Long-term survival after emergency portacaval shunting for bleeding varices in patients with alcoholic cirrhosis

Liver transplantation due to iatrogenic injuries: two case reports

The transjugular intrahepatic portosystemic shunt (TIPS) is an acceptable procedure that has proven benefits in the treatment of patients who have complications from portal hypertension due to liver cirrhosis. In the literature few reports have described complications after TIPS placement. Initial surgery and local hemostasis have been needed to manage abdominal bleeding: if this treatment is insufficient, it may be necessary to perform a liver transplantation. This report describes the role of liver transplantation to manage dangerous complications in 2 patients after TIPS placement, when surgical procedures and hemostasis were unable to stop the bleeding.

Role of emergency transjugular intrahepatic portosystemic shunts

Transjugular intrahepatic portosystemic shunts (TIPS) is a highly effective treatment for bleeding esophageal varices, with control of the bleeding in over 90% of the patients. TIPS is recommended as "rescue" treatment if primary hemostasis cannot be obtained with endoscopic and pharmacological therapy, or if uncontrollable early rebleeding occurs within 48 hours. TIPS is also a very effective technique for patients presenting with severe refractory bleeding gastric and ectopic varices, cases where endoscopic techniques are less effective. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and sclerotherapy fail, before the clinical condition worsens. Every effort should be made to stabilize the patient before TIPS, including the use of tamponade tubes and aggressive correction of coagulopathy. Patients with acute variceal bleeding with a Child-Pugh score > 12, Apache score II > 18 points, hemodynamically unstable, receiving vasopressors and coagulopathy, and/or bilirrubin > 6 mg/dL have a high risk of early death after TIPS. Expedite liver transplantation after emergency TIPS should be considered for high-risk patients.

Transjugular intra-hepatic portosystemic shunt for refractory variceal bleeding

BACKGROUND

The most dramatic complication of portal hypertension in cirrhotic patients is oesophageal variceal bleeding. Moreover, patients with bleeding unresponsive to medical and endoscopic treatment have a poor prognosis.

OBJECTIVE

The aim of this study was to evaluate the efficacy of early transjugular intra-hepatic portosystemic shunt (TIPS) in patients with refractory variceal bleeding.

PATIENTS AND METHODS

TIPS was performed for 28 patients (17 were stage Child C), successfully in 26. Variceal bleeding was controlled in all but one successfully stented patient.

RESULTS

There was no mortality associated with the procedure. The two patients with a failure of TIPS insertion died of persistent bleeding in the first 48 h after failed TIPS. The 40-day mortality rate was 25%. Five patients died (one from persistent bleeding from gastric varices and four from multi-organ failure). Using multivariate analysis, the only independent factor associated with early mortality was the total bilirubin value. Fifteen surviving patients were listed for liver transplantation: four deaths occurred, eight patients were transplanted in the 6 months after TIPS and three are still waiting. Among the six patients who survived but were ineligible for transplantation, two died and four are still alive. Two episodes of early rebleeding and eight of late rebleeding occurred. Actuarial survival was 75% at one year and 52% at two years.

CONCLUSIONS

Early TIPS is an effective rescue therapy for controlling refractory variceal bleeding.

Current status of transjugular intrahepatic portosystemic shunts

The use of the transjugular intrahepatic portosystemic shunt (TIPS) has emerged as an important nonoperative modality for variceal bleeding, intractable ascites, and for selected cases of hepatic venous obstruction. We believe that TIPS should be viewed as a 'bridge' to liver transplantation and should be carried out only in experienced centres. The adverse haemodynamic changes on the cardiopulmonary system after TIPS should be borne in mind. Prospective trials to evaluate the role of TIPS versus sclerotherapy in variceal bleeding will be watched with interest. There is, however, an urgent need to improve long-term results of TIPS as stent thrombosis and stenosis occur frequently. We advocate routine surveillance to detect these problems at an early stage.

Effects of transjugular intrahepatic portosystemic shunts on hepatic metabolic function determined with serial monitoring of arterial ketone bodies

PURPOSE

To investigate the effects of transjugular intrahepatic portosystemic shunt (TIPS) on hepatic metabolic function by measuring serial arterial ketone body ratio (acetoacetate/-hydroxybutyrate; AKBR).

MATERIAL AND METHODS

The arterial blood of 30 TIPS patients was assayed before TIPS, 30 minutes after TIPS, and 24 hours after TIPS for acetoacetate, beta-hydroxybutyrate, and glucose. The authors compared the AKBR values to clinical outcome stratified by Child class, emergent versus elective TIPS, and before-TIPS AKBR value < or = 0.5 versus before-TIPS AKBR value > 0.5.

RESULTS

A significant change was noted between the AKBR values obtained before TIPS and values 30 minutes after TIPS (0.76 +/- 0.09 vs 0.61 +/- 0.05, P < .05) and between 30 minutes and 24 hours after TIPS (0.81 +/- 0.10, P < .001), but not between the value obtained before TIPS and that obtained 24 hours after TIPS. The 30-day mortality rate in emergency TIPS patients was 50% compared to 7% in the elective TIPS patients (P < .01). The pre-TIPS AKBR values were significantly suppressed in the emergency TIPS patients compared to the elective TIPS patients (0.56 +/- 0.04 vs 0.99 +/- 0.17, P < .005). The 30-day mortality rate in patients with a pre-TIPS AKBR value < or = 0.5 was 75%, which was significantly higher than the 14% rate in patients with a pre-TIPS AKBR value > 0.5 (P < .01).

CONCLUSION

A low pre-TIPS AKBR may be predictive of poor outcome after TIPS. Furthermore, AKBR may be of value in determining the timing for performing an elective TIPS.

Bleeding oesophageal varices

BACKGROUND

The Danish contribution to evaluation and treatment of bleeding oesophageal varices.

METHODS

Danish papers dealing with portal hypertension and oesophageal varices have been reviewed and set in relation to international publications.

RESULTS

The Danish papers have mainly contributed with controlled clinical trials concerning both primary and secondary prophylaxis. Furthermore, they have dealt with pathophysiologic, clinical and experimental studies concerning portal haemodynamics and the evolution and treatment of variceal bleeding.

CONCLUSION

The Danish studies have been well designed and are frequently cited. Further prospective randomized studies in the new treatment modalities are encouraged.

Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts

PURPOSE

To establish a safe and effective method for occluding a transjugular intrahepatic portosystemic shunt (TIPS) in patients who develop uncontrollable, disabling encephalopathy.

PATIENTS AND METHODS

The study population consisted of five patients who developed refractory encephalopathy following TIPS. The indication for TIPS was bleeding in four patients and ascites in one. Wallstents that were 10 mm in diameter and 68 mm long were used to bridge the hepatic parenchyma in all patients. The onset of encephalopathy from the time of the TIPS procedure ranged from 24 hours to 210 days. Because encephalopathy was not responsive to conventional medical management, shunt thrombosis was induced by means of temporary inflation of an 11.5-mm-diameter latex occlusion balloon within the midportion of the stent.

RESULTS

All shunts were successfully thrombosed when the balloon was inflated for 12 hours or more. Encephalopathy resolved in four patients and improved in the remaining patient. One patient experienced recurrent bleeding within 24 hours of the TIPS occlusion that was controlled medically.

CONCLUSION

Temporary occlusion of a TIPS with latex balloons successfully induces shunt thrombosis and improves encephalopathy. However, the patient is again exposed to risks related to complications of portal hypertension.

Prospective randomized trial of emergency portacaval shunt and emergency medical therapy in unselected cirrhotic patients with bleeding varices

A prospective randomized trial was conducted in unselected, consecutive patients with bleeding esophageal varices resulting from cirrhosis comparing (1) emergency portacaval shunt performed within 8 hr of initial contact (21 patients) with (2) emergency medical therapy (intravenous vasopressin and esophageal balloon tamponade) followed in 9 to 30 days by elective portacaval shunt in survivors (22 patients). All patients underwent the same diagnostic workup within 3 to 6 hr of initial contact, and received identical supportive therapy initially. All patients were followed up for at least 10 yr. The protocol contained no escape or cross-over provisions. There were no statistically significant differences between the two treatment groups in the incidence of any of the clinical variables, results of laboratory tests or degree of portal hypertension. Child's risk classes in the shunt group were A-2 patients, B-8 patients and C-11 patients, whereas in the medical group they were A-10 patients, B-5 patients, and C-7 patients, a significant difference (p < 0.01) that might have favored emergency medical treatment. Bleeding was controlled initially and permanently by emergency shunt in every patient, but by medical therapy in only 45% (p < 0.001). Mean requirement for blood transfusion was 7.1 +/- 2.6 units in the shunt group and 21.4 +/- 2.6 units in the medical group (p < 0.001). Eighty-one percent of the patients in the shunt group were discharged alive compared with 45% in the medical group (p = 0.027). Five- and 10-yr observed survival rates were 67% and 57%, respectively, after emergency shunt compared with 18% and 18%, respectively, after the combination of emergency medical therapy and elective shunt (p < 0.01). These survival rates produced by emergency shunt performed within 8 hr of initial contact confirm the effectiveness of this procedure observed in our previous unrandomized studies.

Emergency oesophageal transection for uncontrolled variceal haemorrhage

Continued haemorrhage from oesophageal varices despite adequate injection sclerotherapy and tamponade has a high mortality rate. Such patients are usually referred for surgery. Over a 10-year period, 30 patients (21 men and nine women of median age 52 (range 21-70) years) with acute variceal haemorrhage uncontrolled by initial treatment underwent early emergency oesophageal transection. Portal hypertension was caused by alcoholic cirrhosis in 22 patients; other forms of cirrhosis were present in seven and portal vein thrombosis in one. Hepatic function immediately before operation was Pugh grade A in two patients, B in six and C in 22. Deterioration between admission and transection from grade A to B occurred in one patient and from B to C in five. Oesophageal transection stopped variceal haemorrhage in 29 of the 30 patients. Rebleeding from gastric varices within 35 days of surgery occurred in five patients. Postoperative haemorrhage also occurred from perioesophageal vessels (two patients), a gastrotomy (one) and oesophageal ulceration (two). Hepatic failure developed in seven patients, renal failure in five and both hepatic and renal failure in four. Mortality at 30 days occurred in neither of the two patients with liver function of grade A, in one of six of grade B and in 18 of 22 of grade C. The overall 30-day mortality rate was thus 63 per cent. Mortality was related to the preoperative Pugh grade (hazard ratio 3.95 per grade; P = 0.013) and preoperative blood transfusion (hazard ratio 1.37 per unit; P = 0.035). Four of six patients with grade B liver function died within 3 months and 21 of 22 with grade C disease within 1 year. Oesophageal transection is effective at stopping variceal bleeding but does not modify the underlying disease. Caution is urged for patients with grade C hepatocellular impairment proceeding to acute oesophageal transection after initial sclerotherapy. Such patients may benefit more from treatment with somatostatin or an intrahepatic porta-systemic stent shunt while awaiting definitive therapy.

Portal decompression after transjugular intrahepatic portosystemic shunt creation with use of a spiral Z stent

PURPOSE

An experimental swine model of acute presinusoidal portal hypertension was used to investigate the feasibility of a spiral Z stent for transjugular intrahepatic portosystemic shunt (TIPS) placement and the correlation between the shunt (stent) size and degree of portal pressure decrease.

MATERIALS AND METHODS

Twelve young swine were used. Acute portal hypertension was induced by means of selective injections of absolute alcohol, ethiodized oil, and polyvinyl alcohol sponge particles into intrahepatic portal branches.

RESULTS

TIPS was successfully created in all swine by using spiral Z stents that were 6, 8, and 10 mm in diameter; each size stent was deployed in four animals. Being sufficiently flexible, spiral Z stents accommodated for curved shunt tracts. An average of 48% portal pressure decrease was achieved with 6-mm-diameter stents, 61% with 8-mm-diameter stents, and 87% with 10-mm-diameter stents.

CONCLUSION

These results are in agreement with our clinical experience with use of Gianturco-Rösch Z stents for TIPS formation.

Is portal-systemic shunt worthwhile in Child's class C cirrhosis? Long-term results of emergency shunt in 94 patients with bleeding varices

A prospective evaluation was conducted of 94 unselected patients ("all comers") with biopsy-proven Child's class C cirrhosis (93% alcoholic) and endoscopically proven acutely bleeding esophageal varices who underwent emergency portacaval shunt (EPCS) (85% side-to-side, 15% end-to-side) within 8 hours of initial contact (mean, 6.1 hours) during the past 12 years. Follow-up has been 100% and includes all patients for at least 1 year, and 61 patients (65%) for 5 to 12 years. Incidence of serious risk factors on initial contact was: ascites, 97%; jaundice, 86%; portal-systemic encephalopathy including past history, 71%; severe muscle wasting, 96%; alcohol ingestion within 7 days, 66%; delirium tremens, 16%; serum albumin, less than or equal to 2.5 g/dL 76%; indocyanine green dye retention greater than or equal to 50% in 45 minutes, 66%; serum glutamic-oxaloacetic transaminase greater than or equal to 100 units/L, 60%; hyperdynamic cardiac output greater than or equal to 6 L/minute, 98%. Mean Child's point score was 13.7 out of a maximum of 15. EPCS reduced mean corrected free portal pressure from 286 to 23 mm saline, and permanently controlled variceal bleeding in every patient. Of the 94 patients, 74 (80%) left the hospital alive and 68 (72%) survived 1 year. Five-year actuarial survival rate is 64%. Hepatic failure was the main cause of death during initial hospitalization as well as during follow-up, when it was related to continued alcoholism. Portal-systemic encephalopathy, which was present on initial contact in 55% of patients, occurred at some time during follow-up in 18.7%, but was recurrent and required dietary protein restriction in only 9%, all of whom had resumed alcoholism. The low incidence of portal-systemic encephalopathy was attributable to the lifelong program of follow-up with regular dietary counseling and continued emphasis on both protein restriction to 60 g/day and abstinence from alcohol. Abstinence was sustained in 69%, liver function improved in 82%, general health was judged excellent or good in 73%, and Child's risk class converted to class B in 73% and class A in 21%. Excluding retirees because of age, 42% were gainfully employed or engaged in full-time housekeeping. Long-term shunt patency was documented in 100% of survivors by yearly angiography or Doppler ultrasonography. It is concluded that EPCS within 8 hours of initial contact permanently controls variceal hemorrhage and results in prolonged survival and a life of acceptable quality in many alcoholic cirrhotic patients in Child's class C.(ABSTRACT TRUNCATED AT 400 WORDS)

The role of portosystemic shunting in the management of portal hypertension

In this chapter, we have tried to indicate the role of the portosystemic shunt in the treatment of portal hypertension. The conclusions are evident: in the last 10 years it has lost its role as leader in the treatment of portal hypertension. However, some firm statements can be made. The selective shunt is an operation that provides both good variceal decompression and satisfactory maintenance of liver function. Its results in great part depend on the skill of the surgeon. Only a patient with good liver function (Child's classes A and B) is a candidate for shunt surgery, with, very occasionally, a patient with severe disease (class C). In an emergency, the operation is used only after failure of sclerotherapy, but it must be used at the right time before the patient's condition has deteriorated. In the prevention of variceal rebleeding, the selective shunt or sclerotherapy can be routine measures. The choice between the two treatments depends on the patient's willingness and the ability of the institution to perform both procedures successfully. If sclerotherapy is chosen, the institution must be able to rapidly rescue a sclerotherapy failure by shunt surgery. Liver transplantation is probably the treatment of the future, but it is at present impossible to suggest that the procedure is feasible for all patients with variceal bleeding and severe liver disease.

Percutaneous control of a portacaval H-graft: description of a new device and its initial clinical application

A percutaneously-controlled inflatable cuff which can change the diameter of a portacaval H-graft has been developed and used in 10 patients. When inflated, the cuff narrows the H-graft to increase portal pressure and reduce shunting. Use of the cuff has been of clinical significance in 3 of 7 long-term surviving patients. Narrowing the shunt improved the clinical state in 2 patients with encephalopathy, and reopening a closed shunt improved ascites in the third patient. Duplex ultrasound and deep Doppler have demonstrated an alteration of hepatic portal blood flow following inflation of the cuff after 6 months. It is concluded that further development of this controlled portacaval H-graft is warranted.

Variceal haemorrhage after failed injection sclerotherapy: the role of emergency oesophageal transection

In a planned sequential policy for the emergency control of continued bleeding from oesophageal varices, oesophageal transection was performed after failure of conservative treatment, including injection sclerotherapy. In 15 patients who underwent emergency oesophageal transection, bleeding was controlled by operation in the majority (87 per cent), but 11 of the 15 patients died in hospital. Mortality in patients with poor liver function (Child's C) was 100 per cent, the majority of deaths resulting from hepatic and renal failure. The results of this study suggest that emergency oesophageal transection to control acute variceal haemorrhage is associated with a poor prognosis in patients with poor liver function and questions its role in a sequential emergency treatment policy.

The use of crystalloidal and colloidal solutions for volume replacement in hypovolemic shock

A wide variety of colloidal and crystalloidal fluids, as well as blood and blood products, are available to the clinician for treatment of the hypovolemic patient. These fluids vary with respect to the size, shape, and concentrations of electrolytes, colloidal molecules, and/or cellular components, duration of volume-expanding effects, incidence of allergic reactions, and effect on the coagulation system. When these fluids are administered intravenously, their distribution in the vascular, interstitial, and cellular compartments can be predicted from fundamental physiological principles as well as from the results of laboratory and clinical research. It is thus recognized that colloidal fluids and blood provide more rapid expansion of the intravascular space when compared with crystalloidal fluids. Similar volumes of crystalloidal fluids more rapidly expand the interstitial and intracellular spaces. These principles guide therapy in hypovolemic shock. A logical decision regarding intravenous fluid therapy may be based on the nature of the volume deficit (blood, plasma, or selective protein loss, loss of free water and/or electrolytes) and the predicted changes in cellular and extracellular compartments.

Effect of delayed operation for bleeding esophageal varices on Child's class and indices of liver function

The charts of 38 patients managed with a period of intensive medical treatment (mean 7 days) prior to portosystemic shunting were examined. We found that the operative delay did not improve the Child's class or the indices of liver function. The operative mortality rates in these patients were 0 in Child's A patients, 13 percent in Child's B patients, and 50 percent in Child's C patients. Based on these findings, we began to operate on patients with bleeding esophageal varices as soon as they stabilized. The charts of 10 consecutive Child's C patients operated on without a period of intensive medical management (mean 3 days) were reviewed and compared with the charts of 8 Child's C patients with delayed operation. The two groups of patients were similar. We recommend that patients who need a shunt should be operated on as soon as possible after bleeding has ceased.

Hyperparathyroidism, cirrhosis, and portacaval shunt. A new clinical syndrome

This is a report of six patients with cirrhosis of the liver in whom primary hyperparathyroidism occurred due to a solitary parathyroid adenoma 3 months to 9 years after undergoing emergency portacaval shunt for hemorrhage from esophageal varices. The presenting symptoms in all six patients were weakness and bone pain. Three patients had a bone fracture after insignificant trauma, one and probably two passed kidney stones, and a duodenal ulcer developed in two. Bone x-ray films showed generalized osteoporosis in all patients. Renal function and arterial blood pH were within normal limits in every patient. The diagnosis of primary hyperparathyroidism in each patient was based on repeated demonstrations of hypercalcemia, hypophosphatemia, and markedly elevated serum immunoreactive parathyroid hormone concentrations. In all six patients, removal of the parathyroid adenoma resulted in disappearance of symptoms; normalization of serum calcium, phosphorus, and immunoreactive parathyroid hormone levels; and in four of the six, improvement in radiographic evidence of osteoporosis during follow-up of from 1 to 6 years. The association of cirrhosis, portacaval shunt, and primary hyperparathyroidism has not been documented previously. Our six patients with primary hyperparathyroidism constitute 3.4 percent of 174 survivors of emergency portacaval shunt in a series of 264 unselected, consecutive patients with cirrhosis and bleeding esophageal varices. Hepatic osteodystrophy is known to have occurred in only 11 of these 174 survivors. Primary hyperparathyroidism may be a more common cause of hepatic osteodystrophy than has been previously recognized, and should be considered in patients with cirrhosis in whom weakness, bone pain, and bone demineralization develop, particularly if they have a portacaval anastomosis.

Emergency portacaval shunt for variceal hemorrhage. A prospective study

Emergency portacaval shunt for variceal bleeding is associated with a high operative mortality, particularly if used as a last resort. Because of this, a strong case has been made against emergency shunt. This report describes an experience with emergency portacaval shunt for the treatment of variceal bleeding when used systematically after hemodynamic stabilization and control of the bleeding episode with balloon tamponade, if necessary, in patients with mild or moderate liver disease. The population studied comprised 62 consecutive patients who rebled from varices while participating in a controlled trial of propranolol for the prevention of rebleeding. Of the 62 patients, nine died of massive hemorrhage and 53 survived the hemorrhage. Of the 53 survivors, 11 had severe liver disease and were not considered for shunt surgery. Of the remaining 42 patients with mild or moderate liver disease, 36 had emergency central portacaval shunt. The interval between endoscopic diagnosis of variceal bleeding and surgery averaged 19 +/- 3 hours (mean +/- SE). The operative mortality rate, defined as in-hospital mortality, was 19%. One- and 2-year survival rates were 78% and 71%, respectively. The incidence of postoperative hepatic encephalopathy was 36%; all patients responded favorably to protein restriction and lactulose. Thus, under specific conditions, emergency portacaval shunt results in an acceptable long-term survival rate. In patients with mild or moderate liver disease, emergency portacaval shunt should be considered when other forms of treatment for the prevention of variceal rebleeding have failed.