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Improved survival in patients with refractory variceal bleeding treated with esophageal stents: A multicenter cohort study

Year: 2025
Type: article
Study design: Observational Study
Abstract: Background and Aims Tamponade is a bridge therapy for refractory variceal bleeding. This study compared esophageal stents (ES) and balloon tamponade (BT) in terms of early bleeding control and mortality. Methods We analyzed a cohort of patients with cirrhosis treated with tamponade in nine French hospitals between 2002 and 2023. The primary outcome was six-week mortality. Multivariable analyses included Cox with time-dependent covariates and logistic regression models, adjusted for MELD score, rescue TIPS (rTIPS), and inverse probability of treatment weighting (IPTW) for ES. Results Sixty-three patients (87.3% male; mean age 55 years; 73.0% Child-Pugh C) were included. ES was used in 30 patients, BT in 33, and rTIPS subsequently in 20. Endoscopic control was attempted in 66.1% of cases. Adverse events were more frequent with ES (56.7% vs. 27.3%, p=0.018), mostly stent migrations without clinical consequence, but less severe than with BT (two esophageal ruptures). Mortality was 42.9% (n=27) at day five and 55.5% (n=35) at six weeks. Univariable analysis revealed lower mortality with ES than with BT (20.0% vs. 63.6% on day five and 36.7% vs. 72.7% on week six, p=0.0015) and with rTIPS (10.0% vs. 58.1% on day five and 25.5% vs. 67.5% on week six, p=0.0009). IPTW-adjusted and IPTW-weighted time-dependent Cox and logistic models confirmed decreased six-week mortality (HR=0.26, p=0.0078) and better five-day bleeding control (OR=6.1, p=0.020) with ES. Conclusions In patients cirrhosis-related refractory variceal bleeding, esophageal stent was associated with significantly better early bleeding control and reduced mortality at both day five and week six compared to balloon tamponade. Prospective studies are warranted to confirm these findings. Impact and implication Tamponade devices are critical in the management of refractory variceal bleeding, with balloon probes being the only option until the early 2000s. More recently, self-expanding esophageal stents have been recommended, although their superiority over balloons in terms of survival has not been demonstrated. Our multicenter cohort study, using propensity score analysis, found that esophageal stents provided superior bleeding control at day five and survival benefit at week six, regardless of severity of liver failure or use of rescue TIPS. These findings highlight esophageal stents as the optimal tamponade device, although they may not obviate the need for prompt rescue TIPS placement.
Source: JHEP Reports
DOI: 10.1016/j.jhepr.2025.101581
Authors: Delphine Weil, Morgane Clément, Charlotte Bouzbib, Jean-Paul Cervoni, Andrimalala Raoto, Grégoire Boivineau, Isabelle Ollivier-Hourmand, Noémi Reboux, Caroline Lemaitre, Cassandra Rayer, Marine Camus-Duboc, Ludovic Caillo, André-Jean Remy, Laure Elkrief, Guillaume Conroy, Faustine Wartel, Armand Garioud, Maeva Guillaume, Edouard Bardou-Jacquet, Stéphane Koch, Jean-Pierre Arpurt, Marika Rudler, Vincent Di Martino
Institutions: Inserm, Centre Hospitalier Universitaire de Besançon, Université Marie et Louis Pasteur, Interactions Hôte-Greffon-Tumeur & Ingénierie Cellulaire et Génique, Assistance Publique – Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Centre Hospitalier Universitaire de Caen Normandie, Groupe Hospitalier du Havre, Centre Hospitalier Universitaire de Rennes, Sorbonne Université, Hôpital Saint-Antoine, Université de Montpellier, Centre Hospitalier Universitaire de Nîmes, Centre Hospitalier de Perpignan, Centre Hospitalier Universitaire de Tours, Centre Hospitalier Régional de Metz-Thionville, Centre Hospitalier de Valenciennes, Centre Hospitalier Intercommunal de Villeneuve-Saint-Georges, Clinique Pasteur, Nutrition, métabolismes et cancer, Université Rennes 1, Université de Rennes
Language: English
Subfield: Hepatology
Field: Medicine
Open Access status: gold
Estimated APC paid: $4,110
Funders: American Association for the Study of Liver Diseases, Institut National de la Santé et de la Recherche Médicale, Association Française pour l'Etude du Foie, Université de Montpellier, Assistance publique-Hôpitaux de Paris, Université de Franche-Comté, Sorbonne Université
OpenAlex ID: W4413849222
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Cites: 17
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Related to: 10