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Meta-Analysis
. 2006 Oct 18;2006(4):CD000553.
doi: 10.1002/14651858.CD000553.pub2.

Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis

S Khan  1 , C Tudur Smith, P Williamson, R Sutton
Affiliations
Meta-Analysis

Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis

S Khan et al. Cochrane Database Syst Rev. .

Abstract

Background: Randomised clinical trials have compared portosystemic shunting procedures with endoscopic therapy for variceal haemorrhage, but there is no consensus as to which approach is preferable.

Objectives: To compare the effects of shunts (total surgical shunt (TS); distal spleno-renal shunts (DSRS) or transjugular intrahepatic porto-systemic shunts (TIPS) with endoscopic therapy (ET, sclerotherapy and/or banding) for prevention of variceal rebleeding in patients with cirrhosis.

Search strategy: The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Library, MEDLINE, EMBASE, conference proceedings, and the references of identified trials were searched (last search February 2004). Researchers in the field and in industry were contacted.

Selection criteria: Randomised clinical trials comparing TS, DSRS or TIPS with ET in patients who had recovered from a variceal haemorrhage and were known to be cirrhotic.

Data collection and analysis: Data were collected to allow intention-to-treat analysis where possible. For each outcome, a pooled estimate of treatment effect (log hazard ratio for time to outcome, Peto odds ratio for binary outcomes, and differences in means for continuous outcomes) across trials was calculated.

Main results: Twenty-two trials evaluating 1409 patients were included. All trials had problems of method. Shunt therapy compared with ET demonstrated significantly less rebleeding (OR 0.24, 95% CI 0.18 to 0.30) at the cost of significantly increased acute hepatic encephalopathy (OR 2.07, 95% CI 1.59 to 2.69) and chronic encephalopathy (OR 2.09, 95% CI 1.20 to 3.62). There were no significant differences regarding mortality (hazard ratio 1.00, 95% CI 0.82 to 1.21) and duration of in-patient stay (weighed mean difference 0.78 day, 95% CI -1.48 to 3.05). The proportion of patients with shunt occlusion or dysfunction was 3.1% (95% CI 0.4 to 10.7%) following TS (two trials), 7.8% (95% CI 3.8 to 13.9%) following DSRS (four trials), and 59% (range 18% to 72%) following TIPS (14 trials).

Authors' conclusions: All shunts resulted in a significantly lower rebleeding rate at the expense of a higher incidence of encephalopathy. TIPS was complicated by a high incidence of shunt dysfunction. No survival advantage was demonstrated with any shunt.

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Conflict of interest statement

None known.

Figures

1
1
Funnel plot of shunt therapy versus endoscopic therapy, showing bias in favour of shunt therapy.
2
2
Funnel plot of shunt therapy versus endoscopic therapy, showing no bias in favour of shunt therapy on hepatic encephalopathy.
3
3
Funnel plot of shunt therapy versus endoscopic therapy, showing no bias in favour of shunt therapy on chronic hepatic encephalopathy.
4
4
Funnel plot of shunt therapy versus endoscopic therapy, showing no bias in favour of shunt therapy on mortality.
1.1
1.1. Analysis
Comparison 1 Shunt therapy versus endoscopic therapy, Outcome 1 Rebleeding (hazard ratio).
1.2
1.2. Analysis
Comparison 1 Shunt therapy versus endoscopic therapy, Outcome 2 Rebleeding.
1.3
1.3. Analysis
Comparison 1 Shunt therapy versus endoscopic therapy, Outcome 3 Development of hepatic encephalopathy (hazard ratio).
1.4
1.4. Analysis
Comparison 1 Shunt therapy versus endoscopic therapy, Outcome 4 Hepatic encephaloapthy.
1.5
1.5. Analysis
Comparison 1 Shunt therapy versus endoscopic therapy, Outcome 5 Chronic hepatic encephalopathy.
1.6
1.6. Analysis
Comparison 1 Shunt therapy versus endoscopic therapy, Outcome 6 Duration of in‐patient stay (days).
1.7
1.7. Analysis
Comparison 1 Shunt therapy versus endoscopic therapy, Outcome 7 Mortality (hazard ratio).
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD000553

References

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MeSH terms