Effectiveness of transjugular intrahepatic portosystemic shunting in the management of cirrhotic patients with refractory ascites

Abstract

Abdominal paracentesis has been long considered the therapeutic procedure of choice for hospitalized liver cirrhotic patients suffering from refractory ascites. It is deemed a safe and cost-effective bedside procedure. However, paracentesis only treats ascites and has to be repeated every time ascites develops. More recently the Transjugular Intrahepatic Portosystemic Shunt (TIPS), a one off procedure, has also been used in the management of ascites. In view of these distinctive alternatives for the management of refractory ascites, the research question guiding the study is: In liver cirrhotic patients with refractory ascites, how does TIPS compare with paracentesis in terms of ascites, hepatic encephalopathy and survival? In an attempt to minimize selection bias, a set of five inclusion and exclusion criteria based upon the PICO question were established before the literature search. This ensured that the validity of articles uncovered during the search for literature was exclusively grounded on these criteria. A methodological search process in several relevant databases ensued with the aim of identifying evidence based research. The search exposed eleven studies that satisfied the inclusion criteria. These were composed of three different study designs, namely five randomised controlled trials (RCTs), four meta-analyses and two systematic reviews. In an attempt to determine their quality, the studies were critically appraised with the help of Critical Appraisal Skills Programme (CASP) tools appropriate to their study design. Results showed that although TIPS achieved total control over ascites, this happened at the expense of a greater incidence of hepatic encephalopathy whilst it did not modify survival. Therefore paracentesis still remains the treatment of choice. These results conclude that the local practice in the management of refractory ascites stands in line with the current results. Following an analysis of the retrieved evidence the recommendations for research, practice and education were drawn. The main recommendations include the need for larger scale studies and a local clinical trial comparing TIPS versus paracentesis in terms of quality of life and costs apart from the other outcomes. This would be beneficial to obtain a local picture.