Published online Jan 10, 2016. doi: 10.4253/wjge.v8.i1.23
Peer-review started: July 2, 2015
First decision: August 4, 2015
Revised: October 8, 2015
Accepted: November 10, 2015
Article in press: November 11, 2015
Published online: January 10, 2016
Despite the advances of medical, endoscopic and radiological therapy over recent years the mortality rates of acute variceal haemorrhage are still 16%-20% and the medium term outcome has not improved in the last 25 years. Early transjugular intrahepatic portosystemic shunt has proved to be an effective therapy for selected groups of patients with a high risk of re-bleeding and moderate liver disease. However, there is an unmet need for a therapy that can be applied in patients with a high risk of re-bleeding and advanced liver disease either as definitive therapy or as a bridge to permanent therapy. Self-expanding metal stents can be placed without the need for endoscopic or fluoroscopic control and, once in place, will provide effective haemostasis and allow a route for oral fluids and nutrition. They can remain in place whilst liver function recovers and secondary prophylaxis is initiated. We review the results of 6 case series including a total of 83 patients and the first randomised controlled trial of self-expanding metal stents vs balloon tamponade (BT) in the management of refractory variceal haemorrhage. We report that self-expanding metal stents provide effective haemostasis and perform better than BT in refractory bleeding, where they are associated with fewer complications. Whilst the most effective place for self-expanding metal stents in the management algorithm needs to be determined by further randomised controlled trials, currently they provide an effective alternative to BT in selected patients.
Core tip: Failure to control bleeding in high-risk patients with variceal haemorrhage is still common, and not all patients are suitable for transjugular intrahepatic portosystemic shunts. Self-expanding metal stents can be placed without the need for endoscopic or fluoroscopic control and, once in place, provide effective haemostasis and allow a route for oral fluids and nutrition. They can remain in place whilst liver function recovers and secondary prophylaxis is initiated or whilst definitive therapy is provided. Self-expanding metal stents provide effective haemostasis and perform better than balloon tamponade in refractory bleeding, where they are associated with fewer complications.