Effectiveness of Transjugular Intrahepatic Portosystemic Shunt in Variceal Bleeding: An Audit from a Tertiary Care Center in North India (original) (raw)
Related papers
World journal of gastroenterology : WJG, 2012
To compare early use of transjugular intrahepatic portosystemic shunt (TIPS) with endoscopic treatment (ET) for the prophylaxis of recurrent variceal bleeding. 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. During the follow-up period (median, 20.7 and 18.7 mo ...
The Portosystemic Shunt for the Control of Variceal Bleeding in Cirrhotic Patients: Past and Present
Canadian Journal of Gastroenterology and Hepatology
Based on an experience of more than 50 years in the treatment of portal hypertension (PHT), the authors review and analyze the evolution of the surgical portocaval shunt (PCS). We would like to provide an insight into the past of PCS, in order to compare it with the current state of the treatment of PHT complications. As a landmark of the past, we shall present statistics of more than 500 cases of PHT operated between 1968 and 1983. From this group, 238 patients underwent surgical portocaval shunting during a fifteen-year period. The behavior of the portal hemodynamics following PCS was studied and the postoperative decrease in portal pressure (PP), as well as the residual PP, were recorded. The portal manometric determinations were made by electronic recordings using the Hellige device and direct intraoperative recordings through the catheterization of a ramus in the portal area. The results of PCS are superposable, in terms of hemodynamic efficiency, with those of the intrahepatic...
CardioVascular and Interventional Radiology, 2006
Purpose: To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the control of bleeding from ectopic varices. Methods: From 1995 to 2004, 24 cirrhotic patients, bleeding from ectopic varices, mean age 54.5 years (range 15-76 years), were treated by TIPS. The etiology of cirrhosis was alcoholic in 13 patients and nonalcoholic in 11 patients. The location of the varices was duodenal (n = 5), stomal (n = 8), ileocolic (n = 6), anorectal (n = 3), umbilical (n = 1), and peritoneal (n = 1). Results: TIPS controlled the bleeding in all patients and induced a decrease in the portacaval gradient from 19.7 € 5.4 to 6.4 € 3.1 mmHg. Postoperative complications included self-limited intra-abdominal bleeding (n = 2), selflimited hemobilia (n = 1), acute thrombosis of the shunt (n = 1), and bile leak treated by a covered stent (n = 1). Median follow-up was 592 days (range 28-2482 days). Rebleeding occurred in 6 patients. In 2 cases rebleeding was observed despite a post-TIPS portacaval gradient lower than 12 mmHg and was controlled by variceal embolization; 1 patient underwent surgical portacaval shunt and never rebled; in 3 patients rebleeding was related to TIPS stenosis and treated with shunt dilatation with addition of a new stent. The cumulative rate of rebleeding was 23% and 31% at 1 and 2 years, respectively. One-and 2-year survival rates were 80% and 76%, respectively. Conclusion: The present series demonstrates that bleeding from ectopic varices, a challenging clinical problem, can be managed safely by TIPS placement with low rebleeding and good survival rates.
Journal of Clinical Gastroenterology, 2004
Background: Pleural effusions(PE) complicate cirrhosis in ~5% of patients. Identification of cause and related complications is imperative. Unlike refractory ascites, large-scale studies on interventions for refractory PE are limited. Methods: Consecutive hospitalized cirrhotics having PE were retrospectively analyzed. None had liver transplantation (LT) within 6-month follow-up. We determined safety, efficacy and mortality predictors for PE managed with standard medical treatment(SMT), thoracentesis, catheter drainage and TIPS. Results: Of 1149 cirrhotics with PE(mean Child-Pugh 10.6 ±1.8 and MELD 21.2 ±7.4), 82.6% had hepatic hydrothorax(HH) and 12.3% were suspected tubercular PE(TBPE). Despite comparable HVPG and MELD scores, patients with HH developed more AKI, encephalopathy and septic shock (all P<0.01) on follow up. Among HH, 73.5% were symptomatic, 53.2% isolated right-sided PE and 21.3% had SBE. Presence of SBP[Odd's ratio,OR:4.5] and catheter drainage[OR:2.1] were independent predictors for SBE. In 70.3% of admissions, HH responded to SMT alone, 12.9% required thoracentesis and 11.5% underwent catheter drainage. 51 patients were selected for TIPS [lower mean CTP 9.9±1.6 and MELD score 18.7±5.4]. Despite reduction in pressure gradient from 23.1±3.8 mm Hg to 7.2±2.5 mm Hg, 25 patients had partial response, 10 had complete HH resolution. Major post-TIPS complications were portosystemic encephalopathy(8 patients, 6 resolved) and ischemic hepatitis(4 patients, 2 resolved). Overall, 35.9% patients with HH had 6-month mortality and independent predictors were MELD >25, SBP and septic shock. Conclusion: Refractory PE in cirrhosis requiring interventions including TIPS has poor outcome. Role of hemodynamics in predicting post-TIPS response and complications is limited. Early referral for LT is imperative.
The transjugular intrahepatic portosystemic shunt [Review]
Journal of Hepatology
URMG TEE last 20 years improvement in endoscopic techniques have resulted in more than 90% success in the management of acute variceal bleeding. However, in the prevention of recurrence of variceal bleeding endoscopic treatment is of limited efficacy, with a l-year rebleeding rate' of more than 40% (1). In patients with insufficient response to endoscopic therapy, surgical shunts and devascularization operations have for many years been used as salvage treatments, but they have become less acceptable in recent years because of their high operative mortality and postoperative morbidity, especially in the many Child-class B and C patients. In 1988, the transjugular intrahepatic portosystemic stent-assisted shunt (TIPS) was introduced into clinical practice (2) and has since then enjoyed rapid acceptance around the world. This may in part be due to the fascinating technique of this novel intervention, but it may also be a consequence of the unfavorable results of the pre-existing therapies. The results presently available suggest that TIPS has a higher efficacy and a lower morbidity and mortality than endoscopic and surgical treatments, respectively. Its major limitations, namely shunt failure and hepatic encephalopathy, must be overcome by specific medication, improved stents and better selection of patients. This review concentrates on the two major indications, variceal bleeding and refractory ascites, and summarizes the results of major studies. TIPS for variceal rebleeding Uncontrolled studies Since its first description in 1988 (2) numerous papers have been published on TIPS for variceal
The transjugular intrahepatic portosystemic shunt
Journal of Hepatology - J HEPATOL, 1996
URMG TEE last 20 years improvement in endoscopic techniques have resulted in more than 90% success in the management of acute variceal bleeding. However, in the prevention of recurrence of variceal bleeding endoscopic treatment is of limited efficacy, with a l-year rebleeding rate' of more than 40% (1). In patients with insufficient response to endoscopic therapy, surgical shunts and devascularization operations have for many years been used as salvage treatments, but they have become less acceptable in recent years because of their high operative mortality and postoperative morbidity, especially in the many Child-class B and C patients. In 1988, the transjugular intrahepatic portosystemic stent-assisted shunt (TIPS) was introduced into clinical practice (2) and has since then enjoyed rapid acceptance around the world. This may in part be due to the fascinating technique of this novel intervention, but it may also be a consequence of the unfavorable results of the pre-existing therapies. The results presently available suggest that TIPS has a higher efficacy and a lower morbidity and mortality than endoscopic and surgical treatments, respectively. Its major limitations, namely shunt failure and hepatic encephalopathy, must be overcome by specific medication, improved stents and better selection of patients. This review concentrates on the two major indications, variceal bleeding and refractory ascites, and summarizes the results of major studies. TIPS for variceal rebleeding Uncontrolled studies Since its first description in 1988 (2) numerous papers have been published on TIPS for variceal
Gastroenterology, 2006
Variceal bleeding refractory to medical treatment with -blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts (TIPS). This prospective randomized trial tested the hypothesis that patients receiving distal splenorenal shunts (DSRS) would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding. Methods: A prospective randomized controlled clinical trial at 5 centers was conducted. One hundred forty patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding were randomized to DSRS or TIPS. Protocol and event follow-up for 2-8 years (mean, 46 ؎ 26 months) for primary end points of variceal bleeding and encephalopathy and secondary end points of death, ascites, thrombosis and stenosis, liver function, need for transplant, quality of life, and cost were evaluated. Results: There was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P ؍ .29) or first encephalopathy event (DSRS, 50%; TIPS, 50%). Survival at 2 and 5 years (DSRS, 81% and 62%; TIPS, 88% and 61%, respectively) were not significantly different (P ؍ .87). Thrombosis, stenosis, and reintervention rates (DSRS, 11%; TIPS, 82%) were significantly (P < .001) higher in the TIPS group. Ascites, need for transplant, quality of life, and costs were not significantly different. Conclusions: DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child-Pugh class A and B patients. Reintervention is significantly greater for TIPS compared with DSRS. Because both procedures have equivalent outcomes, the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed.
European Journal of Gastroenterology & Hepatology, 2002
• Cirrhotic patients who survive an episode of acute variceal haemorrhage are at high risk of recurrent bleeding. • Transjugular intrahepatic portosystemic shunt (TIPS) is more effective than medical (drug and endoscopic) therapies in preventing rebleeding in patients with cirrhosis. • Randomized studies comparing TIPS to medical therapies have shown that TIPS has no effect on survival when used as secondary prophylaxis in patients with cirrhosis following index variceal haemorrhage. • Medical therapies cause less encephalopathy and more frequent improvement in Child-Pugh class at a lower cost than TIPS. • Transjugular intrahepatic portosystemic shunt should not be used as first-line therapy to prevent variceal rebleeding in patients with cirrhosis, but should be limited to rescue patients with uncontrolled or recurrent variceal bleeding after failed medical therapy. Cirrhotic patients who survive an episode of acute variceal haemorrhage are at high risk of recurrent bleeding. Many treatments have been found to be effective at preventing rebleeding, including drug therapy, endoscopic treatments and transjugular intrahepatic portosystemic stunt (TIPS). In this issue of European Journal of Gastroenterology & Hepatology, Jalan et al. compared three historical cohorts of patients with cirrhosis after index variceal bleed and found a lower rebleeding rate in patients receiving TIPS (16.2%) compared to either band ligation (39.3%) or endoscopic variceal sclerotherapy (74.6%). Despite the efficacy of TIPS in preventing variceal rebleeding, there was no significant difference in survival between the three cohorts. However, subgroup analysis found a lower mortality in patients with Child-Pugh class C cirrhosis receiving TIPS. Unfortunately, this promising observation in patients with advanced cirrhosis is not supported by the results of meta-analysis of randomized studies. Therefore, we do not recommend TIPS as first-line therapy to prevent variceal rebleeding in patients with cirrhosis.
Hepatology, 1999
The optimal management of ruptured gastric varices in patients with cirrhosis has not been codified yet. The present study reports the use of transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory gastric variceal bleeding. Thirty-two consecutive patients were included. All had been unresponsive to vasoactive agents infusion, sclerotherapy, and/or tamponade and were considered poor surgical candidates. They were followed-up until death, transplantation, or at least 1 year (median: 509 days; range 4 to 2,230). Hemostasis was achieved in 18 out of 20 patients actively bleeding at the time of the procedure. In the whole sample of 32 patients, rebleeding rates were 14%, 26%, and 31%, respectively at 1 month, 6 months, and 1 year. De novo encephalopathy was observed in 5 (16%) patients. Seven patients experienced complications and consequently 4 of these patients died. TIPS primary patency rates were 84%, 74%, and 51%, respectively, at 1 month, 6 months, and 1 year. For the same periods of time, survival rates were 75%, 62%, and 59%. These results suggest that TIPS can be used in cirrhotic patients with refractory gastric variceal bleeding and are effective in achieving hemostasis as well as in preventing rebleeding.
Hepatology Research, 1999
With the development of sclerotherapy, transjugular intrahepatic portasystemic shunting and liver transplantation, the role of surgically-constructed portacaval shunts in the treatment of variceal hemorrhage is in evolution. Further, when these shunts are indicated, there is controversy as to the appropriate shunt type that should be created. A selective portosystemic shunt (distal splenorenal shunt) has an advantage of having a decreased encephalopathy rate without an increase in shunt thrombosis and rebleeding compared to total portosystemic shunts. There are currently no reports comparing the partially selective H-graft shunt with the distal splenorenal shunt.