Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta-analysis

Endoscopic treatment (ET) is frequently used to prevent variceal rebleeding but this still occurs in about 50% of patients. Recently, transjugular int rahepatic portosystemic shunt (TIPS) has been compared with ET in several t rials. Using a meta-analysis, we evaluated randomized trials comparing TIPS to ET assessing prevention of rebleeding, survival, and the effects on res ource use and the quality of patients' lives. Medical databases were search ed between January 1988 and January 1999 as well as published citations and conference proceedings. Sensitivity analyses for type of publication, meth odological quality score, mean duration of follow-up, type of ET, etiology, and severity of liver disease were performed. Eleven randomized trials inv olving 811 patients fulfilled the selection criteria. The median follow-up ranged from 10 to 32 months. Variceal rebleeding was significantly more fre quent with ET (47%) compared with TIPS (19%) (odds ratio [OR], 3.8; 95% con fidence interval [CI], 2.8-5.2; P <.001), but there was no difference in mo rtality (OR, 0.97; 95% CI, 0.71-1.34). Post-treatment encephalopathy occurr ed significantly less often after ET (19%) than after TIPS (34%) (OR, 0.43; 95% CI, 0.30-0.60; P <.001). In the studies showing resource use this was more extensive for TIPS. The sensitivity analyses did not alter the main co nclusion, and sole comparison with endoscopic ligation did not alter these results. In conclusion, in patients with variceal bleeding, TIPS compared w ith ET reduces the rebleeding rate, but does not improve survival, and incr eases the incidence of encephalopathy in a period of 1 to 2.5 years. Thus, TIPS cannot be recommended as the first choice treatment for prevention of variceal rebleeding.