Secondary prophylaxis of variceal bleeding for cirrhotic patients: a multiple-treatments meta-analysis

Objective To evaluate comprehensively the effects of 12 prophylaxis interventions for secondary prophylaxis of variceal bleeding using multiple-treatments meta-analysis. Methods PubMed, EMBASE and the Cochrane Library were searched prior to November 2011. Randomized controlled trials (RCTs) comparing the interventions for secondary prophylaxis of variceal bleeding. The primary study outcomes were variceal rebleeding, mortality due to rebleeding and mortality due to all causes. Results We systematically reviewed 51 RCTs. Transjugular intrahepatic portosystemic shunt (TIPS), beta-blockers combined with endoscopic injection sclerotherapy (EIS) and endoscopic banding ligation (EBL) combined with EIS were superior to beta-blockers [odds ratios (OR) 0.13, 0.23 and 0.13, respectively] and EIS (0.19, 0.34 and 0.18, respectively) in reducing the rate of rebleeding. To reduce the mortality rate due to rebleeding, TIPS was more efficacious than beta-blockers (0.11), EBL (0.13), EIS (0.19), beta-blockers combined with isosorbide-5-mononitrate (5-ISMN) (0.16) and beta-blockers combined with EIS (0.14). In addition, beta-blockers combined with 5-ISMN were significantly more efficacious than beta-blockers (0.56) and EBL (0.64) to reduce the mortality rate due to all causes. EBL combined with argon plasma coagulation showed the best profile of reduction in rebleeding rate and mortality rate due to all causes. To reduce the mortality rate due to rebleeding, TIPS had the highest probability. EBL combined with EIS was the best choice according to the cumulative probabilities of being among the three most efficacious interventions for the three outcomes. Conclusions Endoscopic banding ligation combined with EIS might be the first choice in the secondary prophylaxis of varices bleeding.