Abstract
Background. In the 1990s, liver transplantations and transjugular intrahepatic portosystemic
shunts (TIPS) have become the most common methods to decompress portal hypertension.
This center has continued to use surgical shunts for variceal bleeding in good-risk
patients who continue to bleed through endoscopic and pharmacologic treatment. This
article reports this center's experience with surgical shunts and TIPS shunts from
1992 through 1999. Methods. Sixty-three patients (Child A, 43 patients; Child B, 20 patients) received surgical
shunts: distal splenorenal, 54 patients; splenocaval, 4 patients; coronary caval,
1 patient; and mesocaval, 4 patients. Sixty-two patients had refractory variceal bleeding,
and 1 patient had ascites with Budd-Chiari syndrome. Two hundred patients (Child A,
24 patients; Child B, 62 patients; Child C, 114 patients) received TIPS shunts. One
hundred forty-nine patients had refractory variceal bleeding, and 51 patients had
ascites, hydrothorax, or hepatorenal syndrome. Data were collected by prospective
databases, protocol follow-up, and phone contact. Results. The 30-day mortality rate was 0% for surgical shunts and 26% for TIPS shunts; the
overall survival rate was 86% (median follow-up, 36 months) for surgical shunts and
53% (median follow-up, 40 months) for TIPS shunts. For surgical shunts, the portal
hypertensive rebleeding rate was 6.3%; the overall rebleeding rate was 14.3%. For
TIPS shunts, the overall rebleeding rate was 25.5% (30-day, 9.4%; late, 22.4%). There
were 4 reinterventions for surgical shunts (6.3%); the reintervention rate for TIPS
shunts in the bleeding group was 33%, and the reintervention rate in the ascites group
was 9.5%. Encephalopathy was severe in 3.1% of the shunt group and mild in 17.5%;
this was not systematically evaluated in the TIPS shunts patients. Conclusions. Surgical shunts still have a role for patients whose condition was classified as
Child A and B with refractory bleeding, who achieve excellent outcomes with low morbidity
and mortality rates. TIPS shunts have been used in high-risk patients with significant
early and late mortality rates and have been useful in the control of refractory bleeding
and as a bridge to transplantation. The comparative role of TIPS shunts versus surgical
shunt in patients whose condition was classified as Child A and B is under study in
a randomized controlled trial. (Surgery 2000;128:540-7.)
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References
- Liver transplantation.N Engl J Med. 1989; 321: 1014-1022
- Portal hypertension.Curr Probl Surg. 1998; 35: 379-452
- Minimal criteria for placement of adults on the liver transplant waiting list: a report of a national conference organized by the American Society of Transplant Physicians and the American Association for the Study of Liver Diseases.Liver Transpl Surg. 1997; 3 ([letter]): 628-637
- The criteria for liver transplantation vary widely throughout the United States.Liver Transpl Surg. 1998; 4: 251
- The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding.N Engl J Med. 1994; 330: 165-171
- The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites.N Engl J Med. 1995; 332: 1191-1197
- TIPS: short-and-long-term results: a survey of 1750 patients.Semin Interv Radiol. 1995; 12: 364-367
- Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients.Gastroenterology. 1995; 108: 1143-1151
- Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: a meta-analysis.Hepatology. 1999; 30: 612-622
- TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials.Radiology. 1999; 212: 411-421
- A prospective trial of transjugular intrahepatic portosystemic stent shunts versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices.Ann Surg. 1996; 224: 378-384
- Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices.N Engl J Med. 1992; 326: 1527-1532
- Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal hemorrhage.Ann Intern Med. 1995; 123: 280-287
- Treatment of ascites in patients with cirrhosis of the liver.J Hepatol. 1986; 2: 504-512
- Atlas of liver surgery.in: Digestive tract surgery: a text and atlas. Lippincott-Raven, Philadelphia1996: 735-813
- Selective splenocaval shunt: report of 26 cases and review of literature.Arch Surg. 1991; 126: 582-585
- Shunt surgery during the era of liver transplantation.Ann Surg. 1997; 226: 51-57
- Selective shunts for portal hypertension: current role of a 21-year experience.Liver Transpl Surg. 1997; 3: 475-480
- Distal splenorenal shunt: role, indications, and utility in the era of liver transplantation.Arch Surg. 1999; 134: 416-420
- Surgical portosystemic shunts for treatment of portal hypertensive bleeding: outcome and effect on liver function.Surgery. 1999; 126: 708-711
- The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art.Liver. 1998; 18: 73-89
- Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis.Ann Int Med. 1990; 112: 262-269
- Selective shunt in the management of variceal bleeding in the era of liver transplantation.Ann Surg. 1992; 216: 248-255
- Fifty years of surgery for portal hypertension at the Cleveland Clinic Foundation.Ann Surg. 1995; 221: 459-468
- Conversion of failed transjugular intrahepatic portosystemic shunt to distal splenorenal shunt in patients with Child A or B cirrhosis.Ann Surg. 1998; 227: 600-603
Article info
Footnotes
*Reprint requests: J. Michael Henderson, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave, A80, Cleveland, OH 44119.
**Surgery 2000;128:540-7
Identification
Copyright
© 2000 Mosby, Inc. Published by Elsevier Inc. All rights reserved.
