Early-TIPS versus current standard therapy for acute variceal bleeding in cirrhosis patients: A systemic review with meta-analysis

Abstract

Background: The survival of early placement (within 72h after admission) of transjugular intrahepatic portosystemic shunts (early-TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) is controversial. Objectives: We performed a systemic review and meta-analysis to assess whether early-TIPS could improve survival in patients with cirrhosis and acute variceal bleeding. Methods: A systematic search of the literature was conducted in PubMed, EMBASE, and Cochrane Library published before 25 June 2019 for eligible studies that compared early-TIPS with a combination of endoscopic variceal ligation (EVL) and pharmacotherapy in the therapeutic effect in AVB patients. Results: A total of five studies with 1,754 participants were enrolled. The early-TIPS demonstrated a significant improvement in prevention of treatment failure (OR = 0.11, 95% CI = 0.05-0.23), 6-weeks mortality (OR = 0.24, 95% CI = 0.13-0.46), rebleeding within 6 weeks (OR=0.21, 95% CI = 0.12-0.36), rebleeding within 1 year (OR = 0.16, 95% CI = 0.07-0.36), new or worsening ascites (OR = 0.33, 95% CI = 0.21-0.53), except in encephalopathy (OR = 1.29, 95% CI = 0.996-1.67). For 1-year mortality, a significant prior effect was also observed in early-TIPS (OR = 0.64, 95% CI = 0.46-0.90), and the beneficial effect in Child-Pugh C patients (OR = 0.35, 95% CI = 0.18-0.68) was equal to Child-Pugh B patients (OR=0.34, 95% CI = 0.25-0.58). No difference in liver transplantation and mortality caused by liver failure was observed. Conclusions: Early covered-TIPS could be recommended for the management of AVB patients in cirrhosis demonstrating a significant improvement in treatment failure, both short- and long-term mortality, rebleeding risk, and new or worsening ascites compared to standard therapy, especially for high-risk AVB patients. It will also apply to patients with Child-Pugh A until solutions to prevent hepatic encephalopathy in future research are found.