portal hypertension , always accompanies by cirrhosis , can lead to lots of complications including varices hemorrhage , ascites , hypersplenism and hepatic encephalopathy .
the risk of varices bleeding in patients with portal hypertension was approximately 30% over 2 years .
nowadays , the treatment for patients with varices hemorrhage mainly depends on medical treatment , endoscopic therapy , and surgical shunting procedures .
transjugular intrahepatic portosystemic shunts ( tipss ) are currently widely used to prevent or control variceal rebleeding for it could serve as a bridge to hepatic transplantation or fit for patients who are in need of portal decompression .
tips was usually regarded as a first - line therapy and cost - effective solution to portal hypertension concomitant with variceal hemorrhage in recent years .
therefore , tips has generally replaced surgical shunts , which require the involvement of surgeons and general anesthesia as the first treatment for patients with portal hypertension . besides advantages of cost - effective and less invasive , tips , however , was always accompanied by complications mainly including stenosis / occlusion , recurrent varices hemorrhage , and hepatic encephalopathy . its effectiveness beyond surgical shunting in bridging to hepatic transplantation , to some extent , was arguable .
in addition , with issues of postoperative shunt stenosis , thrombosis and migration , almost half of the patients undergoing tips experienced shunt failure within 1 year of tips placement .
however , surgical shunting that mostly refers to distal splenorenal shunts ( dsrss ) , portacaval shunts ( pcss ) or h - graft pcss ( hgpcss ) has generally disappeared for the widespread application of tips .
recent article reported that patients receiving dsrs would have significantly lower rebleeding and encephalopathy rates than tips in the management of refractory variceal bleeding .
also , pcs was reported significantly superior to endoscopic therapy in a longer survival rate , less morbidity and lower direct and indirect costs . with more randomized controlled trials ( rcts ) comparing tips with
surgical shunting undertaken , the optimal management for patients with portal hypertension can be tested .
there was still no all - round systemic evaluation comparing tips with surgical shunts for patients with portal hypertension .
specifically , we focused on comparing postoperative complications ( including recurrent variceal hemorrhage , shunt stenosis , and encephalopathy ) , mortality and survival rate after surgery in patients undergoing tips versus surgical shunting .
therefore , we performed a meta - analysis of all rcts concerning tips and surgical shunting ( including dsrs , pcs , and hgpcs ) to evaluate the optimal management for patients with portal hypertension .
the aims of this study were to give more information concerning tips and surgical shunting with our proposed approach in evaluating the morbidity , mortality , and long - term survival .
all databases including cbm , cnki , wfpd , pubmed , medline , embase and cochrane were searched using the mesh terms :  hypertension , portal / complications , 
 liver cirrhosis / complications ,   portosystemic shunt , transjugular intrahepatic / mortality , 
 portosystemic shunt , surgical ,   esophageal and gastric varices / surgery ,   hypertension , portal / surgery  independently or in combination for clinical trials comparing tips with surgical shunts .
all literatures were screened to identify all suitable published rcts for eligibility until february 2014 .
all eligible rcts were screened for their methods , characteristics and risk of bias strictly . in this meta - analysis ,
two different kinds of groups were generated from the included papers that met the criterion : the tips group and the surgical shunting group .
the surgical shunting group referred to traditional portosystemic shunts that contained dsrs , hgpcs , and pcs . in sub - group analysis , hgpcs and pcs could be recognized as one group for their similar modus operandi and decompression principle . in our research , 246 patients underwent tips and 247 patients underwent surgical shunts .
all included rcts were required to contain a direct comparison between portosystemic shunts ( including dsrs , hgpcs , and pcs ) and tips in a controlled manner .
each trial was required to include postoperative complications , mortality and long - term survival rate in detail .
primary outcomes to be assessed were mortality , 2- and 5-year survival and postoperative complications including recurrent variceal hemorrhage , shunt stenosis , and hepatic encephalopathy .
secondary outcomes to be assessed were length of hospital stay , operating time and hospitalization charges .
each of these papers was assessed using a standardized evaluation form by two investigators ( author # 1 , author # 5 ) independently for extraction in this meta - analysis .
when consensus could nt be reached , discussion and joint collection of the paper could resolve .
otherwise , a third reviewer ( author # 2 ) would take part in the discussion and determine the definite inclusion of papers as a referee .
general information collected from abstracts , included the authors , publication year , characteristics of patients and outcomes .
all papers were assessed for the risk of bias by two investigators ( author # 1 , author # 5 ) on the following areas : random sequence generation , allocation concealment , blinding of participants and personnel , blinding of outcome assessment , incomplete outcome data , selective reporting , other sources of bias .
outcomes , including morbidity , mortality , 2-year survival rate , 5-year survival rate , hospital stay , operating time and hospitalization charge , were extracted from included papers .
survival was defined as the time from the shunt procedure to the time of death from any cause .
mortality in this meta - analysis was defined as postoperative death before discharge or within 30 postoperative days .
transjugular intrahepatic portosystemic shunt placement referred to the technical procedure via interventional therapy that stents were placed between the portal vein and hepatic vein until a 510 mmhg gradient was achieved .
the technique of hgpcs was described that small - diameter ( 810 mm ) externally ring - reinforced polytetrafluoroethylene graft was used with beveled ends oriented perpendicular ( 90 ) to each other to accommodate for the orientation of the portal vein to the inferior vena cava .
pcs was defined as direct pcs , usually side to side , rarely end to side .
dsrs was defined as distal splenic vein and renal vein shunted from end to side .
the verified data were analyzed using review manager ( version 4.2 , oxford , england , the cochrane collaboration , 2003 ) .
the odds ratio ( or ) , mean difference ( md ) and their corresponding 95% confidence intervals ( 95% cis ) were calculated for dichotomous or continuous outcome data respectively .
statistical heterogeneity was assessed with the i test and q - test to justify the accuracy of the fixed or random effects model .
a significant effect was assumed if the 95% ci did not include the value 1.0 for or or 0 for md .
a fixed - effect model was used in case of no relevant statistical heterogeneity when i was < 50% and p > 0.1 .
if the heterogeneity was high ( i > 50% and p < 0.1 ) , a sub - group analysis could be used to decrease the risk of bias .
a fixed - effect model also could be used in sub - group analysis for decreased heterogeneity .
a random - effect model was used when i > 50% and p < 0.1 .
all databases including cbm , cnki , wfpd , pubmed , medline , embase and cochrane were searched using the mesh terms :  hypertension , portal / complications , 
 liver cirrhosis / complications ,   portosystemic shunt , transjugular intrahepatic / mortality , 
 portosystemic shunt , surgical ,   esophageal and gastric varices / surgery ,   hypertension , portal / surgery  independently or in combination for clinical trials comparing tips with surgical shunts .
all literatures were screened to identify all suitable published rcts for eligibility until february 2014 .
all eligible rcts were screened for their methods , characteristics and risk of bias strictly . in this meta - analysis ,
two different kinds of groups were generated from the included papers that met the criterion : the tips group and the surgical shunting group .
the surgical shunting group referred to traditional portosystemic shunts that contained dsrs , hgpcs , and pcs . in sub - group analysis , hgpcs and pcs could be recognized as one group for their similar modus operandi and decompression principle . in our research , 246 patients underwent tips and 247 patients underwent surgical shunts .
all included rcts were required to contain a direct comparison between portosystemic shunts ( including dsrs , hgpcs , and pcs ) and tips in a controlled manner .
each trial was required to include postoperative complications , mortality and long - term survival rate in detail .
primary outcomes to be assessed were mortality , 2- and 5-year survival and postoperative complications including recurrent variceal hemorrhage , shunt stenosis , and hepatic encephalopathy .
secondary outcomes to be assessed were length of hospital stay , operating time and hospitalization charges .
each of these papers was assessed using a standardized evaluation form by two investigators ( author # 1 , author # 5 ) independently for extraction in this meta - analysis .
when consensus could nt be reached , discussion and joint collection of the paper could resolve .
otherwise , a third reviewer ( author # 2 ) would take part in the discussion and determine the definite inclusion of papers as a referee .
general information collected from abstracts , included the authors , publication year , characteristics of patients and outcomes .
all papers were assessed for the risk of bias by two investigators ( author # 1 , author # 5 ) on the following areas : random sequence generation , allocation concealment , blinding of participants and personnel , blinding of outcome assessment , incomplete outcome data , selective reporting , other sources of bias .
outcomes , including morbidity , mortality , 2-year survival rate , 5-year survival rate , hospital stay , operating time and hospitalization charge , were extracted from included papers .
survival was defined as the time from the shunt procedure to the time of death from any cause .
mortality in this meta - analysis was defined as postoperative death before discharge or within 30 postoperative days .
transjugular intrahepatic portosystemic shunt placement referred to the technical procedure via interventional therapy that stents were placed between the portal vein and hepatic vein until a 510 mmhg gradient was achieved .
the technique of hgpcs was described that small - diameter ( 810 mm ) externally ring - reinforced polytetrafluoroethylene graft was used with beveled ends oriented perpendicular ( 90 ) to each other to accommodate for the orientation of the portal vein to the inferior vena cava .
pcs was defined as direct pcs , usually side to side , rarely end to side .
dsrs was defined as distal splenic vein and renal vein shunted from end to side .
the verified data were analyzed using review manager ( version 4.2 , oxford , england , the cochrane collaboration , 2003 ) .
the odds ratio ( or ) , mean difference ( md ) and their corresponding 95% confidence intervals ( 95% cis ) were calculated for dichotomous or continuous outcome data respectively .
statistical heterogeneity was assessed with the i test and q - test to justify the accuracy of the fixed or random effects model .
a significant effect was assumed if the 95% ci did not include the value 1.0 for or or 0 for md .
a fixed - effect model was used in case of no relevant statistical heterogeneity when i was < 50% and p > 0.1 .
if the heterogeneity was high ( i > 50% and p < 0.1 ) , a sub - group analysis could be used to decrease the risk of bias .
a fixed - effect model also could be used in sub - group analysis for decreased heterogeneity .
a random - effect model was used when i > 50% and p < 0.1 .
searching in medline , embase , pubmed and cochrane data of clinical trials was 376 trials .
after checking for abstracts according to our predefined inclusion and exclusion criterion , 76 references remained for further evaluation .
eventually , four rcts that documented adequate comparisons between tips and surgical shunting for portal hypertension were determined for this meta - analysis .
no additional eligible studies were found after carefully examined the reference lists of all included papers [ figure 1 ] .
the characteristics and risk of bias for included four studies that compared tips and surgical shunting for portal hypertension are performed in table 1 as suggested in the cochrane handbook .
three included papers reported patients from america while the remaining one from india [ table 1 ] . characteristics of included rcts and risk of the bias summary tips : transjugular intrahepatic portosystemic shunting ; dsrs : distal splenorenal shunts ; pcs : portacaval shunts ; hgpcs : h - graft portacaval shunt ; rct : randomized clinical trial . from the four included trials , 493 patients of child - pugh a to c were included in our analysis .
long - term results and postoperative complications mainly including recurrent variceal hemorrhage , shunt stenosis , and encephalopathy are summarized in table 2 .
results and clinical characteristics comparing tips with surgical shunting tips : transjugular intrahepatic portasystemic shunting ; dsrs : distal splenorenal shunts ; pcs : portacaval shunts ; hgpcs : h - graft portacaval shunt ; sd : standard deviation ; na : not applicable .
variceal rebleeding occurred in 27.6% of patients in tips group and in 4.5% of patients in surgical shunting group , shunt stenosis occurred in 66.1% of patients in tips group and in 9.9% of patients in surgical shunting group , hepatic encephalopathy occurred in 53.9% of patients in tips group and in 32.0% of patients in surgical shunting group . from our meta - analysis ,
morbidity in variceal rehemorrhage was significantly higher in tips than in surgical shunts ( or = 7.45 , 95% ci : ( 3.9314.15 ) , p < 0.00001 ) [ figure 2 ] .
patients occurring postoperative shunt stenosis also was significantly higher in tips than in surgical shunts ( or = 20.01 , 95% ci : ( 6.6759.99 ) , p < 0.000001 ) [ figure 3 ] . besides , morbidity in hepatic encephalopathy was also significantly higher in tips than in surgical shunts ( or = 2.50 , 95% ci : ( 1.633.84 ) , p < 0.0001 ) , especially when compared with pcs in sub - group analysis ( or = 6.00 , 95% ci : ( 2.9312.27 ) , p < 0.00001 ) [ figure 4 ] .
a sub - group analysis was conducted in the comparison of variceal rehemorrhage (  = 8.07 , p = 0.04 , i = 62.8% ) and hepatic encephalopathy (  = 12.41 , p = 0.002 , i = 83.9% ) to decrease high heterogeneity .
mortality in this meta - analysis referred to the death rate at 30 days . in our research ,
mortality was equivalent among patients undergoing tips or surgical shunts ( or = 0.76 ; 95% ci : ( 0.451.30 ) , p = 0.32 ) [ figure 5 ] .
no significant heterogeneity was found from the trials (  = 1.80 , p = 0.61 , i = 0% ) .
survival at 2 years in sub - group analysis was also significantly higher among patients undergoing pcs than patients undergoing tips ( or = 0.48 ; 95% ci : ( 0.290.77 ) , p = 0.003 ) , but in sub - group analysis survival at 2 years was equivalent among patients undergoing tips and dsrs ( or = 1.38 , 95% ci : ( 0.662.88 ) , p = 0.39 ) .
significant heterogeneity was found from the trials , and a sub - group analysis was conducted (  = 6.30 , p = 0.10 , i = 52.4% ) [ figure 6 ] .
survival at 5 years was greater for patients undergoing surgical shunting than patients undergoing tips ( or = 0.44 ; 95% ci : ( 0.300.65 ) , p < 0.0001 ) , and survival in sub - group analysis was also higher among patients undergoing pcs than patients undergoing tips ( or = 0.29 ; 95% ci : ( 0.170.47 ) , p < 0.00001 ) .
significant heterogeneity was found from the trials , and a sub - group analysis was conducted (  = 12.32 , p = 0.002 , i = 83.8% ) [ figure 7 ] .
five - year survival comparing transjugular intrahepatic portosystemic shunt with surgical shunting . in the included rcts ,
only 1 paper reported the length of hospital stay in the form of the mean and standard deviation ( sd ) comparing tips with dsrs ( 3.1 [ 4.3 day ] vs. 10.5 [ 11.3 day ] ) , which suggested tips treatment had a shorter hospital stay [ table 2 ] . in this research ,
only 1 trial reported hospitalization charges comparing tips with dsrs ( 21,607 vs. 28,734 ) .
however , cost analysis data of this article showed no overall significant difference in the cost of managing patients with either procedure [ table 2 ] . in our meta - analysis , only 1 paper reported operating time in the form of the mean and the range comparing tips with pcs ( 3 [ 1.2525 ] h vs. 3.8 [ 2.611 ] h ) [ table 2 ] .
searching in medline , embase , pubmed and cochrane data of clinical trials was 376 trials .
after checking for abstracts according to our predefined inclusion and exclusion criterion , 76 references remained for further evaluation .
eventually , four rcts that documented adequate comparisons between tips and surgical shunting for portal hypertension were determined for this meta - analysis .
no additional eligible studies were found after carefully examined the reference lists of all included papers [ figure 1 ] .
the characteristics and risk of bias for included four studies that compared tips and surgical shunting for portal hypertension are performed in table 1 as suggested in the cochrane handbook .
three included papers reported patients from america while the remaining one from india [ table 1 ] . characteristics of included rcts and risk of the bias summary tips : transjugular intrahepatic portosystemic shunting ; dsrs : distal splenorenal shunts ; pcs : portacaval shunts ; hgpcs : h - graft portacaval shunt ; rct : randomized clinical trial . from the four included trials , 493 patients of child - pugh a to c were included in our analysis .
long - term results and postoperative complications mainly including recurrent variceal hemorrhage , shunt stenosis , and encephalopathy are summarized in table 2 .
results and clinical characteristics comparing tips with surgical shunting tips : transjugular intrahepatic portasystemic shunting ; dsrs : distal splenorenal shunts ; pcs : portacaval shunts ; hgpcs : h - graft portacaval shunt ; sd : standard deviation ; na : not applicable .
variceal rebleeding occurred in 27.6% of patients in tips group and in 4.5% of patients in surgical shunting group , shunt stenosis occurred in 66.1% of patients in tips group and in 9.9% of patients in surgical shunting group , hepatic encephalopathy occurred in 53.9% of patients in tips group and in 32.0% of patients in surgical shunting group . from our meta - analysis ,
morbidity in variceal rehemorrhage was significantly higher in tips than in surgical shunts ( or = 7.45 , 95% ci : ( 3.9314.15 ) , p < 0.00001 ) [ figure 2 ] .
patients occurring postoperative shunt stenosis also was significantly higher in tips than in surgical shunts ( or = 20.01 , 95% ci : ( 6.6759.99 ) , p < 0.000001 ) [ figure 3 ] . besides , morbidity in hepatic encephalopathy was also significantly higher in tips than in surgical shunts ( or = 2.50 , 95% ci : ( 1.633.84 ) , p < 0.0001 ) , especially when compared with pcs in sub - group analysis ( or = 6.00 , 95% ci : ( 2.9312.27 ) , p < 0.00001 ) [ figure 4 ] .
a sub - group analysis was conducted in the comparison of variceal rehemorrhage (  = 8.07 , p = 0.04 , i = 62.8% ) and hepatic encephalopathy (  = 12.41 , p = 0.002 , i = 83.9% ) to decrease high heterogeneity .
mortality in this meta - analysis referred to the death rate at 30 days . in our research ,
mortality was equivalent among patients undergoing tips or surgical shunts ( or = 0.76 ; 95% ci : ( 0.451.30 ) , p = 0.32 ) [ figure 5 ] .
no significant heterogeneity was found from the trials (  = 1.80 , p = 0.61 , i = 0% ) .
survival at 2 years in sub - group analysis was also significantly higher among patients undergoing pcs than patients undergoing tips ( or = 0.48 ; 95% ci : ( 0.290.77 ) , p = 0.003 ) , but in sub - group analysis survival at 2 years was equivalent among patients undergoing tips and dsrs ( or = 1.38 , 95% ci : ( 0.662.88 ) , p = 0.39 ) .
significant heterogeneity was found from the trials , and a sub - group analysis was conducted (  = 6.30 , p = 0.10 , i = 52.4% ) [ figure 6 ] .
survival at 5 years was greater for patients undergoing surgical shunting than patients undergoing tips ( or = 0.44 ; 95% ci : ( 0.300.65 ) , p < 0.0001 ) , and survival in sub - group analysis was also higher among patients undergoing pcs than patients undergoing tips ( or = 0.29 ; 95% ci : ( 0.170.47 ) , p < 0.00001 ) .
significant heterogeneity was found from the trials , and a sub - group analysis was conducted (  = 12.32 , p = 0.002 , i = 83.8% ) [ figure 7 ] .
in the included rcts , only 1 paper reported the length of hospital stay in the form of the mean and standard deviation ( sd ) comparing tips with dsrs ( 3.1 [ 4.3 day ] vs. 10.5 [ 11.3 day ] ) , which suggested tips treatment had a shorter hospital stay [ table 2 ] .
in this research , only 1 trial reported hospitalization charges comparing tips with dsrs ( 21,607 vs. 28,734 ) . however , cost analysis data of this article showed no overall significant difference in the cost of managing patients with either procedure [ table 2 ] .
in our meta - analysis , only 1 paper reported operating time in the form of the mean and the range comparing tips with pcs ( 3 [ 1.2525 ] h vs. 3.8 [ 2.611 ] h ) [ table 2 ] .
nowadays , tips placement has become the preferred first - line management for patients with portal hypertension .
the present study is the first meta - analysis of studies comparing tips with surgical shunting in patients with portal hypertension focused on complications and survival . this meta - analysis included
four rcts , the populations in three studies were from america and in the remaining study were from india .
currently , there were few papers concerning tips versus surgical shunting in outcomes and survival rates , so the difference between tips and surgical shunting was unclear . in clinical practice , there was the lack of a definite guidance to determine the optimal treatment for patients with portal hypertension .
this meta - analysis would help make a better decision in clinical work or develop a guideline .
transjugular intrahepatic portosystemic shunt was generally considered as a first - line therapy in the definitive treatment of portal hypertension concomitant with variceal bleeding ; however , trials comparing tips with surgical shunts were few and drew little attention , so some disadvantages of tips were ignored . in this meta - analysis , we conducted a comparison between tips and surgical shunting in patients with cirrhosis , portal hypertension and bleeding varices from four trials , in order to get an all - around evaluation and give more information about how to decide the optimal management for patients with portal hypertension .
as the measurement of patient 's survival and postoperative complications was representative , we could conclude that long - term survival and morbidity after shunting were promoted by surgical shunting relative to tips .
but surgical shunts in this meta - analysis included dsrs and hgpcs , and the relations between the two types of surgeries and tips were unclear .
as a result , the outcomes of this meta - analysis were proved to be helpful in answering questions that arose when comparing tips with surgical shunting . although each included
trial did nt individually reveal the comparison between surgical shunting and tips in all respects , the outcomes of this meta - analysis proved the superiority of surgical shunting over tips . as a matter of fact ,
the outcomes were obvious that the results supported a role for surgical shunts in patients with portal hypertension over tips . in terms of morbidity , mortality , 2- and 5-year survival ,
in the included papers , three of four trials found significantly higher postoperative bleeding , stenosis and encephalopathy rates after tips .
postoperative complications , including recurrent variceal hemorrhage , hepatic encephalopathy , shunt stenosis , severe infection and so on , were all deadly sign for patients after surgery that could lead to a series of disorders in metabolic systems .
complications of tips placement proved to be critical when hepatic encephalopathy occurred , a limited number of procedures should be typically considered for the management .
the postoperative rehemorrhage rate of nearly 11% after tips was the lowest reported in included trials while the rebleeding rate was reaching 5.5% after dsrs in two included papers and 7.5% after hgpcs in included paper . shunt stenosis could also cause recurrent variceal hemorrhage and result in a series of severe syndromes .
the comparison of shunt stenosis between tips and surgical shunting was obvious as the rate was reaching almost 82% after tips and no more than 11% after surgical shunts .
tips could effectively lower portal hypertension due to cirrhosis . according to past experience , it is significantly effective for hemorrhage of the digestive tract due to rupture of esophageal and fundic veins and for ascites and hydrothorax caused by portal hypertension .
although shunt dysfunction has confused surgeons for the incidence of tips stenosis and occlusion , trials of successful treatment with tips of recurrent massive rectal bleeding due to portal hypertension has reinforced the confidence of surgeons in tips .
recent article also reported bleeding from focal varices in the stoma could be treated with tips that spread the use of tips in other situations .
in addition , a 25% incidence of hernia complications following tips creation in patients being treated for refractory ascites was higher than expected
. the most common indications for tips placement were refractory ascites and variceal hemorrhage , also in properly selected candidate , tips placement could serve as a bridge to liver transplantation for tips was initially less expensive and led to an easier transplantation process .
tips also performed as an effective way in preventing variceal rebleeding and may be more cost effective . in other words , it was equal to surgical procedures in preventing variceal rebleeding in patients who are medical failures .
besides , when aimed at treating the budd  chiari syndrome , a therapeutic strategy has been proposed that angioplasty for short length venous stenosis , tips , and ultimately liver transplantation could be done in proper order .
although tips revealed superiority in some parts of treatment in patients with portal hypertension , the results of this meta - analysis performed significant deficiency in morbidity and survival .
to some extent , people preferred shunting subjectively only when nonshunting modalities to control variceal bleeding failed or when these modalities were considered nonapplicable , thus strong points of this method were difficult to appear .
this meta - analysis , which contained a number of patients in these trials , was able to give great credibility to the results and conclusions .
pcs permanently stopped variceal bleeding and gained a longer time survival than tips , but nowadays the widespread practice of using pcs only served as a management for failure of endoscopic therapy or tips in unselected patients with cirrhosis .
however , the 2-year survival was higher in pcs than in tips ( or = 0.48 ; 95% ci : ( 0.290.77 ) , p = 0.003 ) , and 5-year survival after pcs was longer than that after tips ( or = 0.29 ; 95% ci : ( 0.170.47 ) , p < 0.00001 ) . no matter what the surgical shunts include ,
the consecutive experiences of shunt operation are important for the improvement of surgical skills , both of the individual surgeon and the team .
since 1988 , more and more patients have received hgpcs treatment for its effectiveness in reducing portal hypertension , and the outcome was favorable that the actual survival was better than predicted before .
the actual 5- and 10-year survival after hgpcs by child class was : ( a ) 67% and 33% , ( b ) 49% and 16% , ( c ) 29% and 7% .
hgpcs has been identified as an effective procedure for the treatment of variceal bleeding , as well as for the prevention of re - bleeding in patients , with a low rate of complications .
some papers indicated that pcs with a small diameter interposition h - graft was an effective procedure for the treatment of variceal bleeding or as an elective or emergency procedure with a low rate of complications .
papers published recently also indicated that the actual survival after hgpcs was better than other surgical procedures .
central splenorenal shunt showed more negatively effect on hemodynamics of left kidney and symptoms of renal venous hypertension obviously due to shunting the large amounts of blood from a system of high pressure to a low .
in contrast , dsrs or 8 mm h - graft shunt showed similar efficacy to tips , and it also served as the proper choice in preventing recurrent variceal bleeding .
dsrs also revealed an effective and reliable procedure for children with portal hypertension and was still useful for selected pediatric patients .
dsrs was suggested to be useful for the management of esophagogastric varices in patients with idiopathic portal hypertension .
although a number of surgical procedures have been developed to manage esophageal varices , dsrs with splenopancreatic disconnection plus gastric transection was considered as an adequate treatment for patients with esophagogastric varices .
the included studies regarding surgical shunting versus tips were rare , and surgical shunts in these papers included several kinds of operation methods .
this could result in instability of the comparison between tips and surgical shunting as the different surgical types of shunts may lead to a slight bias of outcome .
although sub - group analysis was taken , the bias of the result still existed . the only way to solve
the problem was that more clinical trials comparing surgical shunting with tips should be undertaken .
data such as cost and hospital stay from the included studies were rare , so further evidence concerning hospital charges and hospital stay was needed to fulfill this meta - analysis .
although tips was performed most often with the use of the covered stent currently , there were no studies comparing covered stent with surgical shunting scientifically .
the outcomes and survival rates between covered and uncovered tips varied , clark et al . concluded that there were no differences in rates of encephalopathy or survival between covered and uncovered tips , but bureau et al .
revealed polytetrafluoroethylene - coated stents were superior to uncovered stents in morbidity , so more rcts concerning covered stents versus surgical shunting should be conducted to provide more evidence .
limited rcts concerning covered tips was the restriction in this meta - analysis , so more clinical trials should be undertaken .
finally , the risk of bias and heterogeneity of included rcts were still existed according to the cochrane handbook .
allocation concealment was missed in some included rcts and high risk of bias was existed in some parts of our bias summary , these could lead to the bias of outcomes and influence the validity of result to some extent , so cochrane risk of bias should be examined exactly to reduce bias . in summary ,
surgical shunting would be recommended because of increased survival rate and fewer postoperative complications when compared with tips .
as the patients with portal hypertension concomitant with variceal hemorrhage always remained in a large number and needed necessary treatment , they should be given more surgical advices for the superiority concerning complications and survival .
 background : the purpose of this article was to clarify the optimal management concerning transjugular intrahepatic portosystemic shunts ( tipss ) and surgical shunting in treating portal hypertension.methods:all databases , including cbm , cnki , wfpd , medline , embase , pubmed and cochrane up to february 2014 , were searched for randomized controlled trials ( rcts ) comparing tips with surgical shunting . 
 four rcts , which were extracted by two independent investigators and were evaluated in postoperative complications , mortality , 2- and 5-year survival , hospital stay , operating time and hospitalization charges.results:the morbidity in variceal rehemorrhage was significantly higher in tips than in surgical shunts ( odds ratio [ or ] = 7.45 , 95% confidence interval[ci ] : ( 3.9314.15 ) , p < 0.00001 ) , the same outcomes were seen in shunt stenosis ( or = 20.01 , 95% ci : ( 6.6759.99 ) , p < 0.000001 ) and in hepatic encephalopathy ( or = 2.50 , 95% ci : ( 1.633.84 ) , p < 0.0001 ) . significantly better 2-year survival ( or = 0.66 ; 95% ci : ( 0.440.98 ) , p = 0.04 ) and 5-year survival ( or = 0.44 ; 95% ci : ( 0.300.66 ) , p < 
 0.00001 ) were seen in patients undergoing surgical shunting compared with tips.conclusions:compared with tips , postoperative complications and survival after surgical shunting were superior for patients with portal hypertension . 
 application of surgical shunting was recommended for patients rather than tips . 
I
M
Search strategy and selection of papers
Reviewing and data extraction
Quality of studies
Outcomes and definition
Data analysis
R
Description of studies
Postoperative morbidity
Mortality
Long-term result
Length of hospital stay
Hospitalization charges
Operating time
D