title: Early transjugular intrahepatic portosystemic shunt in cirrhotic patients with acute variceal bleeding: a systematic review and meta-analysis of controlled trials.
abstract: BACKGROUND
  There is conflicting evidence on the benefit of early transjugular intrahepatic portosystemic shunt (TIPSS) on the survival of patients with acute variceal bleeding (AVB).
  
  
  OBJECTIVE
  To assess the effect of early TIPSS on patient prognosis.
  
  
  METHODS
  We carried out a meta-analysis of trials evaluating early TIPSS in cirrhotic patients with AVB.
  
  
  RESULTS
  Four studies were included. Early TIPSS was associated with fewer deaths [odds ratio (OR)=0.38, 95% confidence interval (CI)=0.17-0.83, P=0.02], with moderate heterogeneity between studies (P=0.15, I=44%). Early TIPSS was not significantly associated with fewer deaths among Child-Pugh B patients (OR=0.35, 95% CI=0.10-1.17, P=0.087) nor among Child-Pugh C patients (OR=0.34, 95% CI=0.10-1.11, P=0.074). There was no heterogeneity between studies in the Child-Pugh B analysis (P=0.6, I=0%), but there was a high heterogeneity in the Child-Pugh C analysis (P=0.06, I=60%). Early TIPSS was associated with lower rates of bleeding within 1 year (OR=0.08, 95% CI=0.04-0.17, P<0.001) both among Child-Pugh B patients, (OR=0.15, 95% CI=0.05-0.47, P=0.001) and among Child-Pugh C patients (OR=0.05, 95% CI=0.02-0.15, P<0.001), with no heterogeneity between studies. Early TIPSS was not associated with higher rates of encephalopathy (OR=0.84, 95% CI=0.50-1.42, P=0.5).
  
  
  CONCLUSIONS
  Cirrhotic patients with AVB treated with early TIPSS had lower death rates and lower rates of clinically significant bleeding within 1 year compared with patients treated without early TIPSS. Additional studies are required to identify the potential risk factors leading to a poor prognosis after early TIPSS in patients with AVB and to determine the impact of the degree of liver failure on the patient's prognosis.
authors.affiliation: aDivision of Gastroenterology and Hepatology bDivision of Radiology, Centre Hospitalier Universitaire Vaudois cInstitute of Social and Preventive Medicine (IUMSP), Lausanne University Hospital, Lausanne, Switzerland dDepartment of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Hôpital Erasme eLaboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium fDepartment of Hepato-Gastroenterology, AP-HP, Hôpital Pitié-Salpêtrière, Paris gDepartment of Hepato-Gastroenterology, CHU Toulouse, Toulouse, France hServicio de Aparato Digestivo, Hospital Universitario Insular de Gran Canaria, Spain.
authors.forename: Pierre
authors.initials: P
authors.lastname: Deltenre
authors.forename: Eric
authors.initials: E
authors.lastname: Trépo
authors.forename: Marika
authors.initials: M
authors.lastname: Rudler
authors.forename: Alberto
authors.initials: A
authors.lastname: Monescillo
authors.forename: Montserrat
authors.initials: M
authors.lastname: Fraga
authors.forename: Alban
authors.initials: A
authors.lastname: Denys
authors.forename: Christopher
authors.initials: C
authors.lastname: Doerig
authors.forename: Nicolas
authors.initials: N
authors.lastname: Fournier
authors.forename: Christophe
authors.initials: C
authors.lastname: Moreno
authors.forename: Darius
authors.initials: D
authors.lastname: Moradpour
authors.forename: Christophe
authors.initials: C
authors.lastname: Bureau
authors.forename: Dominique
authors.initials: D
authors.lastname: Thabut
mesh_terms: D018849:Controlled Clinical Trials as Topic; D004932:Esophageal and Gastric Varices / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D016017:Odds Ratio; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000009:adverse effects / Q000401:mortality; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome