A Cochrane review (abstract , review ) included 22 studies with a total of 1409 subjects. Shunt therapy compared with ET demonstrated significantly less rebleeding (OR 0.24, 95% CI 0.18 to 0.30) at the cost of significantly increased acute hepatic encephalopathy (OR 2.07, 95% CI 1.59 to 2.69) and chronic encephalopathy (OR 2.09, 95% CI 1.20 to 3.62). There were no significant differences regarding mortality (hazard ratio 1.00, 95% CI 0.82 to 1.21) and duration of in-patient stay (WMD 0.78 day, 95% CI -1.48 to 3.05). The proportion of patients with shunt occlusion or dysfunction was 3.1% (95% CI 0.4 to 10.7%) following TS (two trials), 7.8% (95% CI 3.8 to 13.9%) following DSRS (four trials), and 59% (range 18% to 72%) following TIPS (14 trials).
A systematic review including 11 RCTs with a total of 811 subjects was abstracted in DARE. Variceal rebleeding was significantly more frequent with endoscopic treatment (46.6% than with TIPS (18.9%), but there was no difference in mortality (OR 0.97, 95% CI 0.71 to 1.34). The absolute risk difference for rebleeding was 0.28, NNT to prevent one variceal bleeding was 4 (95% CI 3 to 5). Post-treatment encephalopathy occurred significantly less often with ET (19%) than with TIPS (34%). The authors conclude that TIPS should not be the first choice for prevention of variceal rebleeding but should be reserved only for patients with recurrent variceal bleeding in whom ET fails.
Comment: The quality of evidence was downgraded by poor trial quality but upgraded by strong association.