Area Editoriale
BACKGROUND: Refractory ascites (ie,ascites that cannot be mobilized despite sodium restriction and diuretictreatment) occurs in 10 per cent of patients with cirrhosis. It is associatedwith substantial morbidity and mortality with a one-year survival rate of lessthan 50 per cent. Few therapeutic options currently exist for the management ofrefractory ascites. OBJECTIVES: To compare transjugular intrahepaticportosystemic stent-shunts (TIPS) versus paracentesis for the treatment of refractoryascites in patients with cirrhosis. SEARCH STRATEGY: We searched The CochraneHepato-Biliary Group Controlled Trials Register (January 2006), the CochraneCentral Register of Controlled Trials in The Cochrane Library (Issue 4, 2005),MEDLINE (1950 to January 2006), EMBASE (1980 to January 2006), CINAHL (1982 toAugust 2004), and Science Citation Index Expanded (1945 to January 2006).SELECTION CRITERIA: We included randomised clinical trials comparing TIPS andparacentesis with or without volume expanders for cirrhotic patients withrefractory ascites. DATA COLLECTION AND ANALYSIS: We evaluated themethodological quality of the randomised clinical trials by the generation ofthe allocation section, allocation concealment, and follow-up. Two authors independentlyextracted data from each trial. We contacted trial authors for additionalinformation. Dichotomous outcomes were reported as odds ratio (OR) with 95%confidence interval (CI). MAIN RESULTS: Five randomised clinical trials,including 330 patients, met the inclusion criteria. The majority of trials hadadequate allocation concealment, but only one employed blinded outcomeassessment. Mortality at 30-days (OR 1.00, 95% CI 0.10 to 10.06, P = 1.0) and24-months (OR 1.29, 95% CI 0.65 to 2.56, P = 0.5) did not differ significantlybetween TIPS and paracentesis. Transjugular intrahepatic portosystemicstent-shunts significantly reduced the re-accumulation of ascites at 3-months(OR 0.07, 95% CI 0.03 to 0.18, P < 0.01) and 12-months (OR 0.14, 95% CI 0.06to 0.28, P < 0.01). Hepatic encephalopathy occurred significantly more oftenin the TIPS group (OR 2.24, 95% CI 1.39 to 3.6, P < 0.01), butgastrointestinal bleeding, infection, and acute renal failure did not differsignificantly between the two groups. AUTHORS' CONCLUSIONS: The meta-analysissupports that TIPS was more effective at removing ascites as compared withparacentesis without a significant difference in mortality, gastrointestinalbleeding, infection, and acute renal failure. However, TIPS patients develophepatic encephalopathy significantly more often.Leggil'articolo