Qi Xingshun, Tian Yulong, Zhang Wei, Zhao Haitao, Han Guohong, Guo Xiaozhong
Liver Cirrhosis Study Group & Meta-analysis Study Interest Group, Department of Gastroenterology, General Hospital of Shenyang Military Area Department of Interventional Radiology & Key Laboratory of Diagnostic Imaging and Interventional Radiology of Liaoning Province, First Affiliated Hospital of China Medical University Medical Ethical Committee, General Hospital of Shenyang Military Area, Shenyang Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China.
Medicine (Baltimore). 2016 Dec;95(50):e5680. doi: 10.1097/MD.0000000000005680.
In the era of bare stents, transjugular intrahepatic portosystemic shunt (TIPS) is the second-line choice of therapy for the prevention of variceal rebleeding in liver cirrhosis. In the era of covered stents, the role of TIPS should be re-evaluated.
The aim of the study was to compare the outcomes of covered TIPS versus the traditional first-line therapy (i.e, drug plus endoscopic therapy) for the prevention of variceal rebleeding in liver cirrhosis.
All relevant randomized controlled trials were searched via the PubMed, EMBASE, and Cochrane Library databases. Hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs) and P values were calculated for the cumulative risk and overall risk, respectively. Heterogeneity among studies was also calculated.
Three of 111 retrieved papers were eligible. Among them, the proportion of patients who were switched from drug plus endoscopic therapy to TIPS was 16% to 25%. The risk of bias was relatively low in all included randomized controlled trials. Meta-analyses demonstrated that the covered TIPS group had a similar overall survival (HR = 0.84, 95% CI = 0.55-1.28, P = 0.41; OR = 1.00, 95% CI = 0.59-1.69, P = 0.99), a significantly lower risk of variceal rebleeding (HR = 0.30, 95% CI = 0.18-0.48, P < 0.00001; OR = 0.24, 95% CI = 0.12-0.46, P < 0.0001), and a similar risk of hepatic encephalopathy (HR = 1.35, 95% CI = 0.72-2.53, P = 0.36; OR = 1.28, 95% CI = 0.54-3.04, P = 0.57). In most of meta-analyses, the heterogeneity among studies was not statistically significant.
Compared with drug plus endoscopic therapy, covered TIPS had a significant benefit of preventing from variceal rebleeding, but did not increase the overall survival or risk of hepatic encephalopathy.
在裸支架时代，经颈静脉肝内门体分流术（TIPS）是预防肝硬化患者静脉曲张再出血的二线治疗选择。在覆膜支架时代，TIPS的作用应重新评估。
本研究旨在比较覆膜TIPS与传统一线治疗（即药物加内镜治疗）预防肝硬化患者静脉曲张再出血的效果。
通过PubMed、EMBASE和Cochrane图书馆数据库检索所有相关的随机对照试验。分别计算累积风险和总体风险的风险比（HRs）、优势比（ORs）以及95%置信区间（CIs）和P值。同时计算研究间的异质性。
检索到的111篇论文中有3篇符合条件。其中，从药物加内镜治疗转为TIPS治疗的患者比例为16%至25%。所有纳入的随机对照试验的偏倚风险相对较低。荟萃分析表明，覆膜TIPS组的总生存率相似（HR = 0.84，95%CI = 0.55 - 1.28，P = 0.41；OR = 1.00，95%CI = 0.59 - 1.69，P = 0.99），静脉曲张再出血风险显著降低（HR = 0.30，95%CI = 0.18 - 0.48，P < 0.00001；OR = 0.24，95%CI = 0.12 - 0.46，P < 0.0001），肝性脑病风险相似（HR = 1.35，95%CI = 0.72 - 2.53，P = 0.36；OR = 1.28，95%CI = 0.54 - 3.04，P = 0.57）。在大多数荟萃分析中，研究间的异质性无统计学意义。
与药物加内镜治疗相比，覆膜TIPS在预防静脉曲张再出血方面有显著益处，但并未提高总生存率或增加肝性脑病风险。
