Study data published in Frontiers in medicine describe the relative effectiveness of various treatments for cirrhosis with portal hypertension. A systematic review of published randomized controlled trials identified 9 treatment strategies, of which transjugular intrahepatic portosystemic shunt (TIPS) and distal splenorenal shunt (DSRS) appeared to provide the best control of bleeding. Overall survival seemed to improve better with endoscopic treatment combined with drugs.
The treatment of portal hypertension caused by cirrhosis of the liver is difficult and varied, with no treatment option recommended to prevent the bleeding. To compare the relative efficacy of existing treatments, the researchers conducted a Bayesian network meta-analysis of randomized controlled trials (RCTs) published on PubMed, Embase, Cochrane Library or Web of Science until June 2020.
Eligible trials compared treatments for cirrhosis and portal hypertension and reported recurrent bleeding and mortality as treatment outcomes. Two researchers independently reviewed and extracted the study data.
The network meta-analysis was performed using a random effects model in a Bayesian framework; the framework was used to calculate odds ratios for all-cause bleeding, bleeding-related mortality, overall survival, treatment failure, and hepatic encephalopathy. A ranked probability analysis was used to illustrate the relative effectiveness of each treatment method for these outcomes.
The literature search identified 9,805 RCTs, of which 40 were selected for full text review. The pooled study cohort consisted of 4,006 patients from clinical sites in 15 countries. A total of 9 distinct treatment strategies were explored: DSRS, Endoscopic Injection Sclerotherapy (EIS), Endoscopic Tissue Adhesive (ETA), Endoscopic Varicose Ligation (EVL), Drug, EVL with EIS, EVL with Drug, EIS with Drug and TIPS. All 40 studies reported rates of recurrent bleeding from all causes.
Meta-analyzes have identified DSRS and TIPS as the most effective in preventing recurrence of bleeding. The next best methods to prevent recurrence of bleeding, in descending order, were: EIS with drug, ETA, EVL with drug, EVL with EIS, EVL only, EIS only, and drug only. This hierarchy largely persisted at 1, 2, and 3 years of follow-up, although TIPS appeared to have greater long-term efficacy compared to DSRS.
Twenty-one articles each reported bleeding-related mortality and overall survival as study results. Bleeding-related mortality appeared lowest with EVL and EIS. The best 1-year overall survival rate was seen with EVL with drug, followed by ETA only, EVL only, TIPS, DSRS, EIS only, and drug only.
Treatment failure, examined in only 9 direct comparisons, was found to be lowest with EVL and drugs, compared to other methods. A total of 1956 patients presented with hepatic encephalopathy in the pooled cohort. In this cohort, DSRS and TIPS were associated with a higher incidence of hepatic encephalopathy compared to EVL, drugs, EIS, EVL with drug, and ETA.
These results provide evidence for the efficacy and safety of 9 methods of treating cirrhosis with portal hypertension. Overall, TIPS and DSRS were associated with the lowest likelihood of recurrent varicose vein bleeding, but were each correlated with a greater risk of hepatic encephalopathy. Analyzes were not adjusted for differential patient characteristics, such as Child-Pugh class, age, and sex; in addition, some treatment subgroups were too small for investigation. As such, the results should be interpreted with caution and more research is needed to better elucidate the effectiveness of these treatment options.
“In conclusion, TIPS and DSRS should be prioritized in patients with portal hypertension and cirrhosis to control recurrent bleeding, which may not improve survival,” the researchers wrote. “[Endoscopic therapy] with medication can improve survival. In addition, the drugs should be used in conjunction with ET or other treatments rather than as the sole therapeutic intervention, ”they concluded.
Yao Q, Chen W, Yan C, Yu J, Jiang T, Cao H. Efficacy and safety of treatments for patients with portal hypertension and cirrhosis: a systematic review and a Bayesian network meta-analysis. Front Med (Lausanne). Published online September 3, 2021. doi: 10.3389 / fmed.2021.712918
This article originally appeared on Gastroenterology advisor