TACE联合TIPS治疗肝癌合并门脉高压有效性和安全性的META分析

Efficacy and Safety of TACE Combined with TIPS in the Treatment of Hepatocellular Carcinoma Complicated with Portal Hypertension: A Meta-Analysis

摘要: 目的：肝细胞癌(HCC)多伴有肝硬化合并门脉高压，经颈静脉肝内门静脉系统分流术(TIPS)可用于缓解门静脉高压和临床症状。经肝动脉化疗栓塞(TACE)已被推荐为中晚期HCC的标准治疗策略。以往的研究已经探讨了经颈静脉肝内门体分流术(TIPS)对肝细胞癌经动脉化疗栓塞(TACE)治疗的影响，但有关文献较少，需要更新。因此，本研究的目的是系统的评价TACE联合TIPS治疗肝癌合并肝硬化门脉高压的有效性及安全性。方法：对PubMed、Cochrane Library、Embase、中国知网、万方医学网、维普等中英文数据库从建库至2023-4-17的研究进行了全面的检索，为了估计客观缓解率(ORR)的合并率及95%置信区间(CI)我们采用了随机效应模型，这篇文章的分析结果均采用Stata 16.0软件进行统计学分析。采用I2指数统计量来评估异质性。结果：经过筛选，我们共纳入了9项符合条件的研究，共包括646名患者。META分析提示客观缓解率为54.9% (95%CI: 35.1%~74.7%)，具有显著异质性(I² = 92.02%, P < 0.001)。TACE + TIPS组的客观缓解率(ORR)低于非TIPS组，合并RR值为0.98 (95%CI: 0.73~1.31)，差异具有统计学意义(P = 0.041)。最常见的并发症为肝性脑病，发生率为16.8% (95%CI: 6.3%~27.3%),异质性较高(I² = 71.03%, P = 0.016)，严重不良事件发生率(SAEs)为14.6% (95%CI: 2.5%~26.7%)，异质性较高(I2 = 63.89%, P = 0.04)。结论：TIPS可能影响TACE治疗效果，同时需注意肝性脑病的风险，受纳入研究的数量和质量的限制，上述结论尚需更多高质量、大样本研究予以验证。

Abstract: Purpose: Hepatocellular carcinoma (HCC) typically manifests in conjunction with cirrhosis and portal hypertension. In such cases, the implementation of a transjugular intrahepatic portal vein shunt (TIPS) can effectively alleviate portal hypertension and associated clinical symptoms. Transcatheter arterial chemoembolization (TACE) has been advocated as a therapeutic approach for advanced HCC. However, the existing body of literature examining the impact of TIPS in con-junction with TACE for HCC is scarce and necessitates further expansion and revision. The objective of this study is to conduct a systematic review on the effectiveness and safety of TACE in com-bination with TIPS for the management of patients diagnosed with HCC. Method: We conducted a comprehensive search for relevant studies published from inception to 17 April 2023, using the PubMed, Cochrane Library, Embase, CNKI, Wangfang and CQVIP databases. In order to estimate the combination rate of Objective response rate (ORR) and 95% confidence interval (CI), we employed a random effects model. Statistical analyses were all performed using the Stata 16.0 software. I2 index statistic was used to assess heterogeneity. Result: Our analysis included nine eligible studies, comprising a total of 646 patients. The results of meta-analysis suggested the pooled objective response rate was 54.9% (95%CI: 35.1%~74.7%) with a significant heterogeneity (I² = 92.02%, P < 0.001). The TACE + TIPS group had an inferior response rate than the non-TIPS group, the pooled RR values was 0.98 (95%CI: 0.73~1.31), and the difference had a statistical significance (P = 0.041). The most common complication was hepatic encephalopathy, the pooled rate was 16.8% (95%CI: 6.3%~27.3%) with high heterogeneity (I² = 71.03% P = 0.016) and the rate of serious adverse events (SAEs) was 14.6% (95%CI: 2.5%~26.7%) with medium heterogeneity (I2 = 63.89% P = 0.04). Conclusion: TIPS may influence the therapeutic effect of TACE while we should pay attention to the risk of hepatic encephalopathy. Limited by the number and quality of included studies, more high-quality and large sample studies are needed to verify the above conclusions.