Transjugular Intrahepatic Portosystemic Shunts Versus Sclerotherapy: A Discussion of Discordant Results
Authors: Harold O. Conn
Journal: Annals of Internal Medicine (1997)

Editorials1 June 1997Transjugular Intrahepatic Portosystemic Shunts Versus Sclerotherapy: A Discussion of Discordant ResultsHarold O. Conn, MDHarold O. Conn, MDYale University, New Haven, CT 06510Note added in proof: After this editorial was typeset, a report by Rossle and colleagues of a randomized clinical trial comparing TIPS and endoscopic sclerotherapy was published in The Lancet [17]. This study is the largest of the four studies published on this topic so far. It differs from the others in that it compares TIPS plus embolization of esophageal varices with endoscopic sclerotherapy that used 1) polidocanol or 2) banding ligation of varices plus propanolol in a dose designed to reduce the heart rate by 25%. Revisions of the stent-shunts and repeated courses of sclerotherapy, the standard methods of applying these therapies, were performed as needed. In 14% of patients in the endoscopy group, TIPS were created when sclerotherapy was deemed unsuccessful.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-126-11-199706010-00010 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail “The best laid plans o' mice and men gang aft agley.”Robert BurnsThis issue presents the initial reports of two randomized, controlled trials that compared endoscopic sclerotherapy with transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of patients who survived hemorrhage from esophageal varices [1, 2]. Only one previous such study has been published as a peer-reviewed article [3]. Although the goals and the experimental designs of these trials are similar, they are not identical. Furthermore, the results of the three studies are quite different.In all three studies, endoscopic sclerotherapy, which is widely held to be the standard ...References1. Sanyal AJ, Freedman AM, Luketic VA, Purdum PP 3d, Shiffman ML, Cole PE, et al. Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage. A randomized, controlled trial. Ann Intern Med. 1997; 126:849-57. Google Scholar2. Cello JP, Ring EJ, Olcott EW, Koch J, Gordon R, Sandhu J, et al. Endoscopic sclerotherapy compared with percutaneous transjugular intrahepatic portosystemic shunt after initial sclerotherapy in patients with acute variceal hemorrhage. A randomized, controlled trial. Ann Intern Med. 1997; 126:858-65. Google Scholar3. Cabrera J, Maynar M, Granados R, Gorriz E, Reyes R, Pulido-Duque JM, et al. Transjugular intrahepatic portosystemic shunt versus sclerotherapy in the elective treatment of variceal hemorrhage. Gastroenterology. 1996; 110:832-9. Google Scholar4. Rossle M, Haag K, Ochs A, Sellinger M, Noldge G, Perarnau JM, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med. 1994; 330:165-7. Google Scholar5. Conn HO. TIPS and portosystemic encephalopathy. In: Conn HO, Palmaz J, Rosch J, Rossle M, eds. TIPS: Transjugular Intrahepatic Portosystemic Shunts. New York: Igaku-Shoin; 1996:281-97. Google Scholar6. Saxon RR, Barton RE, Keller FS, Rosch J. Stenosis and occlusion after TIPS: prevention and correction. In: TIPS: Transjugular Intrahepatic Portosystemic Shunts. New York: Igaku-Shoin; 1996:267-80. Google Scholar7. Cook DJ, Guyatt GH, Ryan G, Clifton J, Buckingham L, Willan A, et al. Should unpublished data be included in meta-analyses? Current convictions and controversies. JAMA. 1993; 269:2749-53. Google Scholar8. Conn HO, Grace ND, Bosch J, Groszmann RJ, Rodes J, Wright SC, et al. Propranolol in the prevention of the first hemorrhage from esophageal varices: a multicenter, randomized clinical trial. The Boston-New Haven-Barcelona Portal Hypertension Study Group. Hepatology. 1991; 13:902-12. Google Scholar9. Friedman HP, Goldberg JD. Meta-analysis: an introduction and point of view. Hepatology. 1996; 23:917-28. Google Scholar10. Conn HO. Interpretation of data from multiple trials: a critical review. J Intern Med. 1997; 241:177-83. Google Scholar11. Yusuf S, Collins R, Peto R, Furberg C, Stampfer MJ, Goldhaber SZ, et al. Intravenous and intracoronary fibrinolytic therapy in acute myocardial infarction: overview of results on mortality, reinfarction and side-effects from 33 randomized, controlled trials. Eur Heart J. 1985; 6:556-85. Google Scholar12. Nony P, Boissel JP, Lievre M, Cucherat M, Haugh MC, Dayoub G. Introduction a la methodologie metaanalytique. Rev Med Interne. 1995; 16:536-46. Google Scholar13. Poynard T, Cales P, Pasta L, Ideo G, Pascal JP, Pagliaro L. Beta-adrenergic-antagonist drugs in the prevention of gastrointestinal bleeding in patients with cirrhosis and esophageal varices. An analysis of data and prognostic factors in 589 patients from four randomized clinical trials. Franco-Italian Multicenter Study Group. N Engl J Med. 1991; 324:1532-8. Google Scholar14. Conn HO, Palmaz J, Rosch J, Rossle M, eds. TIPS: Transjugular Intrahepatic Portosystemic Shunts. New York: Igaku-Shoin; 1996:376. Google Scholar15. Garceau AJ, Donaldson RM Jr, O'Hara ET, Callow AD, Muench H, Chalmers TC. A controlled trial of prophylactic portacaval-shunt surgery. N Engl J Med. 1964; 270:496-500. Google Scholar16. Morillas RM, Planas R, Cabre E, Galan A, Quer JC, Feu F, et al. Propranolol plus isosorbide-5-mononitrate for portal hypertension in cirrhosis: long-term hemodynamic and renal effects. Hepatology. 1994; 20:1502-8. Google Scholar17. Rossle M, Delbert P, Haag K, Ochs A, Olschewski M, Siegerstetter V, et al. Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propanolol for prevention of variceal bleeding. Lancet. 1997; 349:1043-9. Google Scholar Author, Article, and Disclosure InformationAffiliations: Yale University, New Haven, CT 06510Note added in proof: After this editorial was typeset, a report by Rossle and colleagues of a randomized clinical trial comparing TIPS and endoscopic sclerotherapy was published in The Lancet [17]. This study is the largest of the four studies published on this topic so far. It differs from the others in that it compares TIPS plus embolization of esophageal varices with endoscopic sclerotherapy that used 1) polidocanol or 2) banding ligation of varices plus propanolol in a dose designed to reduce the heart rate by 25%. Revisions of the stent-shunts and repeated courses of sclerotherapy, the standard methods of applying these therapies, were performed as needed. In 14% of patients in the endoscopy group, TIPS were created when sclerotherapy was deemed unsuccessful.Corresponding Author: Harold O. Conn, MD, 160 Morgan Avenue, East Haven, CT 06512. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoTransjugular Intrahepatic Portosystemic Shunts Compared with Endoscopic Sclerotherapy for the Prevention of Recurrent Variceal Hemorrhage Arun J. Sanyal , Arthur M. Freedman , Velimir A. Luketic , Preston P. Purdum III , Mitchell L. Shiffman , Patricia E. Cole , Jaime Tisnado , and Sharon Simmons Endoscopic Sclerotherapy Compared with Percutaneous Transjugular Intrahepatic Portosystemic Shunt after Initial Sclerotherapy in Patients with Acute Variceal Hemorrhage John P. Cello , Ernest J. Ring , Eric W. Olcott , Johannes Koch , Roy Gordon , Jeet Sandhu , Douglas R. Morgan , James W. Ostroff , Don C. Rockey , Peter Bacchetti , Jeanne LaBerge , John R. Lake , Kenneth Somberg , Catherine Doherty , Marta Davila , Kenneth McQuaid , and Susan D. Wall Metrics Cited byLiver DiseaseEthical issues concerning therapeutic studies in inflammatory bowel diseaseLong-term portosystemic shunt patency as a determinant of outcome in Budd–Chiari syndromeRupture de varices oesophagiennesPrise en charge des hémorragies par rupture de varices œsophagiennes chez les patients porteurs d'une cirrhoseAugmentation de la perméabilité à long terme des anastomoses porto-caves par voie transjugulaire (TIPS) chez 218 patients cirrhotiques, grâce à un suivi strictLa technique du shunt porto-sushépatique par voie transjugulaireCost-effectiveness analysis of transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic therapy for the prevention of recurrent esophageal variceal bleedingOutcome of Budd-Chiari syndrome: A multivariate analysis of factors related to survival including surgical portosystemic shuntingTransjugular Intrahepatic Portosystemic Shunt (TIPS)Is transjugular intrahepatic portasystemic shunt a panacea for the complications of portal hypertension?Development of pseudointima and stenosis after transjugular intrahepatic portasystemic shunts: Characterization of cell phenotype and functionTIPS: Randomized Clinical Trials and Research 1 June 1997Volume 126, Issue 11Page: 907-910KeywordsBrain diseasesCirrhosisDeath ratesHemorrhageInformation storage and retrievalPatientsRandomized trialsResearch designStenosisStent implantation ePublished: 15 August 2000 Issue Published: 1 June 1997 Copyright & PermissionsCopyright © 1997 by American College of Physicians. 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