For the prevention of recurrent esophageal variceal bleeding, studies show that patients treated with transjugular intrahepatic portosystemic shunt (TIPS) have lower rebleeding rates compared with endoscopic therapy. However, TIPS is associated with higher rates of portosystemic encephalopathy and possibly higher costs. The aim of this study was to conduct a cost-effectiveness analysis comparing TIPS with endoscopic sclerotherapy and endoscopic ligation for the prevention of recurrent esophageal variceal bleeding. Data for rates of rebleeding, death, complications, and crossover from endoscopy to TIPS were obtained from the literature. Costs for procedures and hospitalizations were obtained from two medical centers. Sensitivity analyses were performed varying probabilities of key variables. The patient population consisted of a hypothetical cohort of cirrhotic patients successfully treated for esophageal variceal bleeding with endoscopic sclerotherapy who received prophylactic sclerotherapy, ligation, or TIPS over 1 year. Endoscopic patients would receive propranolol. Mortality was similar for the three groups. The number of bleeds per patient for sclerotherapy, ligation, and TIPS would be 0.39, 0.32, and 0.07, respectively. The total annual costs per patient for sclerotherapy, ligation, and TIPS were $23,459, $23,111, and $26,275, respectively. The incremental cost per bleed prevented for TIPS compared with sclerotherapy and ligation was $8,803 and $12,660, respectively. The incremental cost per bleed prevented for TIPS compared with sclerotherapy or ligation was sensitive to the cost of TIPS and the TIPS stenosis rate. Ligation had lower costs and lower recurrent bleeding rates than sclerotherapy. Compared with endoscopic therapy, TIPS leads to lower recurrent variceal bleeding rates and it is more cost effective in the short term for the prevention of recurrent esophageal variceal bleeding. (HEPATOLOGY 2000;31:358-363.)
Variceal bleeding is a major cause of morbidity and mortality in patients with cirrhosis. Variceal bleeding occurs in 33% of patients with cirrhosis and carries a mortality of 30% to 50%. [1][2][3] Up to 70% of patients have recurrent bleeding within the first year of the first bleeding episode. 1,3 Strategies have been developed for the prevention of recurrent esophageal bleeding in the high-risk group of patients who have had a first bleed.
Treatment for acute variceal bleeding includes endoscopic therapy and the transjugular intrahepatic portosystemic shunt (TIPS). Endoscopic sclerotherapy can stop bleeding in 75% to 85% of cases, but recurrent bleeding occurs in 30% to 50% of patients within the first year. [4][5][6][7][8][9] Studies comparing endoscopic sclerotherapy to endoscopic ligation (banding) show higher rates for controlling bleeding with ligation and lower, but still substantial, recurrent bleeding rates of 26% to 36%. 5,8,9 Twelve percent to 28% of patients undergoing follow-up endoscopy have recurrent variceal bleeding and receive TIPS. [10][11][12][13][14][15][16] TIPS reduces the portosystemic gradient by placing a stent joining the hepatic and portal veins. By reducing portal hypertension, TIPS decompresses varices and prevents recurrent bleeding. Randomized controlled trials comparing TIPS with endoscopic sclerotherapy for recurrent variceal bleeding show that recurrent bleeding rates are 15% to 20% at 1 year, which is 28% to 38% lower than sclerotherapy. 11,[13][14][15][16] Although TIPS leads to lower recurrent bleeding rates, it may lead to hepatic encephalopathy. [10][11][12][13][14][15] Because TIPS leads to lower recurrent bleeding rates compared with endoscopic sclerotherapy, it may be an attractive alternative for treating variceal bleeding. Some authorities believe TIPS may be the procedure of choice over endoscopic therapy in select populations. [17][18][19] Others favor endoscopic therapy because of high rates of encephalopathy with TIPS. 10,11,13,20 In addition, TIPS may be associated with greater costs because of high rates of stenosis.
Most studies show mortality is similar in patients treated with TIPS and sclerotherapy. 11,[13][14][15][16] Sanyal et al. 10 reported a higher mortality in the TIPS group compared with the sclerotherapy group, 29% versus 18% (P Ο .03). Results from this study may differ from the others because of a greater proportion of patients with Child-Pugh class C cirrhosis in this study compared with the other studies. Also, not all of the deaths in the TIPS group were directly related to the shunt. 10,19 A meta-analysis of trials comparing TIPS with endoscopic therapy for the prevention of recurrent esophageal variceal bleeding reported that TIPS is associated with a 28% reduction in recurrent bleeding compared with endoscopic therapy. 21 Mortality from recurrent bleeding was lower in the TIPS Abbreviations: TIPS, transjugular intrahepatic portosystemic shunt.