Transjugular Intrahepatic Portosystemic Shunt Compared With Endoscopic Treatment Plus β-blocker For Prevention Of Variceal Rebleeding: A Meta-analysis

Background: Esophagogastric varices bleeding(EVB)is the most common complication of cirrhosis.It is associated with a high mortality during the acute episode and a high rate of recurrence in the patients who survive.So how to prevent esophagogastric variceal rebleeding and how to reduce the mortality rates are particularly important.The latest Chinese guidelines recommend endoscopic treatment(ET)plus nonselective β-blocker therapy as a standard treatment for secondary prevention,and transjugular intrahepatic portosystemic shunt(TIPS)as a salvage therapy.However,there is still lack of high-quality study evaluating TIPS and ET plus β-blocker on efficacy and safety of secondary prevention in variceal bleeding.Objective: To Compare TIPS with ET plus β-blocker on esophagogastric variceal rebleeding rate,the incidence of hepatic encephalopathy,rebleeding rate and mortality evaluation.Methods: Randomized controlled trials were identified in the PubMed,Embase,The Cochrane Library,Wanfang Data,CNKI,raging from January 1st,1960 to February 1st,2016,and literatures about TIPS with ET plus nonselective β-blocker therapy to prevent esophageal variceal rebleeding were enrolled.The Cochrane Collaboration’s Rev Man 5.3 Software were used to investigate esophagogastric varices rebleeding rate,the incidence of hepatic encephalopathy,rebleeding mortality and total mortality,and heterogeneity test,sensitivity analysis and publication biases were evaluated.Results: Five randomized controlled trials,including 439 cases of patients(220 cases of TIPS group,219 cases of ET plus nonselective β-blocker group)were enrolled in the study.Compared with ET plus β-blocker,TIPS significantly reduced the incidence of rebleeding(OR=0.25,95% CI 0.14-0.45,P<0.05).Futher analysis showed that,TIPS significantly reduced the incidence of rebleeding in the first year(OR=0.19,95% CI 0.10-0.37,P<0.05),but the difference disappeared during the second year(OR=0.16,95% CI 0.02-1.46,P>0.05).TIPS was more likely to lead to hepatic encephalopathy than ET plus β-blocker(OR=2.20,95% CI 1.42-3.40,P<0.05),especially in the first year(OR=2.27,95% CI 1.34-3.84,P<0.05)but the difference disappeared(OR=1.14,95% CI 0.46-2.28,P>0.05)at year 2.All of the rebleeding mortality(OR=0.31,95% CI 0.12-1.03),the first year mortality(OR=1.12,95% CI 0.57-2.22),the second year mortality(OR=0.51,95% CI 0.22-1.19)and total mortality(OR=0.98,95% CI 0.62-1.53)between two therapies had no significant difference(P>0.05).Conclusions: 1 Compared with ET plus nonselective β-blocker therapy,TIPS can significantly reduce the incidence of rebleeding in the short term,but the incidence of hepatic encephalopathy will be increased,however,this difference gradually disappears.2 Compared with ET plus nonselective β-blocker therapy,TIPS has no significant improment on long-term prognosis for patients with esophageal varices,but in some special circumstances,it may be treated as a secondary prevention of bleeding esophageal varices.