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

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紏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.

Impact of transjugular intrahepatic portosystemic shunt on post-colectomy complications in patients with ulcerative colitis and primary sclerosing cholangitis

Objective:Primary sclerosing cholangitis(PSC)occurs in approximately 5%of patients with ulcerative colitis(UC).The risk of colon cancer is higher in patients undergoing colectomy,who have simultaneous PSC&UC.Our aim was to study the impact,in terms of post-colectomy survival and complications,of transjugular intrahepatic portosystemic shunt(TIPS)before colectomy in these patients.Methods:In this retrospective,case-control study,information was obtained on demographics,disease characteristics,TIPS characteristics,and post-colectomy complications.Nine patients with PSC and UC who underwent TIPS prior to colectomy(the Study group)and 37 patients with PSC and UC who underwent only colectomy without TIPS(the Control group)were included.Either an analysis of variance or the non-parametric Kruskal-Wallis test were used for continuous variables and Fisher’s Exact test or Pearson’s chi-squared test was used for categorical factors.Results:There was no difference in themean age between the two groups;however patients in the Study group had lower platelet count(P=0.005)as well as higher Model for End-Stage Liver disease(MELD)scores(P<0.001).Also,patients in the Study group had increased PSC severity as determined by Mayo PSC Risk Scores(1.50 vs.0.20)(P=0.001).Total bilirubin levels were higher in the Study group(2.3 vs.0.8mg/dL)(P=0.011).Comparing the post-operative complication rates without adjusting for disease severity,the Study group hadmore wound infections(P=0.034),more wound dehiscence(P=0.022),and a higher re-admission rate within 30 days(P=0.032);however,the post-operativemortality was not significantly different.Conclusion:Patients with PSC and UC who underwent TIPS prior to colectomy had higher rates of complications;however,this was probably due to the greater severity of cirrhosis and PSC in this population.