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Maruyama H, Shiina S. Collaterals in portal hypertension: anatomy and clinical relevance. Quant Imaging Med Surg 2021; 11:3867-3881. [PMID: 34341755 DOI: 10.21037/qims-20-1328] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/07/2021] [Indexed: 12/14/2022]
Abstract
Portal hypertension is a key pathophysiology of chronic liver diseases typified with cirrhosis or noncirrhotic portal hypertension. The development of collateral vessels is a characteristic feature of impaired portal hemodynamics. The paraumbilical vein (PUV), left gastric vein (LGV), posterior gastric vein (PGV), short gastric vein (SGV), splenorenal shunt (SRS), and inferior mesenteric vein (IMV) are major collaterals, and there are some rare collaterals. The degree and hemodynamics of collateral may affect the portal venous circulation and may compensate for the balance between inflow and outflow volume of the liver. Additionally, the development of collateral shows a relation with the liver function reserve and clinical manifestations such as esophageal varices (EV), gastric varices, rectal varices and the other ectopic varices, hepatic encephalopathy, and prognosis. Furthermore, there may be an interrelationship in the development between different collaterals, showing additional influences on the clinical presentations. Thus, the assessment of collaterals may enhance the understanding of the underlying pathophysiology of the condition of patients with portal hypertension. This review article concluded that each collateral has a specific function depending on the anatomy and hemodynamics and is linked with the relative clinical presentation in patients with portal hypertension. Imaging modalities may be essential for the detection, grading and evaluation of the role of collaterals and may help to understand the pathophysiology of the patient condition. Further investigation in a large-scale study would elucidate the basic and clinical significance of collaterals in patients with portal hypertension and may provide information on how to manage them to improve the prognosis as well as quality of life.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | - Shuichiro Shiina
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
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A Thought-Provoking Case of Successfully Treated Carcinoma of the Head of the Pancreas with Metachronous Lung Metastasis: Impact of Distal Spleno-Renal Shunt for Regional Invasion on Long-Term Period after Pancreaticoduodenectomy. Case Rep Surg 2021; 2021:6689419. [PMID: 34136302 PMCID: PMC8179775 DOI: 10.1155/2021/6689419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 05/14/2021] [Indexed: 12/03/2022] Open
Abstract
When performing pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein, division of the splenic vein may cause sinistral portal hypertension resulting in gastrointestinal bleeding, splenic congestion, and hypersplenism. To prevent these adverse events, it is important to intentionally decompress the splenic vein. This report is of a 68-year-old woman with stage IA carcinoma of the head of the pancreas who survived for more than six years following tumor resection and pancreaticoduodenectomy and distal splenorenal shunt. A 68-year-old woman was diagnosed with carcinoma of the head of the pancreas that involved the confluence of the superior mesenteric vein, portal vein, and splenic vein. No unresectable cancer sites or distant metastases were detected. Pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein was performed. The superior mesenteric vein and portal vein were anastomosed in the end-to-end fashion, and the remnant splenic vein was anastomosed to the superior aspect of the left renal vein in the end-to-side fashion. At 22 months after the initial surgery, the patient underwent partial lung resection for a metachronous lung metastasis. For 6 years after the initial surgery, the venous reconstructions have maintained their patency without any obstruction of splenic venous flow, and the patient has remained in good health without further metastases or recurrences. This case has shown the importance of early diagnosis of carcinoma of the head of the pancreas, as appropriate and timely surgical management can result in good outcome. This patient responded well and remains alive six years following pancreaticoduodenectomy and preservation of the spleen with the use of a distal splenorenal shunt.
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Richards WO. W. Dean Warren, MD, FACS, Father of Selective Shunts for Variceal Hemorrhage: Lessons Learned. Am Surg 2020; 86:1049-1055. [PMID: 33049164 DOI: 10.1177/0003134820942146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dr Dean Warren was born in 1924 and died prematurely from cancer in 1989. He was a man of uncommon intelligence, wit, collegiality, integrity, honesty, and a true leader in American surgery. In 1966, he and his colleagues (Drs Zeppa and Fomon) presented a new concept for surgical shunts to control variceal hemorrhage while maintaining portal perfusion or hepatopetal blood flow. He termed this new shunt the distal splenorenal shunt (DSRS), which was the first selective shunt invented. The DSRS selective shunt was a brilliant improvement over the total shunt concept proposed by Nicolai Eck and was practiced worldwide during the 1980s. In a space of 2 decades, Dr Warren's pioneering work would show that the selective DSRS was superior to total shunts for treatment of portal hypertension, but that endoscopic sclerotherapy was a better first-line treatment for variceal hemorrhage than his own creation. His absolute adherence to the principles he espoused in his presidential address to the Society for Surgery of the Alimentary Tract in 1973 were employed in his research and treatment of patients. This paper details Dr Warren's extraordinary research accomplishments and sets a lesson for us that well-designed clinical trials including randomization are essential in the advancement of the care of surgical patients.
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Affiliation(s)
- William O Richards
- Department of Surgery, University of South Alabama, College of Medicine, Mobile, AL, USA
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Levi DM, Levi JU. The Inseparable Histories of the Southern Surgical Association and Surgery for Portal Hypertension. J Am Coll Surg 2016; 222:712-6. [PMID: 26831365 DOI: 10.1016/j.jamcollsurg.2015.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 12/23/2015] [Indexed: 11/18/2022]
Affiliation(s)
- David M Levi
- Department of Surgery, Carolinas Medical Center, Charlotte, NC.
| | - Joe U Levi
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
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Alhaizaey A, Ghanekar A, Oreopoulos G. Inferior vena cava stent grafting closure of a high-flow portacaval shunt. J Vasc Surg Venous Lymphat Disord 2015; 4:88-91. [PMID: 26946901 DOI: 10.1016/j.jvsv.2015.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 05/02/2015] [Indexed: 02/07/2023]
Abstract
Portacaval (PC) shunts can be of congenital or acquired types. Acquired PC shunts are usually created in patients with end-stage liver disease to manage complications associated with portal hypertension or may be part of selected adult-adult living donor liver transplantation procedures to decrease the chance of the small-for-size syndrome. The main potential complication of these acquired high-flow PC shunts is early hepatic encephalopathy. We present a case of a high-flow acquired PC shunt after liver transplantation that was complicated by uncontrolled encephalopathy. This was treated by endovascular inferior vena cava stent grafting for shunt closure.
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Affiliation(s)
- Abdullah Alhaizaey
- Division of Vascular Surgery, Department of Surgery, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Division of General Surgery, Department of Surgery, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - George Oreopoulos
- Division of Vascular Surgery, Department of Surgery, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada; Division of Vascular Surgery and Division of Vascular Interventional Radiology, Departments of Surgery and Medical Imaging, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.
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Maruyama H, Kamezaki H, Kondo T, Sekimoto T, Shimada T, Takahashi M, Okugawa H, Yokosuka O. Effects of inferior mesenteric vein flow in patients with cirrhosis. Clin Gastroenterol Hepatol 2013; 11:1648-54. [PMID: 23876594 DOI: 10.1016/j.cgh.2013.06.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 06/11/2013] [Accepted: 06/11/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The inferior mesenteric vein (IMV) is detected in more than 90% of computed tomography images. Little is known about the hemodynamic features of IMV as a collateral vessel in portal hypertension, or its effects in clinical presentation and outcome. We investigated the roles of the IMV in portal hemodynamics, clinical presentation, and outcomes of patients with cirrhosis. METHODS We performed a prospective study of 467 patients with cirrhosis (274 men; age, 64.6 ± 10.9 y). We assessed hemodynamics in the IMV using Doppler sonography and compared these data with patients' clinical presentation and patient outcome. RESULTS IMV was detected in 94 patients (20.1%); 51 patients had hepatopetal flow, 33 patients had hepatofugal flow, and 10 patients had to-and-fro flow. Those with hepatofugal flow had a significantly greater number of ascites than those with hepatopetal flow, higher Child classification (P = .004), and a higher incidence of decompensated liver (51.5% vs 27.5%; P = .015) and rectal varices (56.3% vs 13.3%; P = .013). The incidence of gastroesophageal varices was lower among those with hepatofugal flow (51.5%; P = .005) or to-and-fro flow (40%; P = .008) than those with hepatopetal flow (80.4%). IMV had similar effects after adjustment for liver function. There were no differences in the cumulative rates of survival during the median 17.2 months of follow-up evaluation, when the patients with and without IMV were stratified by Child classification. CONCLUSIONS In patients with cirrhosis, hepatofugal flow of the IMV appears to increase the risk of ascites and liver decompensation but reduce the risk for gastroesophageal varices. Although IMV is associated with reduced liver function, it does not affect survival.
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Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology and Hepatology, Chiba University Graduate School of Medicine, Inohana, Chuou-ku, Chiba, Japan.
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Alternative Treatment for Bleeding Peristomal Varices: Percutaneous Parastomal Embolization. Cardiovasc Intervent Radiol 2013; 36:1399-404. [DOI: 10.1007/s00270-013-0588-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 01/30/2013] [Indexed: 01/21/2023]
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ, Orloff SL. Alcoholic versus nonalcoholic cirrhosis in a randomized controlled trial of emergency therapy of bleeding varices. J Surg Res 2012; 174:98-105. [PMID: 21195430 PMCID: PMC3084337 DOI: 10.1016/j.jss.2010.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 10/28/2010] [Accepted: 11/03/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND It has been proposed that portal-systemic shunts be avoided in alcoholic cirrhotics because survival rate is allegedly lower in alcoholics than in nonalcoholics. We examined this issue in a randomized controlled trial. METHODS Two hundred eleven unselected, consecutive patients with cirrhosis and bleeding esophageal varices were randomized to endoscopic sclerotherapy (EST) (n = 106) or emergency portacaval shunt (EPCS) (105). Treatment was initiated within 8 h. EST failure was treated by rescue portacaval shunt (PCS). Ten-year follow-up was 96%. RESULTS Results strongly favored EPCS over EST (P < 0.001). Among EPCS patients, 83% were alcoholic and 17% nonalcoholic. Outcomes were (1) permanent control of bleeding 100% versus 100%; (2) 5-y survival 71% versus 78%; (3) encephalopathy 14% versus 19%; (4) yearly charges $38,300 versus $43,000. CONCLUSIONS EPCS results were similar in alcoholic and nonalcoholic cirrhotics. EPCS is an effective first line emergency treatment in all forms of cirrhosis, including alcoholic.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego Medical Center, 200West Arbor Drive, San Diego, CA 92103-8999, USA.
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Hammond KL. Ostomy Hemorrhage: Diagnosis and Current Therapeutic Options. SEMINARS IN COLON AND RECTAL SURGERY 2012. [DOI: 10.1053/j.scrs.2011.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Khan F, Vessal S, Gordon-Williams R. Bleeding from peristomal varices: a complication of portal hypertension. BMJ Case Rep 2011; 2011:bcr.08.2011.4598. [PMID: 22679272 DOI: 10.1136/bcr.08.2011.4598] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Peristomal varices are a recognised complication of stomas in the presence of portal hypertension. There has been a progression of treatment options described in the literature, including the transjugular intrahepatic portosystemic shunt (TIPS). The use of TIPS, a percutaneous procedure allowing connection between the portal and systemic circulations within the liver, is a well-recognised method of treating the complications of portal hypertension. This report presents a case of peristomal varices successfully treated with TIPS and subsequently reviews the literature relating to its management.
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Affiliation(s)
- Faraan Khan
- Department of General Medicine, Barnet Hospital, London, UK.
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Sato T, Akaike J, Toyota J, Karino Y, Ohmura T. Clinicopathological features and treatment of ectopic varices with portal hypertension. Int J Hepatol 2011; 2011:960720. [PMID: 21994879 PMCID: PMC3170857 DOI: 10.4061/2011/960720] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Accepted: 05/12/2011] [Indexed: 12/12/2022] Open
Abstract
Bleeding from ectopic varices, which is rare in patients with portal hypertension, is generally massive and life-threatening. Forty-three patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The frequency of ectopic varices was 43/1218 (3.5%) among portal hypertensive patients in our ward. The locations of the ectopic varices were rectal in thirty-two, duodenal in three, intestinal in two, vesical in three, stomal in one, and colonic in two patients. Endoscopic or interventional radiologic treatment was performed successfully for ectopic varices. Hemorrhage from ectopic varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan,*Takahiro Sato:
| | - Jun Akaike
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Jouji Toyota
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Yoshiyasu Karino
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Takumi Ohmura
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
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Portale Hypertension. PRAXIS DER VISZERALCHIRURGIE. GASTROENTEROLOGISCHE CHIRURGIE 2011. [PMCID: PMC7123479 DOI: 10.1007/978-3-642-14223-9_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Während die Pathologie, die zur portalen Hypertension führt, im prähepatischen, hepatischen und posthepatischen venösen Gefäßbett liegen kann, machen die intrahepatischen Erkrankungen mit Abstand den Großteil aus. In unseren Breitengraden ist es die durch Alkoholabusus bedingte ethyltoxische Leberzirrhose, weltweit die durch Infektionen (HCV, HBV) bedingten Zirrhosen. Die chronische Hepatitis C mit ihren Komplikationen (Leberzellversagen, portale Hypertension und hepatozelluläres Karzinom) wird in den kommenden Jahren trotz moderner Therapieverfahren noch an Bedeutung gewinnen.
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Vist GE, Bryant D, Somerville L, Birminghem T, Oxman AD. Outcomes of patients who participate in randomized controlled trials compared to similar patients receiving similar interventions who do not participate. Cochrane Database Syst Rev 2008; 2008:MR000009. [PMID: 18677782 PMCID: PMC8276557 DOI: 10.1002/14651858.mr000009.pub4] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Some people believe that patients who take part in randomised controlled trials (RCTs) face risks that they would not face if they opted for non-trial treatment. Others think that trial participation is beneficial and the best way to ensure access to the most up-to-date physicians and treatments. This is an updated version of the original Cochrane review published in Issue 1, 2005. OBJECTIVES To assess the effects of patient participation in RCTs ('trial effects') independent both of the effects of the clinical treatments being compared ('treatment effects') and any differences between patients who participated in RCTs and those who did not. We aimed to compare similar patients receiving similar treatment inside and outside of RCTs. SEARCH STRATEGY In March 2007, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, The Cochrane Methodology Register, SciSearch and PsycINFO for potentially relevant studies. Our search yielded 7586 new references. In addition, we reviewed the reference lists of relevant articles. SELECTION CRITERIA Randomized studies and cohort studies with data on clinical outcomes of RCT participants and similar patients who received similar treatment outside of RCTs. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed studies for inclusion, assessed study quality and extracted data. MAIN RESULTS We identified 30 new non-randomized cohort studies (45 comparisons): no new RCTs were found. This update now includes five RCTs (yielding 6 comparisons) and 80 non-randomized cohort studies (130 comparisons), with 86,640 patients treated in RCTs and 57,205 patients treated outside RCTs. In the randomised studies, patients were invited to participate in an RCT or not; these comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions they addressed. When the results of RCTs and non-randomized cohorts that reported dichotomous outcomes were combined, there were 98 comparisons; there was also heterogeneity (P < 0.00001, I(2) = 42.2%) between studies. No statistical significant differences were found for 85 of the 98 comparisons. Eight comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs. There was significant heterogeneity (P < 0.00001, I(2) = 58.2%) among the 38 continuous outcome comparisons. No statistically significant differences were found for 30 of the 38 comparisons. Three comparisons reported statistically significant better outcomes for patients treated within RCTs, and five comparisons reported statistically significant worse outcomes for patients treated within RCTs. AUTHORS' CONCLUSIONS This review indicates that participation in RCTs is associated with similar outcomes to receiving the same treatment outside RCTs. These results challenge the assertion that the results of RCTs are not applicable to usual practice.
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Affiliation(s)
- Gunn Elisabeth Vist
- Department of Evidence-Based Health Services, Norwegian Knowledge Centre for Health Services, PO Box 7004, St Olavs Plass, Oslo, Norway, 0130.
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Spier BJ, Fayyad AA, Lucey MR, Johnson EA, Wojtowycz M, Rikkers L, Harms BA, Reichelderfer M. Bleeding stomal varices: case series and systematic review of the literature. Clin Gastroenterol Hepatol 2008; 6:346-52. [PMID: 18328439 DOI: 10.1016/j.cgh.2007.12.047] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage. METHODS We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients. RESULTS We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices. CONCLUSIONS Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.
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Affiliation(s)
- Bret J Spier
- Section of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Boyer TD, Henderson JM, Heerey AM, Arrigain S, Konig V, Connor J, Abu-Elmagd K, Galloway J, Rikkers LF, Jeffers L, DIVERT Study Group. Cost of preventing variceal rebleeding with transjugular intrahepatic portal systemic shunt and distal splenorenal shunt. J Hepatol 2008; 48:407-14. [PMID: 18045724 PMCID: PMC2743029 DOI: 10.1016/j.jhep.2007.08.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Collaborators] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Revised: 08/06/2007] [Accepted: 08/09/2007] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIMS We examined the cost and cost effectiveness of distal splenorenal shunt (DSRS) and transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of variceal rebleeding. METHODS Patients participated in a randomized controlled trial comparing DSRS to TIPS. Quality of life (QOL) was measured using SF-36 preceding randomization and yearly thereafter. Cost utility analysis was performed using TreeAge DATA. Costs for both in- and out-patient events and interventions were obtained for each patient. Costs using coated stents were estimated using different rates of stenosis. Incremental cost effectiveness ratios (ICERs) were determined at 1, 3 and 5 years. RESULTS The average yearly costs of managing patients after TIPS and DSRS over 5 years were similar, $16,363 and $13,492, respectively. Cost of TIPS for surviving patients exceeded the cost of DSRS at years 3 and 5 but not significantly. ICERs per life saved favored TIPS at year 5 ($61,000). If coated rather than bare stents were used the cost effectiveness of TIPS increased slightly. CONCLUSIONS TIPS is as effective as DSRS in preventing variceal rebleeding and may be more cost effective. TIPS, in all aspects, is equal to DSRS in the prevention of variceal rebleeding in patients who are medical failures.
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Affiliation(s)
- Thomas D Boyer
- Department of Medicine, University of Arizona, Liver Research Institute, Tucson, AZ 85724, USA.
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Collaborators
J Michael Henderson, David S Barnes, Michael Geisinger, Mark Sands, Susan Curtas, Thomas D Boyer, John R Galloway, Enrique Martinez, Qiang Cai, Louis G Martin, Joanne Halcomb, Sharon Behan, Alicia Whitcher, Lennox Jeffers, Enrique G Molina, Arie Regev, Joe U Levi, Alan S Livingstone, Jorge Guerra, Jeffrey Raskin, K Rajender Reddy, Eugene R Schiff, Andreas Tzakis, Jose Yrizarry, Edward Russell, Thomas Scagnelli, Joy Ness, Adrianna Arcila, Amy Siebert, Kareem Abu-Elmagd, Kapil B Chopra, Albert Zajko, John J Fung, Geoffrey Bond, F Leland Thaete, C Andrew Bonham, Hugo Vargas, Diane Morton, Darlene Koritsky, Holly Chapman, Cindy Blaha, Layton F Rikkers, Kevin Block, Michael Lucey, Munci Kalayoglu, Myron Wojtowycz, Ian Sproat, Deb Chicks, Janice Cooney, Michael Kutner, Jason Connor, Marlene Goormastic, Susana Arrigain, Adrienne Heerey, Vicky Konig, Debbie Bick, Thomas D Boyer, Adrienne Heerey, Douglas Labrecque, Donald Jensen, Theodore Karrison, Jeanne LaBerge, Roger Jenkins, Patricia Robuck,
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Iacono C, Verlato G, Zamboni G, Scarpa A, Montresor E, Capelli P, Bortolasi L, Serio G. Adenocarcinoma of the ampulla of Vater: T-stage, chromosome 17p allelic loss, and extended pancreaticoduodenectomy are relevant prognostic factors. J Gastrointest Surg 2007; 11:578-588. [PMID: 17468917 DOI: 10.1007/s11605-007-0136-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the prognostic significance of different clinico-pathological and molecular factors, and to compare survival after standard and extended pancreaticoduodenectomy (PD) in ampulla of Vater adenocarcinoma (AVAC). There are discordant data on factors affecting prognosis, and hence therapeutic choices, in AVAC. PATIENTS AND METHODS Clinical-pathological factors were evaluated in 59 patients, subjected to PD for AVAC; in 42 subjects information on chromosome 17p and 18q allelic losses (LOH) and microsatellite instability (MSI) was also available. The association between survival and type of PD was investigated in the 25 patients operated between 1990 and 2001 (16 standard and nine extended). RESULTS The overall 5- and 10-year tumor-related survival rates were 46% and 33%, respectively. Sixteen patients had T-stages 1-2, 14 T-stage 3, and 29 T-stage 4 cancers. Chromosome 17p and 18q LOH were detected in 23 (55%) and 15 cases (36%), respectively, and in 12 cases (29%) coexisted. Five cases were MSI-positive (12%). At univariate analysis, poor survival was associated with cancer ulceration (P = 0.051), poor differentiation (P = 0.008), T-stage 4 (P < 0.001), nodal metastases (P = 0.004), chromosome 17p (P < 0.001) and 18q LOH (P = 0.002), and absence of MSI (P = 0.009). At multivariate analysis, only T-stage (P = 0.002) and 17p LOH (P = 0.001) were independent predictors of survival. All patients with MSI-positive cancers were long-survivors (>12 yrs), whereas only 30% of MSI-negative cancer patients survived at 5 years. Extended pancreaticoduodenectomy was associated with a 3-year disease-related survival higher than standard resection (83% vs 31%; P = 0.018). CONCLUSION MSI and chromosome 17p status allow to better define prognosis within ampullary cancers at the same stage. Surgery alone resulted curative in MSI-positive cancer patients, whereas it was inadequate in patients showing allelic losses, who might benefit from adjuvant therapy. In this observational study, extended PD was associated with increased survival compared to standard procedures.
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Affiliation(s)
- Calogero Iacono
- Department of Surgery and Gastroenterology, University of Verona Medical School, Verona, Italy.
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Vist GE, Hagen KB, Devereaux PJ, Bryant D, Kristoffersen DT, Oxman AD. Outcomes of patients who participate in randomised controlled trials compared to similar patients receiving similar interventions who do not participate. Cochrane Database Syst Rev 2007:MR000009. [PMID: 17443630 DOI: 10.1002/14651858.mr000009.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Some people believe that patients who take part in randomised controlled trials (RCTs) face risks that they would not face if they opted for non-trial treatment. Others think that trial participation is beneficial and the best way to ensure access to the most up to date physicians and treatments. OBJECTIVES To assess the effects of patient participation in RCTs ('trial effects') independent both of the effects of the clinical treatments being compared ('treatment effects') and any differences between patients who participated in RCTs and those who did not. SEARCH STRATEGY In May 2001, we searched The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, The Cochrane Methodology Register, SciSearch and PsycINFO for potentially relevant studies. Our search yielded over 10,000 references. In addition, we reviewed the reference lists of relevant articles and wrote to over 250 investigators to try to obtain further information. SELECTION CRITERIA Randomised studies and cohort studies with data on clinical outcomes of RCT participants and similar patients who received similar treatment outside of RCTs. DATA COLLECTION AND ANALYSIS At least two reviewers independently assessed studies for inclusion, assessed study quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS We included five randomised studies (yielding 6 comparisons) and 50 non-randomised cohort studies (85 comparisons), with 31,140 patients treated in RCTs and 20,380 patients treated outside RCTs. In the randomised studies, patients were invited to participate in an RCT or not; these comparisons provided limited information because of small sample sizes (a total of 412 patients) and the nature of the questions they addressed. There was statistically significant heterogeneity (P < 0.002, I(2) = 36.2%) among the 73 dichotomous outcome comparisons; none of the potential explanatory factors we investigated helped to explain this heterogeneity. No statistically significant differences were found for 63 of the 73 comparisons. Eight comparisons reported statistically significant better outcomes for patients treated within RCTs, and two comparisons reported statistically significant worse outcomes for patients treated within RCTs. There were no statistically significant differences in heterogeneity (P = 0.53, I(2) = 0%) or in outcomes (SMD 0.01, 95% CI -0.10 to 0.12) of patients treated within and outside RCTs in the 18 comparisons which had used continuous outcomes. AUTHORS' CONCLUSIONS This review indicates that participation in RCTs is not associated with greater risks than receiving the same treatment outside RCTs. These results challenge the assertion that the results of RCTs are not applicable to usual practice.
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Affiliation(s)
- G E Vist
- Norwegian Knowledge Centre for Health Services, PO Box 7004, St Olavs Plass, Oslo, Norway, 0130.
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Fassi-Fehri H, Zakaria Y, Marechal JM, Marcotte G, Colombel M, Martin X, Badet L. Néphrectomie élargie gauche chez deux patients atteints d’hypertension portale porteurs d’un shunt veineux spléno-rénal. Prog Urol 2007; 17:101-4. [PMID: 17373247 DOI: 10.1016/s1166-7087(07)92235-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The authors report two cases of hepatic cirrhosis complicated by portal hypertension with splenorenal venous shunt presenting with left renal tumour that was treated by left radical nephrectomy with preservation of the shunt.
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Affiliation(s)
- Hakim Fassi-Fehri
- Service d'Urologie et de la Transplantation, Hôpital Edouard Herriot, Lyon, France.
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19
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Minami S, Okada K, Matsuo M, Kamohara Y, Sakamoto I, Kanematsu T. Treatment of bleeding stomal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol 2007; 42:91-5. [PMID: 17323000 DOI: 10.1007/s00535-006-1960-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Accepted: 09/20/2006] [Indexed: 02/04/2023]
Abstract
Although stomal varices are a rare complication, bleeding stomal varices often need to be treated owing to symptoms of hypovolemic shock, recurrence of stomal bleeding, or deterioration in the quality of life. Various treatment strategies for the management of bleeding stomal varices have thus far been reported. We report the case of a 60-year-old woman with refractory recurrent bleeding from varices in a sigmoid stoma, along with nonalcoholic steatohepatitis and marked splenomegaly. A physical examination revealed that the skin was discolored and bluish around the circumference of the sigmoid stoma. The venous phase of a celiac arteriogram revealed an afferent vein from the splenic vein and another from the inferior mesenteric vein, and veins draining into the left superficial epigastric vein. A balloon-occluded retrograde transvenous obliteration (BRTO) procedure was performed. The skin around the stoma, initially discolored bluish, improved markedly. After 10 months of follow-up, the patient has remained well without further episodes of stomal bleeding. To our knowledge, this is the first case of recurrent hemorrhage from stomal varices that was successfully treated by BRTO in a patient with portal hypertension.
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Affiliation(s)
- Shigeki Minami
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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20
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Santambrogio R, Opocher E, Costa M, Bruno S, Ceretti AP, Spina GP. Natural history of a randomized trial comparing distal spleno-renal shunt with endoscopic sclerotherapy in the prevention of variceal rebleeding: A lesson from the past. World J Gastroenterol 2006; 12:6331-8. [PMID: 17072957 PMCID: PMC4088142 DOI: 10.3748/wjg.v12.i39.6331] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare endoscopic sclerotherapy (ES) with distal splenorenal shunt (DSRS) in the prevention of recurrent variceal bleeding in cirrhotic patients during a long-term follow-up period.
METHODS: In 1984 we started a prospective, controlled study of patients with liver cirrhosis. Long-term follow-up presents a natural history of liver cirrhosis complicated by advanced portal hypertension. In this study the effects of 2 types of treatment, DSRS or ES, were evaluated. The study population included 80 patients with cirrhosis and portal hypertension referred to our department from October 1984 to March 1991. These patients were drawn from a pool of 282 patients who underwent either elective surgery or ES during the same period of time. Patients were assigned to one of the 2 groups according to a random number table: 40 to DSRS and 40 to ES using polidocanol.
RESULTS: During the postoperative period, no DSRS patient died, while one ES patient died of uncontrolled hemorrhage. One DSRS patient had mild recurrent variceal hemorrhage despite an angiographically patent DSRS and another patient suffered duodenal ulcer rebleeding. Eight ES patients suffered at least one episode of gastrointestinal bleeding: 4 from varices and 4 from esophageal ulcerations. Eight ES patients developed transitory dysphagia. Long-term follow-up was completed in all patients except for 5 cases (2 DSRS and 3 ES patients). Five-year survival rates for shunt (73%) and ES (56%) groups were statistically different: in this follow-up period and in subsequent follow-ups this difference decreased and ceased to be of statistical relevance. The primary cause of death became hepatocellular carcinoma (HCC). Four DSRS patients rebled due to duodenal ulcer, while eleven ES patients had recurrent bleeding from esophago-gastric sources (seven from varices, three from hypertensive gastropathy, one from esophageal ulcerations) and two from unknown sources. Nine DSRS and 2 ES patients developed a chronic encephalopathy; 13 DSRS and 5 ES patients suffered at least one episode of acute encephalopathy. Five ES patients had esophageal stenoses, which were successfully dilated.
CONCLUSION: In a subgroup of patients with good liver function, DSRS with a correct portal-azygos disconnection more effectively prevents variceal rebleeding than ES. However, this positive effect did not influence the long-term survival because other factors (e.g. HCC) were more important in deciding the fate of the cirrhotic patients with portal hypertension.
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Affiliation(s)
- Roberto Santambrogio
- Unità di Chirurgia Bilio-pancreatica, Azienda Ospedaliera San Paolo-Università degli Studi di Milano, Italy.
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21
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Khan S, Tudur Smith C, Williamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2006. [PMID: 17054131 DOI: 10.1002/14651858.cd000553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Randomised clinical trials have compared portosystemic shunting procedures with endoscopic therapy for variceal haemorrhage, but there is no consensus as to which approach is preferable. OBJECTIVES To compare the effects of shunts (total surgical shunt (TS); distal spleno-renal shunts (DSRS) or transjugular intrahepatic porto-systemic shunts (TIPS) with endoscopic therapy (ET, sclerotherapy and/or banding) for prevention of variceal rebleeding in patients with cirrhosis. SEARCH STRATEGY The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Library, MEDLINE, EMBASE, conference proceedings, and the references of identified trials were searched (last search February 2004). Researchers in the field and in industry were contacted. SELECTION CRITERIA Randomised clinical trials comparing TS, DSRS or TIPS with ET in patients who had recovered from a variceal haemorrhage and were known to be cirrhotic. DATA COLLECTION AND ANALYSIS Data were collected to allow intention-to-treat analysis where possible. For each outcome, a pooled estimate of treatment effect (log hazard ratio for time to outcome, Peto odds ratio for binary outcomes, and differences in means for continuous outcomes) across trials was calculated. MAIN RESULTS Twenty-two trials evaluating 1409 patients were included. All trials had problems of method. Shunt therapy compared with ET demonstrated significantly less rebleeding (OR 0.24, 95% CI 0.18 to 0.30) at the cost of significantly increased acute hepatic encephalopathy (OR 2.07, 95% CI 1.59 to 2.69) and chronic encephalopathy (OR 2.09, 95% CI 1.20 to 3.62). There were no significant differences regarding mortality (hazard ratio 1.00, 95% CI 0.82 to 1.21) and duration of in-patient stay (weighed mean difference 0.78 day, 95% CI -1.48 to 3.05). The proportion of patients with shunt occlusion or dysfunction was 3.1% (95% CI 0.4 to 10.7%) following TS (two trials), 7.8% (95% CI 3.8 to 13.9%) following DSRS (four trials), and 59% (range 18% to 72%) following TIPS (14 trials). AUTHORS' CONCLUSIONS All shunts resulted in a significantly lower rebleeding rate at the expense of a higher incidence of encephalopathy. TIPS was complicated by a high incidence of shunt dysfunction. No survival advantage was demonstrated with any shunt.
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Affiliation(s)
- S Khan
- Queen Elizabeth Hospital, Liver Unit (Hepatobiliary Pancreatic and Liver Transplant), Metchley Lane, Edgbaston, Birmingham, West Midlands, UK.
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22
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Macedo TA, Andrews JC, Kamath PS. Ectopic varices in the gastrointestinal tract: short- and long-term outcomes of percutaneous therapy. Cardiovasc Intervent Radiol 2005; 28:178-84. [PMID: 15719183 DOI: 10.1007/s00270-004-0148-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
To evaluate the results of percutaneous management of ectopic varices, a retrospective review was carried out of 14 patients (9 men, 5 women; mean age 58 years) who between 1992 and 2001 underwent interventional radiological techniques for management of bleeding ectopic varices. A history of prior abdominal surgery was present in 12 of 14 patients. The interval between the surgery and percutaneous intervention ranged from 2 to 38 years. Transhepatic portal venography confirmed ectopic varices to be the source of portal hypertension-related gastrointestinal bleeding. Embolization of the ectopic varices was performed by a transhepatic approach with coil embolization of the veins draining into the ectopic varices. Transjugular intrahepatic portosystemic shunt (TIPS) was performed in the standard fashion. Eighteen procedures (12 primary coil embolizations, 1 primary TIPS, 2 re-embolizations, 3 secondary TIPS) were performed in 13 patients. One patient was not a candidate for percutaneous treatment. All interventions but one (re-embolization) were technically successful. In 2 of 18 interventions, re-bleeding occurred within 72 hr (both embolization patients). Recurrent bleeding (23 days to 27 months after initial intervention) was identified in 9 procedures (8 coil embolizations, 1 TIPS due to biliary fistula). One patient had TIPS revision because of ultrasound surveillance findings. New encephalopathy developed in 2 of 4 TIPS patients. Percutaneous coil embolization is a simple and safe treatment for bleeding ectopic varices; however, recurrent bleeding is frequent and reintervention often required. TIPS can offer good control of bleeding at the expense of a more complex procedure and associated risk of encephalopathy.
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Affiliation(s)
- Thanila A Macedo
- Department of Radiology, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA.
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23
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24
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Lonjedo E, Ripollés T. Vascular imaging and interventional procedures in hepatic cirrhosis. Semin Ultrasound CT MR 2002; 23:130-40. [PMID: 11866219 DOI: 10.1016/s0887-2171(02)90033-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Changes in the vascularization of the cirrhotic liver are related to the progression of the disease. Knowledge of normal hepatic vascular anatomy and anatomic is essential for understanding the altered hepatic circulation seen in cirrhosis. We analyze the changes in liver perfusion with special interest in the anatomic features that are important in interventional procedures. The indications, technical notes, and complications of transjugular liver biopsy, transiugular intrahepatic portosystemic shunt (TIPS), and embolization of hepatocellular carcinoma, are reviewed.
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MESH Headings
- Biopsy, Needle
- Carcinoma, Hepatocellular/diagnostic imaging
- Carcinoma, Hepatocellular/therapy
- Embolization, Therapeutic
- Hepatic Artery/diagnostic imaging
- Hepatic Veins/diagnostic imaging
- Humans
- Hypertension, Portal/complications
- Hypertension, Portal/diagnostic imaging
- Hypertension, Portal/surgery
- Liver/diagnostic imaging
- Liver/pathology
- Liver Cirrhosis/complications
- Liver Cirrhosis/diagnostic imaging
- Liver Cirrhosis/therapy
- Liver Neoplasms/diagnostic imaging
- Liver Neoplasms/therapy
- Portal Vein/diagnostic imaging
- Portasystemic Shunt, Surgical
- Portasystemic Shunt, Transjugular Intrahepatic
- Radiography, Interventional
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Affiliation(s)
- Elena Lonjedo
- Department of Radiology, Doctor Peset University Hospital, Valencia, Spain.
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25
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Shibata D, Brophy DP, Gordon FD, Anastopoulos HT, Sentovich SM, Bleday R. Transjugular intrahepatic portosystemic shunt for treatment of bleeding ectopic varices with portal hypertension. Dis Colon Rectum 1999; 42:1581-5. [PMID: 10613477 DOI: 10.1007/bf02236211] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE In the setting of hepatic failure and portal hypertension, hemorrhage from stomal and rectal varices is a well-described problem. It has recently been suggested that transjugular intrahepatic portosystemic shunting may be useful in the therapy of bleeding from parastomal or anorectal varices in patients unresponsive to conservative therapy. METHODS We retrospectively review our institution's experience of five patients with parastomal varices and seven patients with anorectal varices who underwent transjugular intrahepatic portosystemic shunting for hemorrhage refractory to conservative management between 1994 and 1998. RESULTS The study group consisted of four Child's A, five Child's B, and three Child's C patients. The mean age of the patients was 60.3 (range, 37-85) years. Mean follow-up was 15 (range, 5-27) months. The mean portosystemic pressure gradient before transjugular intrahepatic portosystemic shunting was 17.4+/-3.1 mm Hg. After transjugular intrahepatic portosystemic shunting, the mean portosystemic pressure gradient was reduced to 5.8+/-1.8 mm Hg (P<0.05). Transjugular intrahepatic portosystemic shunting were successful in complete resolution of bleeding in all patients. Three patients had encephalopathic changes after transjugular intrahepatic portosystemic shunting. Two patients died within 30 days of transjugular intrahepatic portosystemic shunting of causes unrelated to the procedure. Four patients required shunt revision within one year of placement. CONCLUSION The transjugular intrahepatic portosystemic shunting procedure is an effective modality in the therapy of cirrhotic patients with bleeding stomal or anorectal varices unresponsive to conservative management. There is an acceptable procedure-related morbidity and mortality.
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Affiliation(s)
- D Shibata
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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26
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Kishimoto K, Hara A, Arita T, Tsukamoto K, Matsui N, Kaneyuki T, Matsunaga N. Stomal varices: treatment by percutaneous transhepatic coil embolization. Cardiovasc Intervent Radiol 1999; 22:523-5. [PMID: 10556416 DOI: 10.1007/s002709900445] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Bleeding from stomal varices in a patient with portal hypertension, uncontrolled by surgical ligation and sclerotherapy, was well controlled by percutaneous transhepatic embolization with platinum and stainless-steel coils.
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Affiliation(s)
- K Kishimoto
- Department of Radiology, Yamaguchi University School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
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27
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Deshmukh N, Ayerdi J, Roldan RC. Surgical technique for inferior mesenteric vein to renal vein shunt in portal hypertension. Am J Surg 1999; 178:55-6. [PMID: 10456704 DOI: 10.1016/s0002-9610(99)00127-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An important role still exists for the creation of surgical portasystemic shunts. Multiple techniques have been described. However, no particular one is satisfactory for all clinical situations. The objective of the present paper is to describe an alternative surgical technique for the creation of a decompressive portasystemic shunt. This technique consists of an end-to-side anastomosis between the inferior mesenteric vein and the left renal vein. In our experience, the inferior mesenteric vein to left renal vein anastomosis may be a useful portal decompressive shunt for patients with otherwise difficult peri-portal or peri-pancreatic anatomic exposures. This technique should be a useful tool in the armamentarium of surgeons dealing with patients who need portal decompressive surgical shunts.
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Affiliation(s)
- N Deshmukh
- Department of General Surgery, Guthrie Clinic/Robert Packer Hospital, Sayre, Pennsylvania 18840, USA
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28
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Zervos EE, Goode SE, Rosemurgy AS. Immediate and long-term portal hemodynamic consequences of small-diameter H-graft portacaval shunt. J Surg Res 1998; 74:71-5. [PMID: 9536977 DOI: 10.1006/jsre.1997.5194] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Effective hepatic blood flow is thought to play a critical role in outcome following portal decompressive procedures. We have shown previously that hepatic arterialization occurs soon after shunting, preserving nutrient flow, but the remote effects of shunting are unknown. The purpose of this study was to determine the effect of small-diameter prosthetic H-graft portacaval shunt (HGPCS) on effective hepatic blood flow (EHF) and portal pressures 1 year from shunt placement. METHODS Patients undergoing 8-mm HGPCS had effective hepatic blood flow determined using low-dose galactose clearance preoperatively, postoperatively, and at 1 year postshunt. Portal blood flow, pressures, and portal vein/inferior vena cava pressure gradients were determined intraoperatively before and after shunt placement and at 1 year. RESULTS Twenty patients undergoing shunting had flows measured. All patients had significant reductions in portal vein/inferior vena cava pressure gradients while effective hepatic flow was maintained immediately postoperatively. At 1 year following shunting, effective hepatic blood flow was significantly lower than both pre- and postoperative rates of flow while portal pressures and gradients were significantly increased. Albumin, cholesterol, and PT were improved at 1 year while total bilirubin was slightly worse. Nineteen of 20 patients are still alive with average follow-up of 26 +/- 10.3 months. Four patients were encephalopathic preop, 5 postop, and none chronically. CONCLUSIONS Recollateralization of varices and progression of cirrhosis may account for the observed reductions in EHF at 1 year. Regardless of the cause, diminution of EHF at 1 year is well compensated as demonstrated by minimal encephalopathy and ascites, improved hepatic function reflected in blood chemistry profiles, and good survival.
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Affiliation(s)
- E E Zervos
- Department of Surgery, College of Medicine, University of South Florida, Tampa 33606, USA
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29
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Mazzaferro V, Regalia E, Pulvirenti A, Baratti D, Montagnino G, Bozzetti F. Renal-splenic shunt for intrahepatic caval occlusion after piggy-back liver transplantation. Transpl Int 1997. [DOI: 10.1111/j.1432-2277.1997.tb00935.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
OBJECTIVE The indications for and the results of portosystemic shunts done in the authors' institution since initiation of a liver transplant program 10 years ago were reviewed. SUMMARY BACKGROUND DATA With the widespread availability of liver transplantation as definitive treatment of chronic liver disease, the role of shunts in the overall management of variceal bleeding needs to be redefined. METHODS Seventy-one variceal bleeders with cirrhosis who received a shunt (82% distal splenorenal shunts) because of sclerotherapy failure or because endoscopic treatment was not indicated were reviewed retrospectively. In 44 patients with well-preserved hepatic reserve, the shunt was used as a long-term bridge to transplantation (shunt group 1). The remaining 27 patients with shunts were not transplant candidates mainly because of uncontrolled alcoholism or advanced age (shunt group 2). Survival of both shunt groups was compared to that of 180 adult patients with a history of variceal bleeding who underwent transplantation soon after referral. RESULTS Because of their more advanced liver disease, the liver transplant group had a higher operative mortality rate (19%) than did either of the shunt groups (5% and 7%, respectively) (p < 0.02). Kaplan-Meier survival analysis showed better survival in shunt group 1 (seven patients thus far transplanted) than in either the liver transplant group or shunt group 2 during the early years and superior survival of shunt group 1 and the liver transplant group as compared to shunt group 2 during the later years of the analysis. Only two patients from shunt group 1 have died of late postoperative hepatic failure without benefit of liver transplantation. CONCLUSIONS A shunt may serve as an excellent long-term bridge to liver transplantation in patients with well-preserved hepatic reserve. Shunt surgery still plays an important role in treatment of selected patients with variceal bleeding who are not present or future transplant candidates.
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Affiliation(s)
- L F Rikkers
- Department of Surgery, University of Nebraska Medical Center, Omaha, USA
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Faust TW, Sorrell MF. The role of the transjugular intrahepatic portal-systemic shunt in the management of variceal bleeding. Clin Liver Dis 1997; 1:85-98, xi. [PMID: 15562670 DOI: 10.1016/s1089-3261(05)70257-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
For patients who present with variceal bleeding refractory to endoscopic and pharmacologic methods, TIPS is a new and effective therapy. Stents are used in selected patients with decompensated liver disease and those who anticipate liver transplantation within 6 to 12 months. Surveillance of TIPS with ultrasound, with or without venography, is recommended to diagnose and treat stenosis or occlusion before variceal hemorrhage recurs. Hepatic encephalopathy may develop in a subset of patients, but it is usually well controlled with conservative measures. Child-Pugh and APACHE scores are predictive of patient survival after TIPS. Randomized controlled trials will be necessary to assess whether TIPS is useful, safe, and cost effective for the management of variceal bleeding in patients with end stage liver disease.
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Affiliation(s)
- T W Faust
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska 68198-3285, USA
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32
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Affiliation(s)
- P A Johnson
- Division of Gastroenterology, University of Kansas School of Medicine, Kansas City, USA
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33
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Johnson SP, Leyendecker JR, Joseph FB, Joseph AE, Diffin DC, Devoid D, Eason J. Transjugular portosystemic shunts in pediatric patients awaiting liver transplantation. Transplantation 1996; 62:1178-81. [PMID: 8900323 DOI: 10.1097/00007890-199610270-00027] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Three pediatric patients from 6 to 11 years of age awaiting liver transplantation for end stage liver disease underwent transjugular intrahepatic portosystemic shunt (TIPS) placement for control of variceal bleeding. Two of the three procedures were performed emergently after endoscopic sclerotherapy failed to stop active bleeding. One procedure was performed electively after multiple prior bleeding episodes. The shunts were created from the middle or left hepatic vein to the left portal vein, and none of the subsequent transplant surgeries was complicated by the presence of the stents. No major or minor complications were related to TIPS placement. Two patients underwent concomitant variceal embolization. Bleeding was successfully controlled in each patient. We conclude that TIPS placement in children is technically feasible, does not complicate subsequent surgery, and is useful treating acute variceal hemorrhage in pediatric patients awaiting liver transplantation.
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Affiliation(s)
- S P Johnson
- Department of Radiology, Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Texas 78236-5300, USA
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Abstract
MR angiography (MRA) has become an increasingly important and practical clinical tool for the noninvasive assessment of abdominal vessels. Both two-dimensional time-of-flight and phase contrast techniques allow accurate evaluation of the portal venous system. This article reviews these two MRA techniques and discusses their impact on the diagnosis of vascular abnormalities of the portal venous system.
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Affiliation(s)
- H V Nghiem
- Department of Radiology, University of Washington Medical Center, Seattle 98195, USA
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Jabbour N, Zajko AB, Orons PD, Irish W, Bartoli F, Marsh WJ, Dodd GD, Aldreghitti L, Colangelo J, Rakela J, Fung JJ. Transjugular intrahepatic portosystemic shunt in patients with end-stage liver disease: results in 85 patients. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1996; 2:139-47. [PMID: 9346640 DOI: 10.1002/lt.500020210] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is becoming an accepted procedure as a bridge to orthotopic liver transplantation (OLT) in patients with end-stage liver disease (ESLD) and bleeding from portal hypertension. It allows the immediate control of acute bleeding and decreases the risk of recurrent acute bleeding while the patient is awaiting OLT. We review in this report, our experience with 85 patients who underwent a TIPS procedure for gastrointestinal variceal bleeding from September 1991 until April 1994. All patients had liver cirrhosis and all had previous sclerotherapy before TIPS. Child-Pugh score was calculated at enrollment, and all patients were evaluated for possible OLT. Thirteen patients were Child A, 49 were Child B, and 23 were Child C. Fifty-three patients were candidates for OLT, and 32 were not. TIPS was performed urgently in 25 patients. At a median follow-up of 582 days (range, 1 to 1,095), 35 patients underwent transplantation, 21 patients died, and 29 patients are still alive and did not undergo transplantation. Technical complications were observed in 7% of patients and new onset of clinical encephalopathy in 37%. The 30-day mortality rate after TIPS was 13%. Actuarial survival was 60% at 1 and 3 years. Child class C and urgent TIPS were shown to be two independent predictor factors for mortality. TIPS was shown to be a valuable procedure, not only as a bridge to OLT but also as palliation for bleeding from portal hypertension in patients who were not candidates for either surgical shunt or OLT. However, its role in bleeding patients with acceptable liver function needs further investigation.
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Affiliation(s)
- N Jabbour
- Pittsburgh Transplantation Institute, University of Pittsburgh Medical Center, PA, USA
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36
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Affiliation(s)
- A Merdad
- Department of Surgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
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37
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Collins JC, Sarfeh IJ. Surgical management of portal hypertension. West J Med 1995; 162:527-35. [PMID: 7618313 PMCID: PMC1022831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Portal hypertension is frequently complicated by upper gastrointestinal tract bleeding and ascites. Hemorrhage from esophageal varices is the most common cause of death from portal hypertension. Medical treatment, including resuscitation, vasoactive drugs, and endoscopic sclerosis, is the preferred initial therapy. Patients with refractory hemorrhage frequently are referred for immediate surgical intervention (usually emergency portacaval shunt). An additional cohort of patients with a history of at least 1 episode of variceal hemorrhage is likely to benefit from elective shunt operations. Shunt operations are classified as total, partial, or selective shunts based on their hemodynamic characteristics. Angiographically created shunts have been introduced recently as an alternative to operative shunts in certain circumstances. Devascularization of the esophagus or splenectomy is done for specific indications. Medically intractable ascites is a separate indication for surgical intervention. Liver transplantation has been advocated for patients whose portal hypertension is a consequence of end-stage liver disease. In the context of an increasingly complex set of treatment options, we present an overview of surgical therapy for complications of portal hypertension.
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Affiliation(s)
- J C Collins
- Surgical Service, Long Beach Veterans Affairs Medical Center, CA 90822, USA
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38
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Moulin G, Champsaur P, Bartoli JM, Chagnaud C, Rousseau H, Monges D. TIPS for portal decompression to allow palliative treatment of adenocarcinoma of the esophagus. Cardiovasc Intervent Radiol 1995; 18:186-8. [PMID: 7544239 DOI: 10.1007/bf00204148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We describe a case in which a transjugular intrahepatic portosystemic shunt (TIPS) was inserted to enable palliative treatment of an adenocarcinoma of the esophagus. The cirrhotic patient presented with esophageal varices in contact with a tumor of the esophagus. By relieving portal pressure, TIPS reduced the risk of hemorrhage during laser resection and prevented recurrence of esophageal varices.
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Affiliation(s)
- G Moulin
- Department of Radiology, La Timone University Hospital, Marseille, France
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39
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Hermann RE, Henderson JM, Vogt DP, Mayes JT, Geisinger MA, Agnor C. Fifty years of surgery for portal hypertension at the Cleveland Clinic Foundation. Lessons and prospects. Ann Surg 1995; 221:459-66; discussion 466-8. [PMID: 7748027 PMCID: PMC1234618 DOI: 10.1097/00000658-199505000-00003] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The 50-year experience with surgery for the treatment of portal hypertension and bleeding varices at the Cleveland Clinic is reviewed. SUMMARY BACKGROUND DATA A variety of procedures have been used to treat bleeding varices during the past 50 years. These include transesophageal ligation of varices or devascularization of the esophagus and stomach with splenectomy; portal-systemic (total) shunts; distal splenorenal (selective) shunts; endoscopic sclerotherapy; transjugular intrahepatic portal-systemic shunts; and liver transplantation. METHODS Our experience with these procedures is reviewed in four time periods: 1946 to 1964, 1965 to 1980, 1980 to 1990, and 1990 to 1994. RESULTS Our use of these procedures has changed as experience and new techniques for managing portal hypertension have evolved. Most ligation--devascularization--splenectomy procedures were performed before 1980; they provide excellent results in patients with normal livers and extrahepatic portal venous obstruction, but a major complication (40-50%) is rebleeding. Total shunts were performed most frequently before 1980; with patient selection, operative mortality was reduced to 8%, control of bleeding was achieved in more than 90%, but the incidence of encephalopathy was high (30%). Selective shunts provide almost equal protection from rebleeding with less post-shunt encephalopathy. We currently use selective shunts for patients with good liver function. Liver transplantation has been used since the mid 1980s for patients with poor liver function and provides good results for this difficult group of patients. CONCLUSIONS The selection of patients for these procedures is the key to the successful management of portal hypertension.
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Affiliation(s)
- R E Hermann
- Department of General Surgery, Cleveland Clinic Foundation, Ohio, USA
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40
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Weinberg GD, Matalon TA, Brunner MC, Patel SK, Sandler R. Bleeding stomal varices: treatment with a transjugular intrahepatic portosystemic shunt in two pediatric patients. J Vasc Interv Radiol 1995; 6:233-6. [PMID: 7787357 DOI: 10.1016/s1051-0443(95)71103-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- G D Weinberg
- Department of Diagnostic Radiology, Rush-Presbyterian-St Luke's Medical Center, Chicago, IL 60610, USA
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41
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Paquet KJ, Lazar A, Koussouris P, Hotzel B, Gad HA, Kuhn R, Kalk JF. Mesocaval interposition shunt with small-diameter polytetrafluoroethylene grafts in sclerotherapy failure. Br J Surg 1995; 82:199-203. [PMID: 7749688 DOI: 10.1002/bjs.1800820219] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- K J Paquet
- Department of Surgery, Heinz Kalk Hospital, Bad Kissingen, Germany
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42
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Radosevich PM, LaBerge JM, Gordon RL. Current status and future possibilities of transjugular intrahepatic portosystemic shunts in the management of portal hypertension. World J Surg 1994; 18:785-9. [PMID: 7975701 DOI: 10.1007/bf00298933] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an exciting new method for treating complications of cirrhosis. Technical advances have allowed TIPS to be widely applied in the treatment of variceal bleeding. This article presents and discusses the results of recent experiences in TIPS placement. TIPS can be successfully placed in almost all patients. The complication rate of the procedure is low. TIPS is an effective means of controlling variceal bleeding and is especially useful for controlling bleeding in patients awaiting liver transplantation. It may also have a role in the treatment of ascites and other conditions related to portal hypertension. The most important issue facing TIPS is the long-term patency of the shunt. Potential solutions to the problem of long-term shunt patency are discussed.
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Affiliation(s)
- P M Radosevich
- Department of Radiology, University of California San Francisco 94143-0628
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43
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Chavez DR, Snyder PM, Juravsky LI, Heaney JA. Recurrent ileal conduit hemorrhage in an elderly cirrhotic man. J Urol 1994; 152:951-3. [PMID: 8051764 DOI: 10.1016/s0022-5347(17)32620-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
One recognized complication of portal hypertension in a patient with an ileal urinary conduit is variceal hemorrhage. The definitive treatment for this rare complication is controversial. Local measures, sclerotherapy, stomal revision and various operative portacaval shunts have been described but they have had limited long-term success. Using a recently developed interventional radiological technique, a transjugular intrahepatic portosystemic shunt was created in a cirrhotic man who had recurrent massive ileal conduit variceal hemorrhage. After the procedure the patient experienced no further life threatening stomal hemorrhage. He died of hepatic failure 6 months later.
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Affiliation(s)
- D R Chavez
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756
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44
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Abstract
The management of children with portal hypertension (PH) has substantially changed owing to the good results and broader application of both endoscopic sclerotherapy and orthotopic liver transplantation (OLT). Since the introduction of sclerotherapy for the treatment of bleeding esophageal varices, the number of surgical procedures has sharply decreased. Until the early 1980s, however, the treatment of choice of bleeding esophageal varices was based on different variations of two main types of open surgery: devacularization and transection operations and portosystemic shunts. The experience with nonshunt procedures is limited in the pediatric population. Literature reports from the last 25 years have emphasized a number of restrictions related to portosystemic shunts in small subjects. However, portosystemic shunts, selective or not, can be performed even in very young subjects with high rates of success. From 1974 to 1984 the distal splenorenal shunt (DSRS) was the procedure of choice for the treatment of children with variceal bleeding in our institution. Forty-two children underwent DSRS during this period. Since 1985, when endoscopic variceal sclerotherapy (EVS) replaced DSRS as the first therapeutic option in our service, this shunt has been performed in only 8 children in whom EVS has failed, none of them during the last 2 years. In this cohort of 50 cases of DSRS, the shunt patency has increased from 71% in the first 7 patients to 95% thereafter. There has been no perioperative mortality. From 1985 to April 1993, 107 children were submitted to EVS sessions for the treatment of esophageal varices bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J G Maksoud
- Department of Surgery, University of São Paulo Medical School, Brazil
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45
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Shapiro MJ. THE ROLE OF THE RADIOLOGIST IN THE MANAGEMENT OF GASTROINTESTINAL BLEEDING. Gastroenterol Clin North Am 1994. [DOI: 10.1016/s0889-8553(21)00121-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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46
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Renard TH, Andrews WS, Rollins N, Zwiener RJ, Andersen J, Shimaoka S, McClelland RN. Use of distal splenorenal shunt in children referred for liver transplant evaluation. J Pediatr Surg 1994; 29:403-6. [PMID: 8201509 DOI: 10.1016/0022-3468(94)90579-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Variceal bleeding remains a common cause of morbidity for children with both intrahepatic and extrahepatic portal hypertension. Occasionally, patients referred for liver transplant evaluation have significant variceal bleeding, despite adequate synthetic liver function. During a 7-year period, 322 children were referred for liver transplant evaluation. Six underwent distal splenorenal shunt surgery after evaluation. There were four boys and two girls. The average age was 11 +/- 4 years, and the average weight was 39 +/- 15 kg. The etiology of variceal bleeding was intrahepatic portal hypertension in five (1 biliary atresia, 2 chronic hepatitis, 2 congenital hepatic fibrosis) and extrahepatic portal vein thrombosis in one. Two patients had no previous attempts at sclerotherapy (one because of an abnormality in platelet function, the other because of extensive gastric varices), and four had multiple previous sclerotherapy treatments. No patient had preoperative encephalopathy. Three cases were Child's class A, and three were Child's class B. Preoperative evaluation of the portasystemic system was performed with magnetic resonance (MR) imaging or splenoportography. All patients underwent a distal splenorenal shunt procedure, four of whom also had splenopancreatic disconnection. One patient required 100 mL of blood replacement, and five required no blood. The average length of hospital stay was 9.8 +/- 2.2 days. Postoperative complications were minimal. All patients are alive, without recurrent gastrointestinal bleeding or encephalopathy, and they have patent shunts, which was confirmed by MR or Doppler ultrasound at a mean of 25 +/- 20 months after shunt surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- T H Renard
- Department of Surgery, University of Texas Southwestern Medical Center at Dallas
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47
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Elcheroth J, Vons C, Franco D. Role of surgical therapy in management of intractable ascites. World J Surg 1994; 18:240-5. [PMID: 8042329 DOI: 10.1007/bf00294408] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Almost 10% of patients with cirrhosis and ascites develop intractable ascites. When large-volume paracentesis fails to relieve ascites, patients may be submitted to one of the three following surgical options: portosystemic shunting, peritoneovenous shunting, or liver transplantation. Portosystemic shunting is efficient in clearing ascites, but it is associated with a high rate of encephalopathy and liver failure. The indications for portosystemic shunting are therefore limited for treatment of intractable ascites and should be performed only in patients with good liver function in whom all other treatments failed. Peritoneovenous shunting has been associated with a high rate of early complications and valve obstruction. Improvements in perioperative care and in the material used have greatly reduced the operative risks and increased the patency rate. Mortality remains high in patients with severe liver failure or with a history of spontaneous bacterial peritonitis or variceal bleeding. Peritoneovenous shunting should not be done when these risk factors are present. In the absence of such risk factors, peritoneovenous shunting is a good procedure and may provide definitive relief of ascites and long-term survival in more than 50% of the operated patients. In patients with poor risk factors liver transplantation may be preferable, and the onset of intractable ascites in a patient with a severely compromised liver should trigger the indication of liver replacement.
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Affiliation(s)
- J Elcheroth
- Groupe de Recherche sur la Chirurgie du Foie et de l'Hypertension Portale, Université Paris XI, Clamart, France
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48
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Henderson JM. Role of distal splenorenal shunt for long-term management of variceal bleeding. World J Surg 1994; 18:205-10. [PMID: 8042324 DOI: 10.1007/bf00294402] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Distal splenorenal shunt (DSRS) has been studied extensively over the past 25 years to define its role in management of variceal bleeding. The operative technique of the shunt has not changed, but more aggressive attempts at portal-azygos disconnection have been studied for their effect on maintenance of portal perfusion. Control of variceal bleeding is achieved in about 90% of patients. Portal flow to the liver is maintained in > 90% of patients with nonalcoholic etiology of portal hypertension and in 50% to 84% of patients with alcoholic cirrhosis depending on the degree of portal-azygos disconnection. Encephalopathy and liver failure do not seem to be accelerated by DSRS but depend on the severity of the underlying liver disease. Reported survival likewise depends on the etiology of portal hypertension and the severity of liver disease: > 90% survival can be achieved in portal vein thrombosis and patients with cirrhosis and normal liver function, but 50% to 60% 3- to 5-year survivals are reported for patients with more advanced disease. DSRS offers one treatment modality for management of variceal bleeding that must fit into an overall strategy for these patients. Full evaluation is the key to allow selection of patients for pharmacotherapy, sclerotherapy, variceal decompression, or liver transplantation.
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Affiliation(s)
- J M Henderson
- Department of General Surgery, Cleveland Clinic Foundation, Ohio 44195
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49
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Yassin YM, Eita MS, el-Mirghani M. Highly selective devascularization for bleeding oesophagogastric varices. Br J Surg 1994; 81:245-7. [PMID: 8156348 DOI: 10.1002/bjs.1800810229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Between 1975 and 1984, 419 patients with bleeding oesophagogastric varices were subjected to the simplified operation of highly selective devascularization. All but three were available for follow-up at 5-10 years. The overall mortality rates for urgent and elective operation were 8 and 2 per cent respectively. The overall recurrent bleeding rates at 1, 5 and 10 years were 8 per cent, 13 per cent (15 per cent of survivors) and 17 per cent (24 per cent of survivors). The overall survival rates at 1, 5 and 10 years were 87, 76 and 57 per cent. Recurrent bleeding was usually controlled by endoscopic sclerotherapy and less often by reoperation. Highly selective devascularization controlled bleeding in emergency and elective situations without compromising hepatic function.
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Affiliation(s)
- Y M Yassin
- Gastroenterology Unit, Kobri-El-Kobba Armed Forces Hospital, Cairo, Egypt
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50
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Bosch J. Shunt surgery and beta-blockers. J Hepatol 1994; 20:3-4. [PMID: 7911137 DOI: 10.1016/s0168-8278(05)80459-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- J Bosch
- Hepatic Haemodynamic Laboratory, Hospital Clínic i Provincial, University of Barcelona, Spain
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