Clinical effect of transjugular intrahepatic portosystemic shunt combined with tissue adhesive embolization in treatment of gastroesophageal variceal rebleeding in cirrhotic patients

Objective To investigate the clinical effect of transjugular intrahepatic portosystemic shunt (TIPS) alone versus TIPS combined with stomach and esophageal variceal embolization (SEVE) in the treatment of gastroesophageal variceal rebleeding in cirrhotic patients.Methods A total of 142 cirrhotic patients with gastroesophageal variceal bleeding who underwent TIPS or TIPS + SEVE in Department of Gastroenterology, Drum Tower Hospital, from January 2009 to December 2013 were enrolled and divided into TIPS group with 31 patients and TIPS + SEVE group with 111 patients. The two groups were analyzed in terms of intraoperative conditions, follow-up results, and risk factors for postoperative rebleeding. The independent samples t-test was used for comparison of continuous data between groups, the chi-square test was used for comparison of categorical data between groups, and the Mann-Whitney U test was used for comparison of ranked data between groups. The Kaplan-Meier method was used to plot the curves of rebleeding rate, shunt dysfunction rate, and survival rate, and the Log-rank test was used for the comparison of cumulative rebleeding rate, shunt dysfunction rate, and survival rate. The Cox proportional hazards regression model was used for univariate and multivariate analyses. Results All 142 patients completed the surgery successfully. There were no significant differences between the TIPS group and the TIPS + SEVE group in mean follow-up time (34 ± 23 months vs32 ± 21 months, t = 0. 501, P > 0. 05) and incidence rate of hepatic encephalopathy after surgery (12. 9% vs 18. 9%, χ2= 0. 641, P >0. 05) . There were no significant differences between the TIPS group and the TIPS + SEVE group in 1-, 2-, 3-, and 5-year cumulative rebleeding rates during follow-up (χ2= 1. 511, P > 0. 05) , while there were significant differences between the two groups in 1-, 2-, 3-, and 5-year cumulative shunt dysfunction rates (13%/21%/34%/34% vs 7%/12%/13%/13%, χ2= 4. 087, P < 0. 05) .There were no significant differences between the two groups in 1-, 2-, 3-, and 5-year cumulative survival rates during follow-up (χ2= 0. 471, P > 0. 05) . Preoperative Child-Pugh class (hazard ratio [HR]= 0. 385, 95% confidence interval [CI]: 0. 165-0. 898, P <0. 05) , stent type (HR = 0. 429, 95% CI: 0. 240-0. 766, P < 0. 05) , and postoperative shunt dysfunction (HR = 5. 840, 95% CI: 2. 566-13. 294, P < 0. 05) were influencing factors for postoperative rebleeding in cirrhotic patients with gastroesophageal variceal bleeding. The multivariate analysis showed that bare stent (relative risk [RR]= 0. 527, 95% CI: 0. 290-0. 954, P < 0. 05) and postoperative shunt dysfunction (RR = 4. 436, 95% CI: 1. 899-10. 360, P < 0. 05) were independent risk factors for postoperative rebleeding in cirrhotic patients with gastroesophageal variceal bleeding. Conclusion Compared with TIPS alone, TIPS + SEVE can reduce the incidence rate of postoperative shunt dysfunction in cirrhotic patients with gastroesophageal variceal bleeding, but it cannot reduce postoperative rebleeding rate or increase survival rate. Bare stent and shunt dysfunction are independent risk factors for postoperative rebleeding in cirrhotic patients with gastroesophageal variceal bleeding.