Long-term follow-up of poor-risk patients undergoing small-diameter portacaval shunts

Self-Expanding Metal Stent (SEMS): an innovative rescue therapy for refractory acute variceal bleeding

BACKGROUND

Acute variceal bleeding (AVB) is a life-threatening complication of liver cirrhosis or less commonly splenic vein thrombosis. Pharmacological and endoscopic interventions are cornerstones in the management of variceal bleeding but may fail in 10 - 15 % of patients. Rescue therapy with balloon tamponade (BT) or transjugular intrahepatic portosystemic shunt (TIPS) may be required to control refractory acute variceal bleeding effectively but with some limitations. The self-expanding metal stent (SEMS) is a covered, removable tool that can be deployed in the lower esophagus under endoscopic guidance as a rescue therapy to achieve hemostasis for refractory AVB.

AIMS

To evaluate the technical feasibility, efficacy, and safety of SEMS as a rescue therapy for AVB.

METHODS

In this review article, we have performed an extensive literature search summarizing case reports and case series describing SEMS as a rescue therapy for AVB. Indications, features, technique, deployment, success rate, limitations, and complications are discussed.

RESULTS

At present, 103 cases have been described in the literature. Studies have reported 97.08 % technical success rates in deployment of SEMS. Most of the stents were intact for 4 - 14 days with no major complications reported. Stent extraction had a success rate of 100 %. Successful hemostasis was achieved in 96 % of cases with only 3.12 % found to have rebleeding after placement of SEMS. Stent migration, which was the most common complication, was observed in 21 % of patients.

CONCLUSION

SEMS is a safe and effective alternative approach as a rescue therapy for refractory AVB.

Long-term results of small-diameter proximal splenorenal venous shunt: A retrospective study

AIM: To investigate recurrent variceal hemorrhage and long-term survival rates of patients treated with partial proximal splenorenal venous shunt.

METHODS: Patients with variceal hemorrhage who were treated with small-diameter proximal splenorenal venous shunt in Ruijin Hospital between 1996 and 2009 were included in this study. Shunt diameter was determined before operation using Duplex Doppler ultrasonography. Peri-operative and long-term results in term of rehemorrhage, encephalopathy and mortality were followed up.

RESULTS: Ninety-eight patients with Child A and B variceal hemorrhage received small-diameter proximal splenorenal venous shunt with a diameter of 7-10 mm. After operation, the patients’ mean free portal pressure (P < 0.01) and the flow rate of main portal vein (P < 0.01) decreased significantly compared with that before operation. The rates of rebleeding and mortality were 6.12% (6 cases) and 2.04% (2 cases), respectively. Ninety-one patients were followed up for 7 mo-14 years (median, 48.57 mo). Long-term rates of rehemorrhage and encephalopathy were 4.40% (4 cases) and 3.30% (3 cases), respectively. Thirteen patients (14.29%) died mainly due to progressive hepatic dysfunction. Five- and ten-year survival rates were 82.12% and 71.24%, respectively.

CONCLUSION: Small-diameter proximal splenorenal venous shunt affords protection against variceal rehemorrhage with a low occurrence of encephalopathy in patients with normal liver function.

Review article: the management of acute variceal bleeding

Variceal haemorrhage is a common medical emergency with a high mortality (30-50%). Adequate resuscitation is vital, and once stabilised the patient should be moved to a high-dependency area. Antibiotics reduce mortality, and the vasoactive drug terlipressin should be administered if early endoscopy is unavailable. Early endoscopy is essential both to make the diagnosis and to allow therapeutic measures to be performed. The evidence suggests that variceal band ligation is the most effective therapy for oesophageal varices. If gastric varices are found at the index endoscopy the evidence at present is inadequate to be certain which is the best treatment, but both endoscopic therapy with cyanoacrylate or thrombin and transjugular intrahepatic portosystemic stent shunt (TIPSS) have been reported to be of benefit. When initial treatments fail, rescue therapy should be initiated. Most authorities agree that TIPSS is the rescue therapy of choice. Many questions remain concerning the treatment of acute variceal bleeding, particularly the ideal therapy for gastric varices and the role of combination vasoactive and endoscopic therapy. Randomised controlled trials are required to answer these important issues.

Preshunt and Postshunt Portal Vein Pressures and Portal Vein-to-inferior Vena Cava Pressure Gradients Do Not Predict Outcome following Partial Portal Decompression

This study was undertaken to determine whether preshunt, postshunt, or changes in portal vein (PV) pressures or portal vein-to-inferior vena cava (PV-IVC) pressure gradients determine outcome following partial portal decompression attained through small-diameter prosthetic H-graft portacaval shunt (HGPCS). Seventy-seven adults underwent HGPCS (Child's class A10%, B 56%, and C 34%) and were prospectively evaluated per protocol. PV pressures and PV-IVC pressure gradients decreased significantly in all patients with shunting ( P < 0.001). Eight (10%) patients died within 30 days of shunting (Child's class B 50% and C 50%); seven of these deaths were due to liver failure. Preshunt, postshunt, and changes in PV pressures or PV-IVC pressure gradients with shunting were not different among eight perioperative deaths and survivors. At a mean follow-up of 3 years 24 (35%) additional patients died. Of late deaths 62 per cent were due to liver failure (Child's class B 40% and C 60%). Again preshunt, postshunt, or changes in PV pressures and PV-IVC pressure gradients with shunting did not predict who would die of late liver failure. We conclude that the small-diameter HGPCS effectively provides partial portal decompression. Preshunt or postshunt PV pressures or PV-IVC pressure gradients or changes in pressures with shunting do not determine outcome following HGPCS. Long-term outcome is influenced by the severity of cirrhosis before shunting and by the self-destructive behaviors typical of patients with alcoholic cirrhosis.

Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis

BACKGROUND/AIMS

The place of transjugular intrahepatic porto-systemic shunt (TIPS) for variceal haemorrhage uncontrolled by sclerotherapy and medical treatment is still undefined. To investigate the outcome of early salvage TIPS for active uncontrolled variceal haemorrhage, and to identify the factors associated with mortality.

METHODS

Salvage TIPS was performed in 58 patients as soon as possible after the diagnosis of variceal bleeding refractory to the combination of sclerotherapy and of pharmacological therapy. Twenty-three variables were assessed prospectively to identify predictors of mortality within 60 days of the procedure.

RESULTS

The haemorrhage was controlled in 52 of 58 patients (90%). Bleeding persisted in six of 58 patients (10%), and recurred in four patients (7%). Overall, 17 (29%) and 20 (35%) patients died within respectively 30 days and 60 days of TIPS: five patients died of persistent bleeding, two patients died of recurrent bleeding, and 13 patients died of terminal liver failure. The actuarial survival following salvage TIPS was 51.7% at 1 year. On multivariate analysis, independent predictors of early mortality were: the presence of sepsis (P=0.001), the use of catecholamines for systemic hemodynamic impairment (P=0.009), and the use of balloon tamponade (P=0.04). Neither a single factor, nor a combination of factors before TIPS allowed to predict mortality confidently in a given patient.

CONCLUSIONS

Early salvage TIPS is an effective treatment to stop active variceal bleeding refractory to sclerotherapy and pharmacological treatment. Pre-treatment prognostic determinants that correlate to mortality can not be used to predict the outcome in individual cases.

Management of acute variceal haemorrhage

Endoscopic therapy and in particular endoscopic variceal banding ligation, in experienced hands, is the treatment of choice for acute variceal bleeding which remains a major cause of death in patients with cirrhosis and portal hypertension. Pharmacological therapy with Glypressin or somatostatin can be useful to gain time when the endoscopic expertise is not available or to help to obtain a clearer endoscopic view. Transjugular intrahepatic porto-systemic stent shunt is currently used for endoscopic failures, producing similar results with the surgical portacaval shunts. Which one of the two should be preferred, since they both work best in relatively compensated patients, should be a balance between the available surgical and radiological expertise, the urgency of the situation and the expected course of the disease.

Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: extended follow-up of an expanded randomized prospective trial

We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a "bridge to transplantation." All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child's class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt (P < 0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) (P < 0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS (P < 0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding.

Liver function and encephalopathy after partial vs direct side-to-side portacaval shunt: a prospective randomized clinical trial

BACKGROUND

The aim of this study was to determine, in a prospective randomized clinical trial, whether the partial portacaval shunt offers any advantage in terms of liver function and encephalopathy rate when compared with direct side-to-side direct portacaval shunt.

METHODS

Forty-six "good risk" patients with cirrhosis and with documented variceal hemorrhage were randomly assigned to either a partial shunt procedure (achieved by 10-mm diameter interposition portacaval H-graft) or direct small-diameter side-to-side portacaval anastomosis.

RESULTS

Operative mortality was zero in both groups. During the follow-up period, encephalopathy developed in 3 patients in the partial shunt group and 9 in the direct shunt group (P =.04). Kaplan-Meier analysis demonstrated that encephalopathy-free survival was significantly longer in the partial shunt group (P =.025). Direct shunt patients had significant hepatic functional deterioration postoperatively compared with the partial shunt group.

CONCLUSIONS

The partial portacaval shunt effectively controls variceal hemorrhage. Compared with direct side-to-side portacaval shunt, partial shunt preserves long-term hepatic function and minimizes postoperative encephalopathy. We conclude that the partial portacaval shunt is the preferred approach over direct shunts for patients with cirrhosis and with variceal bleeding.

A prospective trial of transjugular intrahepatic portasystemic stent shunts versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices

OBJECTIVE

The authors compare transjugular intrahepatic portasystemic stent shunts (TIPS) to small-diameter prosthetic H-graft portacaval shunts (HGPCS).

SUMMARY BACKGROUND DATA

Transjugular intrahepatic portasystemic stent shunts have been embraced as a first-line therapy in the treatment of bleeding varices due to portal hypertension, although they have not been compared to operatively placed shunts in a prospective trial.

METHODS

In 1993, the authors began a prospective, randomized trial to compare TIPS with HGPCSs. All patients had bleeding varices and had failed nonoperative management. Shunting was undertaken as definitive therapy in all. Failure of shunting was defined as an inability to accomplish shunting despite repeated attempts, unexpected liver failure leading to transplantation, irreversible shunt occlusion, major variceal rehemorrhage, or death. Mortality and failure rates were analyzed at 30 days (early) and after 30 days (late) using Fischer's exact test.

RESULTS

There were 35 patients in each group, with no difference in age, gender, Child's class, etiology of cirrhosis, urgency of shunting, or incidence of ascites or encephalopathy between groups. In two patients, TIPS could not be placed despite repeated attempts. Transjugular intrahepatic portasystemic stent shunts reduced portal pressures from 32 +/- 7.5 mmHg (standard deviation) to 25 +/- 7.5 mmHg (p < 0.01), whereas HGPCS reduced them from 30 +/- 4.6 mmHg to 19 +/- 5.3 mmHg (p < 0.01; paired Student's test). Irreversible occlusion occurred in three patients after placement of TIPS. Total failure rate after TIPS placement was 57%; after HGPCS placement, it was 26% (p < 0.02).

CONCLUSIONS

Both TIPS and HGPCS reduced portal pressure. Placement of TIPS resulted in more deaths, more rebleeding, and more than twice the treatment failures. Mortality and failure rates promote the application of HGPCS over TIPS.

Mesocaval interposition shunt with small-diameter polytetrafluoroethylene grafts in sclerotherapy failure

Fifty-seven patients with failed sclerotherapy received a mesocaval interposition shunt with an externally supported, ringed polytetrafluoroethylene prosthesis of either 10 or 12 mm diameter. Thirty-one patients had Child-Pugh grade A disease and 26 grade B; all had a liver volume of 1000-2500 ml. Follow-up ranged from 16 months to 6 years 3 months. Three patients (5 per cent) died in the postoperative period. There were two postoperative recurrences of variceal haemorrhage and one recurrent bleed in the second year after surgery. The cumulative shunt patency rate was 95 per cent and the incidence of encephalopathy 9 per cent; the latter was successfully managed by protein restriction and/or lactulose therapy. The actuarial survival rate for the whole group at 6 years was 78 per cent, for those with Child-Pugh grade A 88 per cent and for grade B 67 per cent. Small-lumen mesocaval interposition shunting achieves portal decompression, preserves hepatopetal flow, has a low incidence of shunt thrombosis, prevents recurrent variceal bleeding and is not associated with significant postoperative encephalopathy.

Partial versus total portacaval shunt in alcoholic cirrhosis. Results of a prospective, randomized clinical trial

OBJECTIVE

Results of the first prospective randomized clinical trial comparing partial and total portacaval shunt for variceal hemorrhage are reported.

SUMMARY BACKGROUND DATA

Total portacaval shunts produce subnormal portal pressures, completely diverting hepatic portal flow. Partial shunts maintain higher pressures and preserve hepatopedal flow. No randomized trials of these two approaches have been performed.

METHODS

Alcoholic patients with cirrhosis (n = 30) and variceal hemorrhage treated at one institution were randomized to receive partial (8-mm diameter portacaval H grafts with collateral ablation, n = 14) or total shunts (16-mm diameter grafts, n = 16). Portography was performed after operation and then yearly. Investigators blinded to shunt type assessed encephalopathy; hospitalizations were reviewed.

RESULTS

Child's class, age, and operative urgency were similar for the two groups. Two patients (with total shunts) died within 30 days. Hepatopedal flow was maintained in 13 partial and 0 total shunt patients (p < 0.0001). Shunt gradients were 16 +/- 5 compared with 6 +/- 3 cm saline after partial and total shunts (p < 0.0001). There were no shunt thromboses or variceal hemorrhages. Encephalopathy-free survival was significantly greater after partial shunts (p = 0.013; life table analysis). Five total compared with zero partial shunt patients required hospitalization for coma (p = 0.02). Long-term survival was not different for the two groups of patients.

CONCLUSIONS

Partial shunts control variceal hemorrhage while maintaining hepatopedal flow and elevated portal pressures. By minimizing encephalopathy rates, partial shunts provide improved quality of survival compared with total shunts.

Narrow-diameter portacaval shunts for management of variceal bleeding

Over the past decade, we have developed and refined a method for partial portosystemic shunting for the control of bleeding esophageal varices in alcoholic cirrhotic patients. The narrow-diameter interposition portacaval H-graft using 8 mm polytetrafluoroethylene has been performed in 32 patients at our institution with low operative mortality (6.3%) and nearly complete cessation of variceal bleeding (96.7%) over a mean follow-up period of 43 months. In comparison with total shunts, diminished rates of postshunt encephalopathy (13% versus 40%) have been observed. Prograde portal blood flow has been preserved in 90% of 30 patients studied by perioperative portography. Shunt patency with continued prograde flow has been demonstrated at up to 9 years of follow-up. Investigators at three other centers have studied partial shunting using substantially similar techniques, with similar findings. Based on these results, we conclude that narrow-diameter shunts provide effective, long-lasting treatment for variceal hemorrhage due to portal hypertension in the alcoholic.