Reply
Authors: Angels Escorsell, Jaime Bosch
Journal: Hepatology (2016)

We read with interest the letter by Dr. Lo. As he correctly points out,1, 2 a decision for an early, preemptive PTFE-covered TIPS should be considered in high-risk patients bleeding from varices, as was the case in 16 of the 28 patients included in our study.3 Not all of these patients were treated in hospitals with the necessary facilities and expertise for placing early TIPS, which is the major limitation of this strategy. Furthermore, the definition of a high-risk patient qualifying for early TIPS may require further refinement.4 In addition, the decision to place early TIPS is never made immediately (though usually within 24-48 hours), so it is fully ethical and necessary to provide emergency treatment before instituting TIPS. Dr. Lo further suggests that when esophageal tamponade/stent is used for massive variceal bleeding, the stent should be kept in place for a period "as short as possible to reduce complications as aspiration pneumonia." This assertion is clearly true for tamponade,1 but our results confirm that this is not the case for esophageal stents, which can be kept safely in place for longer periods; doing so allowed for treating underlying comorbidities to the point that, in some cases, the use of an emergency TIPS was no longer needed. Dr. Lo is probably correct in suggesting that according to our results, esophageal stent followed by combined long-term pharmacological and endoscopic therapy may be superior to tamponade followed by TIPS; however, this possibility should be confirmed in adequate clinical trials. Although the 40% mortality in our patients receiving balloon tamponade was high, it was not much different from what is expected in patients having a median Child-Pugh score of 10. Half of these patients had active bleeding at initial endoscopy despite having received therapy with vasoactive drugs. We agree with Dr. Lo that all patients who survive a variceal hemorrhage should receive an effective secondary prophylaxis to prevent rebleeding. Of the 15 patients randomly assigned to balloon tamponade, 10 were treated by TIPS; the remaining five patients did not receive TIPS due to total portal vein thrombosis (two patients), no known hepatocellular carcinoma in the trajectory of TIPS (one patient), and active sepsis requiring assisted ventilation and renal support (two patients). In one patient, rupture of the gastric balloon precluded the correct positioning of the stent. This is a common cause of failed stent deployment that is primarily a safety precaution, because the balloon will rupture if overdistended or inflated in the esophagus. In our experience, however, deployment of both devices was technically easy overall. Finally, we stand by our endorsement of the use of esophageal stents over balloon tamponade in patients with acute variceal bleeding that is not controlled with medical or endoscopic treatment. We do not deny that balloon tamponade should still be used with caution, but we expect that most medical treatment facilities will use esophageal stents increasingly in the near future. Angels Escorsell, M.D. Jaime Bosch, M.D., Ph.D. Liver Unit Hospital Clinic Barcelona, Spain