7, 8 Finally, the increase in the rate of hepatic encephalopathy (HE) by the shunt, the strongest argument against the TIPS treatment, was not confirmed by the study of García-Pagán et al.1 If this finding were extended to patients with Child-Pugh class A or B disease, they might also be regarded as candidates for early TIPS treatment. Because of the great influence of NVP-BGJ398 datasheet this study on the treatment strategy for variceal bleeding, specific attention should be paid to those results differing from previous studies or experiences. The results of the medical group are largely as expected.9, 10 In contrast, some results of the early TIPS group are unexpected. The fact that the authors used bleeding

and not survival as the primary endpoint reveals that they expected a small difference in survival requiring an impossibly high sample size. Indeed, the patients had advanced disease

and a mean bilirubin concentration of 3.7± 4.8 mg/dL at the baseline. Thus, approximately half of the patients had a bilirubin concentration greater than 3 mg/dL, which predicts reduced survival after TIPS.4, 11, 12 When such patients are treated electively, they have 6-week and 1-year survival rates of only 85% and 75%, respectively.13 Survival rates were, however, comparable between Child-Pugh class selleck products A and B patients treated electively (95% and 85%) and the early TIPS group (97% and 86%). It can be speculated that bleeding might cause an acute but transient deterioration that upgrades a patient’s Child-Pugh score, which does not reliably reflect the baseline liver function.

In contrast to the study under discussion, randomized studies of secondary prophylaxis did not find a survival benefit for TIPS patients.4, 9 This may be due to the fact that these studies excluded acute bleeders and thus selected survivors with a lower risk of bleeding-related deaths. In addition, the previous studies used uncovered stents with a high rate of shunt insufficiency, which led to a higher rate of recurrent bleeding. As for HE, the results of the study by García-Pagán et al.1 and the studies of secondary prophylaxis are also different. Although TIPS increased the incidence Rolziracetam of HE in patients treated for secondary prophylaxis,4, 9 this was not observed in the study by García-Pagán et al. (8 patients with early TIPS and 12 patients with medical treatment). The lower rate of HE, as expected, may be due to the fact that in the study by García-Pagán, stents were initially dilated to 8 mm, and a further dilatation to 10 mm was performed only if the gradient did not decrease below the threshold of 12 mm Hg. Despite this, the mean pressure gradient after TIPS of 6.2 ± 3 mm Hg was lower than that needed and provided the chance for a further reduction in the incidence of HE with even smaller shunts.