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TIPS for Prevention of Recurrent Bleeding in Patients with Cirrhosis: Meta-analysis of Randomized Clinical Trials¹

¹ From the Departments of Radiology (A.L., R.L.G., M.M.) and Internal Medicine (G.D.) and the Institute of Internal Medicine and Pneumology (A.L., L.P.), University of Palermo, Ospedale V Cervello, Via Trabucco 180, 90146 Palermo, Italy, and the Institute of Medical Statistics and Biometry, University of Milan, Italy (A.M.). Received May 1, 1998; revision requested July 6; revision received August 26; accepted January 25, 1999. Address reprint requests to A.L.

PURPOSE: To compare the effects of transjugular intrahepatic portosystemic shunt (TIPS) creation with those of endoscopic treatment with or without propranolol administration (ie, conventional treatment) on recurrent bleeding, encephalopathy, and mortality by using meta-analysis of 11 published randomized clinical trials.

MATERIALS AND METHODS: Data from 11 relevant studies were retrieved by means of computerized and manual search. The combinability of the studies was assessed in terms of clinical and statistical criteria. Data were extracted on the basis of the intention-to-treat principle, and treatment effects were measured as risk differences between TIPS creation and conventional treatment. Pooled estimates were computed according to a random-effects model.

RESULTS: A total of 750 patients were included in 11 trials. No significant heterogeneity was found for any of the outcomes. Pooled risk differences were recurrent bleeding, -31% (95% CI, -39%, -23%); encephalopathy, +16% (95% CI, +10%, +22%); death due to all causes, +2% (95% CI, -4%, +9%); and death due to bleeding, -5% (95% CI, -11%, +6%). Clinically important complications occurred in 22% of patients and were associated with both treatments. TIPS dysfunction occurred in 55% of patients.

CONCLUSION: TIPS creation markedly reduces risk of rebleeding but increases risk of encephalopathy without affecting survival. Therefore, TIPS creation may not be the best first-choice therapy for prevention of recurrent variceal bleeding. Criteria for selection of candidates for TIPS creation should be assessed in future prospective studies.

Index terms: Liver, cirrhosis, 761.794 • Liver, hemorrhage, 761.458. 761.75 • Liver, interventional procedures, 761.1299 • Radiology and radiologists, outcomes studies • Shunts, portosystemic, 95.1268 • Varices, 71.75

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