| Objective The aim of the present study was to compare the efficacy and safety of transjugular intrahepatic portosystemic shunt(TIPS)and endoscopic treatment plus anticoagulation(ETPA)to provide a reference for the clinical management of esophageal variceal bleeding(EVB)and portal vein thrombosis(PVT)in cirrhotic patients.Methods A retrospective analysis was performed on 66 cirrhotic patients with EVB and PVT at the First Affiliated Hospital of Anhui Medical University between January2016 and January 2021.They were divided into the TIPS group(n=31)and the ETPA group(n=35)according to the treatment methods.The demographic and clinical data of the patients including PVT recanalization,variceal rebleeding,complications including hepatic encephalopathy(HE)and survival in the two groups were collected and compared.Factors influencing PVT recanalization,rebleeding,HE and survival were analyzed using univariate and multivariate COX regression.Results1.There were no statistically significant difference between the ETPA group and the TIPS group in terms of ages,genders,etiologies,Child-Pugh classification,PVT classification,routine blood count,liver and kidney function indices,anti-coagulant functions,pre-operative ascites and HE(P>0.05).2.Thirty-two patients in the ETPA group showed complete eradication of esophageal varices(EVs)after endoscopic treatment,with a mean number of 3.13±1.84 sesseions.Three patients did not achieve complete elimination of EVs due to early death of variceal bleeding.Nine patients were treated with warfarin postoperatively and 26 patients received subcutaneous injection of low molecular weight heparin.3.All 31 patients in the TIPS group were successfully treated with TIPS,achieving the technical success rate of 100.0%.Among them,24 received variceal embolization.In addition,3 patients underwent endovascular catheterization thrombolytic therapy.The mean portacaval pressure gradient was decreased by 9.40 mm Hg± 3.00(from 29.05 mm Hg±4.02 to 19.65 mm Hg±4.27,P<0.001)after TIPS.Following TIPS,7 patients received oral warfarin and 24 patients received anti-platelet therapy.4.Nine patients in the TIPS group developed shunt dysfunction,The cumulative 1-,3-and 5-year incidences of TIPS patency was 93.5,78.8 and 40.8%,respectively.5.During treatment and follow-up,15 patients in the ETPA group showed variceal rebleeding,with cumulative variceal rebleeding rates of 31.4%,41.7%,and 50.1% at 1,3,and 5 years,respectively.Six patients in the TIPS group showed variceal rebleeding,with cumulative variceal rebleeding rates of 9.7%,13.8%,and 31.0% at 1,3,and 5years,respectively.The variceal rebleeding rate was significantly higher in the ETPA group than in the TIPS group(P=0.017).Univariate COX regression analysis showed that ETPA therapy was the only independent risk factor of variceal rebleeding.6 The cumulative rates of overall PVT recanalization(including partial and complete recanalization)and complete recanalization were significantly higher in the TIPS group than in the ETPA group(96.8% vs.62.9%;P=0.001;85.5% vs.19.6%;P<0.001).Univariate COX regression analysis showed that ETPA treatment with oral warfarin affected complete recanalization of PVT;multivariate COX regression analysis showed that ETPA treatment was a risk factor for the failure in complete recanalization of PVT.7.HE occurred in 2 patients of the ETPA group and in 8 patients of the TIPS group,4 of whom had recurrent HE.The incidence of HE was higher in the TIPS group than in the ETPA group and the difference was statistically significant(25.8% vs.5.7%;P=0.037).Univariate COX regression analysis showed that TIPS treatment,increased the MELD score and serum bilirubin were associated with a higher incidence of HE.In the multivariate COX regression analysis,TIPS treatment was the independent risk factor of HE.8.The difference between the two groups in the incidence of complications related to portal hypertension(e.g.spontaneous peritonitis,hepatorenal syndrome)was not statistically significant(P=0.116).In addition,there was no statistically significant difference in the incidence of postoperative adverse effects(e.g.fever,nausea and vomiting,postoperative pain)between the two groups(P=0.915).9.Four patients died in the ETPA group,with a cumulative survival rate of 96.8,96.8and 74.1% at 1,3 and 5 years,respectively.Four patients died in the TIPS group,with a cumulative survival rate of 91.4%,85.7% and 85.7% at 1,3 and 5 years,respectively.No significant difference in the survival rates was observed between the two groups.In the univariate COX regression analysis,increased age and Child-Pugh score,total bilirubin and hemoglobin were associated with high mortality risk.In the multivariate analysis,age and hemoglobin were significantly correlated with mortality.Conclusion TIPS was superior to ETPA in preventing variceal rebleeding and achieving recanalization of PVT but increased the incidence of HE without improving the survival rate.Objective To compare the efficacy and safety of balloon-compression endoscopic injection sclerotherapy(bc-EIS)and TIPS in the prevention of esophageal varices rebleeding in liver cirrhosis and explore a more efficient and safe secondary prophylaxis of EVB in liver cirrhosis.Methods Between June 2020 and September 2021,cirrhotic patients with EVB who were admitted to the First Affiliated Hospital of Anhui Medical University(42 in the bc-EIS group and 39 in the TIPS group)were evaluated retrospectively.The occurrence of variceal rebleeding,HE or other complications,as well as liver functions and survival rate were compared between two groups in the 12 months of follow-up.Results1.The differences between the bc-EIS group and the TIPS group in terms of ages,genders,etiologies,Child-Pugh classification,preoperative laboratory tests and clinical data were not statistically significant(P>0.05).2.Forty(95.24%)patients in the bc-EIS group achieved the eradication of EVs with a mean number of 1.80±0.94 sessions,2 patients did not achieve variceal eradication due to massive rebleeding and received rescue TIPS.3.All the patients in the TIPS group were successfully treated with TIPS,achieving a technical success rate of 100.0%,32 of whom underwent variceal embolization.The mean portacaval pressure gradient was decreased from 29.39 mm Hg ± 5.87 to 19.58 mm Hg ± 5.40(P < 0.001).4.The overall variceal rebleeding rate,early rebleeding rate and late rebleeding rate in the bc-EIS group were 16.67%,4.76% and 11.90% respectively.The overall variceal rebleeding rate,early rebleeding rate and late rebleeding rate in the TIPS group were17.95%,5.13% and 12.82% respectively.There was no statistical significance in the overall variceal rebleeding rate,early rebleeding rate and late rebleeding rate during the12 months of follow-up between the two groups(P = 0.879,P = 1.000,P = 1.000)5.The incidence of HE in the TIPS group during the postoperative 12 months was significantly higher than that of the bc-EIS group(17.95% vs.2.38%;P = 0.026).No significant difference was observed between the two groups in the incidence of other complications(P=0.506).6.Albumin was significantly elevated after treatment in the bc-EIS group(P = 0.020).In contrast,total bilirubin measured at month 12 after TIPS placement were significantly higher than the baseline(P=0.046).Furthermore,the TIPS group showed significantly higher TBIL than the bc-EIS group at each time point following treatment(P <0.05).In addition,The level of ALP in the TIPS group increased significantly after operation(P<0.001).7.Three patients died during the 12 months of follow-up in the TIPS group,while there was no death in the bc-EIS group.The TIPS group exhibited an increased mortality rate than the bc-EIS group,however,the difference was not statistically significant(7.69%vs.0.00%,P =0.107).Conclusion Bc-EIS is comparable to TIPS with regard to the survival benefit and control of variceal rebleeding,but associated with decreased risk of HE and liver dysfunction. |
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