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Transjugular intrahepatic portosystemic shunt vs endoscopic therapy in preventing variceal rebleeding  [cached]
Hui Xue,Meng Zhang,Jack XQ Pang,Fei Yan
World Journal of Gastroenterology , 2012, DOI: 10.3748/wjg.v18.i48.7341
Abstract: AIM: To compare early use of transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic treatment (ET) for the prophylaxis of recurrent variceal bleeding. METHODS: In-patient data were collected from 190 patients between January 2007 and June 2010 who suffured from variceal bleeding. Patients who were older than 75 years; previously received surgical treatment or endoscopic therapy for variceal bleeding; and complicated with hepatic encephalopathy or hepatic cancer, were excluded from this research. Thirty-five cases lost to follow-up were also excluded. Retrospective analysis was done in 126 eligible cases. Among them, 64 patients received TIPS (TIPS group) while 62 patients received endoscopic therapy (ET group). The relevant data were collected by patient review or telephone calls. The occurrence of rebleeding, hepatic encephalopathy or other complications, survival rate and cost of treatment were compared between the two groups. RESULTS: During the follow-up period (median, 20.7 and 18.7 mo in TIPS and ET groups, respectively), rebleeding from any source occurred in 11 patients in the TIPS group as compared with 31 patients in the ET group (Kaplan-Meier analysis and log-rank test, P = 0.000). Rebleeding rates at any time point (6 wk, 1 year and 2 year) in the TIPS group were lower than in the ET group (Bonferroni correction α’ = α/3). Eight patients in the TIPS group and 16 in the ET group died with the cumulative survival rates of 80.6% and 64.9% (Kaplan-Meier analysis and log-rank test χ2 = 4.864, P = 0.02), respectively. There was no significant difference between the two groups with respect to 6-wk survival rates (Bonferroni correction α’ = α/3). However, significant differences were observed between the two groups in the 1-year survival rates (92% and 79%) and the 2-year survival rates (89% and 64.9%) (Bonferroni correction α’ = α/3). No significant differences were observed between the two treatment groups in the occurrence of hepatic encephalopathy (12 patients in TIPS group and 5 in ET group, Kaplan-Meier analysis and log-rank test, χ2 = 3.103, P = 0.08). The average total cost for the TIPS group was higher than for ET group (Wilcxon-Mann Whitney test, 52 678 RMB vs 38 844 RMB, P < 0.05), but hospitalization frequency and hospital stay during follow-up period were lower (Wilcxon-Mann Whitney test, 0.4 d vs 1.3 d, P = 0.01; 5 d vs 19 d, P < 0.05). CONCLUSION: Early use of TIPS is more effective than endoscopic treatment in preventing variceal rebleeding and improving survival rate, and does not increase occurrence of hepatic encepha
Application of Endoscopy in Improving Survival of Cirrhotic Patients with Acute Variceal Hemorrhage  [PDF]
Yao-Chun Hsu,Chen-Shuan Chung,Hsiu-Po Wang
International Journal of Hepatology , 2011, DOI: 10.4061/2011/893973
Abstract: Playing a central role in the modern multidisciplinary management of acute gastroesophageal variceal hemorrhage, endoscopy is essential to stratify patient at risk, control active hemorrhage, and prevent first as well as recurrent bleeding. Before endoscopic procedure, antibiotic prophylaxis along with vasoactive medication is now routine practice. Intravenous erythromycin effectively cleanses stomach and may improve the quality of endoscopy. The timing of endoscopy should be on an urgent basis as delay for more than 15 hours after presentation is associated with mortality. Active variceal bleeding on endoscopy in a patient with hepatic decompensation heralds poor prognosis and mandates consideration of aggressive strategy with early portosystemic shunting. Band ligation has become the preferred modality to control and prevent bleeding from esophageal varices, although occasionally sclerotherapy may still be used to achieve hemostasis. Addition of pharmacotherapy with nonselective beta blockade to endoscopic ligation has become the current standard of care in the setting of secondary prophylaxis but remains controversial with inconsistent data for the purpose of primary prophylaxis. Gastric varices extending from esophagus may be treated like esophageal varices, whereas variceal obliteration by tissue glue is the endoscopic therapy of choice to control and prevent bleeding from fundic and isolated gastric varices. 1. Introduction Acute variceal hemorrhage (AVH) from esophageal varices (EV) or gastric varices (GV) is a devastating complication of portal hypertension. It is a leading cause of death in cirrhotic patients, particularly in those with hepatic decompensation. Early cohort studies observing the natural course of patients with AVH revealed that the short-term mortality rate was as high as 50%, with uncontrolled active hemorrhage and recurrent bleeding as the major causes of death [1–3]. As a witness of progress in modern medicine, the prognosis of AVH has remarkably improved for the last 3 decades, although the short-term mortality (conventionally defined as within 6 weeks of each episode) in recent series remained approximately 15–20% [4]. The improved outcome of cirrhotic patients with AVH probably results from advancement in the multidisciplinary approaches that include pharmacological therapy (vasoactive agents, antibiotic prophylaxis), endoscopic intervention (band ligation for EV, variceal obliteration for GV), transjugular intrahepatic portosystemic shunt (TIPS), and surgery. Being an essential part in the management of acute upper
Transjugular Retrograde Obliteration prior to Liver Resection for Hepatocellular Carcinoma Associated with Hyperammonemia due to Spontaneous Portosystemic Shunt  [PDF]
Fumio Chikamori,Nobutoshi Kuniyoshi
Case Reports in Hepatology , 2013, DOI: 10.1155/2013/809543
Abstract: A 67-year-old woman had hepatocellular carcinoma (HCC) measuring 3.7?cm at S8 of the liver with hyperammonemia due to a spontaneous giant mesocaval shunt. Admission laboratory data revealed albumin, 2.9?g/dL; total bilirubin, 1.3?mg/dL; plasma ammonia level (NH3), 152?g/dL; total bile acid (TBA) 108.5?μmoL/L; indocyanine green retention rate at 15?min (ICG15), 63%. Superior mesenteric arterial portography revealed a hepatofugal giant mesocaval shunt, and the portal vein was not visualized. Before surgery, transjugular retrograde obliteration (TJO) for the mesocaval shunt was attempted to normalize the portal blood flow. Via the right internal jugular vein, a 6 F occlusive balloon catheter was inserted superselectively into the mesocaval shunt. The mesocaval shunt was successfully embolized using absolute ethanol and a 50% glucose solution. Eleven days after TJO, NH3, TBA, and ICG15 decreased to 56, 44, and 33, respectively. Superior mesenteric arterial portography after TJO revealed a hepatopetal portal flow. Partial hepatectomy of S8 was performed 25 days after TJO. The subsequent clinical course showed no complications, and the woman was discharged on postoperative day 14. We conclude that the combined therapy of surgery and TJO is an effective means of treating HCC with hyperammonemia due to a spontaneous portosystemic shunt. 1. Introduction Hepatocellular carcinoma (HCC) with hyperammonemia due to a spontaneous portosystemic shunt (PSS) is not common, and the guidelines for such a condition have not been established yet [1]. Liver function is an important factor to determine the treatment strategy for HCC. To lower morbidity after hepatic resection, the Makuuchi criteria, including the presence or absence of ascites, serum total bilirubin level, and the plasma indocyanine green retention rate at 15?min (ICG15), are widely used [2, 3]. However, the existence of PSS often increases the level of ICG15 and the plasma ammonia level (NH3) and reduces the hepatopetal portal blood flow. We previously reported that transjugular retrograde obliteration (TJO) for PSS reduced ICG15 and NH3 [4]. A mesocaval shunt is one of the PSSs. Here, we describe a case of HCC associated with hyperammonemia due to a spontaneous mesocaval shunt treated by the combined therapy of surgery and TJO. 2. Case Report A 67-year-old woman suffered from HCC with hyperammonemia due to a spontaneous giant mesocaval shunt. Six months before that, she had undergone interferon therapy for hepatitis C. However, follow-up CT examination revealed HCC, so she was referred to our department for
Variceal bleeding: Management options  [cached]
Al Mofleh Ibrahim,Al Rashed Rashed,Al Amri Saleh
Saudi Journal of Gastroenterology , 1995,
Abstract: Portal hypertension with esophageal varices represents an important source of upper gastrointestinal bleeding. Variceal bleeding is associated with high rebleeding and mortality rates. Various treatment modalities are effective in control of bleeding. Endoscopic Sclerotherapy (ES) is the standard method for management of acute variceal bleeding alone or in combination with vasoactive drugs. Alternative methods are considered in case of sclerotherapy failure. Portosystemic shunt operation is complicated by systemic encephalopathy. Therefore, it is replaced by other surgical procedures. These include esophageal stapled transection, splenectomy with devascularization, distal splenorenal shunt (DSRS), DSRS combined with pancreatic disconnection, narrow diameter mesocaval (NDMC) or portocaval (NDPC) shunts and liver transplantation . Recently. transjugular intrahepatic portosystemic stent-shunting (TIPSS) has been introduced in the management of patients with refractory variceal bleeding waiting for liver transplanation.
The Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Portal Hypertension: Current Status  [PDF]
Gilles Pomier-Layrargues,Louis Bouchard,Michel Lafortune,Julien Bissonnette,Dave Guérette,Pierre Perreault
International Journal of Hepatology , 2012, DOI: 10.1155/2012/167868
Abstract: The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.
The Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Portal Hypertension: Current Status  [PDF]
Gilles Pomier-Layrargues,Louis Bouchard,Michel Lafortune,Julien Bissonnette,Dave Guérette,Pierre Perreault
International Journal of Hepatology , 2012, DOI: 10.1155/2012/167868
Abstract: The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients. 1. Introduction Portal hypertension is associated with severe and often life-threatening complications. Increased intrahepatic resistance results in increasing splanchnic blood flow and development of venous collaterals, which may bleed, and also causes splenomegaly. A hyperdynamic circulation develops with an increased cardiac output and a decrease in systemic vascular resistance. Pooling of splanchnic blood may result in a systemic hypovolemia, which can trigger activation of vasoactive systems, mainly vasoconstrictors. This in turn may lead to sodium retention, ascites, and ultimately hepatorenal syndrome [1]. The correction of severe portal hypertension by portacaval shunt surgery has been used for many years, but the morbidity and mortality were high. Moreover, this technique was contraindicated in the presence of liver failure. The transjugular intrahepatic portosystemic shunt (TIPS) was used for the first time by R?sch et al. in 1969 [2] in dogs and in a cirrhotic patient by Colapinto in 1982 [3]. This treatment was aimed at nonsurgically decreasing portal hypertension. Originally, a tract was created by balloon dilatation of the parenchyma between the hepatic vein and the portal vein after transjugular portal vein catheterization. Unfortunately,
Transjugular intrahepatic portosystemic shunt in liver transplant recipients  [cached]
Armin Finkenstedt, Ivo W Graziadei, Karin Nachbaur, Werner Jaschke, Walter Mark, Raimund Margreiter, Wolfgang Vogel
World Journal of Gastroenterology , 2009,
Abstract: AIM: To evaluate the efficacy of transjugular intrahepatic portosystemic shunts (TIPSs) after liver transplantation (LT).METHODS: Between November 1996 and December 2005, 10 patients with severe recurrent hepatitis C virus infection (n = 4), ductopenic rejection (n = 5) or portal vein thrombosis (n = 1) were included in this analysis. Eleven TIPSs (one patient underwent two TIPS procedures) were placed for management of therapy-refractory ascites (n = 7), hydrothorax (n = 2) or bleeding from colonic varices (n = 1). The median time interval between LT and TIPS placement was 15 (4-158) mo.RESULTS: TIPS placement was successful in all patients. The mean portosystemic pressure gradient was reduced from 12.5 to 8.7 mmHg. Complete and partial remission could be achieved in 43% and 29% of patients with ascites. Both patients with hydrothorax did not respond to TIPS. No recurrent bleeding was seen in the patient with colonic varices. Nine of 10 patients died during the study period. Only one of two patients, who underwent retransplantation after the TIPS procedure, survived. The median survival period after TIPS placement was 3.3 (range 0.4-20) mo. The majority of patients died from sepsis with multiorgan failure.CONCLUSION: Indications for TIPS and technical performance in LT patients correspond to those in non-transplanted patients. At least partial control of therapy-refractory ascites and variceal bleeding could be achieved in most patients. Nevertheless, survival rates were disappointing, most probably because of the advanced stages of liver disease at the time of TIPS placement and the high risk of sepsis as a consequence of immunosuppression.
Bacteremia and "Endotipsitis" following transjugular intrahepatic portosystemic shunting  [cached]
Mizrahi Meir,Roemi Lilach,Shouval Daniel,Adar Tomer
World Journal of Hepatology , 2011, DOI: 10.4254/wjh.v3.i5.130
Abstract: AIM: To identify all cases of bacteremia and suspected endotipsitis after Transjugular intrahepatic portosystemic shunting (TIPS) at our institution and to determine risk factors for their occurrence. METHODS: We retrospectively reviewed records of all patients who underwent TIPS in our institution between 1996 and 2009. Data included: indications for TIPS, underlying liver disease, demographics, positive blood cultures after TIPS, microbiological characteristics, treatment and outcome. RESULTS: 49 men and 47 women were included with a mean age of 55.8 years (range 15-84). Indications for TIPS included variceal bleeding, refractory ascites, hydrothorax and hepatorenal syndrome. Positive blood cultures after TIPS were found in 39/96 (40%) patients at various time intervals following the procedure. Seven patients had persistent bacteremia fitting the definition of endotipsitis. Staphylococcus species grew in 66% of the positive cultures, Candida and enterococci species in 15% each of the isolates, and 3% cultures grew other species. Multi-variate regression analysis identified 4 variables: hypothyroidism, HCV, prophylactic use of antibiotics and the procedure duration as independent risk factors for positive blood cultures following TIPS (P < 0.0006, 0.005, 0.001, 0.0003, respectively). Prophylactic use of antibiotics before the procedure was associated with a decreased risk for bacteremia, preventing mainly early infections, occurring within 120 d of the procedure. CONCLUSION: Bacteremia is common following TIPS. Risk factors associated with bacteremia include failure to use prophylactic antibiotics, hypothyroidism, HCV and a long procedure. Our results strongly support the use of prophylaxis as a means to decrease early post TIPS infections.
Role of Self-Expandable Metal Stents in Acute Variceal Bleeding  [PDF]
Fuad Maufa,Firas H. Al-Kawas
International Journal of Hepatology , 2012, DOI: 10.1155/2012/418369
Abstract: Acute variceal bleeding continues to be associated with significant mortality. Current standard of care combines hemodynamic stabilization, antibiotic prophylaxis, pharmacological agents, and endoscopic treatment. Rescue therapies using balloon tamponade or transjugular intrahepatic portosystemic shunt are implemented when first-line therapy fails. Rescue therapies have many limitations and are contraindicated in some cases. Placement of fully covered self-expandable metallic stent is a promising therapeutic technique that can be used to control bleeding in cases of refractory esophageal bleeding as an alternative to balloon tamponade. These stents can be left in place for as long as two weeks, allowing for improvement in liver function and institution of a more definitive treatment.
The Evolution of Transjugular Intrahepatic Portosystemic Shunt: Tips  [PDF]
Fabrizio Fanelli
ISRN Hepatology , 2014, DOI: 10.1155/2014/762096
Abstract: Since Richter’s description in the literature in 1989 of the first procedure on human patients, transjugular intrahepatic portosystemic shunt (TIPS) has been worldwide considered as a noninvasive technique to manage portal hypertension complications. TIPS succeeds in lowering the hepatic sinusoidal pressure and in increasing the circulatory flow, thus reducing sodium retention, ascites recurrence, and variceal bleeding. Required several revisions of the shunt TIPS can be performed in case of different conditions such as hepatorenal syndrome, hepatichydrothorax, portal vein thrombosis, and Budd-Chiari syndrome. Most of the previous studies on TIPS procedure were based on the use of bare stents and most patients chose TIPS 2-3 years after traditional treatment, thus making TIPS appear to be not superior to endoscopy in survival rates. Bare stents were associated with higher incidence of shunt failure and consequently patients required several revisions during the follow-up. With the introduction of a dedicated e-PTFE covered stent-graft, these problems were completely solved, No more reinterventions are required with a tremendous improvement of patient’s quality of life. One of the main drawbacks of the use of e-PTFE covered stent-graft is higher incidence of hepatic encephalopathy. In those cases refractory to the conventional medical therapy, a shunt reduction must be performed. 1. Introduction Portal hypertension is the result of pressure increase within the portal vein when the blood flowing through the liver is blocked. Increase of pressure usually leads to the development not only of varices in the esophagus and stomach but also of ascites [1]. The most common cause of portal hypertension is cirrhosis or liver scarring [2]. Cirrhosis results from the healing of a liver injury provoked by hepatitis, by alcohol abuse, or by any serious liver damage. In cirrhosis, blood flowing through the liver is obstructed by the scarred tissue that slows down its forward movement [3, 4]. Thrombosis and clotting in the portal vein are equally responsible for portal hypertension. Portal hypertension can also be related to a prehepatic disease, such as inflammation of the umbilical vein in early infancy, resulting in portal vein thrombosis and cavernomatous transformation. A block in the portal flow located before the sinusoids of the liver does not create an increased portal hypertension and usually causes neither a disturbance in the function of hepatocytes nor ascites [2, 3]. There also exists a form of portal hypertension caused by blockage of effluent blood from
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