Comparative study of endoscopy vs. transjugular intrahepatic portosystemic shunt in the management of gastric variceal bleeding

Gursimran Singh Kochhar; Udayakumar Navaneethan; Jason Hartman; Jose Mari Parungao; Rocio Lopez; Ranjan Gupta; Baljendra Kapoor; Paresh Mehta; Madhu Sanaka

doi:10.1093/gastro/gou095

Comparative study of endoscopy vs. transjugular intrahepatic portosystemic shunt in the management of gastric variceal bleeding

Gastroenterol Rep (Oxf). 2015 Feb;3(1):75-82. doi: 10.1093/gastro/gou095.

Authors

Gursimran Singh Kochhar¹, Udayakumar Navaneethan¹, Jason Hartman¹, Jose Mari Parungao¹, Rocio Lopez¹, Ranjan Gupta¹, Baljendra Kapoor¹, Paresh Mehta¹, Madhu Sanaka²

Affiliations

¹ Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA, Case Western School of Medicine, Cleveland, OH, USA and Department of Vascular and Interventional Radiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
² Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA, Case Western School of Medicine, Cleveland, OH, USA and Department of Vascular and Interventional Radiology, Cleveland Clinic Foundation, Cleveland, OH, USA sanakam@ccf.org.

Abstract

Background and aim: Gastric varices are associated with high mortality. There have been conflicting reports on whether endoscopic treatment with cyanoacrylate or the placement of a transjugular intrahepatic portosystemic shunt (TIPS) is more effective in the treatment of gastric varices. We compared the outcomes of patients treated with cyanoacrylate glue or TIPS for the management of acute gastric variceal bleeding.

Methods: The study was designed as a retrospective cohort analysis of patients undergoing either TIPS or endoscopic treatment with cyanoacrylate for acute gastric variceal bleeding at our institution from 2001 to 2011. Primary compared to studied between the two treatment modalities were the short-term treatment outcomes, including re-bleeding within 30 days, length of hospital stay and in-hospital mortality. Kaplan-Meier survival analysis was performed to assess factors associated with in-hospital mortality.

Results: A total of 169 patients were included in the analysis. The TIPS arm contained 140 patients and the cyanoacrylate arm contained 29 patients. There was no evidence to suggest any significant differences in demographics or disease severity. There were no differences between the TIPS arm and the cyanoacrylate armtwo groups in treatment outcomes including re-bleeding within 30 days (17.4% vs. 17.2%; P = 0.98), median length of stay in the hospital (4.5 days vs. 6.0 days; P = 0.35) or in-hospital mortality (9.0% vs. 11.1%; P = 0.74). In-hospital mortality was evaluated for 149 patients and lower albumin (P = 0.015), higher MELD score (P < 0.001), higher CTP score (P = 0.005) and bleeding (P = 0.008) were all significantly associated with in-hospital death.

Conclusion: These findings suggest that both treatments are equally effective. Cyanoacrylate offers a safe, effective alternative to TIPS for gastric varices, and physician may choose the best therapy for each patient, factoring in the availability of TIPS or cyanoacrylate, the individual patient's presentation, and cost.

Keywords: cyanoacrylate injection; gastric varices; gastrointestinal bleeding; transjugular intrahepatic portosystemic shunt (TIPS).