The portacaval shunt. Is it still indicated?

Experimental Transjugular Portacaval Shunt

A transjugular portacaval intrahepatic stented shunt was created in 16 pigs without induced portal hypertension. A fine needle (OD 0.7 mm) was used for the transjugular puncture of the portal vein. The puncture was done directly from the inferior vena cava in 5 cases and from the right liver vein in 11 cases. The puncture tract was dilated and subsequently supported by a Strecker stent. The stented shunt was patent in all cases immediately after the stent placement, but was obstructed by fibrous tissue in 7 of 8 cases reexamined by angiography and autopsy after 4 weeks. Complications seem to be related to the choice of the puncture site, with fewer complications when the puncture was done via the right hepatic vein.

Transjugular intrahepatic portosystemic shunt placement for variceal bleeding: predictors of mortality

PURPOSE

To identify factors that predict survival in patients with variceal bleeding who have undergone transjugular intrahepatic portosystemic shunt (TIPS) placement.

PATIENTS AND METHODS

TIPS was performed in 64 of 65 patients. Indications were bleeding esophagogastric varices in 64 patients and hemorrhoidal bleeding in one. Child-Pugh classifications were A in two patients, B in 32, and C in 31. Acute bleeding was controlled before TIPS in 26 patients in stable condition but not in 39 patients whose condition was unstable.

RESULTS

Twelve patients died within 30 days of TIPS, and another 14 died thereafter. The cumulative survival rate was 67% at 6 months and 56% at 1 year. Cumulative 30-day survival was 96% for stable and 69% for unstable patients, a significant difference (P = .0135). Thirty-day survival was 91% for patients in Child-Pugh classes A and B combined and 71% for patients in class C (P = .042).

CONCLUSION

Efforts to control acute bleeding and improve a patient's metabolic status before TIPS are likely to improve 30-day survival.

Surgical management of acute variceal hemorrhage

The advent of more effective nonoperative therapies, mainly endoscopic variceal sclerosis, has decreased the need for emergency surgery for control of acute variceal hemorrhage. In centers where it is available, nonoperative portal decompression by transjugular intrahepatic portosystemic shunting (TIPS) is likely to have a further impact. When acute or chronic sclerotherapy fails or when bleeding is secondary to gastric varices or portal hypertensive gastropathy, emergency surgery may be life-saving and should be done promptly before worsening hepatic functional decompensation develops. Child's class C liver disease is not a contraindication to emergency surgery; many patients who fail nonoperative attempts at control of bleeding are of this risk status. The most commonly utilized emergency procedures are portacaval and interposition mesocaval shunts, both of which are effective, and esophageal transection, which is associated with a higher incidence of late rebleeding. An emergency distal splenorenal shunt is appropriate for selected patients who are not actively bleeding at the time of surgery. TIPS is the preferred alternative for acute or chronic endoscopic sclerotherapy failures who are candidates for liver transplantation within the succeeding 6 to 12 months.

Hepatic [14C]aminopyrine demethylation capacity after portocaval shunting. Comparative study in patients with and without arterialization of portal vein

The [14C]aminopyrine breath test (ABT) was used before and after surgical portocaval shunting in 29 cirrhotic patients, 15 with arterialization of the portal vein and 14 without. These two subgroups were comparable with regard to age, prothrombin time, serum albumin, serum total bilirubin concentrations, Child classification, and preoperative ABT. After portocaval shunt, a striking reduction in ABT values was observed after 6 and 12 months (90.7 +/- 8.0%, P < 0.05 and 77.3 +/- 7.5%, P < 0.005, respectively). No further decrease was observed between 12 and 24 months. The microsomal function was reduced to a greater extent in patients with postnecrotic cirrhosis (55 +/- 4.8%, P < 0.01) than in those with alcoholic cirrhosis (84.8 +/- 10.4%, P < 0.05). Arterialization of the portal stump of the portal vein did not prevent the reduction in hepatocellular function. No significant change in prothrombin time, serum albumin, or bilirubin concentrations was observed during the follow-up period in any of the groups. Overall, preoperative ABT was significantly higher in those surviving one year (0.29 +/- 0.12% administered dose) than in those who died within this time period (0.12 +/- 0.01%, P < 0.005). This observation suggests that portocaval anastomosis induces an early decrease in microsomal function that is not prevented by arterialization of the portal vein. It also suggests that ABT might be helpful in selecting patients for shunt surgery.

Variceal rebleeding after portosystemic shunting. Strategies and solutions to a vexing problem

The purpose of this review was to discuss an approach to the treatment of recurrent bleeding from esophageal or gastric varices after portosystemic shunt. From our own clinical experience, as well as that of others, it appears that re-establishment of portal decompression should offer the best chance at long-term survival. Luckily, innovations in angiographic technique have allowed attainment of this goal without the inordinate risk of an operative procedure. However, not all patients' situations will be amenable to such treatment. For some of them, operative decompression of the portal venous system can be carried out in an anatomic area previously untouched. For those patients in whom no decompression is possible, direct endoscopic treatment of the varices will offer an alternative, albeit temporizing, approach.