RANDOMIZED TRIAL OF TRANSJUGULAR-INTRAHEPATIC-PORTOSYSTEMIC SHUNT VERSUS ENDOSCOPY PLUS PROPRANOLOL FOR PREVENTION OF VARICEAL REBLEEDING

Background The transjugular-intrahepatic-portosystemic shunt is a new interventional treatment for portal hypertension, The aim of our study was to compare the transjugular shunt with endoscopic treatment for t he prophylaxis of recurrent variceal bleeding. Methods Between March, 1993, and March, 1996, 126 patients with variceal bleeding were random ly assigned either transjugular shunt (n=61) or endoscopic treatment ( n=65), Patients were followed up for a median of 14 (IQR 8-25) months and 13 (8-25) months, respectively, In 31 (51%) of the shunted patient s, simultaneous transjugular-variceal embolisation was done at the tim e of shunt placement, Endoscopic treatment consisted of sclerotherapy and/or banding ligation and was combined with propranolol medication. Findings Technical success was achieved in all patients assigned to th e shunt group. During follow-up, the cumulative 1-year variceal reblee ding rates in the shunted and endoscopically treated patients were 15% and 41% and the 2-year rates were 21% and 52% (p=0.001), respectively . In nine (12%) patients from the endoscopic group treatment failed an d the patients received the transjugular-shunt treatment, A total of 1 9 bleeding episodes from any source occurred in 15 patients in the shu nt group compared with 100 episodes in 33 patients in the endoscopic g roup, There was no difference in survival with estimated 1-year surviv al rates for shunted and endoscopically treated patients of 90% and 89 %, and 2-year survival rates of 79% and 82%, respectively, The inciden ce of clinically significant hepatic encephalopathy after 1 year was h igher in the shunt group (36% vs 18%, p=0.011). Interpretation These r esults suggest, that the transjugular shunt is more effective than end oscopic treatment in prevention of variceal rebleeding but has a consi derable risk of hepatic encephalopathy. Survival is similar in the two groups.