Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis
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 methods
The Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, conference proceedings, and the references of identified trials were searched (last search September 2006). 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.
PICOs
Plain language summary
Portosystemic shunts compared with sclerotherapy/banding lowers variceal rebleeding, but increases hepatic encephalopathy
A third of deaths from cirrhosis are due to variceal bleeding. Randomised clinical trials have compared three types of portosystemic shunting separately against endoscopic therapy. The shunts included in these trials have been total portocaval shunts, distal splenorenal shunts, and transjugular intrahepatic portocaval shunts. The authors found that when compared to endoscopic therapy all three types of shunt lowered the rate of rebleeding at the cost of a higher incidence of hepatic encephalopathy, without any statistically significant difference in survival.
