A COMPARATIVE-STUDY OF EMERGENCY TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT-SHUNT AND ESOPHAGEAL TRANSECTION IN THE MANAGEMENT OF UNCONTROLLED VARICEAL HEMORRHAGE

Transjugular intrahepatic portosystemic stent-shunts (TIPSS) have been shown to reduce portal hypertension consistently and have recently be en reported to arrest active variceal hemorrhage. This retrospective a nd nonrandomized study compares the results of TIPSS with esophageal t ransection (ET) and devascularization in patients with uncontrolled va riceal hemorrhage admitted to a single center with an interest in vari ceal bleeding. Patients and Methods: Two hundred and sixty cirrhotic p atients have been referred with variceal bleeding over the past 7 yr. In 41 patients (15.8%), hemorrhage was uncontrolled despite two treatm ents with sclerotherapy. Thirty-eight patients were eligible for analy sis. Nineteen were considered for ET and 19 for TIPSS. Patients in the two groups were well matched for age, sex, etiology of liver disease, and its severity and complications. They have been followed for 13 pa tient years (TIPSS-7, longest 20 months; ET-6, longest 23 months). Dat a for survival and rebleeding were analyzed by the Kaplan-Meier method on an intention-to-treat basis. Results: Seven of the 19 were conside red unfit for surgery, and 12 underwent esophageal transection and dev ascularization. TIPSS was undertaken successfully in 17 patients, the Palmaz stent being used in 4 and the Wallstent in 13. Successful TIPSS reduced the mean portal pressure gradient from 22.2 (SE 1.2) to 9.7 ( SE 0.7) mm Hg (p < 0.001). Mortality within 30 days of the initial ble ed was 42% in the TIPSS group compared with 79% in the ET group (p < 0 .05). Rebleeding occurred in 15.6% patients with TIPSS, compared with 26.2% in the ET group. Encephalopathy in the two groups of patients wa s not significantly different (TIPSS 25% and ET 22%). TIPSS was follow ed by active infection in 20% compared with 36% after ET. can be perfo rmed successfully on these patients who are often not suitable for sur gery. Mortality rates were significantly lower in patients treated by TIPSS. Compared with ET, TIPSS should be regarded as the preferred mod e of treatment for uncontrolled variceal hemorrhage in patients with c irrhosis.