A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding

Prevention of recurrent variceal bleeding

Patients surviving a first episode of variceal bleeding have a risk of over 60% of experiencing recurrent haemorrhages within 1 year from the index episode. Because of this, all patients surviving a variceal bleeding should receive active treatments for the prevention of rebleeding. beta-Blockers+/-isosorbide-5-mononitrate and band ligation are effective in preventing recurrent bleeding and both can be used. Combination of beta-blockers+/-isosorbide-5-mononitrate and band ligation may be the best treatment to prevent rebleeding but more studies are needed to confirm this issue. In patients with recurrent variceal bleeding despite appropriate medical and endoscopic treatment, transjugular intrahepatic porto-systemic shunt is highly effective in controlling bleeding. The efficacy is not significantly different from that of shunt surgery (distal splenorenal shunt or 8mm H-graft shunt), especially since the introduction of polytetrafluoroethylene-covered stents. Therefore, in this situation, transjugular intrahepatic porto-systemic shunt using polytetrafluoroethylene stents should be the treatment of choice.

Therapeutic options for endoscopic haemostatic failures: the place of the surgeon and radiologist in gastrointestinal tract bleeding

The management of gastrointestinal tract bleeding has changed dramatically due to improvements of interventional endoscopy and radiology. The place of the radiologist has become very important, not only for diagnostic modalities but also for therapeutic embolisation to control the bleeding. The place of the surgeon is limited to the situation where both these less invasive techniques have failed to stop the bleeding. For arterial bleeding in the whole GI tract, angiography with subsequent embolisation is performed after failed endoscopy. For variceal bleeding the preferred treatment after endoscopic failure is transjugular intrahepatic portosystemic stent shunting (TIPS). Surgery is only needed in exceptional cases. Embolisation can be performed successfully without compromising the bowel vascularisation or inducing ischaemia, whereas surgery has a high rate of complications and mortality. For treatment of GI bleeding a multidisciplinary team including a gastroenterologist, radiologist and surgeon is mandatory.