The availability of a highly effective treatment with a very low rate of bleeding-related mortality (3%) even in high-risk patients might call into question the need for primary prophylaxis for variceal bleeding. Thus, the need for (and adverse effects of) regular endoscopic procedures and years of drug therapy could be avoided, and this would probably improve patients’ quality of life. In this context, the knowledge that primary prophylaxis Small molecule library cell assay delayed neither the occurrence of varices nor the first occurrence of variceal bleeding is important.6

Furthermore, in patients who receive early TIPS for their first variceal bleeding, the role of secondary prophylaxis in the prevention of rebleeding will be limited. In these patients, drugs and endoscopic treatments might be primarily applied as temporary measures to stop bleeding until TIPS implantation is performed.

According to this study, early TIPS placement might be beneficial only in a minority of patients with variceal bleeding. Thus, only 63 of 359 patients (17.5%) with acute variceal bleeding were randomly allocated to the treatment groups: 18 refused to participate; 112 had Child-Pugh class A or B cirrhosis without active bleeding on endoscopy; and 166 Acalabrutinib manufacturer were excluded for various reasons, such as isolated gastric variceal bleeding, Child-Pugh scores greater than 13 points, previous failure to respond to treatment with drugs and endoscopic band ligation, age greater than 75 years, portal vein thrombosis, hepatocellular carcinoma, and renal failure. However, MCE in everyday practice, many of the patients excluded from this randomized study might be considered good candidates for early TIPS treatment. In particular, patients with gastric variceal bleeding, patients with renal failure, and patients who have failed to respond to previous medical treatment might benefit from the early use of TIPS. Patients older than 75 years might also be regarded as good candidates for early TIPS placement because they have poor tolerance for rebleeding. In addition, the general exclusion of patients with hepatocellular

carcinoma from early TIPS treatment might not be justified. TIPS could have a place as a palliative treatment in patients with an adequate prognosis and an increased risk of rebleeding. The largest group excluded from the study was the group of patients with Child-Pugh class A or B disease without active bleeding on endoscopy (31%). Because of the 97% survival rate at 6 weeks in patients with Child-Pugh class B or C disease, we might suggest that the survival of patients with Child-Pugh class A or B disease who received early TIPS placement would be close to 100%, which could hardly be improved by any other treatment. In addition, rebleeding after TIPS placement would be a rare occurrence in such patients, and thus secondary prevention could be avoided.