When is liver transplant indicated in cirrhosis with bleeding varices?

Update on Shunt Surgery

Background

Bleeding from esophagogastric varices is a life-threatening complication from portal hypertension. It occurs in 15% of patients and has a mortality rate of 20-35%.

Summary

The primary therapy for variceal bleeding is medical. In cases of recurrent bleeding, a definitive therapy is required. In cases of parenchymal decompensation, liver transplantation is the causal therapy, but if liver function is preserved, portal decompression is the therapy of choice. The use of the transjugular intrahepatic portosystemic shunt (TIPS) has achieved widespread acceptance, although evidence for surgical shunts is comparable or better in patients with good hepatic reserve. The type of surgical shunt depends on the patent veins of the portomesenteric system. If total occlusion is present, a devascularization procedure might be indicated.

Key Messages

Therapy, taking into account liver function, morphology of the portovenous system, and imminent liver transplantation, should be performed by an interdisciplinary team of gastroenterologists, interventional radiologists, and gastrointestinal surgeons.

Clinical Management of Chronic Portal/Mesenteric Vein Thrombosis: The Surgeon's Point of View

BACKGROUND

Bleeding from esophageal varices is a life-threatening complication of chronic portal hypertension (PH), occuring in 15% of patients with a mortality rate between 20 and 35%.

METHODS

Based on a literature review and personal experience in the therapy of PH, we recommend a therapy strategy for the secondary prophylaxis of variceal bleeding in PH.

RESULTS

The main causes for PH in western countries are alcoholic/viral liver cirrhosis and extrahepatic portal/mesenteric vein occlusion, mainly caused by myeloproliferative neoplasms or hypercoagulability syndromes. The primary therapy is medical; however, when recurrent bleeding occurs, a definitive therapy is required. In the case of parenchymal decompensation, liver transplantation is the causal therapy, but in case of good hepatic reserve or without underlying liver disease, a portal decompressive therapy is necessary. Transjugular intrahepatic portosystemic shunt has achieved a widespread acceptance, although evidence is comparable with or better for surgical shunting procedures in patients with good liver function. The type of surgical shunt should be chosen depending on the patent veins of the portovenous system and the personal expertise.

CONCLUSION

The therapy decision should be based on liver function, morphology of the portovenous system, and imminent liver transplantation and should be made by an interdisciplinary team of gastroenterologists, interventional radiologists, and visceral surgeons.

[Portosystemic shunt surgery between TIPS and liver transplantation]

Portosystemic shunt surgery in addition to transjugular intrahepatic portosystemic shunt (TIPS) insertion must still be regarded as a current treatment option for portomesenteric decompression in patients with pharmacological and endoscopic treatment failure, where liver transplantation is not imminent. This applies to secondary prophylaxis of rebleeding from varices in patients with well preserved liver function, e.g. liver cirrhosis CHILD A or extrahepatic portal vein thrombosis. Even if emergency endoscopy represents the treatment of choice in the acute bleeding situation, latest data from San Diego on emergency portacaval shunt surgery are encouraging. Likewise, portacaval shunt procedures can be an attractive alternative to TIPS or liver transplantation for acute Budd-Chiari syndrome or veno-occlusive disease.This article is an update on the systematics and methodology of portacaval shunt surgery, emphasizing the significance of this treatment option based on latest studies.

Surgical Shunting versus Transjugular Intrahepatic Portasystemic Shunting for Bleeding Varices Resulting from Portal Hypertension and Cirrhosis: A Meta-Analysis

Surgical shunting was the mainstay in treating portal hypertension for years. Recently, trans-jugular intrahepatic portasystemic shunting (TIPS) has replaced surgical shunting, first as a “bridge” to transplantation and ultimately as first-line therapy for bleeding varices. This study was undertaken to examine evidence from trials comparing TIPS with surgical shunting to reassess the role of surgery in treating portal hypertension. The National Library of Medicine and the National Institutes of Health were searched for clinical trials comparing surgical shunting with TIPS. Meta-analysis using the fixed effects model was undertaken with end points of 30-day and 1- and 2-year survival and shunt failure (inability to complete shunt, irreversible shunt occlusion, major rehemorrhage, unanticipated liver transplantation, death). Three prospective randomized trials and one retrospective case-controlled study were identified. Analysis was limited to patients of Child Classes A or B. Significantly better 2-year survival (OR 2.5 [1.2-5.2]) and significantly less frequent shunt failure (OR 0.3 [0.1-0.9]) were seen in patients undergoing surgical shunting compared with TIPS. Meta-analysis promotes surgical shunting relative to TIPS because of improved survival and less frequent shunt failure. Surgical shunting should be accepted as first-line therapy for bleeding varices resulting from portal hypertension.

TIPS in Florida: is its application a result of evidence-based medicine?

BACKGROUND

The typical resident in surgery in the US will not care for a patient with advanced portal hypertension and will not participate in a portacaval shunt. The aim of this study is to compare the number of transjugular intrahepatic portasystemic stent shunts (TIPS) with the number of surgical shunts undertaken in the State of Florida and to assess whether these numbers are consistent with today's evidence-based medicine.

METHODS

We examined the database of the Agency for Health Care Administration of the State of Florida from January 1, 2002, through September 30, 2005, for "intraabdominal venous shunt" (ICD-9 code, 39.1). Data collected include "case mix," "case severity," length of stay, total gross charges, and discharge status. Conclusions about longterm survival from a prospective randomized clinical trial comparing TIPS to surgical shunting were applied to this dataset to determine if the relative frequency of TIPS application in Florida was supported by evidence-based medicine.

RESULTS

TIPS was undertaken more than 12 times as often as surgical shunting (860 patients versus 70 patients). After TIPS versus surgical shunts, average length of stay and hospital charges were less, but case mix, case severity, and in-hospital mortality (11.4% for each) were not different. Applying survival data from a randomized trial comparing TIPS with surgical shunting to the State of Florida database, 129 more people (p < 0.0001) would be alive at 2 years and 137 more (p < 0.0001) would be alive at 5 years after shunting if surgical shunts had been used in lieu of TIPS.

CONCLUSIONS

TIPS leads to shorter hospitalizations and reduced hospital charges and is applied in numbers much greater than surgical shunts, despite evidence that suggests inferior longterm efficacy and survival. Current application of TIPS is not a result of evidence-based medicine, and application of surgical shunting is encouraged.

Gastrointestinal hemorrhage: is the surgeon obsolete?

The management of GI hemorrhage has undergone tremendous evolution in recent decades. Once commonly managed by surgeons, the almost continuous introduction of new technologies and pharmacotherapies has dramatically improved clinicians' ability to identify and control sources of bleeding without surgery. Although a gastroenterologist can successfully manage most cases of GI hemorrhage endoscopically, surgical consultation remains an important consideration for the emergency physician in selected cases.