Upper GI bleed: varices: distal spleno-renal shunt decreases rebleeding.

Clinical bottom line (level 1a)

  1. Patients with variceal bleeds who are given distal spleno-renal shunt, are less likely to suffer a rebleed than those given sclerotherapy.
  2. Patients given distal spleno-renal shunt have no clear difference in mortality.
Spina et al: Journal of Hepatology 1992; 16: 338-345
Expires October 2002

The study

Systematic review of randomised of
  • Patients: bled from varices before trial entry
  • Intervention: distal spleno-renal shunt compared with sclerotherapy
  • Outcome: rebleeding and mortality


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Selection criteria: as above
Appraisal criteria: detailed in text
Articles excluded if: total shunts, emergency shunts and not randomised

4 trials were included
  • The patient groups had similar ages, but differed as to aetiology of liver disease, interval between variceal bleeding and treatment and severity of liver disease.
  • Randomisation methods used were; sealed envelopes (2 trials), Efron's biased coin design (1) and computerised random number table (1).
  • The data were collected on the basis of the published data and a questionnaire of study methodology, clinical characteristics and primary results sent to the 4 principal authors.
Tested with chi-squared test and L'Abbe plots. The chi-squared test for heterogeneity of mortality was statistically significant.

The evidence

Outcome Time to outcome CEREERRRR
(95% CI)		ARR
(95% CI)		NNT
(95% CI)
rebleeding unknown 68
(45.3%)		 13
(9.15%)		 80.0%
(65.0% to 88.0%)		 36.2%
(26.9% to 45.5%)		 3
(2 to 4)
death unknown 55
(36.7%)		 45
(31.69%)		 14.0%
(-19.0% to 37.0%)		 4.98%
(-5.89% to 15.8%)		 20
(NNT = 6 to infinity;
NNH = 17 to infinity)

Comments

  1. The meta-analysis is too small to show any clear difference in death between the two groups.
  2. Some of the authors of the meta-analysis were also authors of the trials included.

Citation

  1. Spina GP, Henderson JM, Rikkers LF, et al: Distal spleno-renal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding: A meta-analysis of 4 randomized clinical trials. Journal of Hepatology 1992; 16: 338-345
Contributor: Clare Wotton and Musab Hayatli, October 1999
Reviewer:

Clinical Question.
    Patient variceal bleeds
    Intervention or Exposure distal spleno-renal shunt
    Comparison endoscopic sclerotherapy
    Outcome prevention of rebleeding and mortality