Secondary prophylaxis of oesophageal variceal haemorrhage: a role for transjugular intrahepatic portosystemic shunt?

Cirrhotic patients who survive an episode of acute variceal haemorrhage are at high risk of recurrent bleeding. Many treatments have been found to be effective at preventing rebleeding, including drug therapy, endoscopic treatments and transjugular intrahepatic portosystemic stunt (TIPS). In this issue of European Journal of Gastroenterology & Hepatology, Jalan et al. compared three historical cohorts of patients with cirrhosis after index variceal bleed and found a lower rebleeding rate in patients receiving TIPS (116.2%) compared to either band ligation (39.3%) or endoscopic variceal sclerotherapy (74.6%). Despite the efficacy of TIPS in preventing variceal rebleeding, there was no significant difference in survival between the three cohorts. However, sub-group analysis found a lower mortality in patients with Child-Pugh class C cirrhosis receiving TIPS. Unfortunately, this promising observation in patients with advanced cirrhosis is not supported by the results of meta-analysis of randomized studies. Therefore, we do not recommend TIPS as first-line therapy to prevent variceal rebleeding in patients with cirrhosis. Eur J Gastroenterol Hepatol 14:591-593 (C) 2002 Lippincott Williams Wilkins.