Should transjugular intrahepatic portosystemic shunt be first-line therapy for preventing esophageal variceal rebleeding? A meta-analysis of clinical outcomes.

Abstract

Introduction: According to Baveno VII guidelines, endoscopic band ligation (EBL) plus nonselective beta-blockers (NSBB) is first-line therapy for preventing esophageal variceal rebleeding, with transjugular intrahepatic portosystemic shunt (TIPS) being used in cases of treatment failure. Our study aimed to compare TIPS with EBL plus NSBB in terms of overall mortality and rate of variceal rebleeding.

Methods: We conducted a comprehensive search on Medline, Google Scholar, Embase, and the Cochrane Library up to January 25, 2025. Randomized control trials (RCTs) comparing TIPS with EBL plus NSBB for variceal bleeding were included in the study.

Results: Eight RCTs with 629 patients, 336 receiving TIPS and 293 receiving EBL + NSBB, were included. TIPS had significantly lower rates of variceal rebleeding (odds ratio 0.30, 95% confidence interval 0.19-0.49, P < 0.00001), all-cause rebleeding (P < 0.0001), total episodes of rebleeding (P < 0.0001), new/worsening ascites (P < 0.0001), and peritonitis (P = 0.01). No significant differences were found in mortality, sepsis/pneumonia, hepatic encephalopathy, or hepatocellular carcinoma.

Conclusion: TIPS offers significant advantages over EBL plus NSBB in reducing variceal rebleeding and other complications but does not improve mortality. Further high-powered trials are needed to refine management strategies for variceal rebleeding in cirrhotic patients.