Covered Transjugular Intrahepatic Portosystemic Shunt Versus Endoscopic Therapy plus β-blocker for Prevention of Variceal Rebleeding
Covered Transjugular Intrahepatic Portosystemic Shunt Versus Endoscopic Therapy plus β-blocker for Prevention of Variceal Rebleeding
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DOI：
10.1002/hep.28318
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发表时间：
2016-02-01
期刊：
影响因子：
13.5
通讯作者：
van Buuren, Henk R.
中科院分区：
文献类型：
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作者：
Holster, I. Lisanne;Tjwa, Eric T. T. L.;van Buuren, Henk R.
肝硬化患者的胃食道静脉曲张出血与显著的发病率和死亡率以及高再出血风险有关。在接受标准的内窥镜、血管活性和抗生素治疗的患者中，经颈静脉肝内门体分流术(TIPS)加覆膜支架的作用的数据有限。在这项多中心随机试验中，72名首次或第二次出现胃底静脉曲张和/或食道静脉曲张出血的患者在接受胃镜、血管活性和抗生素治疗后血流动力学稳定后，进行了长期内窥镜静脉曲张结扎术(EVL)或胶体注射+β-受体阻滞剂治疗与TIPS治疗的比较。随机分组根据Child-Pugh评分进行分层。Kaplan-Meier(无事件)生存估计用于终点再出血、死亡、治疗失败和肝性脑病。在23个月的中位随访期间，内窥镜+β-受体阻滞剂组35名患者中有10名(29%)发生静脉曲张再出血，而TIPS组37名患者中0名(0%)发生再出血(P=0.001)。死亡率(TIPS 32%对内窥镜26%；P=0.418)和治疗失败(TIPS 38%对内窥镜34%；P=0.685)在组间没有差别。TIPS组早期肝性脑病(1年内)的发生率显著高于TIPS组(35%比14%；P=0.035)，但在长期随访中这种差异缩小(38%比23%；P=0.121)。结论：在未经选择的肝硬变患者中，对于静脉曲张破裂出血成功地接受了内窥镜止血的患者，覆盖TIPS在减少静脉曲张再出血方面优于EVL+β-受体阻滞剂，但并不能提高存活率。TIPS与较高的早期肝性脑病发生率相关。
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 + beta-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 + beta-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 longterm 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 + beta-blocker for reduction of variceal rebleeding, but did not improve survival. TIPS was associated with higher rates of early hepatic encephalopathy.