Esophageal Stent for Refractory Variceal Bleeding: A Systemic Review and Meta-Analysis

Abstract

Background. Preliminary studies suggest that covered self-expandable metal stents may be helpful in controlling esophageal variceal bleeding. Aims. To evaluate the effectiveness and safety of esophageal stent in refractory variceal bleeding in a systematic review and meta-analysis. Methods. A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 1970 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using I (2) test. Results. Five studies involving 80 patients were included in the analysis. The age of patients ranged from 18 to 91 years. The mean duration of follow-up was 46.8 d (range, 30-60 d). The success rate of stent deployment was 96.7% (95% CI: 91.6%-99.5%) and complete response to esophageal stenting was in 93.9% (95% CI: 82.2%-99.6%). The incidence of rebleeding was 13.2% (95% CI: 1.8%-32.8%) and the overall mortality was 34.5% (95% CI: 24.8%-44.8%). Most of patients (87.4%) died from hepatic or multiple organ failure, and only 12.6% of patients died from uncontrolled bleeding. There was no stent-related complication reported and the incidence of stent migration was 21.6% (95% CI: 4.7%-46.1%). Conclusion. Esophageal stent may be considered in patients with variceal bleeding refractory to conventional therapy.

Figure 1

Study selection flow chart. Of a total of 387 studies, only 5 studies met selection criteria. TIPS indicates transjugular intrahepatic portosystemic shunt.

Figure 2

Deployment of esophageal stent in patients with refractory variceal bleeding. The esophageal stents were successfully deployed in 96.7% (95% CI: 91.6%–99.5%) of the 80 patients in the 5 studies. There was no heterogeneity among the studies (P = 0.37).

Figure 3

Response to esophageal stent in refractory variceal bleeding. (a) Forest plot shows that 93.9% (95% CI: 82.2%–99.6%) of the 80 patients in the 5 studies had a complete response (resolution of acute variceal bleeding without further need for other treatments) after deployment of esophageal stent. There was evidence of heterogeneity among the studies (P = 0.03). (b) Just over one-tenth (13.2%) of the patients treated with esophageal stents rebled after this procedure. There was evidence of heterogeneity among studies (P = 0.00).

Figure 4

Mortality and causes of death of patients treated with esophageal stents. (a) Forest plot shows that about one-third [34.5% (95% CI: 24.8%–44.8%)] of the 80 patients in the 5 studies died within 30 or 60 d of undergoing esophageal stents. There was no evidence of heterogeneity among studies (P = 0.60). (b) About nine-tenth [87.4% (95% CI: 71.2%–97.5%)] of deaths were due to hepatic or multiple organ failure in patients treated with esophageal stents. There was no evidence of heterogeneity among studies (P = 0.25). (c) Just over one-tenth [12.6% (95% CI: 2.5%–28.8%)] of deaths were contributed to uncontrolled bleeding. There was no evidence of heterogeneity among studies (P = 0.30).

Figure 5

Stent migration after stent deployment. Stent migration was noted in about one-fifth [21.6% (95% CI: 4.7%–46.1%)] of the 80 patients in the 5 studies. There was, however, evidence of heterogeneity among the studies (P = 0.00).