Intervention Review

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

  1. Saboor A Khan1,*,
  2. Catrin Tudur Smith2,
  3. Paula R Williamson2,
  4. Robert Sutton3

Editorial Group: Cochrane Hepato-Biliary Group

Published Online: 18 OCT 2006

Assessed as up-to-date: 20 AUG 2006

DOI: 10.1002/14651858.CD000553.pub2

How to Cite

Khan SA, Tudur Smith C, Williamson PR, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD000553. DOI: 10.1002/14651858.CD000553.pub2.

Author Information

  1. 1

    Birmingham, UK

  2. 2

    University of Liverpool, Centre for Medical Statistics and Health Evaluation, Liverpool, UK

  3. 3

    Royal Liverpool University Hospital, Department of Surgery, University of Liverpool,, Liverpool, UK

*Saboor A Khan, Birmingham, UK. saboor.711@gmail.com. sab00r_khan@yahoo.co.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 18 OCT 2006

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

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.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

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.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

比較以門體靜脈分流術對照內視鏡治療靜脈曲張再出血的肝硬化病人

隨機臨床試驗已針對靜脈曲張出血比較了門體靜脈分流術和內視鏡治療,但是對於哪種方法較有優勢還沒有達成一致意見。

目標

比較各種分流術(全手術分流(total surgical shunt,TS);遠端脾腎靜脈分流術(distal splenorenal shunts,DSRS),經頸靜脈肝內門體分流術(TIPS)與內視鏡治療(endoscopic therapy,ET, 硬化療法和/或結紮術),以預防肝硬化病人靜脈曲張再出血的療效。

搜尋策略

The Cochrane HepatoBiliary Group Controlled Trials Register, Cochrane Library中的Cochrane Central Register of Controlled Trials in The Cochrane Library 、MEDLINE、EMBASE、Science Citation Index Expanded、研討會摘要集、已找出之試驗的參考文獻清單列表 (截至到2006年9月)。 聯繫該領域和行業的的研究人員。

選擇標準

比較TS、DSRS、TIPS,與ET用於治療靜脈曲張出血已恢復且確診為肝硬化病人的隨機臨床試驗。

資料收集與分析

收集資料以利進行治療意向分析。對於每個結果(outcome),合併計算全部試驗中治療療效的估計值 (得出結果的時間以log hazard ratio表示,二分法結果以Peto odds ratio表示,連續性結果的平均值差異表示)。

主要結論

共22個試驗,包括1409 位病人。所有試驗都存在方法學的問題。和ET比較,分流療法顯示能夠顯著降低再出血率 (OR 0.24, 95% CI 0.18 to 0.30),但代價是顯著增加急性肝性腦病變 (OR 2.07, 95% CI 1.59 – 2.69)和慢性腦病變 (OR 2.09, 95% CI 1.20 – 3.62)的發病率。兩者在死亡率(hazard ratio1.00, 95% CI 0.82 to 1.21),住院日 (weighed mean difference 0.78 天,95% CI −1.48 3.05)等方面沒有顯著差異。在實施TS (2個試驗),DSRS (4個試驗),TIPS (14個試驗)之後,出現分流堵塞或功能障礙的病人比例分別是3.1% (95% CI 0.4 – 10.7%) ,7.8% (95% CI 3.8 13.9%) 和59% (範圍18% – 72%)。

作者結論

所有分流術可以顯著降低再出血率,但是以增加腦病變發生率為代價。TIPS 會導致分流功能障礙的機率較高,任何分流術並沒有對存活率有助益。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

和內視鏡硬化療法/結紮術比較,門體靜脈分流術降低靜脈曲張再出血率,但是增加肝性腦病變的發病率。1/3患有肝硬化的人由於靜脈曲張出血導致死亡。隨機臨床試驗分別比較三種門體靜脈分流術和內視鏡治療。這類試驗包括的分流術有全體門體靜脈分流;遠端脾腎靜脈分流術,和經頸靜脈肝內門體分流術。作者發現和內視鏡治療比較,3種分流手術都可以降低再出血的比率,但代價是增加肝性腦病變的發病率,而在存活率方面沒有統計學意義上的顯著差異。