Secondary prophylaxis of variceal bleeding for cirrhotic patients: a multiple-treatments meta-analysis.

Objective: To evaluate comprehensively the effects of 12 prophylaxis interventions for secondary prophylaxis of variceal bleeding using multiple-treatments meta-analysis.

Methods: PubMed, EMBASE and the Cochrane Library were searched prior to November 2011. Randomized controlled trials (RCTs) comparing the interventions for secondary prophylaxis of variceal bleeding. The primary study outcomes were variceal rebleeding, mortality due to rebleeding and mortality due to all causes.

Results: We systematically reviewed 51 RCTs. Transjugular intrahepatic portosystemic shunt (TIPS), β-blockers combined with endoscopic injection sclerotherapy (EIS) and endoscopic banding ligation (EBL) combined with EIS were superior to β-blockers [odds ratios (OR) 0·13, 0·23 and 0·13, respectively] and EIS (0·19, 0·34 and 0·18, respectively) in reducing the rate of rebleeding. To reduce the mortality rate due to rebleeding, TIPS was more efficacious than β-blockers (0·11), EBL (0·13), EIS (0·19), β-blockers combined with isosorbide-5-mononitrate (5-ISMN) (0·16) and β-blockers combined with EIS (0·14). In addition, β-blockers combined with 5-ISMN were significantly more efficacious than β-blockers (0·56) and EBL (0·64) to reduce the mortality rate due to all causes. EBL combined with argon plasma coagulation showed the best profile of reduction in rebleeding rate and mortality rate due to all causes. To reduce the mortality rate due to rebleeding, TIPS had the highest probability. EBL combined with EIS was the best choice according to the cumulative probabilities of being among the three most efficacious interventions for the three outcomes.

Conclusions: Endoscopic banding ligation combined with EIS might be the first choice in the secondary prophylaxis of varices bleeding.