Early TIPSS in secondary prophylaxis of variceal Bleeding: A Meta-Analysis

Objectives: Variceal bleeding is a life threatening complication of cirrhosis that requires secondary prophylaxis after the acute bleed. Present guidelines recommend medical therapy as the first-line treatment, and TIPSS for recurrent bleeding. Results from several studies comparing best medical treatment versus early TIPSS have been conflicting. In this systematic review and meta-analysis, we aimed to discern whether early-TIPSS is actually beneficial over conventional therapy in terms of mortality and rebleeding. Methods: A comprehensive search of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus was conducted to search for comparative studies of TIPSS for variceal bleeding. The outcomes of interest included all cause mortality, rebleeding rate, hepatic encephalopathy, new or worsening ascites, and adverse effects including sepsis. Results: Seven randomized controlled trials (RCTs), and five non-RCTs with a total of 1093 patients were included. Conventional therapy was associated with an increased incidence of overall rebleed (OR: 4.651, 95% CI: 2.939- 7.360, p-value: 0.00), and development of new/worsening ascites (OR: 2.913, 95% CI: 1.489-5.700, p-value: 0.002), but no significant difference in mortality (OR= 1.231, 95% CI: 0.879- 1.726. P-value: 0.226), hepatic encephalopathy (OR: 0.396, 95% CI: 0.393- 1.222, p-value: 0.205), or sepsis (OR: 0.714, 95% CI: 0.337-1.511, p-value: 0.378). Conclusion: The current systematic review and meta-analysis showed that early TIPSS was superior to the best medical therapy in decreasing the risk of rebleeding, and decreasing the risk of development of new or worsening ascites. There was no effect on mortality, hepatic encephalopathy, or sepsis. Key words: Portal Hypertension, esophago-gastric variceal bleeding, Transjugular Intrahepatic PortoSystemic Shunt, Secondary Prophylaxis