Surgical Shunting versus Transjugular Intrahepatic Portasystemic Shunting for Bleeding Varices Resulting from Portal Hypertension and Cirrhosis: A Meta-Analysis WHALEN CLARK, M.D., JONATHAN HERNANDEZ, M.D., BRIANNE MCKEON, DESIREE VILLADOLID, M.P.H., SAM AL-SAADI, M.D., JOHN MULLINAX, M.D., SHARONA B. ROSS, M.D., ALEXANDER S. ROSEMURGY II, M.D. From the Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida Surgical shunting was the mainstay in treating portal hypertension for years. Recently, trans- jugular intrahepatic portasystemic shunting (TIPS) has replaced surgical shunting, first as a ‘‘bridge’’ to transplantation and ultimately as first-line therapy for bleeding varices. This study was undertaken to examine evidence from trials comparing TIPS with surgical shunting to reassess the role of surgery in treating portal hypertension. The National Library of Medicine and the National Institutes of Health were searched for clinical trials comparing surgical shunting with TIPS. Meta-analysis using the fixed effects model was undertaken with end points of 30-day and 1- and 2-year survival and shunt failure (inability to complete shunt, irreversible shunt oc- clusion, major rehemorrhage, unanticipated liver transplantation, death). Three prospective ran- domized trials and one retrospective case-controlled study were identified. Analysis was limited to patients of Child Classes A or B. Significantly better 2-year survival (OR 2.5 [1.2–5.2]) and significantly less frequent shunt failure (OR 0.3 [0.1–0.9]) were seen in patients undergoing sur- gical shunting compared with TIPS. Meta-analysis promotes surgical shunting relative to TIPS because of improved survival and less frequent shunt failure. Surgical shunting should be ac- cepted as first-line therapy for bleeding varices resulting from portal hypertension. T HE MANAGEMENT OF patients with variceal bleeding resulting from cirrhosis and portal hypertension can be divided into two steps: control of acute variceal hemorrhage and prevention of recurrent variceal hem- orrhage. The control of acute hemorrhage generally rests on medical and endoscopic therapy with variceal decompressing shunting procedures being reserved for variceal bleeding refractory to or not amenable to med- ical and endoscopic therapies. 1 As well, the prevention of recurrent variceal hemorrhage generally rests on medical and endoscopic therapy with hepatic trans- plantation or variceal decompressing shunting pro- cedures being reserved for patients with end-stage hepatic decompensation or variceal bleeding refractory to or not amenable to medical and endoscopic thera- pies. 1 Hepatic transplantation is the only curative ap- proach to cirrhosis and portal hypertension, but many patients experiencing variceal bleeding do not have hepatic insufficiency or lack the social, psychological, and/or economic means to undergo transplantation. Portal decompression is currently near universally achieved through transjugular intrahepatic portasyste- mic shunts (TIPS), because they are now undertaken more than 10 times more frequently than surgical shunts to prevent or control variceal rebleeding. 2 This exten- sive use represents a departure from the past, when surgery was commonly used to control variceal bleed- ing and surgeons were responsible for the care of pa- tients with cirrhosis, portal hypertension, and variceal bleeding. The evolution of medical and surgical care over the last several decades has been toward minimally invasive therapeutics, and the management of portal hyperten- sion has paralleled this change. For internists caring for patients with variceal bleeding, ordering TIPS is no more different than ordering a CT scan. For the patients Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Birmingham, Alabama, February 9–12, 2008. Address correspondence and reprint requests to Alexander S. Rosemurgy II, M.D., Professor of Surgery and Professor of Med- icine, Director, Division of General Surgery, University of South Florida, Tampa General Hospital, P.O. Box 1289, Room F145, Tampa, FL 33601. E-mail: arosemur@health.usf.edu. 857