| Part 1:Risk factors for esophageal variceal bleeding in patients with liver cirrhosis:A meta-analysisObjective:To systematically evaluate the risk factors of cirrhosis with esophageal variceal bleeding and provide medical evidence for prevention of esophageal variceal bleedingMethod:We searched the PubMed,the Cochrane Library,EMBASE,Web of Science,CNKI,VIP database,Wanfang database through January,2018 for cohort studies that assessing the risk factors for cirrhosis with esophageal variceal bleeding.Review Manager verson5.3 software were selected for Meta analysis.The quality of the included literature was evaluated by newcastle-ottawa scale.Result:17 articles were included,all of which were case-control study.With a total of 3168 patients,of whom 1435 were EVB patients,accounting for 45.3%.The results of Meta-analysis showed that the risk factors of EVB include hemoglobin count[MD=-16.32,95%CI:-20.65-(-12.00)],prothrombin time[SMD=0.88,95%CI:0.51-1.25],prothrombin activity[MD=-6.05,95%CI:-8.58-(-3.53)],albumin levels[MD=-1.02,95%CI:-1.93-(-0.10)],red sign[RD=0.46,95%CI:0.37-0.55],portal vein diameter[SMD = 0.69,95%CI:0.52-0.86],spleen vein diameter[SMD=0.58,95%CI:0.47-0.68],spleen thickness[SMD=0.53,95%CI:0.23-0.83],Child C grade[OR=1.55,95%CI:1.25-1.94],severe esophageal varices[OR=6.43,95%CI:4.07-10.16],ascites[RR = 1.29,95%CI:1.02-1.62].There were no significance differences between patient with ages,gender,etiology of cirrhosis,leukocy,bilirubin level,hepatic encephalopathy.Conclusion:The risk factors of the esophageal variceal bleeding are the prolonged prothrombin time,decreased prothrombin activity,hypoalalbuminemia,red sign,extended portal vein width,extended splenic vein width,spleen thickness,Child C grade,severe esophageal varices and ascites.However,age,gender,etiology of cirrhosis,bilirubin,leukocyte,hepatic encephalopathy were not directly related to the formation of EVB.Part 2:Early-TIPS versus endoscopic therapy for prevention of esophageal variceal rebleeding:A meta-analysisObjective:To evaluate the role of early transjugular intrahepatic portosystemic shunt and endoscopic treatment in the prevention of variceal hemorrhage and provide medical evidence for the secondary prophylaxis of variceal bleeding in liver cirrhosis.Method:We searched the PubMed,the Cochrane Library,EMBASE,Web of Science,CNKI,VIP database,Wanfang database through January,2018 for studies that assessed the effect of early transjugular intrahepatic portosystemic shunt vs endoscopic treatment in patients with cirrhosis and esophageal variceal bleeding.Review Manager verson5.3 software were selected for Meta analysis.The quality of the included literature was evaluated by jadad scale or newcastle-ottawa scale.Result:13 articles were included in the study,11 were randomized controlled trials and 2 were non-randomized controlled trials.A total of 801 patients with gastroesophageal variceal hemorrhage were enrolled in this study.Among them,410 were treated with early TIPS and 391 treated with endoscopy.Meta analysis showed that:① Compared with the endoscopic treatment group,the early TIPS group had a lower 5-day rebleeding rate[OR = 0.30,95%Cl:0.02-1.58],6-week rebleeding rate[OR = 0.12,95%CI:0.05-0.33],6-week mortality[OR= 0.21,95%CI:0.07-0.58],one year rebleeding rate[OR = 0.16,95%CI:0.11-0.23],one year mortality[OR= 0.63,95%CI:0.44-0.90]and rebleeding-related mortality[OR = 0.26,95%Cl:0.14-0.48];②There is no statistics difference between early transjugular intrahepatic portosystemic shunt and endoscopic treatment in hepatic encephalopathy rate[OR = 1.31,95%CI:0.84-2.04],liver-related mortality[OR = 1.53,95%CI:0.96-2.45],liver transplantation rate[OR = 1.34,95%CI:0.66-2.73].While in the subgroup analysis according to the stent type,bare TIPS group and coverd TIPS group both had a lower one year rebleeding rate[OR=0.24,95%CI:0.15-0.38;OR=0.08,95%CI:0.003-0.20],no statistics difference in 1-year mortality[OR=0.71,95%CI:0.48-1.06;OR= 0.53,95%CI:0.11-2.67].But the 1-year encephalopathy rate of bare TIPS group was higher than the endoscopic group[OR=2.32,95%CI:1.38-3.90],and it was equal between coverd TIPS group and endoscopic group[OR=0.76,95%CI:0.45-1.27].Conclusion:In the secondary prophylaxis of variceal rebleeding in severe liver cirrhosis,early-TIPS was superior to endoscopy,with a lower 6-week rebleeding rate,6-week mortality,one year rebleeding rate and rebleeding-related mortality;6-week and one year survival rate improve;There is no statistics difference between early-TIPS and endoscopic treatment in hepatic encephalopathy,liver-related mortality and liver transplantation rate.It was concluded that TIPS with covered stent might be considered the preferred choice of therapy in patients with severe liver disease for secondary prophylaxis. |
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