Uncovered transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis.
OBJECTIVE
Several trials showed that uncovered transjugular intrahepatic portosystemic shunt (TIPS) is superior to paracentesis for the control of refractory ascites. However, the results for encephalopathy and mortality were not consistent across trials. We performed a systematic review of randomized controlled trials of TIPS for refractory ascites to assess the overall treatment effects and to explore potential reasons of heterogeneity.


METHODS
Pertinent studies were retrieved trough MEDLINE (1968-2004), EMBASE (1986-2004), the Cochrane Library (2004;4), and reference lists of key articles. Outcome measures were recurrence of ascites, encephalopathy, and mortality. Metaregression analysis was used to explore heterogeneity.


RESULTS
Five trials were identified including 330 patients. Successful TIPS placement ranged from 77% to 100% and portosystemic pressure gradient reduction ranged from 6.0 to 14.0 mm Hg. Metaregression analysis showed that bilirubin levels and successful TIPS placement rates were associated significantly with log-odds ratio for death after TIPS, explained heterogeneity of trials for mortality, and suggested an outlier trial. After exclusion of the outlier trial, pooled odds ratios for recurrence of ascites with TIPS was .14 (confidence interval, .07-.27), for encephalopathy was 2.26 (confidence interval, 1.35-3.76), and for mortality was .74 (confidence interval, .40-1.37), without any significant heterogeneity.


CONCLUSIONS
Uncovered TIPS is significantly better than paracentesis for control of refractory ascites. Although it increases encephalopathy, it also is associated with a trend toward improvement of survival. Future TIPS trials should select patients on the basis of bilirubin levels and predictors of the risk for post-TIPS encephalopathy, and assess costs and quality of life.
D'Amico
Gennaro
G
Unit of Gastroenterology, Ospedale V. Cervello, Palermo, Italy. gedamico@libero.it
Luca
Angelo
A
Morabito
Alberto
A
Miraglia
Roberto
R
D'Amico
Mario
M
D001201:Ascites / Q000628:therapy*; D006801:Humans; D019168:Portasystemic Shunt, Transjugular Intrahepatic; D016032:Randomized Controlled Trials as Topic; D012044:Regression Analysis; D016896:Treatment Outcome