Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial

BACKGROUND & AIMS: Variceal bleeding refractory to medical treatment with beta-blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts (TIPS). This prospective randomized trial tested the hypothesis that patients receiving distal splenorenal shunts (DSRS) would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding. METHODS: A prospective randomized controlled clinical trial at 5 centers was conducted. One hundred forty patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding were randomized to DSRS or TIPS. Protocol and event follow-up for 2-8 years (mean, 46 +/- 26 months) for primary end points of variceal bleeding and encephalopathy and secondary end points of death, ascites, thrombosis and stenosis, liver function, need for transplant, quality of life, and cost were evaluated. RESULTS: There was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P = .29) or first encephalopathy event (DSRS, 50%; TIPS, 50%). Survival at 2 and 5 years (DSRS, 81% and 62%; TIPS, 88% and 61%, respectively) were not significantly different (P = .87). Thrombosis, stenosis, and reintervention rates (DSRS, 11%; TIPS, 82%) were significantly (P < .001) higher in the TIPS group. Ascites, need for transplant, quality of life, and costs were not significantly different. CONCLUSIONS: DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child-Pugh class A and B patients. Reintervention is significantly greater for TIPS compared with DSRS. Because both procedures have equivalent outcomes, the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed.     

Differences in long-term survival after transjugular intrahepatic portosystemic shunt for refractory ascites and variceal bleed

OBJECTIVE: To compare the survival after transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites and variceal bleed, and to identify the factors predictive of survival. METHODS: Single tertiary center, retrospective-prospective study. Chart review was performed on all patients who underwent TIPS between 1993 and 2000 and prospective follow-up to determine survival. Pre- and post-TIPS clinical parameters were compared and Kaplan-Meier analysis was applied to compare the survival of both groups. Cox regression was used to identify predictors of survival after TIPS. RESULTS: A total of 163 patients were included, 62 with refractory ascites and 101 with variceal bleed. Both groups had similar age (48.2 vs 48.9 year; P = 0.65) and consisted of predominantly Caucasians (51%) and Mexican-Americans (39%). More than 75% had chronic hepatitis C, alcoholic liver disease or both. Overall, the median survival was significantly better for variceal bleed (2 years) compared with refractory ascites (6 months) (P < 0.001). This survival advantage persisted in patients with Mayo risk score greater than 1.17. Transjugular intrahepatic portosystemic shunt improved severe ascites in 45% of patients (P = 0.03). Mayo risk score was highly predictive of survival after TIPS with a hazard ratio of 2.3, followed by Child-Pugh score, creatinine, albumin and ethnicity, with better survival among Mexican-Americans. Shunt dysfunction (31%) and hepatic encephalopathy (27%) were the most common complications of TIPS. CONCLUSIONS: Patients who received TIPS for variceal bleed had significantly longer survival compared with those for refractory ascites. Mexican-Americans had an improved long-term survival compared with Caucasians. The reason for this ethnic difference in survival is unclear and warrants further prospective evaluation.     

Appraisal of DSRS with SPGD for esophagogastric varices: a retrospective comparative study according to the underlying liver diseases

BACKGROUND/AIMS: The differences in long-term results of distal splenorenal shunt with splenopancreatic and gastric disconnection (DSRS with SPGD) for portal hypertension of different etiologies including non-cirrhotic portal hypertension have yet to be reported. The data are important to determine the indications and contraindications for this procedure. METHODOLOGY: Records of 54 patients of esophagogastric varices who survived 3 years or longer after DSRS with SPGD operation were reviewed. Patients were divided into three groups based on underlying liver disease; posthepatitic cirrhosis (HC) group, alcoholic cirrhosis (AC) group, and idiopathic portal hypertension (IPH) group. RESULTS: The only serious long-term complication of DSRS with SPGD was portal thrombosis in two patients in the IPH group. Postoperative bleeding occurred in two cases of each group; one in IPH group was the only variceal bleeding and others were bleeding from portal hypertensive gastropathy. Hepatocellular carcinoma (HCC) was developed in 28.6% patients in both the HC group and AC group. In all the cases, treatment for HCC was accomplished without aggravation of the varices. The cumulative survival rate was similar in the three groups, and no patient died of gastrointestinal bleeding. CONCLUSIONS: A favorable outcome was achieved by DSRS with SPGD operation both in the patients with cirrhosis or IPH. Underlying liver disease is not a factor when considering DSRS with SPGD for portal hypertension.     

Natural history of a randomized trial comparing distal spleno-renal shunt with endoscopic sclerotherapy in the prevention of variceal rebleeding： A lesson from the past

INTRODUCTION The selective distal splenorenal shunt (DSRS) proposed by Warren[1] in 1967 has been considered to be the best procedure available for surgical decompression of patients with portal hypertension[2-4]. DSRS has been compared with sclerotherapy…     

Results of distal splenorenal shunt with versus without splenopancreatic disconnection

From December 1973 to December 1987, we performed a distal splenorenal shunt (DSRS) in 112 cases of portal hypertension, including 107 with postnecrotic liver cirrhosis and 5 with idiopathic portal hypertension (IPH). They comprised about 50% of our surgical cases with esophageal varices. In 1981, we modified our operative procedure towards a more extended splenopancreatic disconnection (SPD) in order to prevent the "stealing" of the shunt through the pancreatic vein. In one group of 69 patients who underwent DSRS alone, the operative mortality was 2.9%; postoperative encephalopathy was seen in 17.4%, late hepatic failure in 40.6%, and recurrence of varices in 4.3%. In the other group, 43 patients who underwent DSRS with SPD, there were no operative deaths, no encephalopathy (better than DSRS alone at p less than 0.05), and late hepatic failure was seen in only 9.3% (better than DSRS alone at p less than 0.025), while the recurrence rate of 7% was the only statistical increase. These data show that DSRS + SPD can improve chances of survival.     

Transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt--a comparative study

BACKGROUND/AIMS: No general consensus exists regarding the proper surgical management of recurrent variceal bleeding due to hepatic cirrhosis. Transjugular intrahepatic portosystemic shunt and distal splenorenal shunt are increasingly being performed in the management of these patients. The present study was undertaken to compare the efficacy, complications and survival rate of these two procedures. METHODOLOGY: Sixty-seven patients with alcoholic liver cirrhosis of Child-Pugh's class A (n = 22) and class B (n = 45) with recurrent variceal bleeding not controlled by conservative means underwent either transjugular intrahepatic portosystemic shunt placement (n = 35) or a distal splenorenal shunt operation (n = 32). These patients were followed for a mean of 887 +/- 189 days. Both groups were compared with respect to the rates of survival, recurrence of gastrointestinal bleeding, encephalopathy, ascitis, shunt blockade and other relevant biochemical parameters. RESULTS: Patients who underwent a distal splenorenal shunt operation had lower rates of recurrence of gastrointestinal bleeding (6.25% vs. 25.71%), encephalopathy (18.75% vs. 42.86%) shunt blockade (6.25% vs. 68.57%) and lower mean fasting blood ammonia levels (56.70 +/- 7.10 mumol/L vs. 61.70 +/- 5.70 mumol/L). However the rate of ascitis was higher amongst these patients (40.63% vs. 11.43%). There was no significant difference in the midterm survival rates between these groups (81.25% vs. 80.00%). Both procedures were effective in controlling functional renal failure, splenomegaly and features of hypersplenism. CONCLUSIONS: Distal splenorenal shunt operation is a better therapeutic option than transjugular intrahepatic portosystemic shunt placement for control of recurrent variceal bleeding due to hepatic cirrhosis.     

Distal spleno-renal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding. A meta-analysis of 4 randomized clinical trials.

Meta-analysis was used to evaluate 4 clinical trials comparing distal spleno-renal shunt (DSRS) with endoscopic sclerotherapy (EVS) in the prevention of variceal rebleeding: the interval between bleeding and therapy ranges from < 14 days to > 100 days. A questionnaire was sent to each author of the published trials concerning methods, definitions and results of the trials in order to obtain more detailed and up-to-date information. The selected end-points for the meta-analysis were: rebleeding, mortality and chronic encephalopathy. Analysis of the results in the questionnaires was made using the method proposed by Collins. The pooled relative risk (i.e. the combined Odds ratio of each trial as an estimate of overall efficacy) of rebleeding was statistically reduced by DSRS (0.16; 95% confidence interval 0.10-0.27). Despite this, the overall risk of death following DSRS was only marginally decreased (0.78; 95% confidence interval 0.47-1.29); the lack of homogeneity in the results does not permit any significant conclusions on this end-point. However, in non-alcoholic patients, the decrease in risk of death was greater, and this without heterogeneity, following DSRS than EVS (0.59; 95% confidence interval 0.23-1.50). The overall risk of chronic encephalopathy was slightly increased after DSRS (1.86; 95% confidence interval 0.90-3.86). In conclusion, DSRS significantly reduced the risk of rebleeding compared to EVS without increasing the risk of chronic hepatic encephalopathy. However, DSRS did not significantly affect the overall death risk. Only in non-alcoholic disease did it seem to show an advantage over EVS.     

Spontaneous portosystemic shunt

This study examined the effect of large spontaneous portosystemic shunts on the incidence of variceal hemorrhage and hepatic encephalopathy. Twenty cases of chronic liver disease with large spontaneous shunts were compared with a group of patients with liver disease and with Cruveilhier-Baumgarten (C-B) murmurs and with a control group having liver disease and absence of large shunts on angiography. Gastrointestinal hemorrhage was present in similar proportions of patients in the three groups. Hepatic encephalopathy occurred more frequently in the spontaneous shunt group and C-B murmur group. The encephalopathy was spontaneous in 12 of 14 patients with large natural shunts whereas it was precipitated by events such as gastrointestinal bleeding, diuretics, or infection in 14 of 15 of the patients with C-B murmur and five of the seven controls. Therefore, spontaneous portosystemic shunts do not protect against gastrointestinal hemorrhage and are associated with an increased risk of spontaneous hepatic encephalopathy.     

Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomised trial

BACKGROUND AND AIMS: The transjugular intrahepatic portosystemic shunt (TIPS) is a new therapeutic modality for variceal bleeding. In this study we compared the two year survival and rebleeding rates in cirrhotic patients treated by either variceal band ligation or TIPS for variceal bleeding. METHODS: Eighty cirrhotic patients (Pugh score 7-12) with variceal bleeding were randomly allocated to TIPS (n=41) or ligation (n=39), 24 hours after control of bleeding. RESULTS: Mean follow up was 581 days in the ligation group and 678 days in the TIPS group. The two year survival rate was 57% in the TIPS group and 56% in the ligation group (NS); the incidence of variceal rebleeding after two years was 18% in the TIPS group and 66% in the ligation group (p<0.001). Uncontrolled rebleeding occurred in 11 patients in the ligation group (eight were rescued by emergency TIPS) but in none of the TIPS group. The incidence of encephalopathy at two years was 47% in the TIPS group and 44% in the ligation group (NS). CONCLUSIONS: TIPS did not increase the two year survival rate compared with variceal band ligation after variceal bleeding in cirrhotic patients with moderate or severe liver failure. It significantly reduced the incidence of variceal rebleeding without increasing the rate of encephalopathy.     

Cost of preventing variceal rebleeding with transjugular intrahepatic portal systemic shunt and distal splenorenal shunt

BACKGROUND/AIMS: We examined the cost and cost effectiveness of distal splenorenal shunt (DSRS) and transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of variceal rebleeding. METHODS: Patients participated in a randomized controlled trial comparing DSRS to TIPS. Quality of life (QOL) was measured using SF-36 preceding randomization and yearly thereafter. Cost utility analysis was performed using TreeAge DATA. Costs for both in- and out-patient events and interventions were obtained for each patient. Costs using coated stents were estimated using different rates of stenosis. Incremental cost effectiveness ratios (ICERs) were determined at 1, 3 and 5 years. RESULTS: The average yearly costs of managing patients after TIPS and DSRS over 5 years were similar, $16,363 and $13,492, respectively. Cost of TIPS for surviving patients exceeded the cost of DSRS at years 3 and 5 but not significantly. ICERs per life saved favored TIPS at year 5 ($61,000). If coated rather than bare stents were used the cost effectiveness of TIPS increased slightly. CONCLUSIONS: TIPS is as effective as DSRS in preventing variceal rebleeding and may be more cost effective. TIPS, in all aspects, is equal to DSRS in the prevention of variceal rebleeding in patients who are medical failures.     

Calibrated portacaval H-graft shunt in variceal hemorrhage. Long-term results

BACKGROUND/AIMS: To analyze the long-term outcome of the calibrated portacaval shunt in the treatment of portal hypertension. METHODOLOGY: Between 1991 and 1996 we undertook a prospective non-randomized study, including 37 cirrhotic patients who underwent small diameter portacaval shunt with polytetrafluoroethylene H-graft, 24 cases with 8 mm and 13 cases with 10 mm. Early and late complications, and survival were analyzed. RESULTS: Overall, 28 corresponded to Child-Pugh class A, 5 to class B and 4 to class C. The cause of cirrhosis was alcoholic in 16 cases, postnecrotic in 12, mixed in 5, primary biliary cirrhosis in 2 and unknown in 1. Postoperative mortality was 10%. Long-term results, after a follow-up of 3-8 years, have shown a rebleeding rate of 12%, mainly after the third postoperative year. Some degree of encephalopathy occurred in 23% of the patients, but in no case was this chronic or incapacitating. The rate of early thrombosis was 5%, but in all cases it was repermeabilized with local thrombolysis. The late thrombosis rate was 6%. The 3-, 5- and 7-year survival rates were 79%, 57%, and 36%, respectively. These rates were not statistically related with the shunt diameter or the etiology of the cirrhosis. CONCLUSIONS: Partial portacaval shunt is a safe option for the treatment of variceal bleeding due to portal hypertension. We consider it to be the treatment of choice in a selected group of cirrhotic patients with well-preserved liver function, after previous failure of medical therapy. Furthermore, it can also be used as a bridge until liver transplantation.     

Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis. A prospective, randomized trial

STUDY OBJECTIVE: To define the roles of endoscopic variceal sclerosis and distal splenorenal shunt in the prevention of recurrent variceal bleeding in patients with cirrhosis. DESIGN: A prospective, randomized clinical trial with crossover for those failing therapy. The median follow-up was 61 months. SETTING: A private, tertiary-referral university hospital. PATIENTS: Seventy-two patients fulfilling inclusion criteria were drawn from a total of 420 patients treated during a 4.5-year interval. TREATMENTS: Endoscopic variceal sclerosis or distal splenorenal shunt. MEASUREMENTS and MAIN RESULTS: Survival was significantly (P = 0.02) improved in patients randomly assigned to receive sclerotherapy: 13 of these 37 (35%) patients failed sclerotherapy and required surgical rescue. A survival advantage (P = 0.01) was seen in patients with alcoholic cirrhosis who had this combined therapy; however, in patients with nonalcoholic cirrhosis, survival for those receiving sclerotherapy and surgical rescue was not significantly (P = 0.36) different from that of patients receiving distal splenorenal shunt. Control of variceal bleeding was significantly (P less than 0.001) better in the distal splenorenal shunt group (34 of 35 [97%] compared with 15 of 37 [41%] in the sclerotherapy group). Using death, uncontrolled rebleeding, or shunt thrombosis as the endpoints resulted in no significant difference between treatment groups. Hepatocyte function and portal perfusion were significantly better maintained in patients with alcoholic cirrhosis who were managed by sclerotherapy rather than shunt (P = 0.01 and P = 0.001, respectively). CONCLUSIONS: Endoscopic sclerotherapy with surgical rescue for uncontrolled bleeding is the optimum therapy for patients with alcoholic cirrhosis and variceal bleeding. Survival is similar in nonalcoholic patients treated with either distal splenorenal shunt or endoscopic sclerotherapy, but shunting provides better control of variceal bleeding.     

Long-term portosystemic shunt patency as a determinant of outcome in Budd-Chiari syndrome

BACKGROUND/AIMS: Portosystemic shunting, whether surgical or transjugular intrahepatic, has been a cornerstone of therapy for Budd-Chiari syndrome. However, the long-term impact of shunt dysfunction remains unknown. We have assessed this long-term impact in patients with surgical shunting. METHODS: Thirty-nine consecutive patients operated on between 1978 and 2000 were analyzed using time-dependent multivariate Cox model. RESULTS: Median follow-up was 110 months. Prosthetic shunts and high preshunt portal venous pressure were predictors of subsequent shunt dysfunction. Among 19 patients with persistently patent shunt, as compared to 20 patients with shunt dysfunction, 1 versus 18 developed refractory ascites; 1 versus 7 had variceal bleeding; 7 versus 2 had encephalopathy; 3 versus 11 (55%) died or underwent liver transplantation; and 0 versus 10 died from end-stage liver disease. Shunt dysfunction was associated with a shorter survival (p=0.001). Out of 20 patients with shunt dysfunction, seven had successful revision of the shunt. None of these seven patients had refractory ascites after revision or died from end-stage liver disease. CONCLUSIONS: In patients with Budd-Chiari syndrome treated with portosystemic shunting, shunt dysfunction has a major impact on morbidity and mortality.     

Longterm follow up of transjugular intrahepatic portosystemic stent shunt (TIPSS) for the treatment of portal hypertension: results in 130 patients.

BACKGROUND: Transjugular intrahepatic portosystemic stent shunts (TIPSS) are increasingly being used to manage the complications of portal hypertension. This study reports on the follow up on 130 patients who have undergone TIPSS. PATIENTS AND METHODS: One hundred and thirty patients (81 male), mean (SD) age 54.7 (12.5) years underwent TIPSS. The majority (64.6%) had alcoholic cirrhosis and 53.2% had Childs C disease. Indications were: variceal haemorrhage (76.2%), refractory ascites (13.1%), portal hypertensive gastropathy (4.6%), others (6.1%). Shunt function was assessed by Doppler ultrasonography and two then six monthly portography and mean follow up for survivors was 18.0 months (range 2-43.5). RESULTS: The procedure was successful in 119 (91.5%). Sixty three episodes of shunt dysfunction were observed in 45 (37.8%) patients. Variceal rebleeding occurred in 16 (13.4%) patients and was always associated with shunt dysfunction. Twenty (16.8%) patients had new or worse spontaneous encephalopathy after TIPSS and 11 (64.7%) patients had an improvement in resistant ascites. Thirty day mortality was 21.8% and one year survival 62.5%. CONCLUSION: TIPSS is an effective treatment for variceal bleeding, resistant ascites, and portal hypertensive gastropathy. Rebleeding is invariably associated with shunt dysfunction, the frequency of which increases with time, therefore regular and longterm shunt surveillance is required.     

介入性门腔分流术治疗门脉高压症所致曲张静脉出血及腹水疗效观察

目的 评价介入性门腔分流术治疗门脉高压症所致曲张静脉出血及腹水的疗效。方法 回顾性分析2004年2月—2010年1月我院55例良性门脉高压症行介入性门腔分流术患者的临床资料,观察分流道近期和远期的通畅情况,并分析生存时间和并发症。结果 手术成功率为100%,患者门静脉压力梯度(portal pressure gradient,PPG)均达到要求,即PPG≤1.60kPa或PPG降低2.00kPa。术后1～5年生存率分别为70.4%、60.8%、60.8%、60.8%、60.8%;分流道再狭窄率分别为7.3%、13.1%、24.0%、24.0%、24.0%;消化道曲张静脉出血复发率分别为9.8%、19.3%、26.0%、26.0%、26.0%;肝性脑病发生率分别为14.8%、23.9%、35.8%、57.2%、57.2%。结论 介入性门腔分流术治疗门脉高压症所致曲张静脉出血及腹水疗效可靠。如应用覆膜支架,门腔分流道通畅率较高。肝性脑病及复发性出血等并发症的发生率较低。     

经颈静脉肝内门腔静脉分流术治疗肝癌合并门静脉高压的临床研究

目的 探讨经颈静脉肝内门腔静脉分流术(TIPS)治疗肝癌合并门静脉高压的有效性、安全性和临床价值.方法 收集肝癌合并门静脉高压患者95例,其中63例行TIPS治疗(TIPS组),观察术后情况并随访生存期资料,其余32例(对照组)行内科支持治疗,随访生存期资料.评估TIPS组术后情况、术后肝性脑病、再出血、死亡原因等.行Kaplan-Meier生存分析比较两组中位生存时间,分析Child-Pugh分级及终末期肝病评估模式(MELD)评分与术后生存时间的关系.结果 TIPS组术后门静脉压力梯度平均降低13.6 cmH2O(1 cmH2O-0.098 kPa),术后6个月肝性脑病和再出血的累积发生率分别为20.6%和26.3%,截至随访结束死亡56例,其中最终死于门静脉高压破裂出血者12例.TIPS组中位生存期较对照组延长.TIPS组中MELD评分≤13分者中位生存时间大于评分>13分者(x2=4.71,P=0.03),Child-Pugh分级A到C级中位生存时间依次缩短(x2=15.6,P=0.00).结论 TIPS是治疗肝癌合并门静脉高压及其并发症安全有效的方法 ,应根据术前肝功能状况选择手术患者.     

Transjugular intrahepatic portosystemic shunt

The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 16 years ago, more than 1,000 publications have appeared demonstrating broad acceptance and increasing clinical use. This review summarizes our present knowledge about technical aspects and complications, follow-up of patients and indications. A technical success rate near 100% and a low occurrence of complications clearly depend on the skills of the operator. The follow-up of the TIPS patient has to assess shunt patency, liver function, hepatic encephalopathy and the possible development of hepatocellular carcinoma. Shunt patency can best be monitored by duplex sonography and can avoid routine radiological revision. Short-term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. Stent grafts covered with expanded polytetrafluoroethylene show promising long-term patency comparable with that of surgical shunts. With respect to the indications of TIPS, much is known about treatment of variceal bleeding and refractory ascites. The thirteen randomized studies that are available to date show that survival is comparable in patients receiving TIPS or endoscopic treatment for acute or recurrent variceal bleeding. Another group comprises patients with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications. Five randomized studies comparing TIPS with paracentesis and one study comparing TIPS with the peritoneo-venous shunt showed good response of ascites but controversial results on survival. In addition, TIPS has been successfully applied to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic variceal bleeding.     

EVS vs TIPS shunt for gastric variceal bleeding in patients with cirrhosis:A meta-analysis

AIM: To evaluate the clinical effects of transjugular intrahepatic portosystemic shunt (TIPS) vs endoscopic variceal sclerotherapy (EVS) in the management of gastric variceal (GV) bleeding in terms of variceal rebleeding, hepatic encephalopathy (HE), and survival by meta-analysis.METHODS: Medline, Embase, and CNKI were searched. Studies compared TIPS with EVS in treating GV bleeding were identified and included according to our predefined inclusion criteria. Data were extracted independently by two of our authors. Studies with prospective randomized design were considered to be of high quality. Hazard ratios (HRs) or odd ratios(ORs) were calculated using a fixed-effects model when there was no inter-trial heterogeneity. Oppositely, a random-effects model was employed.RESULTS: Three studies with 220 patients who had at least one episode of GV bleeding were included in the present meta-analysis. The proportions of patients with viral cirrhosis and alcoholic cirrhosis were 39% (range 0%-78%) and 36% (range 12% to 41%), respectively. The pooled incidence of variceal rebleeding in the TIPS group was significantly lower than that in the EVS group (HR = 0.3, 0.35, 95% CI: 0.17-0.71, P = 0.004). However, the risk of the development of any degree of HE was significantly increased in the TIPS group (OR = 15.97, 95% CI: 3.61-70.68). The pooled HR of survival was 1.26(95% CI: 0.76-2.09, P = 0.36). No inter-trial heterogeneity was observed among these analyses. CONCLUSION: The improved effect of TIPS in the prevention of GV rebleeding is associated with an increased risk of HE. There is no survival difference between the TIPS and EVS groups. Further studies are needed to evaluate the survival benefit of TIPS in cirrhotic patients with GV bleeding.     

Transjugular intrahepatic portosystemic shunt vs endoscopic therapy in preventing variceal rebleeding

AIM:To compare early use of transjugular intrahepatic portosystemic shunt(TIPS) with endoscopic treatment(ET) for the prophylaxis of recurrent variceal bleeding.METHODS:In-patient data were collected from 190 patients between January 2007 and June 2010 who suffured from variceal bleeding.Patients who were older than 75 years;previously received surgical treatment or endoscopic therapy for variceal bleeding;and complicated with hepatic encephalopathy or hepatic cancer,were excluded from this research.Thirty-five cases lost to follow-up were also excluded.Retrospective analysis was done in 126 eligible cases.Among them,64 patients received TIPS(TIPS group) while 62 patients received endoscopic therapy(ET group).The relevant data were collected by patient review or telephone calls.The occurrence of rebleeding,hepatic encephalopathy or other complications,survival rateand cost of treatment were compared between the two groups.RESULTS:During the follow-up period(median,20.7 and 18.7 mo in TIPS and ET groups,respectively),rebleeding from any source occurred in 11 patients in the TIPS group as compared with 31 patients in the ET group(Kaplan-Meier analysis and log-rank test,P = 0.000).Rebleeding rates at any time point(6 wk,1 year and 2 year) in the TIPS group were lower than in the ET group(Bonferroni correction α' = α/3).Eight patients in the TIPS group and 16 in the ET group died with the cumulative survival rates of 80.6% and 64.9%(Kaplan-Meier analysis and log-rank test c2 = 4.864,P = 0.02),respectively.There was no significant difference between the two groups with respect to 6-wk survival rates(Bonferroni correction α' = α/3).However,significant differences were observed between the two groups in the 1-year survival rates(92% and 79%) and the 2-year survival rates(89% and 64.9%)(Bonferroni correction α' = α/3).No significant differences were observed between the two treatment groups in the occurrence of hepatic encephalopathy(12 patients in TIPS group and 5 in ET group,KaplanMeier analysis and log-rank test,c2 = 3.103,P = 0.08).The average total cost for the TIPS group was higher than for ET group(Wilcxon-Mann Whitney test,52 678 RMB vs 38 844 RMB,P 0.05),but hospitalization frequency and hospital stay during follow-up period were lower(Wilcxon-Mann Whitney test,0.4 d vs 1.3 d,P = 0.01;5 d vs 19 d,P 0.05).CONCLUSION:Early use of TIPS is more effective than endoscopic treatment in preventing variceal rebleeding and improving survival rate,and does not increase occurrence of hepatic encephalopathy.     

Further report of a prospective randomized trial comparing distal splenorenal shunt with end-to-side portacaval shunt. An analysis of encephalopathy, survival, and quality of life

We electively compared the distal splenorenal ("selective") shunt with the end-to-side portacaval shunt in 80 prospectively randomized patients with variceal bleeding. Selective shunts required more operative time (3.9 vs. 2.8 h) and blood replacement (4.6 vs. 2.5 U) and postoperative mortality was slightly higher (5 of 38 selective vs. 0 of 40 portacaval). Postoperative complication rates were similar. After 65-mo mean follow-up, both shunts have protected well against late gastrointestinal bleeding (5 selective, 4 portacaval episodes). However, after selective shunts, spontaneous encephalopathy occurred less often (23% vs. 40% of patients), was severe in fewer patients (12% vs. 33%), and precipitated fewer hospital admissions (6 admissions in 4 selective patients vs. 26 admissions in 13 portacaval patients). Furthermore, selective shunt patients remained longer without functional disability (83% vs. 70% of postoperative patient months). Long-term survival was not significantly different in the two groups (5-yr survival: selective 51%, portacaval 56%).