Is TIPS really superior to endoscopic therapy in the prevention of rebleeding from gastric varices?

We read with interest the paper by Lo et al. that compared transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic cyanoacrylate injection for the prevention of rebleeding from gastric varices [1]. The authors randomized 72 patients with cirrhosis admitted to a single center for acute gastric variceal bleeding to receive either TIPS or repeated sessions of cyanoacrylate glue injection until obliteration of gastric varices was considered endoscopically to be complete. During the 36-month follow-up, they reported a higher rebleeding rate in the endoscopic treatment group than in the TIPS group (38 % vs. 11 %, P = 0.014), but no differences in survival or complications. As expected, episodes of hepatic encephalopathy were more frequent in patients from the TIPS group than in patients receiving endoscopic treatment [2]. The authors concluded that TIPS could be the treatment of choice to prevent rebleeding from gastric varices in patients with cirrhosis.

This study is well designed, includes a large number of patients with a sufficient follow-up, and the therapeutic procedures described correspond to the standard of care. However, given the high rate of rebleeding in the cyanoacrylate group in the early months of follow-up (according to the authors' Fig. 3), we believe that additional important information is mandatory before the conclusion of this paper can be accepted. First, it is not entirely clear to the reader whether all patients received cyanoacrylate injection at index bleed. Second, the numbers of patients with actively bleeding varices at initial endoscopy should be clearly stated and there should be equal numbers of these patients in both groups, because they are at particularly high risk of early rebleeding [3]. Third, the time from randomization to the implementation of treatment in each arm must be provided and must be similar in both groups. The time intervals between hospital admission, randomization, and the start of treatment are of crucial importance in the analysis of rebleeding and survival data in bleeding related to portal hypertension, as reported elsewhere [4]. Current recommendations are to start secondary prophylaxis as soon as possible to prevent rebleeding [5], to prefer endoscopic obturation using tissue adhesive for patients who have bled from gastric varices, and to consider TIPS only in those in whom endoscopic treatment has failed [6]. Until the above-mentioned issues are clarified, we believe the data from the article by Lo et al. are not sufficiently robust to modify the recommended management of bleeding gastric varices.

Competing interests: None

References

• 1 Lo G H, Liang H L, Chen W C. et al . A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding.  Endoscopy. 2007;  39 679-685
• 2 Papatheodoridis G V, Goulis J, Leandro G. et al . Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta-analysis.  Hepatology. 1999;  30 612-622
• 3 Goulis J, Armonis A, Patch D. et al . Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage.  Hepatology. 1998;  27 1207-1212
• 4 Burroughs A K, Mezzanotte G, Phillips A. et al . Cirrhotics with variceal hemorrhage: the importance of the time interval between admission and the start of analysis for survival and rebleeding rates.  Hepatology. 1989;  9 801-807
• 5 de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension.  J Hepatol. 2005;  43 167-176
• 6 Garcia-Tsao G, Sanyal A J, Grace N D, Carey W D. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.  Am J Gastroenterol. 2007;  102 2086-2102