Transjugular intrahepatic portosystemic stent shunt for medically refractory hepatic hydrothorax: A systematic review and cumulative meta-analysis

Table 1 Checklist summarizing compliance with meta-analysis of observational studies in Epidemiology Guidelines

MOOSE criteriaa	Met (yes/no)
Reporting background should include
Problem definition	Yes
Hypothesis statement	No
Description of study outcome(s)	Yes
Type of exposure or intervention used	Yes
Type of study designs used	Yes
Study population	Yes
Reporting of search strategy should include
Qualifications of searchers (e.g., librarians and investigators)	Yes
Search strategy, including time period included in the synthesis and keywords	Yes
Effort to include all available studies, including contact with authors	Yes
Databases and registries searched	Yes
Search software used, name and version, including special features used (e.g., explosion)	Yes
Use of hand searching (e.g., reference lists of obtained articles)	Yes
List of citations located and those excluded, including justification	Yes
Method of addressing articles published in languages other than English	Yes
Method of handling abstracts and unpublished studies	No
Description of any contact with authors	No
Reporting methods should include
Description of relevance or appropriateness of studies assembled for assessing the hypothesis to be tested	Yes
Rationale for the selection and coding of data (e.g., sound clinical principles or convenience)	Yes
Documentation of how data were classified and coded (e.g., multiple raters, blinding, and interrater reliability)	Yes
Assessment of confounding (e.g., comparability of cases and controls in studies where appropriate)	No
Assessment of study quality, including blinding of quality assessors; stratification or regression on possible predictors of study results	Yes
Assessment of heterogeneity	Yes
Description of statistical methods (e.g., complete description of fixed or random effects models, justification of whether the chosen models account for predictors of study results, dose-response models, or cumulative meta-analysis) in sufficient detail to be replicated	Yes
Provision of appropriate tables and graphics	Yes
Reporting of results should include
Graphic summarizing individual study estimates and overall estimate	Yes
Table giving descriptive information for each study included	Yes
Results of sensitivity testing (e.g., subgroup analysis)	No
Indication of statistical uncertainty of findings	Yes
Reporting of discussion should include
Quantitative assessment of bias (e.g., publication bias)	NA
Justification for exclusion (e.g., exclusion of non-English-language citations)	Yes
Assessment of quality of included studies	Yes
Reporting of conclusions should include
Consideration of alternative explanations for observed results	Yes
Generalization of the conclusions (e.g., appropriate for the data presented and within the domain of the literature review)	Yes
Guidelines for future research	Yes
Disclosure of funding source	Yes

^aAdapted from Stroup et al[29]. Used with permission. MOOSE: Meta-analysis of Observational Studies in Epidemiolgy; NA: Not applicable.

Table 2 Characteristics of 6 studies evaluating the effectiveness of transjugular intrahepatic portosystemic stent shunt in patients with refractory hepatic hydrothorax

Ref.	Methods and patients	Outcomes/complications	Remarks
Gordon et al[14]	Retrospective chart review of 24 consecutive patients with medically RHH	Post-TIPSS response was categorized as complete, partial, or absent	11 patients had variceal bleeding > 4 wk before TIPSS
	Post-TIPSS patients underwent Doppler US studies every 3 to 6 mo	Mean change in HVPG	Stent revision if decreased flow noted
	Mean follow-up was 7.2 mo (range, 0.25-49.0 mo)	TIPSS patency was assessed by change in CTP score, survival, and new or worsened HE	5 failures were CTP C
	Patients with infection were excluded		12 patients had medically RHH; the rest of the 9 patients had TIPSS and RHH as a secondary indication with the primary indication being intractable ascites (n = 7) and gastric varices (n = 2)
Jeffries et al[24]	Retrospective chart review of 12 consecutive patients with medically RHH	Post-TIPSS response at ≤ 1 or > 1 mowas categorized as complete, partial, or absent	Immediate pre- and post-TIPSS prophylactic antibiotics given
	Post-TIPSS, patients had Doppler US studies every 3 mo	TIPSS-related complications: ≤ 30 and > 30 d	Shunt thrombosis or decreased velocities requiredangioplastic revision
	Mean follow-up was 173 d (range, 7-926 d)	New-onset or worsened HE survival	4 patients had shunt revisions
	Patients with heart failure, HCC, alcoholic hepatitis, or intrinsic renal disease were excluded	Mean change in HVPG	Patients who died or underwent transplant ≤ 30 d after TIPSS were classified as nonresponders to TIPSS
Siegerstetter et al[26]	Retrospective chart review of 40 consecutive patients with medically RHH	Post-TIPSS response was categorized as complete, partial, or absent	8 patients had no ascites; RHH was diagnosed by intraperitoneal methylene blue injection or technetium-Tc-99
	Post-TIPSS, patients had Doppler US studies at 4 wk, then every 3 mo	Predictors of survival:	2 stent size reductions due to chronic HE
	Mean (SD) follow-up was 14 mo	Mean change in HVPG
	[14 (range, 1-54 mo)]	New-onset or worsened HE
	Patients with infection were excluded	CTP score improvement
		Survival at 1 yr
Spencer et al[27]	Retrospective chart review of 21 consecutive patients with medically RHH	30-d mortality	Prophylactic antibiotics administered
	Post-TIPSS, patients had Doppler US studies at 1, 3, and 6 mo, then every 6 mo	Post-TIPSS complications: Early ( ≤ 30 d) or late(> 30 d)	Radiographic and clinical response
	Mean follow-up was 223 d	New-onset or worsened HE	TIPSS placement 100% successful
	Patients with severe right-sided heart failure and patients with PVT with cavernous transformation were excluded	Post-TIPSS response was categorized as complete, partial, or absent	1 patient with a partial response was weaned off oxygen due to decreased pleural fluid
		Mean change in HVPG
		Cumulative survival
Wilputte et al[28]	Retrospective chart review of 28 consecutive patients with medically RHH	Mean change in HVPG	Stent revised for stenosis, obstruction, or relapsing RHH
	Post-TIPSS, patients had Doppler US at 24 h and at 1, 2, 3, 6, 9, and 12 mo, then every 6 mo	30-d mortality post-TIPSS	Patients who underwent transplant were censored at surgery date
	Mean (SD) follow-up was 358 d (121 d); 3 patients were excluded due to grade 3 HE, HCC, cardiopulmonary disease, and infection	Response to TIPSS was categorized as complete, partial, and absent	6 patients required TIPSS revision
			2 patients had TIPSS reduction due to intractable HE
			Both covered and uncovered stents were used
Dhanasekaran et al[23]	Retrospective chart review of 73 consecutive patients with medically RHH	Post-TIPSS response at 1 mo and 6 mo was categorized as complete, partial, or absent	TIPSS catheterization used if stenosis suspected or RHH reaccumulated
	Patients had Doppler US every 3 mo for 12 mo, then annually	Evaluated predictors of response to TIPSS	Angioplasty performed, if needed
	Patients with heart failure, pulmonary disease, infection, severe HE, portal vein thrombosis, and multiple hepatic cysts were excluded	Assessed for new or worsening HE	Uncovered and covered stents used
		Mean change in HVPG
		Overall and 30-d mortality

CTP: Child-Turcotte-Pugh; HE: Hepatic encephalopathy; HCC: Hepatocellular carcinoma; HVPG: Hepatic venous pressure gradient; PVT: Portal vein thrombosis; RHH: Refractory hepatic hydrothorax; TIPSS: Transjugular intrahepatic portosystemic shunt; US: Ultrasound.

Table 3 Summary of studies included in the pooled analyses of transjugular intrahepatic portosystemic shunt in patients with refractory hepatic hydrothorax

Ref.	No. of patients	Complete response (%)	Partial response (%)	45-d mortality (%)	1-yr survival (%)	Predictors of mortality
Gordon et al[14]	24	58	21	21	NA	TIPSS nonresponse
						CTP class C
Jeffries et al[24]	12	42	17	25	NA	Age > 65 yr
Siegerstetter et al[26]	40	53	28	13	64	Age > 60 yr
Spencer et al[27]	21	57	10	29	NA	Medical comorbidities
Wilputte et al[28]	28	57	11	14	41	CTP score > 10
						Mayo score > 1.5
Dhanasekaran	73	59	21	19	48	MELD > 15
et al[23]						Nonresponse
						Elevated creatinine

CTP: Child-Turcotte-Pugh; MELD: Model for end-stage liver disease; NA: Not applicable; TIPSS: Transjugular intrahepatic portosystemic stent shunt.