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Previous Volume 342:1701-1707 June 8, 2000 Number 23 Next

	Full Text PDF Editorial by Lake, J. R. Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background In patients with cirrhosis and ascites, creation of a transjugular intrahepatic portosystemic shunt may reduce the ascites and improve renal function. However, the benefit of this procedure as compared with that of large-volume paracentesis is uncertain.

Methods We randomly assigned 60 patients with cirrhosis and refractory or recurrent ascites (Child–Pugh class B in 42 patients and class C in 18 patients) to treatment with a transjugular shunt (29 patients) or large-volume paracentesis (31 patients). The mean (±SD) duration of follow-up was 45±16 months among those assigned to shunting and 44±18 months among those assigned to paracentesis. The primary outcome was survival without liver transplantation.

Results Among the patients in the shunt group, 15 died and 1 underwent liver transplantation during the study period, as compared with 23 patients and 2 patients, respectively, in the paracentesis group. The probability of survival without liver transplantation was 69 percent at one year and 58 percent at two years in the shunt group, as compared with 52 percent and 32 percent in the paracentesis group (P= 0.11 for the overall comparison, by the log-rank test). In a multivariate analysis, treatment with transjugular shunting was independently associated with survival without the need for transplantation (P=0.02). At three months, 61 percent of the patients in the shunt group and 18 percent of those in the paracentesis group had no ascites (P=0.006). The frequency of hepatic encephalopathy was similar in the two groups. Of the patients assigned to paracentesis in whom this procedure was unsuccessful, 10 received a transjugular shunt a mean of 5.5±4 months after randomization; 4 had a response to this rescue treatment.

Conclusions In comparison with large-volume par-acentesis, the creation of a transjugular intrahepatic portosystemic shunt can improve the chance of survival without liver transplantation in patients with refractory or recurrent ascites.

Source Information

From the Medizinische Klinik II (M.R., A.O., V.S., P.D.) and the Department of Medical Biometry (M.O.), Albrecht-Ludwigs-Universität, Freiburg, and the Medizinische Klinik II (V.G., J.H., A.L.G.) and the Institute of Diagnostic Radiology (M.R.), Klinikum Grosshadern, Ludwig-Maximilians-Universität, Munich — both in Germany.

Address reprint requests to Dr. Rössle at the Albrecht-Ludwigs-Universität, Department of Gastroenterology, Hugstetterstr. 55, 79106 Freiburg, Germany, or at roessle{at}mm21.ukl.uni-freiburg.de.

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