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


OBJECTIVE
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.


METHODS
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.


METHODS
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.


METHODS
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.


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).


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.
Khan
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S
Queen Elizabeth Hospital, Liver Unit (Hepatobiliary Pancreatic and Liver Transplant), Metchley Lane, Edgbaston, Birmingham, West Midlands, UK. saboor.711@gmail.com
Tudur Smith
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Williamson
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Sutton
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R
D004724:Endoscopy / Q000379:methods*; D004932:Esophageal and Gastric Varices / Q000517:prevention & control / Q000628:therapy*; D006471:Gastrointestinal Hemorrhage / Q000517:prevention & control / Q000628:therapy*; D006501:Hepatic Encephalopathy / Q000209:etiology; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D011170:Portasystemic Shunt, Surgical / Q000009:adverse effects / Q000379:methods*; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000009:adverse effects; D016032:Randomized Controlled Trials as Topic; D055502:Secondary Prevention; D013164:Splenorenal Shunt, Surgical / Q000009:adverse effects