Emergency portacaval shunt for variceal hemorrhage. A prospective study

Percutaneous mesocaval shunt creation for portal thrombosis in a patient with a JAK2V617F mutation

Myeloproliferative neoplasms (MPN) are the most common cause of noncirrhotic, nontumoral portal vein thrombosis (PVT). Over 90 % of MPN patients with PVT carry the JAK2V617F mutation. Compared to other etiologies of PVT, patients with JAK2V617F MPNs are at increased risk of developing significant portal hypertension. However, when these patients develop refractory portal hypertensive complications requiring portosystemic shunt placement, they have limited options. Transjugular intrahepatic portosystemic shunt (TIPS) insertion is often not feasible, as these patients tend to have extensive, occlusive portal thrombus with cavernous transformation. Surgical portosystemic shunt creation can be an alternative; however, this is associated with significant mortality. In this report, we describe the novel use of a percutaneous mesocaval shunt for successful portomesenteric decompression in a patient with portal hypertension from PVT associated with JAK2V617F positive essential thrombocythemia.

Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt

Cirrhotic patients with recurrent variceal bleeds who have failed prior medical and endoscopic therapies and are not transjugular intrahepatic portosystemic shunt candidates face a grim prognosis with limited options. We propose that mesocaval shunting be offered to this group of patients as it has the potential to decrease portal pressures and thus decrease the risk of recurrent variceal bleeding. Mesocaval shunts are stent grafts placed by interventional radiologists between the mesenteric system, most often the superior mesenteric vein, and the inferior vena cava. This allows flow to bypass the congested hepatic system, reducing portal pressures. This technique avoids the general anesthesia and morbidity associated with surgical shunt placement and has been successful in several case reports. In this paper we review the technique, candidate selection, potential pitfalls and benefits of mesocaval shunt placement.

[Mexican consensus on portal hypertension]

The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.

Randomized controlled trial of emergency transjugular intrahepatic portosystemic shunt versus emergency portacaval shunt treatment of acute bleeding esophageal varices in cirrhosis

BACKGROUND

Emergency treatment of bleeding esophageal varices (BEV) in cirrhosis is of paramount importance because of the resultant high mortality rate. Emergency therapy today consists mainly of endoscopic and pharmacologic measures, with use of transjugular intrahepatic portosystemic shunt (TIPS) when bleeding is not controlled. Surgical portosystemic shunt has been relegated to last resort salvage when all other measures fail. Regrettably, no randomized controlled trials have been reported in which TIPS and surgical portosystemic shunt were compared in unselected patients with acute BEV, with long-term follow-up. This is a report of a long-term prospective randomized controlled trial (RCT) that compared TIPS with emergency portacaval shunt (EPCS) in patients with cirrhosis and acute BEV.

STUDY DESIGN

A total of 154 unselected, consecutive cirrhotic patients ("all comers") with acute BEV were randomized to TIPS (n = 78) or EPCS (n = 76), and the two treatments were compared with regard to effect on survival, control of bleeding, portal-systemic encephalopathy (PSE), and disability. Diagnostic workup was completed within 6 h and TIPS or EPCS was initiated within 24 h. Regular follow-up was accomplished in 100 % of patients and lasted for 5 to 10 years in 85 % and 3 to 4.5 years in the remainder. This report focuses on control of bleeding and survival.

RESULTS

The clinical characteristics of the two groups were similar, and the distribution of Child classes A, B, and C was almost identical. TIPS was successful in controlling BEV for 30 days in 80 % of patients but achieved long-term control of BEV in only 22 %. In contrast, EPCS controlled BEV immediately in all patients and permanently in 97 % (p < 0.001). TIPS patients required almost twice as many units of blood transfusion as EPCS patients. Survival rate at all time intervals and in all Child classes was significantly greater following EPCS than after TIPS (p < 0.001). Median survival was over 10 years following EPCS, compared to 1.99 years following TIPS. Stenosis or occlusion of TIPS was demonstrated in 84 % of patients who survived 21 days, 63 % of whom underwent TIPS revision, which failed in 80 %. In contrast, EPCS remained permanently patent in 97 % of patients. Recurrent PSE was threefold more frequent following TIPS than after EPCS (61 versus 21 %).

CONCLUSIONS

EPCS was uniformly effective in the treatment of BEV, while TIPS was disappointing. EPCS accomplished long-term survival while TIPS resulted in a survival rate that was less than one fifth that of EPCS. The results of this RCT in unselected, consecutive patients justify the use of EPCS as a first-line emergency treatment of BEV in cirrhosis (clinicaltrials.gov #NCT00734227).

Intravascular ultrasound-guided mesocaval shunt creation in patients with portal or mesenteric venous occlusion

Extrahepatic mesocaval shunts were successfully created in three patients with refractory variceal hemorrhage, complete portal vein or superior mesenteric vein occlusion, and contraindications to shunt surgery. The use of intravascular ultrasound guidance and covered stents allowed safe and effective transvenous shunt creation without the necessity of percutaneous transabdominal mesenteric venous puncture.

The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension: current status

The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.

Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis

BACKGROUND

The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage.

STUDY DESIGN

A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death.

RESULTS

The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01).

CONCLUSIONS

EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027).

Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding

Increased portal pressure during variceal bleeding may have an influence on the treatment failure rate, as well as on short- and long-term survival. However, the usefulness of hepatic hemodynamic measurement during the acute episode has not been prospectively validated, and no information exists about the outcome of hemodynamically defined high-risk patients treated with early portal decompression. Hepatic venous pressure gradient (HVPG) measurement was made within the first 24 hours after admission of 116 consecutive patients with cirrhosis with acute variceal bleeding treated with a single session of sclerotherapy injection during urgent endoscopy. Sixty-four patients had an HVPG less than 20 mm Hg (low-risk [LR] group), and 52 patients had an HVPG greater than or equal to 20 mm Hg (high-risk [HR] group). HR patients were randomly allocated into those receiving transjugular intrahepatic portosystemic shunt (TIPS; HR-TIPS group, n = 26) within the first 24 hours after admission and those not receiving TIPS (HR-non-TIPS group). The HR-non-TIPS group had more treatment failures (50% vs. 12%, P =.0001), transfusional requirements (3.7 +/- 2.7 vs. 2.2 +/- 2.3, P =.002), need for intensive care (16% vs. 3%, P <.05), and worse actuarial probability of survival than the LR group. Early TIPS placement reduced treatment failure (12%, P =.003), in-hospital and 1-year mortality (11% and 31%, respectively; P <.05). In conclusion, increased portal pressure estimated by early HVPG measurement is a main determinant of treatment failure and survival in variceal bleeding, and early TIPS placement reduces treatment failure and mortality in high risk patients defined by hemodynamic criteria.

Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding

Increased portal pressure during variceal bleeding may have an influence on the treatment failure rate, as well as on short- and long-term survival. However, the usefulness of hepatic hemodynamic measurement during the acute episode has not been prospectively validated, and no information exists about the outcome of hemodynamically defined high-risk patients treated with early portal decompression. Hepatic venous pressure gradient (HVPG) measurement was made within the first 24 hours after admission of 116 consecutive patients with cirrhosis with acute variceal bleeding treated with a single session of sclerotherapy injection during urgent endoscopy. Sixty-four patients had an HVPG less than 20 mm Hg (low-risk [LR] group), and 52 patients had an HVPG greater than or equal to 20 mm Hg (high-risk [HR] group). HR patients were randomly allocated into those receiving transjugular intrahepatic portosystemic shunt (TIPS; HR-TIPS group, n = 26) within the first 24 hours after admission and those not receiving TIPS (HR-non-TIPS group). The HR-non-TIPS group had more treatment failures (50% vs. 12%, P =.0001), transfusional requirements (3.7 +/- 2.7 vs. 2.2 +/- 2.3, P =.002), need for intensive care (16% vs. 3%, P <.05), and worse actuarial probability of survival than the LR group. Early TIPS placement reduced treatment failure (12%, P =.003), in-hospital and 1-year mortality (11% and 31%, respectively; P <.05). In conclusion, increased portal pressure estimated by early HVPG measurement is a main determinant of treatment failure and survival in variceal bleeding, and early TIPS placement reduces treatment failure and mortality in high risk patients defined by hemodynamic criteria.

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.

Clinical results of the transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of variceal bleeding

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) has been popularized for the treatment of refractory variceal bleeding. The aim of this study was to assess the safety and long-term effect of TIPS in the treatment of variceal bleeding that is not controlled with pharmacological and endoscopic treatment.

METHODS

Thirty-six patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) due to refractory variceal bleeding were included in the study. The effectiveness of portal decompression and bleeding control was evaluated. Upper gastrointestinal endoscopy was performed to analyse the degree of varices and portal hypertensive gastropathy (PHG) before TIPS procedure and one to three weeks after TIPS. Angiography was performed in surviving patients, if bleeding recurred, or if ultrasonography or endoscopy suggested stent dysfunction.

RESULTS

TIPS were successfully placed in 36 of 38 patients (94.6%). TIPS achieved hemostasis of variceal bleeding in 34 patients (94.4%). Portal venous pressure decreased from an initial average of 28.7 +/- 7.9 to 23.2 +/- 9.4 mmHg after TIPS (p < 0.05). The portosystemic pressure gradient was significantly decreased from 15.5 +/- 6.3 to 7.8 +/- 4.1 mmHg (p < 0.01). The degree of esophagogastric varices and PHG was significantly improved after TIPS. The total length of follow-up was from one day to 54 months (mean: 355 days). The actuarial probability of survival was 83% at one year and 74% at two years. Overall, 16 episodes of stent dysfunction were diagnosed during follow-up. Stent revision by means of angioplasty was successfully performed in 14 of these episodes.

CONCLUSION

TIPS is an effective and reliable nonoperative means of lowering portal pressure. This procedure has proved useful in the management of acute variceal bleeding refractory to endoscopic treatment. Surveillance by ultrasonography, endoscopy, and angiographic intervention is useful for the maintenance of shunt patency.

Esophageal varices. II. TIPS (transjugular intrahepatic portosystemic shunt) and surgical therapy

The role of surgery in the prevention and treatment of variceal hemorrhage is reviewed. Types of available surgery, their physiologic basis, and literature supporting their use are discussed in the context of the natural history of variceal hemorrhage. The evolution of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment modality for variceal hemorrhage is reviewed. The effects of TIPS on portal and systemic hemodynamics and clinical usefulness in the management of variceal hemorrhage are discussed. A treatment algorithm for the integrated use of the various treatments is provided.

The use and misuse of transjugular intrahepatic portasystemic shunts

Transjugular intrahepatic portasystemic shunts, or TIPS, are used to create a low-resistance channel between the hepatic vein and the intrahepatic portion of the portal vein by deployment of an expandable metal stent. TIPS function like side-to-side surgical portacaval shunts, but their placement does not require anesthesia and major surgery. This article reviews the uses and misuses of TIPS in current practice. The uses include variceal hemorrhage and ascites as well as miscellaneous indications such as Budd-Chiari syndrome, veno-occlusive disease, bleeding ectopic and rectal varices, hepatic hydrothorax, and portal hypertensive gastropathy. TIPS is not indicated for primary prophylaxis of variceal hemorrhage, prehepatic portal hypertension, correction of hypersplenism and thrombocytopenia, pulmonary hypertension and hepatopulmonary syndrome, and portal hypertension associated with polycystic liver disease or Caroli's disease. Also reviewed herein is the management of patients after TIPS placement.

Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices

The optimal management of ruptured gastric varices in patients with cirrhosis has not been codified yet. The present study reports the use of transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory gastric variceal bleeding. Thirty-two consecutive patients were included. All had been unresponsive to vasoactive agents infusion, sclerotherapy, and/or tamponade and were considered poor surgical candidates. They were followed-up until death, transplantation, or at least 1 year (median: 509 days; range 4 to 2,230). Hemostasis was achieved in 18 out of 20 patients actively bleeding at the time of the procedure. In the whole sample of 32 patients, rebleeding rates were 14%, 26%, and 31%, respectively at 1 month, 6 months, and 1 year. De novo encephalopathy was observed in 5 (16%) patients. Seven patients experienced complications and consequently 4 of these patients died. TIPS primary patency rates were 84%, 74%, and 51%, respectively, at 1 month, 6 months, and 1 year. For the same periods of time, survival rates were 75%, 62%, and 59%. These results suggest that TIPS can be used in cirrhotic patients with refractory gastric variceal bleeding and are effective in achieving hemostasis as well as in preventing rebleeding.

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.

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.

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.

Complications and limitations of injection sclerotherapy in portal hypertension

Injection sclerotherapy is now the accepted first line treatment for bleeding oesophageal varices, although it is associated with an impressive list of rare complications. The main problem concerns the strategy for uncontrollable or recurrent bleeding. Patients with uncontrolled bleeding may be referred for surgery after considerable blood loss and are then extremely difficult to assess. The effects of blood loss on liver function can lead to an unduly pessimistic assessment of liver status. An effective choice of emergency surgical procedure may require considerable surgical expertise. Oesophageal transection and devascularisation are satisfactory for many patients with oesophageal varices secondary to cirrhosis and should nearly always control bleeding. Difficulties arise in patients who are grossly obese and in those who have undergone extensive surgery in the upper abdomen. Problems may also be encountered in those treated by repeated sclerotherapy, which may have caused severe inflammatory change and thickening around the lower oesophagus and upper stomach. We believe that an emergency mesocaval shunt using either a vein graft or a synthetic material such as polytetrafluoroethylene is the procedure of choice for this difficult group of very sick patients. The surgical exposure is satisfactory and not unduly prolonged in even the largest patients and the technique does not interfere with any subsequent transplant operation. There is a greater choice in the management of the patient with less urgent bleeding from recurrent varices after sclerotherapy. Repeat sclerotherapy may be effective for small oesophageal varices while liver transplantation may be indicated in the patient with deteriorating liver function. A selective distal splenorenal shunt should be considered for patients with intact splenic and left renal veins and a mesocaval vein graft for the remainder. We would therefore suggest that surgery should still be considered for the management of portal hypertension, particularly in the following circumstances: (1) Uncontrollable bleeding during the initial course of sclerotherapy; (2) Life threatening haemorrhage from recurrent varices; (3) Bleeding from ectopic varices not accessible to sclerotherapy; (4) Uncontrollable bleeding from oesophageal ulceration secondary to injection sclerotherapy; (5) Severe, symptomatic hypersplenism; (6) For patients who live in communities remote from blood transfusion facilities and adequate medical care. The management of the complications of portal hypertension continues to pose problems. We believe that the best results should come from a combined management approach using injection sclerotherapy as primary treatment and surgery for complications and for haemorrhage from unusual anatomical sites.

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.

Surgical emergencies in liver disease

In this chapter the surgical management of bleeding oesophageal varices, ruptured hepatocellular carcinoma and fulminant liver failure have been discussed. Bleeding oesophageal varices can usually be successfully treated with vasopressin, balloon tamponade and injection sclerotherapy. Emergency surgery should be considered if two courses of injection sclerotherapy have failed to achieve haemostasis. Stapled oesophageal transection and portosystemic shunting are currently the two most popular procedures. The former is associated with a lower morbidity and mortality as well as a lower incidence of subsequent encephalopathy. Ruptured hepatocellular carcinomas are usually associated with liver cirrhosis and impaired liver function. Selective coeliac axis cannulation followed by embolization of the hepatic artery branches supplying the tumour is an effective method of achieving haemostasis and is associated with a lower morbidity and mortality than emergency hepatic artery ligation or liver resection. If haemostasis is achieved by embolization the patient may subsequently be assessed for an elective resection of the tumour. Fulminant liver failure may be managed by supportive medical therapy or orthotopic liver transplantation. Patients whose liver failure is graded as mild (grade I) should be treated by medical therapy, whereas those with severe liver damage (grades III and IV) should be assessed for transplantation. Accurate monitoring of the patient's clinical progress and prognostic indicators are vital in deciding whether conservative treatment should be continued or liver transplantation performed.

[Therapy of bleeding esophageal varices in West Germany--results of a survey]

An inquiry concerning bleeding of esophageal varices included 1076 surgical and medical departments in the Federal Republic of Germany (West). Prevailing forms of treatment are acute sclerotherapy or esophageal balloon tamponade followed by long-term sclerotherapy. In case of medically uncontrollable bleeding oesophagogastric devascularization procedures are preferred to portacaval shunt. Beta-blockers are applied in medical departments for the prophylaxis of recurrence. Only after several rebleedings, despite of sclerotherapy, approx. half of the departments consider an elective shunt. The distal splenorenal shunt described by Warren and portacaval anastomosis clearly prevail over all other shunts.

Esophageal varices

Bleeding from esophageal varices is related to the size and pressure of varices, endoscopic danger signs, and severity of liver failure. Prevention of bleeding with propranolol has given conflicting results in controlled trials, but is a safe treatment. Prophylactic sclerotherapy has been shown to reduce bleeding in European studies, but this has not been confirmed by studies in the United States. Acute variceal bleeding can usually be controlled by sclerotherapy, which may be supplemented by pharmacotherapy with vasopressin, nitroglycerin, or somatostatin. Recurrent bleeding is prevented initially by sclerotherapy, with surgery reserved for patients who have not responded to this treatment. Once bleeding has been controlled, the suitability and timing of hepatic transplantation must be considered.

Emergency surgical treatment of variceal hemorrhage

Emergency surgery should be considered one of the treatment options for the patient with acute variceal bleeding in whom the usual nonsurgical modes of therapy fail, and who is deemed fit to tolerate a major operation. A total shunt (portacaval or mesocaval) is recommended for most of these patients, although a distal splenorenal shunt might be considered for some very good risk, nonalcoholic patients who have only moderate bleeding. Devascularization procedures have a limited role in the emergency situation, but they may be useful in patients who are nonshuntable because of splanchnic venous thrombosis. The Sugiura type of operation is appropriate for the nonalcoholic patient, and esophageal transection is appropriate for the alcoholic patient with cirrhosis. Patients with end-stage nonalcoholic liver disease should also be considered for liver transplantation.

A comparison of sclerotherapy with staple transection of the esophagus for the emergency control of bleeding from esophageal varices

We compared two procedures for the emergency treatment of bleeding esophageal varices in patients who did not respond to blood transfusion and vasoactive drugs. We randomly assigned 101 patients with cirrhosis of the liver and bleeding esophageal varices to undergo either emergency sclerotherapy (n = 50) or staple transection of the esophagus (n = 51). Four patients assigned to sclerotherapy and 12 assigned to staple transection did not actually undergo those procedures, but all analyses were made on an intention-to-treat basis. Total mortality did not differ significantly between the two groups; the relative risk of death for staple transection as compared with sclerotherapy was 0.88 (95 percent confidence interval, 0.51 to 1.54). Mortality at six weeks was 44 percent among those assigned to sclerotherapy and 35 percent among those assigned to staple transection. Complication rates were similar for the two groups. An interval of five days without bleeding was achieved in 88 percent of those assigned to staple transection and in 62 percent of those assigned to sclerotherapy after a single injection (P less than 0.01) and 82 percent after three injections. In only 2 of the 11 patients who received a third sclerotherapy injection was bleeding controlled for more than five days, and 9 died. We conclude that staple transection of the esophagus is as safe as sclerotherapy for the emergency treatment of bleeding esophageal varices and that it is more effective than a single sclerotherapy procedure. We currently recommend surgery after two injection treatments have failed.

The surgeon's role in the management of portal hypertension

Patients with portal hypertension are referred to surgeons for several reasons. These include the management of continued active variceal bleeding; therapy after a variceal bleed to prevent further recurrent bleeds; consideration for prophylactic surgical therapy to prevent the first variceal bleed; or, rarely, an unusual cause of portal hypertension which may require some specific surgical therapy. Injection sclerotherapy is the most widely used treatment for both acute variceal bleeding and long-term management after a variceal bleed. Unfortunately it has probably been overused in the past. The need to identify the failures of sclerotherapy early and to treat them by other forms of major surgery is emphasized. The selective distal splenorenal shunt is the most widely used portosystemic shunt today, particularly in nonalcoholic cirrhotic patients. The standard portacaval shunt is still used for the management of acute variceal bleeding as well as for long-term management, particularly in alcoholic cirrhotic patients. For acute variceal bleeding the surgical alternative to sclerotherapy or shunting is simple staple-gun esophageal transection, whereas in long-term management the main alternative is an extensive devascularization and transection operation. Liver transplantation is the only therapy that cures both the portal hypertension and the underlying liver disease. All patients with cirrhosis and portal hypertension should be assessed as potential liver transplant recipients. If they are candidates for transplantation, sclerotherapy should be used to treat bleeding varices whenever possible, as this will interfere least with a subsequent liver transplant.