Li Shuang, Zhang Chao, Lin Lu-Lu, Wang Qi, Zuo Hong-Xia, Zhan Ai-Ling, Luo Jie, Niu Yu-Ming, Zhong Guo-Qing
Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China.
Department of Anesthesiology, Central Hospital of Shanghai Songjiang District, Shanghai, China.
Front Pharmacol. 2020 May 20;11:603. doi: 10.3389/fphar.2020.00603. eCollection 2020.
The survival of early placement (within 72h after admission) of transjugular intrahepatic portosystemic shunts (early-TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) is controversial.
We performed a systemic review and meta-analysis to assess whether early-TIPS could improve survival in patients with cirrhosis and acute variceal bleeding.
A systematic search of the literature was conducted in PubMed, EMBASE, and Cochrane Library published before 25 June 2019 for eligible studies that compared early-TIPS with a combination of endoscopic variceal ligation (EVL) and pharmacotherapy in the therapeutic effect in AVB patients.
A total of five studies with 1,754 participants were enrolled. The early-TIPS demonstrated a significant improvement in prevention of treatment failure (OR=0.11,95%CI=0.05-0.23), 6-weeks mortality (OR=0.24,95%CI=0.13-0.46), rebleeding within 6 weeks (OR=0.21,95%CI=0.12-0.36), rebleeding within 1 year (OR=0.16,95%CI=0.07-0.36), new or worsening ascites (OR=0.33,95%CI=0.21-0.53), except in encephalopathy (OR=1.29,95%CI=0.996-1.67). For 1-year mortality, a significant prior effect was also observed in early-TIPS (OR=0.64,95%CI=0.46-0.90), and the beneficial effect in Child-Pugh C patients (OR=0.35,95%CI=0.18-0.68) was equal to Child-Pugh B patients (OR=0.34,95%CI=0.25-0.58). No difference in liver transplantation and mortality caused by liver failure was observed.
Early covered-TIPS could be recommended for the management of AVB patients in cirrhosis demonstrating a significant improvement in treatment failure, both short- and long-term mortality, rebleeding risk, and new or worsening ascites compared to standard therapy, especially for high-risk AVB patients. It will also apply to patients with Child-Pugh A until solutions to prevent hepatic encephalopathy in future research are found.
肝硬化合并急性静脉曲张出血（AVB）患者早期（入院后72小时内）放置经颈静脉肝内门体分流术（早期TIPS）的生存率存在争议。
我们进行了一项系统评价和荟萃分析，以评估早期TIPS是否能提高肝硬化合并急性静脉曲张出血患者的生存率。
在PubMed、EMBASE和Cochrane图书馆中对2019年6月25日前发表的文献进行系统检索，以寻找比较早期TIPS与内镜下静脉曲张结扎术（EVL）联合药物治疗对AVB患者治疗效果的合格研究。
共纳入5项研究，1754名参与者。早期TIPS在预防治疗失败（OR=0.11，95%CI=0.05-0.23）、6周死亡率（OR=0.24，95%CI=0.13-0.46）、6周内再出血（OR=0.21，95%CI=0.12-0.36）、1年内再出血（OR=0.16，95%CI=0.07-0.36）、新发或加重腹水（OR=0.33，95%CI=0.21-0.53）方面有显著改善，但在肝性脑病方面（OR=1.29，95%CI=0.996-1.67）无改善。对于1年死亡率，早期TIPS也有显著的先验效应（OR=0.64，95%CI=0.46-0.90），Child-Pugh C级患者的有益效果（OR=0.35，95%CI=0.18-0.68）与Child-Pugh B级患者（OR=0.34，95%CI=0.25-0.58）相当。在肝移植和肝衰竭导致的死亡率方面未观察到差异。
对于肝硬化合并AVB的患者，与标准治疗相比，早期覆膜TIPS在治疗失败、短期和长期死亡率、再出血风险以及新发或加重腹水方面有显著改善，可推荐用于此类患者的治疗，尤其是高危AVB患者。在未来研究找到预防肝性脑病的解决方案之前，它也适用于Child-Pugh A级患者。
