageal and Gastric Varices / Q000150:complications* / Q000401:mortality / Q000601:surgery; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000401:mortality / Q000517:prevention & control* / Q000601:surgery; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000401:mortality; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D055502:Secondary Prevention / Q000379:methods
keywords: Early TIPS; acute variceal bleeding