Download PDF
Endoscopy 2007; 39(8): 679-685
DOI: 10.1055/s-2007-966591
Original article

© Georg Thieme Verlag KG Stuttgart · New York

A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding

G.-H.  Lo1, 2 , H.-L.  Liang3 , W.-C.  Chen2 , M.-H.  Chen2 , K.-H.  Lai2 , P.-I.  Hsu2 , C.-K.  Lin2 , H.-H.  Chan2 , H.-B.  Pan1 ,3
  • 1Department of Medical Research and Education, Kaohsiung Veterans General Hospital, National Yang-Ming University, Kaohsiung, Taiwan
  • 2Division of Gastroenterology, Department of Medicine, Kaohsiung Veterans General Hospital, National Yang-Ming University, Kaohsiung, Taiwan
  • 3Department of Radiology, Kaohsiung Veterans General Hospital, National Yang-Ming University, Kaohsiung, Taiwan
Further Information

Publication History

eingereicht 14 May 2006

akzeptiert 31 December 2006

Publication Date:
30 July 2007 (online)

Also available at
    Permissions and Reprints

See also:

Commentaire de travail de G.-H. Lo et al., pp. 679Endoscopy 2007; 39(08): 844-844
DOI: 10.1055/s-0032-1306965

Background and study aims: Both endoscopic obturation and transjugular intrahepatic portosystemic shunts (TIPSs) have proven to be effective in preventing rebleeding from gastric varices. This study compared the efficacy and complications of these modalities.

Patients and methods: Cirrhotic patients with acute bleeding from gastric varices were considered for inclusion. After initial control, eligible patients were randomly allocated to two groups: TIPS (n = 35) and obturation using cyanoacrylate (n = 37). In the cyanoacrylate group, treatment was repeated regularly until gastric varices were obliterated. Patients of both groups received regular follow-up. The end points were gastric variceal rebleeding or death.

Results: Stent shunt insertion was successful in all TIPS patients, and mean portal pressure gradient decreased from 21.4 ± 7.5 mm Hg to 7.5 ± 3.5 mm Hg (P < 0.001). Variceal obliteration was achieved in 19 patients in the cyanoacrylate group (51 %) compared with seven TIPS patients (20 %) (P < 0.02). After a median follow up of 33 months, upper gastrointestinal bleeding occurred in 15 TIPS patients (43 %) and 22 cyanoacrylate patients (59 %) (P = 0.12). Rebleeding from gastric varices was encountered in four TIPS patients (11 %) and 14 cyanoacrylate patients (38 %) (P = 0.014; odds ratio 3.6, 95 %CI 1.2 - 11.1). Blood transfusion requirements were lower in the TIPS group than in the cyanoacrylate group (P < 0.01). Survival and frequency of complications were similar in both groups.

Conclusions: TIPS proved more effective than glue injection in preventing rebleeding from gastric varices, with similar survival and frequency of complications.

References

  • 1 Groszmann R J, de Franchis R. Portal hypertension. In: Schiff ER, Sorrell MF, Maddrey WC (eds). Schiff’s diseases of the liver. Philadelphia; Lippincott-Raven 1998: 387-442
    Search in Google Scholar
  • 2 Ryan B M, Stockbrugger R W, Ryan J M. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.  Gastroenterology. 2004;  126 1175-1189
    CrossrefPubMedSearch in Google Scholar
  • 3 Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices.  Gastrointest Endosc. 1986;  32 264-268
    CrossrefPubMedSearch in Google Scholar
  • 4 Gimson A ES, Westaby D, Williams R. Endoscopic sclerotherapy in the management of gastric variceal hemorrhage.  J Hepatol. 1991;  13 274-278
    PubMedSearch in Google Scholar
  • 5 Williams S GJ, Peters R A, Westaby D. Thrombin - an effective treatment for gastric variceal hemorrhage.  Gut. 1994;  35 1287-1289
    CrossrefPubMedSearch in Google Scholar
  • 6 Lo G H, Lai K H, Cheng J S. et al . A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices.  Hepatology. 2001;  33 1060-1064
    CrossrefPubMedSearch in Google Scholar
  • 7 Lo G H, Lai K H. Is detachable snare really safe and effective for large gastric varices?.  Gastrointest Endosc. 2003;  57 438-439
    CrossrefPubMedSearch in Google Scholar
  • 8 Soehendra N, Nam V C, Grimm H, Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate.  Endoscopy. 1986;  18 25-26
    PubMedSearch in Google Scholar
  • 9 Ramond M J, Valla D, Mosnier J F. et al . Successful endoscopic obliteration of gastric varices with butyl cyanoacrylate.  Hepatology. 1989;  10 488-493
    PubMedSearch in Google Scholar
  • 10 Huang Y H, Yeh H Z, Chen G H. et al . Endoscopic treatment of bleeding gastric varices by N-butyl-2-cyanoacrylate (Histoacryl) injection: long-term efficacy and safety.  Gastrointest Endosc. 2000;  52 160-167
    CrossrefPubMedSearch in Google Scholar
  • 11 Chau T N, Patch D, Chan Y W. et al . Salvage transjugular intrahepatic portosystemic shunts: gastric fundal compared with esophageal variceal bleeding.  Gastroenterology. 1998;  114 981-987
    PubMedSearch in Google Scholar
  • 12 Stanley A J, Jalan R, Ireland H M. et al . A comparison between gastric and oesophageal variceal haemorrhage treated with transjugular intrahepatic protosystemic stent shunt (TIPSS).  Aliment Pharm Ther. 1997;  11 171-176
    CrossrefPubMedSearch in Google Scholar
  • 13 Barange K, Peron J M, Imani K. et al . Transjugular intrahepatic protosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices.  Hepatology. 1999;  30 1139-1143
    CrossrefPubMedSearch in Google Scholar
  • 14 Tripathi D, Therapondos G, Jackson E. et al . The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and hemodynamic correlations.  Gut. 2002;  51 270-274
    CrossrefPubMedSearch in Google Scholar
  • 15 Matsumoto A, Kitamoto M, Imamura M. et al . Three-dimensional portography using multislice helical CT is clinically useful for management of gastric fundal varices.  Am J Roentgenol. 2001;  176 899-905
    PubMedSearch in Google Scholar
  • 16 Thomas P G, D’Cruz A J. Distal splenorenal shunting for bleeding gastric varices.  Br J Surg. 1994;  81 241-244
    PubMedSearch in Google Scholar
  • 17 Pugh R NN, Murray-Lyon I M, Dawson J L. et al . Transection of esophagus for bleeding esophageal varices.  Br J Surg. 1973;  60 646-649
    CrossrefPubMedSearch in Google Scholar
  • 18 Sarin S K, Lahoti D, Saxena S P. et al . Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients.  Hepatology. 1992;  16 1343-1349
    CrossrefPubMedSearch in Google Scholar
  • 19 Bass N M, Yao F Y. Portal hypertension and variceal bleeding. In: Feldman M, Friedman LS, Sleisenger MH (eds). Sleisenger and Fordtran’s gastrointestinal and liver disease. 7th edn. Philadelphia; Saunders 2002: 1487-1515
    Search in Google Scholar
  • 20 Lo G H, Lai K H, Cheng J S. et al . A prospective, randomized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices.  Hepatology. 1995;  22 466-471
    CrossrefPubMedSearch in Google Scholar
  • 21 Sarin S K, Govil A, Jain A K. et al . Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal rcurrence.  J Hepatol. 1997;  26 826-832
    CrossrefPubMedSearch in Google Scholar
  • 22 Lo G H, Chen W C, Chen M H. et al . Endoscopic ligation versus nadolol in the prophylaxis of first variceal bleeding in cirrhosis.  Gastrointest Endosc. 2004;  59 333-338
    CrossrefPubMedSearch in Google Scholar
  • 23 Sarin S K, Jain A K, Jain M, Gupta R. A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices.  Am J Gastroenterol. 2002;  97 1010-1015
    CrossrefPubMedSearch in Google Scholar
  • 24 Binmoeller K F, Soehendra N. ”Superglue“: the answer to variceal bleeding and fundal varices?.  Endoscopy. 1995;  27 392-396
    PubMedSearch in Google Scholar
  • 25 Greenwald B D, Caldwell S H, Hespenheide E E. et al . N-2-butyl-cyanoacrylate for bleeding gastric varices: a United States pilot study and cost analysis.  Am J Gastroenterol. 2003;  98 1982-1988
    CrossrefPubMedSearch in Google Scholar
  • 26 Papatheodoridis G, Goulis J, Leandro G. et al . Transjugular intrahepatic portosystemic sunt compared with endoscopic treatment for prevention of variceal rebleeding: a meta-analysis.  Hepatology. 1999;  30 612-622
    CrossrefPubMedSearch in Google Scholar
  • 27 Boyer T D, Haskal Z J. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension.  Hepatology. 2005;  41 386-400
    CrossrefPubMedSearch in Google Scholar
  • 28 Spahr L, Dufresne M P, Bui B T. et al . Efficacy of TIPS in the prevention of rebleeding from esophageal and fundal varices: a comparative study [abstract].  Hepatology. 1995;  22 296A
    PubMedSearch in Google Scholar
  • 29 Sarin S K, Primignani M, Agarwal S R. Gastric varices. In: de Franchis R (eds). Portal hypertension III, Proceedings of the Third Baveno International Consensus Workshop on Definitions, Methodology and Therapeutic Strategies. Oxford; Blackwell Science 2001: 76-94
    Search in Google Scholar
  • 30 Sanyal A J, Freedman A M, Luketic V A. et al . The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts.  Gastroenterology. 1997;  112 889-898
    CrossrefPubMedSearch in Google Scholar
  • 31 Owens C A, Bartolone C, Warner D L. et al . The inaccuracy of Duplex ultrasonography in predicting patency of transjugular intrahepatic protosystemic shunts.  Gastroenterology. 1998;  114 975-980
    PubMedSearch in Google Scholar
  • 32 Lo G H, Lai K H. Should GOV1 be treated as for esophageal varices.  Gastroenterology. 2004;  127 1014-1015
    PubMedSearch in Google Scholar
  • 33 Lo G H, Lai K H, Shen M T, Chang C F. A comparison of the incidence of transient bacteremia and infectious sequelae after sclerotherapy and rubber band ligation of bleeding esophageal varices.  Gastrointest Endosc. 1994;  40 675-679
    PubMedSearch in Google Scholar
  • 34 Wahl P, Lammer F, Conen D. et al . Septic complications after injection of n-butyl-2-cyanoacrylate: report of two cases and review.  Gastrointest Endosc. 2004;  59 911-916
    CrossrefPubMedSearch in Google Scholar
  • 35 Angermayr B, Cejna M, Koenig F. et al . Survival in patients undergoing transjugular intrahepatic protosystemic shunt: ePTFE-covered stent grafts versus bare stents.  Hepatology. 2003;  38 1043-1050
    CrossrefPubMedSearch in Google Scholar

G.-H. Lo, MD

Department of Medicine

Division of Gastroenterology

Kaohsiung Veterans General Hospital

386 Ta-Chung 1st Road

Kaohsiung 813

Taiwan

Fax: +886-7-3468237

Email: ghlo@isca.vghks.gov.tw