Transjugular intrahepatic portosystemic shunt after adult liver transplantation: experience in eight patients.

BACKGROUND: Transjugular intrahepatic portosystemic shunting (TIPS) has become an effective treatment for the complications of portal hypertension. We assessed the feasibility and outcome of TIPS in liver transplant recipients. METHODS: During the period from December 1992 to January 1998, eight adults presenting recurrent hepatitis C virus (five patients) and hepatitis B virus (one patient) infection, veno-occlusive disease (one patient), and secondary biliary cirrhosis (one patient) had TIPS because of refractory ascites (five patients), bleeding esophageal varices (one patient), refractory hepatic hydrothorax (one patient), retransplantation (two patients), and redo-biliary surgery (one patient). RESULTS: In two patients, the procedure was difficult due to cavo-caval implantation. Ascites, hydrothorax, and variceal bleeding were controlled in all patients. Moderate to severe encephalopathy developed in four patients; two patients had worsening of their existing encephalopathy. Three of five patients treated with cyclosporine needed a drastic dose reduction due to the development of severe side effects. No long-term survivor developed shunt stenosis or occlusion. Two patients did moderately well at 6 and 14 months, respectively; the former died due to chronic rejection while waiting for a retransplantation. Three did well at 14, 36, and 28 months, respectively; the latter patient died of liver failure 32 months after TIPS. One jaundiced patient died after 1.5 months due to necrotic pancreatitis. Two patients died after 4 and 8.5 months, respectively, due to liver failure; the latter was doing well until 7 months after TIPS. CONCLUSIONS: TIPS is feasible in transplant recipients in cases of decompensated allograft cirrhosis, of allograft veno-occlusive disease or when retransplantation or redo-biliary surgery are scheduled in the presence of portal hypertension. At transplantation, the surgeon should keep in mind the eventuality of a later TIPS procedure. Close immunosuppression monitoring is warranted because modified metabolization of cyclosporine (and probably tacrolimus) may cause serious side effects.     

Preoperative transjugular intrahepatic portosystemic shunt (TIPS) for cirrhotic patients undergoing abdominal and pelvic surgeries

Background  Surgery for patients with cirrhosis is associated with increased morbidity and mortality. Perioperative complications including hemorrhage, wound dehiscence, and peritonitis result from underlying portal hypertension. Perioperative control of portal hypertension could decrease the risk of such complications. This study aimed to describe the authors’ experience with the placement of transjugular intrahepatic portosystemic shunts (TIPS) in patients with cirrhosis to improve surgical outcomes. Methods  A retrospective chart review was performed for seven patients who underwent TIPS placement before elective abdominal or pelvic surgery at the University of Colorado Health Sciences Center from 1998 to 2006. The TIPS indication for each patient was to minimize perioperative complications. Results  The seven patients in this study underwent their planned surgical procedure within a mean of 13 days from the time of TIPS placement. Two patients required a blood transfusion of two units or less. Three patients experienced a total of four postoperative complications including wound infection, peritonitis, pneumonia, and new ascites. One patient died of liver failure 14 months after surgery. Conclusions  The preparation of patients with cirrhosis and portal hypertension for elective surgery using preoperative portal decompression may decrease the risk of perioperative morbidity and mortality.     

Laparoscopic Division of a Portosystemic Shunt for Recurrent Life-Threatening Rectal Variceal Bleeding: Report of a Case

In patients with severe portal hypertension related to liver cirrhosis, recanalization of umbilical veins may lead to both development and rupture of massive anorectal varices. In this setting, while transjugular intrahepatic portosystemic shunt (TIPS) is considered as the treatment of choice, the management of these patients remains unclear in case of contraindications to TIPS. Laparoscopic division of massive portosystemic shunts has been reported to yield beneficial effects in patients with isolated hepatic encephalopathy but has never been attempted in a context of life-threatening lower gastrointestinal bleeding. In the present case report, we both describe the operative technique of laparoscopic division of recanalized umbilical veins to treat recurrent massive haemorrhage following rupture of giant rectal varices in a 68-year-old Child C cirrhotic patient contraindicated to TIPS and report the postoperative course of the patient.     

Association of transjugular intrahepatic portosystemic shunt with embolization in the treatment of bleeding duodenal varix refractory to sclerotherapy

BACKGROUND: Bleeding from duodenal varices are often severe (mortality as high as 40%), and more difficult to sclerose than esophageal varices. We report a patient with a bleeding duodenal varix, refractory to sclerotherapy, successfully treated by the association of portosystemic shunt placement and varix embolization, via the same transjugular intrahepatic route. METHODS: A 40-year-old Black male underwent emergency TIPS and duodenal varix embolization after failure of endoscopic sclerotherapy. The portosystemic pressure gradient droped from 16 to 9 mm Hg following TIPS. At 5 months from TIPS, the patient is well, with a patent shunt at Doppler ultrasound. CONCLUSION: The present report of successful control of duodenal varix, actively bleeding and refractory to sclerotherapy, by means of combined TIPS and embolization, supports the role of TIPS and suggests that its association to embolization can be valuably considered in the difficult setting of portal hypertension with bleeding duodenal varices.     

Conversion of failed transjugular intrahepatic portosystemic shunt to distal splenorenal shunt in patients with Child A or B cirrhosis.

OBJECTIVE: The authors demonstrate the feasibility of converting failed transjugular intrahepatic portosystemic shunt (TIPS) to distal splenorenal shunt (DSRS) in patients with good hepatic reserve for long-term control of variceal bleeding. SUMMARY BACKGROUND DATA: TIPS is an effective method for decompressing the portal venous system and controlling bleeding from esophageal and gastric varices. TIPS insufficiency is, however, a common problem, and treatment alternatives in patients with an occluded TIPS are limited because most have already failed endoscopic therapy. METHODS: The records of five patients who underwent conversion from TIPS to DSRS because of TIPS failure or complication in the past 36 months were reviewed. RESULTS: Four patients had ethanol-induced cirrhosis and one patient had hepatitis C virus cirrhosis. Three patients were Child-Pugh class A and two were class B. All patients had excellent liver function, with galactose elimination capacities ranging from 388 to 540 mg/min (normal 500 +/- 100 mg/min). The patients had TIPS placed for acute (2) or sclerotherapy-resistant (3) variceal hemorrhage. All five TIPS stenosed 3 to 23 months after placement, with recurrent variceal hemorrhage and failed TIPS revision. One patient had stent migration to the superior mesenteric vein that was removed at the time of DSRS. All five patients underwent successful DSRS, and none have had recurrent hemorrhage 18 to 36 months after surgery. CONCLUSIONS: TIPS provides inadequate long-term therapy for some Child-Pugh A or B patients with recurrent variceal hemorrhage. TIPS failure in patients with good liver function can be salvaged by DSRS in many cases.     

Transjugular intrahepatic portosystemic shunt (TIPS) versus laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in the treatment of recurrent variceal bleeding

Background

The aim of the present study was to compare elective transjugular intrahepatic portosystemic shunt (TIPS) and laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in their efficacy in preventing recurrent bleeding and improving the long-term liver function in patients with liver cirrhosis and portal hypertension.

Methods

Between January 2009 and March 2012, we enrolled 83 patients (55 with TIPS, defined as the TIPS group, and 28 with LS plus preoperative EVL, defined as the LS group) with portal hypertension and a history of gastroesophageal variceal bleeding resulting from liver cirrhosis. The clinical characteristics, perioperative outcomes, and follow-up were recorded.

Results

No significant differences were observed between the two treatment groups with respect to the patients’ characteristics and preoperative variables. Within 30 days after surgery, one patient in the TIPS group died of multiple organ dysfunction syndrome, whereas no patient in the LS group died. Complications occurred in 14 patients in the TIPS group, which included rebleeding, encephalopathy, ascites, bleeding from a pseudoaneurysm of the thoracoabdominal aorta, and pulmonary infection, compared with 5 patients in the LS group, which included pulmonary effusion, pancreatic leakage, and portal vein thrombosis. During a mean follow-up of 13.6 months in the TIPS group and 12.3 months in the LS group, the actuarial survival was 85.5 % in the TIPS group versus 100 % in the LS group. The long-term complications included rebleeding and encephalopathy in the TIPS group.

Conclusions

LS plus EVL was superior to TIPS in the prevention of gastroesophageal variceal rebleeding in cirrhotic patients. This treatment was associated with a low rate of portosystemic encephalopathy and improvements in the long-term liver function.     

血管离断术联合经颈静脉肝内门体分流术对门静脉血流动力及肝肾功能的影响

目的分析腹腔镜贲门-胃底周围血管离断联合经颈静脉肝内门体分流术（TIPS）对肝硬化门静脉高压症效果的影响。 方法选择2016年2月至2018年2月宜宾市第二人民医院接受治疗的肝硬化门静脉高压症导致胃底食管静脉曲张患者94例,随机数字表法分成两组,各47例,其中对照组行腹腔镜贲门-胃底周围血管离断术,观察组在对照组基础上行TIPS术,观察两组患者临床疗效、实验室指标以及围手术期门静脉血流动力学。 结果（1）观察组患者总有效率为95.74%（45/47）,显著高于对照组的82.98%（39/47）,差异有统计学意义（Z=5.173,P=0.005）。（2）术后6个月时,观察组患者脾静脉血流量（SVF）、门体压力梯度、门静脉直径（PVD）、脾静脉内径（SVD）、门静脉血流量（PVF）较术前下降,且显著低于同期对照组水平,而脾静脉流速（SVV）及门静脉流速（PVV）较术前升高,显著高于同期对照组水平（P<0.05）。（3）术后1、6个月时,观察组患者血清尿素水平较术前下降,并显著低于同期对照组水平,而白蛋白（ALB）水平较术前上升,显著高于同期对照组水平,术后1个月观察组患者血清丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）水平高于术前,但低于对照组,术后6个月观察组ALT及AST水平低于术后1个月和对照组（P<0.05）。（4）术后1、6个月时,观察组患者血清内皮素（ET）、血管紧张素Ⅱ（ATⅡ）及血浆肾素活度（PRA）表达水平较术前下降,且显著低于同期对照组水平,差异有统计学意义（P<0.05）。 结论腹腔镜贲门-胃底周围血管离断联合TIPS治疗肝硬化门静脉高压导致的胃底食管静脉曲张,可显著改善患者的肝、肾功能及门静脉血流动力学。     

TIPS治疗对门静脉高压症患者食管、胃底组织内微血管生成的影响

目的:研究TIPS治疗对门静脉高压症患者食管、胃底组织内微血管生成的影响,探讨血管生成在门静脉高压症食管、胃底静脉曲张形成中的作用。方法:取门静脉高压症Sugiura术患者的食管贲门吻合圈标本78例。(1)PHT组:术前未行TIPS治疗。食管组织118例,胃组织25例;(2)TIPS组:术前曾行TIPS治疗,食管组织5例,胃组织12例。正常食管组织10例、胃组织8例作为对照组。应用免疫组化技术分别检测食管胃底组织内的微血管密度。结果:食管胃底组织微血管高密度区主要位于粘膜固有层,其次为粘膜下层。粘膜固有层微血管密度3组差别无统计学意义(P>0.05);粘膜下层微血管密度PHT组明显高于正常组(P<0．01)和TIPS组(p<0．05),TIPS组和正常组差别无统计学意义(P >0.05)。结论:食管胃底组织内的微血管密度与门静脉压力改变有关。门静脉高压时,食管胃底组织粘膜下层血管生成活跃,可能参与了食管胃底粘膜下静脉曲张的形成;经TIPS治疗后,粘膜下层血管生成减少。     

Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients: a case-control comparison

HYPOTHESIS: In good-risk patients with variceal bleeding undergoing portal decompression, surgical shunt is more effective, more durable, and less costly than angiographic shunt (transjugular intrahepatic portasystemic shunt [TIPS]). DESIGN: Retrospective case-control study. SETTING: Academic referral center for liver disease. PATIENTS: Patients with Child-Pugh class A or B cirrhosis with at least 1 prior episode of bleeding from portal hypertension (gastroesophageal varices, portal hypertensive gastropathy). INTERVENTION: Portal decompression by angiographic (TIPS) or surgical (portacaval, distal splenorenal) shunt. MAIN OUTCOME MEASURES: Thirty-day and long-term mortality, postintervention diagnostic procedures (endoscopic, ultrasonographic, and angiographic studies), hospital readmissions, variceal rebleeding episodes, blood transfusions, shunt revisions, and hospital and professional charges. RESULTS: Patients with Child-Pugh class A or B cirrhosis undergoing TIPS (n = 20) or surgical shunt (n = 20) were followed up for 385 and 456 patient-months, respectively. Thirty-day mortality was greater following TIPS compared with surgical shunt (20% vs 0%; P =.20); long-term mortality did not differ. Significantly more rebleeding episodes (P<.001); rehospitalizations (P<.05); diagnostic studies of all types (P<.001); shunt revisions (P<.001); and hospital (P<.005), professional (P<.05), and total (P<. 005) charges occurred following TIPS compared with surgical shunt. CONCLUSIONS: Operative portal decompression is more effective, more durable, and less costly than TIPS in Child-Pugh class A and B cirrhotic patients with variceal bleeding. Good-risk patients with portal hypertensive bleeding should be referred for surgical shunt.     

Transjugular Intrahepatic Portosystemic Shunt and Laparoscopic Colorectal Resection: the ideal minimally-invasive management for the treatment of colorectal cancer in severe cirrhotic patients. A case report and literature review

Surgical interventions on gastrointestinal tract are often not well tolerated by patients with cirrhosis and severe portal hypertension, impairing their prognosis if suffering from malignant disease. Combining the benefits of two minimally invasive techniques such as Transjugular intrahepatic portosystemic shunt (TIPS) and Laparoscopic Colorectal Resection (LCR), the complications related to surgical intervention might be reduced and thus, it allows patients with liver disease, to undergo a curative intervention. One patient with cirrhosis and portal hypertension diagnosed with a rectal cancer underwent a meticulous preoperative preparation through placement of TIPS before laparoscopic surgery. TIPS placement was performed without intraprocedure complications. The patient was successfully operated by laparoscopic technique 36 days after TIPS placement without intraoperative bleeding or postoperative complications. Our experience, despite being based on one case, allows us to conclude that decompression of portal system by TIPS, already used in open surgery, may be applicable as a preoperative laparoscopic procedure with equally satisfactory results.     

Atracurium et cirrhose : étude clinique de l''action curarisante

Hepatic function influences the action of muscle relaxants. Among these drugs, the elimination of atracurium does not depend on liver function. The clinical effects of atracurium were studied in ten patients with portal hypertension and some degree of liver dysfunction and in ten normal patients. The cirrhotic patients underwent resection of oesophageal varices while control patients underwent abdominal surgery. All patients received 0.6 mg X kg-1 atracurium as a first intravenous bolus injection and 0.2 mg X kg-1 incremental doses. The delay of action, the degree of neuromuscular block and the delay of reversal of the block were compared. No statistically significant differences were observed. It is suggested that non significant differences observed could be attributed to an increased volume of distribution of drugs in the cirrhotic patient. These results would suggest that atracurium may be the best relaxant in patients with severe liver failure.     

Results of Surgical Treatment (Modified Sugiura-Futagawa Operation) of Portal Hypertension Associated to Complete Splenomesoportal Thrombosis and Cirrhosis

Background Hemorrhagic portal hypertension, secondary to both intrahepatic and extrahepatic portal hypertension, is an uncommon entity. In this condition, the extrahepatic and the intrahepatic obstruction of the portal vein, due to chronic liver disease, produce a more severe form of hemorrhagic portal hypertension that is more difficult to control. The results of surgical treatment (modified Sugiura- Futagawa operation) in this subset of patients is analyzed.Methods Among 714 patients with a history of hemorrhagic portal hypertension, 14 cases were found with histologically proven liver cirrhosis and complete splenomesoportal thrombosis demonstrated by means of preoperative angiography. Patients with incomplete (partial) splenomesoportal thrombosis were excluded. There were nine males and 5 females with a mean age of 51 years. Alcoholic cirrhosis was demonstrated in 50% of the cases, post hepatitic cirrhosis in 28%, primary biliary cirrhosis in 7%, and cryptogenic cirrhosis in 14%. There were nine Child-Pugh A and 5 B cases. All cases were treated by means of our modified Sugiura-Futagawa procedure.Results Bleeding recurrence from esophagogastric varices was shown in one case, colonic varices in one case and hypertensive gastropathy in another of the survivors. Post operative encephalopathy was shown in 3 of the cases. The thirty-six month survival rate was 30% (Kaplan-Meier).Conclusions The combination of intrahepatic plus extrahepatic portal hypertension has a worse prognosis. Treatment options are limited (sclerotherapy and/or devascularization), because shunt surgery, TIPS and liver transplantation have a very restricted role and postoperative outcome is poor.     

Endoscope assisted surgery for the treatment of bleeding esophageal varices

In attempts to obtain complete control of bleeding esophageal varices, terminal esophago-proximal gastrectomy (TEPG) and its modification proximal gastric transection (PGT) were performed, under endoscopic assistance, in 42 patients with cirrhotic portal hypertension. Complete disappearance of varices was confirmed in all patients at surgery and 4 weeks after surgery, and this condition was maintained for up to 60 months in 15 patients of TEPG and 16 of PGT. Recurrent varices in 3 (17 per cent) TEPG and 8 (34 per cent) PGT were attributed to the advance in the liver cirrhosis in 7, hepatoma in 3 and portal vein thrombosis in 1. In 8 of 11 recurrences, type C variceal blood circulation drained into the cervical veins. Endoscopic assistance during surgical treatment for bleeding esophageal varices plays a decisive role.     

Transthoracic cardiectomy with infraesophago-supragastric devascularization for bleeding esophageal varices

Based on the thoughts that transthoracic approaches give less load to the liver than transabdominal ones, and that effectiveness for bleeding esophageal varices is secured by cardiectomy with complete devascularization of lower esophagus and upper stomach, a new operative procedure for esophageal varices is described which is more safely applicable to the risky patients. Twenty cases with portal hypertension were operated, including eight cirrhotic patients with severe hepatic dysfunction, six cases of emergency bleeding and six reoperated cases. No operative death was encountered, but three cirrhotic patients died during the late follow up period. The remaining 17 patients had uneventful postoperative courses without recurrence of esophageal bleeding during 20 months follow up period. Thus this operation may eliminate the shortcoming of previous operative methods for portal hypertension.     

Distal pancreatectomy and islet autotransplantation for chronic pancreatitis.

Eight patients with chronic pancreatitis underwent 95% pancreatectomy and islet autotransplantation. The partially purified islet material was transplanted into the liver at the time of surgery via embolization into the portal vein. Hyperglycemia requiring insulin therapy developed in all patients immediately followed surgery. Six patients subsequently became normoglycemic an average of 28 days following the transplant (range: 8-90 days). Three of these patient have remained normoglycemic on a regular diet nine, 18, and 22 months following transplant. The other three redeveloped hyperglycemia and insulin dependency three, six, and eight months after surgery. Indirect measurement of functioning islet cell mass by intravenous glucose tolerance testing preoperatively was predictive of the outcome of the transplant. All patients developed portal hypertension (14-60 cm H2O) during tissue injection into the portal vein. Portal hypertension persisted in one patient and required treatment with a mesocaval shunt. The patient subsequently died of hepatic necrosis. Postoperative catheterization in four patients, three to 12 months posttransplant, revealed that portal pressure had returned to normal. Clinically, all seven surviving patients were improved following surgery.     

Transthoracic cardiectomy with infraesophago-supragastric devascularization for bleeding esophageal varices.

Based on the thoughts that transthoracic approaches give less load to liver than transabdominal ones, and that effectiveness for bleeding esophageal varices is secured by cardiectomy with complete devascularization of lower esophagus and upper stomach, a new operative procedure for esophageal varices is described which is more safely applicable to the risky patients. Twenty cases with portal hypertension were operated, including eight cirrhotic patients with severe hepatic dysfunction, six cases of emergency bleeding and six reoperated cases. No operative death was encountered, but three cirrhotic patients died during the late follow up period. The remaining 17 patients had uneventful postoperative courses without recurrence esophageal bleeding during 20 months follow up period. Thus this operation may eliminate the shortcoming of previous operative methods for portal hypertension.     

Effect of a portal venous stent for gastrointestinal hemorrhage from jejunal varices caused by portal hypertension after pancreatoduodenectomy

We report herein the case of a 64-year-old man successfully treated by portal venous stent placement for repeated gastrointestinal bleeding associated with jejunal varices. He was admitted to our hospital with melena 8 years after having a pancreatoduodenectomy for carcinoma of the papilla of Vater. From portogram findings showing severe portal vein (PV) stenosis and dilated collaterals through the jejunal vein of the Roux-en-Y loop, jejunal varices resulting from PV stenosis were suspected as the cause of the melena. A metallic stent was placed in the PV following percutaneous transhepatic PV angioplasty. Although the cure of hemorrhagic jejunal varices caused by PV stenosis is difficult in patients who have undergone major abdominal surgery, patency of the stent in this patient has been maintained for 32 months without gastrointestinal hemorrhage. Metallic stent placement is recommended as a useful treatment for PV stenosis that is less invasive than open surgery.     

Eradication of oesophageal varices recurring after portal non-decompressive surgery by injection sclerotherapy

The results of injection sclerotherapy for oesophageal varices which recurred after portal non-decompressive surgery were analysed retrospectively to evaluate its efficacy. We treated 60 consecutive patients with portal hypertension; 19 were treated on an emergency basis, seven electively and 34 on a prophylactic basis. All acute bleeding was controlled with one session of sclerotherapy using a transparent overtube. After eradication by sclerotherapy, no bleeding episodes occurred and there was no recurrence of the varices, except in three uncompliant patients, during a mean follow-up period of 33.1 months. Bleeding from a gastric ulcer and gastritis occurred in one patient each. Oesophageal stenosis occurred in nine (15 per cent) patients and gastric varices developed in two (3 per cent) patients. Twelve patients died, five from liver failure and six with hepatoma, but there was no bleeding from the gastrointestinal tract. The overall 4-year survival rate was 80 per cent. We recommend the use of sclerotherapy as the primary treatment for recurrent oesophageal varices.     

Transjugular intrahepatic portosystemic shunt migration in patients undergoing liver transplantation

Transjugular intrahepatic portosystemic shunt (TIPS) is a useful procedure for patients with variceal bleeding and refractory ascites. Migration of TIPS can potentially complicate the subsequent transplant procedure. The aim of this study was to compare survival, operating time, and blood transfusion requirements in patients with migrated and nonmigrated TIPS undergoing liver transplantation. Of 152 patients, 21 received TIPS; stent migration was noted in seven patients-six distally and one proximally. Mean age of the patients was 54 +/- 11 years (range, 27-65 years), and there were 12 men and 9 women. The etiology of liver disease included the following: hepatitis C virus, six patients; cryptogenic cirrhosis, seven patients; alcoholic cirrhosis, four patients; primary biliary cirrhosis, three patients; and autoimmune hepatitis, one patient. The mean Child-Pugh-Turcotte score was 10 +/- 2. Mean length of hospital stay for patients with migrated TIPS was 22.2 days and for nonmigrated TIPS was 23.5 days. Patient and graft survival (actual) was 81% in both groups with a mean follow-up of 27.9 months. Migration of TIPS is not rare, and in our study it did not affect survival, length of surgery, or blood transfusion requirements compared with patients in whom TIPS had not migrated.