Portal venous decompression with H-type mesocaval shunt using autologous vein graft: A North American experience (original) (raw)

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

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

Current use of transjugular intrahepatic portosystemic shunts

Current Gastroenterology Reports, 2003

The principal indication for transjugular intrahepatic portosystemic shunts (TIPS) continues to be rescue therapy for variceal hemorrhage that cannot be controlled by endoscopic or medical therapy. TIPS provide no survival advantage in prevention of rebleeding or refractory ascites. The indications for TIPS continue to expand, however, especially for Budd-Chiari syndrome and hydrothorax. Other more novel indications include bleeding portal hypertensive gastropathy or ectopic varices, Budd-Chiari syndrome, veno-occlusive disease, hepatorenal syndrome, hepatopulmonary syndrome, hepatocellular carcinoma, and polycystic liver disease. Great strides have been made recently in models to predict mortality and complications following TIPS placement. Graft stents hold promise based on early studies. Finally, complications are common and may be life threatening.

Transjugular intrahepatic portosystemic shunt: Where are we?

The Turkish journal of gastroenterology, 2014

Background/Aims: The purpose of this study was to evaluate the technical/hemodynamic success, complications, and biochemical/ hematologic consequences of transjugular intrahepatic portosystemic shunt (TIPS) created with 10-mm bare stents in our patients. Materials and Methods: Data of 27 cirrhotic patients (18 men and 9 women; mean age, 39.7±18.7 years) with a median MELD score 14 (range 7-31) treated with TIPS between January 2000 and August 2010 were evaluated retrospectively. Results: The indications were refractory bleeding varices in 48.2%, refractory ascites in 22.2%, and Budd-Chiari syndrome in 29.6% of the patients. Technical and hemodynamic success rates were 96.3% and 92.3%, respectively. Mean portosystemic pressure gradient decreased from 21.5±5.3 mm Hg to 9±2.7 mm Hg (p<0.05). The rate of primary stent patency was 76.9% 1 year after the procedure. No statistically significant difference in shunt dysfunction was found between the groups of patients treated for Budd-Chiari syndrome and other indications (p>0.05). One patient (3.7%) had shunt dysfunction due to thrombosis within 24 hours. New and/or worsening hepatic encephalopathy occurred in 34.6% of patients. Increased age (≥40 years) was significantly related to hepatic encephalopathy in both univariate and multivariate analyses (p<0.05). Thirty-day mortality rate and 1-year transplant-free survival rate were 0% and 80.7%, respectively. Conclusion: Transjugular intrahepatic portosystemic shunt procedure is a safe treatment for many patients with cirrhosis, but post-procedure hepatic encephalopathy and shunt dysfunction are still problems. Especially, patient age should be taken into consideration in predicting hepatic encephalopathy risk.

Selective shunts for portal hypertension: Current role of a 21-year experience

Liver Transplantation, 1997

The results of treatment of hemorrhagic portal hypertension with selective shunts over a 21-year period in a selected patient population are reported. Patients selected for surgical treatment had good cardiopulmonary and renal function, and most also had adequate liver function (141 Child-Pugh class A, 59 class B). Among 734 patients treated surgically for bleeding portal hypertension, 221 had selective shunts (168 distal splenorenal and 53 splenocaval shunts). Global operative mortality (in the 21-year period) was 14% and 12% for Child- Pugh A patients. Operative mortality in Child-Pugh A patients in the last 5 years was only 5%. The rate of rebleeding was 6%, rate of incapacitating encephalopathy was 5%, and rate of survival was 65% at 15 years (last 5 years: 88% at 1 year and 85% at 5 years). Good quality of life was demonstrated in 80% of surviving patients. Shunt patency was 94%. Postoperative portal blood flow changes occurred in 23% of cases (8% diameter reduction, 14% thrombosis). Compared with other forms of therapy (pharmacotherapy, sclerotherapy, and transjugular intrahepatic shunting), only liver transplantation offers similar results for these patients. In countries in which liver transplantation is not routinely performed, shunting with selective shunts is the treatment of choice for patients with good liver function.

Surgical portosystemic shunts in the era of TIPS and liver transplantation are still relevant

HPB, 2014

Background: The surgical portosystemic shunts (PSS) are a time-proven modality for treating portal hypertension. Recently, in the era of liver transplantation and the transjugular intrahepatic portosystemic shunts (TIPS), use of the PSS has declined. Objectives: This study was conducted to evaluate changes in practice, referral patterns, and short-and longterm outcomes of the use of the surgical PSS before and after the introduction of the Model for End-stage Liver Disease (MELD). Methods: A retrospective analysis of 47 patients undergoing PSS between 1996 and 2011 in a single university hospital was conducted. Results: Subgroups of patients with cirrhosis (53%), Budd-Chiari syndrome (13%), portal vein thrombosis (PVT) (26%), and other pathologies (9%) differed significantly with respect to shunt type, Child-Pugh class, MELD score and perioperative mortality. Perioperative mortality at 60 days was 15%. Five-year survival was 68% (median: 70 months); 5-year shunt patency was 97%. Survival was best in patients with PVT and worst in those with Budd-Chiari syndrome compared to other subgroups. Patency was better in the subgroups of patients with cirrhosis and other pathologies compared with the PVT subgroup. Substantial changes in referral patterns coincided with the adoption of the MELD in 2002, with decreases in the incidence of cirrhosis and variceal bleeding, and increases in non-cirrhotics and hypercoagulopathy. Conclusions: Although the spectrum of diseases benefiting from surgical PSS has changed, surgical shunts continue to constitute an important addition to the surgical armamentarium. Selected subgroups with variceal bleeding in well-compensated cirrhosis and PVT benefit from the excellent longterm patency offered by the surgical PSS.