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Lee HL, Lee SW. The role of transjugular intrahepatic portosystemic shunt in patients with portal hypertension: advantages and pitfalls. Clin Mol Hepatol 2021; 28:121-134. [PMID: 34571587 PMCID: PMC9013617 DOI: 10.3350/cmh.2021.0239] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/25/2021] [Indexed: 12/31/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an effective interventional procedure to relieve portal hypertension, which is a main mechanism for the development of complications of liver cirrhosis (LC), such as variceal hemorrhage, ascites, and hepatorenal syndrome. However, the high incidence of adverse events after TIPS implementation limits its application in clinical practice. Esophageal variceal hemorrhage is one of the major indications for TIPS. Recently, preemptively performed TIPS has been recommended, as several studies have shown that TIPS significantly reduced mortality as well as rebleeding or failure to control bleeding in patients who are at high risk of treatment failure for bleeding control with endoscopic variceal ligation and vasoactive drugs. Meanwhile, recurrent ascites is another indication for TIPS with a proven survival benefit. TIPS may also be considered as an effective treatment for other LC complications, usually as an alternative therapy. Although there are concerns about the development of hepatic encephalopathy and hepatic dysfunction after TIPS implementation, careful patient selection using prognostic scores can lead to excellent outcomes. Assessments of cardiac and renal function prior to TIPS may also be considered to improve patient prognosis.
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Affiliation(s)
- Hae Lim Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,The Catholic Liver Research Center, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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152
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Yeoh SW, Kok HK. Transjugular intrahepatic portosystemic shunts in portal vein thrombosis: A review. J Dig Dis 2021; 22:506-519. [PMID: 34323378 DOI: 10.1111/1751-2980.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 12/11/2022]
Abstract
The presence of portal vein thrombosis (PVT) has previously been considered a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS). However, patients with PVT may have portal hypertension complications and may thus benefit from TIPSS to reduce portal venous pressure. There is an increasing body of literature that discusses the techniques and outcomes of TIPSS in PVT. This review summarizes the techniques, indications and outcomes of TIPSS in PVT in published case reports, case series and comparative trials, especially regarding the reduction in portal hypertensive complications such as variceal bleeding. A comprehensive literature search was conducted using MEDLINE and PubMed databases. Manuscripts published in English between 1 January 1990 and 1 March 2021 were used. Abstracts were screened and data from potentially relevant articles analyzed. TIPSS in PVT has been reported with high levels of technical success, short-term portal vein recanalization and long-term PV patency and TIPSS patency outcomes. Several comparative studies, including randomized controlled trials, have shown favorable outcomes of TIPSS compared with non-TIPSS treatment of PVT complications. Outcomes of TIPSS with PVT appear similar to those in TIPSS without PVT. However, TIPSS may be more technically difficult in the presence of PVT, and such procedures should be performed in expert high-volume centers to mitigate the risk of procedural complications. The presence of PVT should no longer be considered a contraindication to TIPSS. TIPSS for PVT has been acknowledged as a therapeutic strategy in recent international guidelines, although further studies are needed before recommendations can be strengthened. KEY POINTS: Portal vein thrombosis (PVT) is no longer a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS) TIPSS often leads to the spontaneous dissolution of PVT, but can be combined with mechanical or pharmacological thrombectomy TIPSS reduces portal hypertensive complications of PVT, such as variceal bleeding, and can also facilitate liver transplantation where PVT may otherwise interfere with vascular anastomoses Studies have shown favorable long-term outcomes of TIPSS compared with TIPSS without PVT; as well as compared with non-TIPSS treatment of PVT complications TIPSS in PVT should be performed in high-volume specialist centers due to technical difficulties.
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Affiliation(s)
- Sern Wei Yeoh
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia.,School of Medical Education, University of Melbourne, Melbourne, Victoria, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Melbourne, Victoria, Australia
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153
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Marschner CA, Geyer T, Froelich MF, Rübenthaler J, Schwarze V, Clevert DA. Diagnostic Value of Contrast-Enhanced Ultrasound for Evaluation of Transjugular Intrahepatic Portosystemic Shunt Perfusion. Diagnostics (Basel) 2021; 11:1593. [PMID: 34573935 PMCID: PMC8472159 DOI: 10.3390/diagnostics11091593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/11/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In patients with liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) displays an effective method for treating portal hypertension. Main indications include refractory ascites and secondary prevention of esophageal bleeding. Color Doppler ultrasound (CDUS) plays a leading role in the follow-up management, whereas contrast-enhanced ultrasound (CEUS) is not routinely considered. We compared the efficacy of CEUS to CDUS and highlighted differences compared to findings of corresponding computed tomography (CT) and magnetic resonance imaging (MRI). (2) Methods: On a retrospective basis, 106 patients with CEUS examination after TIPS were included. The enrollment period was 12 years (between 2008 and 2020) and the age group ranged from 23.3 to 82.1 years. In addition, 92 CDUS, 43 CT and 58 MRI scans were evaluated for intermodal comparison. (3) Results: Intermodal analysis and comparison revealed a high level of concordance between CDUS, CT and MRI in the vast majority of cases. In comparison to CDUS, the correlation of the relevant findings was 92.5%, 95.3% for CT and 87.9% for MRI. In some cases, however, additional information was provided by CEUS (4) Conclusions: CEUS depicts a safe and effective imaging modality for follow-up after TIPS. In addition to CDUS, CEUS enables specific assessment of stent pathologies and stent dysfunction due to its capacity to dynamically visualize single microbubbles at high spatial and temporal resolution. Due to the low number of adverse events regarding the application of contrast agents, CEUS can be administered to a very broad patient population, thus avoiding additional radiation exposure compared to CT angiography in cases with divergent findings during follow-up.
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Affiliation(s)
- Constantin A. Marschner
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
| | - Thomas Geyer
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
| | - Matthias F. Froelich
- Department of Clinical Radiology and Nuclear Medicine, University Medical Centre Mannheim, 68167 Mannheim, Germany;
| | - Johannes Rübenthaler
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
| | - Vincent Schwarze
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
| | - Dirk-André Clevert
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (T.G.); (J.R.); (V.S.); (D.-A.C.)
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154
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Ferrarese A, Passigato N, Cusumano C, Gemini S, Tonon A, Dajti E, Marasco G, Ravaioli F, Colecchia A. Antibiotic prophylaxis in patients with cirrhosis: Current evidence for clinical practice. World J Hepatol 2021; 13:840-852. [PMID: 34552691 PMCID: PMC8422913 DOI: 10.4254/wjh.v13.i8.840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/08/2021] [Accepted: 07/28/2021] [Indexed: 02/06/2023] Open
Abstract
Patients with cirrhosis show an increased susceptibility to infection due to disease-related immune-dysfunction. Bacterial infection therefore represents a common, often detrimental event in patients with advanced liver disease, since it can worsen portal hypertension and impair the function of hepatic and extra-hepatic organs. Among pharmacological strategies to prevent infection, antibiotic prophylaxis remains the first-choice, especially in high-risk groups, such as patients with acute variceal bleeding, low ascitic fluid proteins, and prior episodes of spontaneous bacterial peritonitis. Nevertheless, antibiotic prophylaxis has to deal with the changing bacterial epidemiology in cirrhosis, with increased rates of gram-positive bacteria and multidrug resistant rods, warnings about quinolones-related side effects, and low prescription adherence. Short-term antibiotic prophylaxis is applied in many other settings during hospitalization, such as before interventional or surgical procedures, but often without knowledge of local bacterial epidemiology and without strict adherence to antimicrobial stewardship. This paper offers a detailed overview on the application of antibiotic prophylaxis in cirrhosis, according to the current evidence.
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Affiliation(s)
- Alberto Ferrarese
- Department of Gastroenterology, Verona University Hospital, Verona 37124, Italy
| | - Nicola Passigato
- Department of Gastroenterology, Verona University Hospital, Verona 37124, Italy
| | - Caterina Cusumano
- Department of Gastroenterology, Verona University Hospital, Verona 37124, Italy
| | - Stefano Gemini
- Department of Gastroenterology, Verona University Hospital, Verona 37124, Italy
| | - Angelo Tonon
- Department of Gastroenterology, Verona University Hospital, Verona 37124, Italy
| | - Elton Dajti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Antonio Colecchia
- Department of Gastroenterology, Verona University Hospital, Verona 37124, Italy
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155
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Mattock R, Tripathi D, O'Neill F, Craig J, Tanner J, Patch D, Aithal G. Economic evaluation of covered stents for transjugular intrahepatic portosystemic stent shunt in patients with variceal bleeding and refractory ascites secondary to cirrhosis. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000641. [PMID: 34429322 PMCID: PMC8386212 DOI: 10.1136/bmjgast-2021-000641] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/18/2021] [Indexed: 12/20/2022] Open
Abstract
Objectives Transjugular intrahepatic portosystemic stent shunt (TIPSS) is clinically effective in variceal bleeding and refractory ascites; however, the cost-effectiveness of TIPSS has yet to be evaluated in the UK. This study aimed to establish the cost-effectiveness of (i) pre-emptive TIPSS versus endoscopic band ligation (EBL) in populations with variceal bleeding and (ii) TIPSS versus large volume paracentesis (LVP) in refractory ascites. Methods A cost-utility analysis was conducted with the perspective including healthcare costs and quality-adjusted life years (QALYs). A Markov model was constructed with a 2-year time horizon, health states for mortality and survival and probabilities for the development of variceal bleeding, ascites and hepatic encephalopathy. A survival analysis was conducted to extrapolate 12-month to 24-month mortality for the refractory ascites indication. Uncertainty was analysed in deterministic and probabilistic sensitivity analyses. Results TIPSS was cost-effective (dominant) and cost saving for both indications. For variceal bleeding, pre-emptive TIPSS resulted in 0.209 additional QALYs, and saved £600 per patient compared with EBL. TIPSS had a very high probability of being cost-effective (95%) but was not cost saving in scenario analyses driven by rates of variceal rebleeding. For refractory ascites, TIPSS resulted in 0.526 additional QALYs and saved £17 983 per patient and had a 100% probability of being cost-effective and cost saving when compared with LVP. Conclusions TIPSS is a cost-effective intervention for variceal bleeding and refractory ascites. TIPSS is highly cost-saving for refractory ascites. Robust randomised trial data are required to confirm whether pre-emptive TIPSS is cost saving for variceal bleeding.
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Affiliation(s)
- Richard Mattock
- York Health Economics Consortium, University of York, York, UK
| | - Dhiraj Tripathi
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Joyce Craig
- York Health Economics Consortium, University of York, York, UK
| | | | - David Patch
- Hepatology and Liver Transplantation, Royal Free London NHS Foundation Trust, London, UK
| | - Guruprasad Aithal
- Faculty of Medicine & Health Sciences, The University of Nottingham, Nottingham, UK
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156
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Senzolo M, Garcia-Tsao G, García-Pagán JC. Current knowledge and management of portal vein thrombosis in cirrhosis. J Hepatol 2021; 75:442-453. [PMID: 33930474 DOI: 10.1016/j.jhep.2021.04.029] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/13/2022]
Abstract
Portal vein thrombosis (PVT) is an increasingly recognised complication of cirrhosis whose incidence increases in parallel with the severity of cirrhosis. Several risk factors have been associated with the occurrence and progression of PVT. Although the negative effect of complete PVT on the surgical outcome of liver transplant recipients is clear, its impact on cirrhosis progression remains uncertain. Treatment options include anticoagulants and interventional thrombolytic therapies, which are chosen almost on a case-by-case basis depending on the characteristics of the patient and the thrombus. In this manuscript, we review current knowledge regarding the epidemiology, risk factors, diagnosis and classification, natural history, clinical consequences and treatment of non-neoplastic PVT in cirrhosis.
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Affiliation(s)
- Marco Senzolo
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy(†).
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA; Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Barcelona, Spain; Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Spain(†)
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157
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Enzymatic liver function measured by LiMAx is superior to current standard methods in predicting transplant-free survival after TIPS implantation. Sci Rep 2021; 11:13834. [PMID: 34226640 PMCID: PMC8257751 DOI: 10.1038/s41598-021-93392-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/22/2021] [Indexed: 12/13/2022] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is one of the main treatment options in patients with decompensated liver cirrhosis but is still associated with partly severe complications. For adequate patient selection, prognostic parameters are of crucial importance. The liver maximum capacity (LiMAx) breath test measures enzymatic liver function and could potentially represent an efficient prognostic marker. We therefore aimed to assess the role of LiMAx in predicting survival of TIPS patients in a prospective analysis. LiMAx was performed for patients who underwent TIPS implantation between October 2016 and February 2018. Associations with transplant-free survival after 24 weeks were assessed by logistic regression. A total number of 30 patients were included, of whom seven received liver transplantation (N = 2) or died (N = 5) during follow-up. LiMAx values after (P = 0.01, OR = 1.24, 95% CI = 1.04-1.47) and before (P = 0.03, OR 1.21, 95% CI = 1.02-1.43) TIPS implantation and MELD score (P = 0.03, OR = 0.79, 95% CI = 0.63-0.98) were significantly associated with transplant-free survival according to univariate logistic regression. In AUROC analysis, LiMAx at day one after TIPS (sensitivity 85.7%, specificity 78.3%, AUROC 0.85, cut-off ≤ 165 µg/kg/h), LiMAx value at the day before TIPS (sensitivity 100%, specificity 73.9%, AUROC 0.82, cut-off ≤ 205 µg/kg/h) and MELD score (sensitivity 71.4%, specificity 73.9%, AUROC 0.82, cut-off ≥ 15) had the highest prognostic accuracy. LiMAx values prior and after TIPS procedure seem to be good prognostic parameters regarding prediction of transplant-free survival of patients undergoing TIPS implantation.
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158
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Yamamoto A, Kawada N, Jogo A, Murai K, Kotani K, Kageyama K, Hamamoto S, Sohgawa E, Uchida-Kobayashi S, Enomoto M, Tamori A, Miki Y. Utility of minimally invasive measurement of hepatic venous pressure gradient via the peripheral antecubital vein. Gut 2021; 70:1199-1201. [PMID: 32816966 PMCID: PMC8108276 DOI: 10.1136/gutjnl-2020-322367] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Norifumi Kawada
- Department of Hepatology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Kazuki Murai
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Kohei Kotani
- Department of Hepatology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Shinichi Hamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | | | - Masaru Enomoto
- Department of Hepatology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Akihiro Tamori
- Department of Hepatology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka City University, Osaka, Japan
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159
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Prediction of overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt treatment: a cohort study. Hepatol Int 2021; 15:730-740. [PMID: 33977364 PMCID: PMC8286937 DOI: 10.1007/s12072-021-10188-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 04/11/2021] [Indexed: 12/14/2022]
Abstract
Background/purpose Overt hepatic encephalopathy (HE) risk should be preoperatively predicted to identify patients suitable for curative transjugular intrahepatic portosystemic shunt (TIPS) instead of palliative treatments. Methods A total of 185 patients who underwent TIPS procedure were randomised (130 in the training dataset and 55 in the validation dataset). Clinical factors and imaging characteristics were assessed. Three different models were established by logistic regression analyses based on clinical factors (ModelC), imaging characteristics (ModelI), and a combination of both (ModelCI). Their discrimination, calibration, and decision curves were compared, to identify the best model. Subgroup analysis was performed for the best model. Results ModelCI, which contained two clinical factors and two imaging characteristics, was identified as the best model. The areas under the curve of ModelC, ModelI, and ModelCI were 0.870, 0.963, and 0.978 for the training dataset and 0.831, 0.971, and 0.969 for the validation dataset. The combined model outperformed the clinical and imaging models in terms of calibration and decision curves. The performance of ModelCI was not influenced by total bilirubin, Child–Pugh stages, model of end-stage liver disease score, or ammonia. The subgroup with a risk score ≥ 0.88 exhibited a higher proportion of overt HE (training dataset: 13.3% vs. 97.4%, p < 0.001; validation dataset: 0.0% vs. 87.5%, p < 0.001). Conclusion Our combination model can successfully predict the risk of overt HE post-TIPS. For the low-risk subgroup, TIPS can be performed safely; however, for the high-risk subgroup, it should be considered more carefully. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s12072-021-10188-5.
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160
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Lv Y, Wang Z, Li K, Wang Q, Bai W, Yuan X, Yu T, Niu J, Yang Z, Zhu X, Zhao J, Xue H, Jiang Z, Zhuge Y, Zhang C, Sun J, Ding P, Ren W, Li Y, Zhang K, Zhang W, Guo W, Luo B, Li X, Yuan J, Han N, Zhu Y, He C, Yin Z, Fan D, Han G. Risk Stratification Based on Chronic Liver Failure Consortium Acute Decompensation Score in Patients With Child-Pugh B Cirrhosis and Acute Variceal Bleeding. Hepatology 2021; 73:1478-1493. [PMID: 32706906 DOI: 10.1002/hep.31478] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 04/29/2020] [Accepted: 06/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child-Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child-Pugh B cirrhosis and AVB. APPROACH AND RESULTS We analyzed the pooled individual data from two previous studies of 608 patients with Child-Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF-C ADs for 6-week and 1-year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P < 0.001] and 0.556 [P < 0.001]) and other prognostic models. With X-tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF-C ADs <48), intermediate risk (CLIF-C ADs 48-56), and high risk (CLIF-C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6-week death, respectively. Nevertheless, the performance of CLIF-C ADs for predicting a composite endpoint of 6-week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF-C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). CONCLUSIONS In patients with Child-Pugh B cirrhosis and AVB, risk stratification using CLIF-C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6-week death or further bleeding, the data-driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.
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Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Qiuhe Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xulong Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Tianlei Yu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jing Niu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zaibo Jiang
- Department of interventional Radiology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Junhui Sun
- Hepatobiliaryand Pancreatic Intervention Center, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Li
- Department of Interventional Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kewei Zhang
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Jie Yuan
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Na Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Ying Zhu
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Chuangye He
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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161
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Abstract
Cirrhosis is the fifth leading cause of death in adults. Advanced cirrhosis can cause significant portal hypertension (PH), which is responsible for many of the complications observed in patients with cirrhosis, such as varices. If portal pressure exceeds a certain threshold, the patient is at risk of developing life-threatening bleeding from varices. Variceal bleeding has a high incidence among patients with liver cirrhosis and carries a high risk of mortality and morbidity. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiologic interventions. In terms of management, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires swift intervention to stop the bleeding and achieve durable hemostasis. We describe the pathophysiology of cirrhosis and PH to contextualize the formation of gastric and esophageal varices. We also discuss the currently available treatments and compare how they fare in each stage of clinical management, with a special focus on drugs that can prevent bleeding or assist in achieving hemostasis.
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162
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Manning C, Elzubeir A, Alam S. The role of pre-emptive Transjugular Intrahepatic Portosystemic Shunt in acute variceal bleeding: a literature review. Ther Adv Chronic Dis 2021; 12:2040622321995771. [PMID: 33747427 PMCID: PMC7940777 DOI: 10.1177/2040622321995771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/19/2021] [Indexed: 12/14/2022] Open
Abstract
The development of portal hypertension has serious implications in the natural history of liver cirrhosis, leading to complications such as ascites, hepatic encephalopathy and variceal bleeding. The management of acute variceal bleeding has improved in the last two decades, but despite the advances in endoscopic methods the overall prognosis remains poor, particularly within a subgroup of patients with more advanced disease. The role of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) is a well-established method of achieving haemostasis by immediate portal decompression; however, its use in an emergency setting as a rescue strategy is still associated with high mortality. It has been shown that ‘early’ use of TIPSS as a pre-emptive strategy in a patient with acute variceal bleed in addition to the standard of care confers superior survival outcomes in a subgroup of patients at high risk of treatment failure and death. The purpose of this review is to appraise the literature around the indications, patient selection, utility, complications and economic considerations of pre-emptive TIPSS.
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Affiliation(s)
- Charelle Manning
- Department of Gastroenterology and Hepatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Amera Elzubeir
- Department of Gastroenterology and Hepatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Syed Alam
- Norfolk and Norwich University Hospital, Norwich, NR4 7UB, UK
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163
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Gillespie SL, McAvoy NC, Yung DE, Robertson A, Plevris JN, Hayes PC. Thrombin Is an Effective and Safe Therapy in the Management of Bleeding Gastric Varices. A Real-World Experience. J Clin Med 2021; 10:785. [PMID: 33669257 PMCID: PMC7920079 DOI: 10.3390/jcm10040785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/09/2021] [Accepted: 02/12/2021] [Indexed: 02/06/2023] Open
Abstract
Variceal haemorrhage is a severe complication of liver disease with high mortality. Human recombinant thrombin has gained popularity in the management of variceal haemorrhage. We report on the use of thrombin for gastric and ectopic varices at a regional tertiary care centre. This was a retrospective observational study. Patients with portal hypertension who received endoscopic injection of recombinant thrombin were identified and data collected on haemostasis and rebleeding rates, complications and mortality. Patients were grouped by indication for thrombin injection: gastric/oesophageal/ectopic varices and endoscopic band ligation (EBL)-induced ulceration. 155 patients (96M/59F, mean age 58.3 years) received endoscopic thrombin injection. Mean volume of thrombin injected at index endoscopy was 9.5 ml/2375IU. Initial haemostasis was achieved in 144 patients (92.9%). Rebleeding occurred in a total of 53 patients (36.8%) divided as follows: early rebleeding (<5 days from index endoscopy)-26 patients (18%); rebleeding within 30 days-42 patients (29.1%); delayed rebleeding (> 30 days)-11 patients (7.6%). There was statistically significant difference in rate of initial haemostasis between Child-Pugh A/B patients vs Child-Pugh C (p = 0.046). There was no significant difference in rebleeding rates between different indication groups (p = 0.78), by presence of cirrhosis or by Child-Pugh Score. All-cause mortality at 6 weeks was 18.7%; 1-year mortality 37.4% (median follow-up 48 months). There was no significant difference in mortality between groups (p = 0.37). No significant adverse events or complications were reported. Thrombin is effective and safe for gastric varices and other portal-hypertension-related bleeding including oesophageal varices, ulcers secondary to EBL and ectopic varices.
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Affiliation(s)
- Sarah-Louise Gillespie
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh H16 4SA, UK; (N.C.M.); (D.E.Y.); (A.R.); (J.N.P.); (P.C.H.)
| | - Norma C. McAvoy
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh H16 4SA, UK; (N.C.M.); (D.E.Y.); (A.R.); (J.N.P.); (P.C.H.)
| | - Diana E. Yung
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh H16 4SA, UK; (N.C.M.); (D.E.Y.); (A.R.); (J.N.P.); (P.C.H.)
| | - Alexander Robertson
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh H16 4SA, UK; (N.C.M.); (D.E.Y.); (A.R.); (J.N.P.); (P.C.H.)
| | - John N. Plevris
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh H16 4SA, UK; (N.C.M.); (D.E.Y.); (A.R.); (J.N.P.); (P.C.H.)
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH8 9YL, UK
| | - Peter C. Hayes
- Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh H16 4SA, UK; (N.C.M.); (D.E.Y.); (A.R.); (J.N.P.); (P.C.H.)
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH8 9YL, UK
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164
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Huang Z, Yao Q, Zhu J, He Y, Chen Y, Wu F, Hua T. Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created using covered stents of different diameters: A systematic review and meta-analysis. Diagn Interv Imaging 2020; 102:279-285. [PMID: 33303394 DOI: 10.1016/j.diii.2020.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study was to make a systematic review and meta-analysis to determine the stent diameter (8mm vs. 10mm) that conveys better safety and clinical efficacy for transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS Four databases were used to identify clinical trials published from inception until March 2020. Data were extracted to estimate and compare one-year and three-year overall survivals, hepatic encephalopathy, variceal rebleeding, and shunt dysfunction rates between patients with 8mm covered stents and those with 10mm covered stents. RESULTS Five eligible studies were selected, which included 489 patients (316 men, 173 women). The 8mm covered stent group had higher efficacy regarding one-year or three-year overall survival (odds ratio [OR], 2.88; P=0.003) and (OR, 1.81; P=0.04) and lower hepatic encephalopathy (OR, 0.69; P=0.04) compared with 10mm covered stent group. There were no significant differences in variceal rebleeding rate (OR 0.80; P=0.67). However, shunt dysfunction was lower in 10mm covered stent group (OR, 2.26; P=0.003). CONCLUSIONS Our results suggest that the use of 8mm covered stents should be preferred to that of 10mm covered stents for TIPS placement when portal pressure is frequently monitored.
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Affiliation(s)
- Zongzhang Huang
- Department of Radiology, Ningbo Yinzhou No. 2 Hospital, 315000 Ningbo, Zhejiang, China
| | - Qigu Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 310058 Hangzhou, China
| | - Jianping Zhu
- Department of Radiology, Ningbo Yinzhou No. 2 Hospital, 315000 Ningbo, Zhejiang, China
| | - Ying He
- Zhejiang Chinese Medical University, 310053 Hangzhou, Zhejiang, China
| | - Yanghao Chen
- Department of Cardiology, The Key Lab of Cardiovascular Disease of Wenzhou, The First Affiliated Hospital of Wenzhou Medical University, 325035 Wenzhou, China
| | - Feng Wu
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, 315000 Ningbo, Zhejiang, China
| | - Teng Hua
- Department of Radiology, Ningbo Yinzhou No. 2 Hospital, 315000 Ningbo, Zhejiang, China.
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165
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Reis D, Noronha Ferreira C. Transjugular Intrahepatic Portosystemic Shunt: A Bridge to Clinical Stability in Decompensated Cirrhosis. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:2-4. [PMID: 33564699 PMCID: PMC7841801 DOI: 10.1159/000510060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 06/06/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Daniela Reis
- Serviço de Gastrenterologia e Hepatologia, Centro Hospitalar Universitário Lisboa Norte, EPE, Lisbon, Portugal
| | - Carlos Noronha Ferreira
- Serviço de Gastrenterologia e Hepatologia, Centro Hospitalar Universitário Lisboa Norte, EPE, Lisbon, Portugal
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
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166
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Khokhar MA, O'Beirne J. Transjugular Intrahepatic Portosystemic Shunts for Hepatorenal Syndrome: TIPping the Scales in Whose Favor? Dig Dis Sci 2020; 65:3069-3071. [PMID: 32472258 DOI: 10.1007/s10620-020-06351-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- M Asim Khokhar
- Department of Gastroenterology and Hepatology, Sunshine Coast University Hospital, 6 Doherty St, Birtinya, QLD, Australia
| | - James O'Beirne
- Department of Gastroenterology and Hepatology, Sunshine Coast University Hospital, 6 Doherty St, Birtinya, QLD, Australia. .,Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast (USC), 90 Sippy Downs Dr, Sippy Downs, QLD, Australia.
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167
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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168
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Hawken J, Upponi S, Corbett G, See TC, Leithead JA. See here! Locating the source of upper GI bleeding. Frontline Gastroenterol 2020; 12:539-540. [PMID: 34712474 PMCID: PMC8515279 DOI: 10.1136/flgastro-2020-101463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/13/2020] [Accepted: 07/09/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- James Hawken
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Sara Upponi
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
| | - Gareth Corbett
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge, Cambridgeshire, UK
| | - Teik Choon See
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
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169
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Khan F, Tripathi D. Editorial: early TIPSS in patients with cirrhosis and acute variceal bleeding-the plot thickens! Aliment Pharmacol Ther 2020; 52:551-554. [PMID: 32656843 DOI: 10.1111/apt.15904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Faisal Khan
- University Hospital Coventry & Warwickshire, Coventry, UK
| | - Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham, NHS Foundation Trust and University of Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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170
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Dunne PDJ, Sinha R, Stanley AJ, Lachlan N, Ireland H, Shams A, Kasthuri R, Forrest EH, Hayes PC. Randomised clinical trial: standard of care versus early-transjugular intrahepatic porto-systemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding. Aliment Pharmacol Ther 2020; 52:98-106. [PMID: 32452561 DOI: 10.1111/apt.15797] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/20/2020] [Accepted: 04/25/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Early-transjugular intrahepatic porto-systemic shunt (TIPSS) has been recommended in international guidelines for high-risk patients with oesophageal variceal bleeding. AIM To validate the results of a previous randomised control trial which supports use of early-TIPSS. METHODS In a two-centre open-label parallel-group randomised control trial, patients with cirrhosis and acute variceal bleeding were recruited following haemostasis with vaso-active drugs and endoscopic band ligation. Participants were randomised to standard of care or early-TIPSS. The primary outcome was 1-year survival, secondary outcomes included early and late rebleeding, and complications of portal hypertension. RESULTS Fifty-eight patients (58 ± 11.12 years; 32.7% female) were randomised. After one year, seven patients died in the standard of care group and six in the early-TIPSS group, a 1-year survival of 75.9% vs 79.3% respectively (P = 0.79). Variceal rebleeding occurred in eight patients in the standard of care group compared with three patients in the early-TIPSS group (P = 0.09). Not all participants randomised to early-TIPSS received the intervention in time. For those receiving TIPSS per-protocol, variceal rebleeding rates were reduced (0% vs 27.6%, P = 0.04) but this had no effect on survival (76.9% vs 75.9%, P = 0.91). Serious adverse events were similar in both treatment groups, except that rates of hepatic encephalopathy were higher in patients receiving TIPSS (46.1% vs 20.7%, P < 0.05). CONCLUSIONS Early-TIPSS reduced variceal rebleeding, increased encephalopathy but had no effect on survival in high-risk patients with oesophageal variceal bleeding. Early-TIPSS may not be feasible in many centres however, larger studies are needed. ClinicalTrials.gov reference: NCT02377141.
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Affiliation(s)
- Philip D J Dunne
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Rohit Sinha
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Neil Lachlan
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Aman Shams
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK.,Department of Gastroenterology, Queen Margaret Hospital, Dunfermline, UK
| | - Ram Kasthuri
- Department of Radiology, Glasgow Royal Infirmary, Glasgow, UK
| | - Ewan H Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
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171
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Stockhoff L, Schultalbers M, Tergast TL, Hinrichs JB, Gerbel S, Meine TC, Manns MP, Simon N, Cornberg M, Meyer BC, Maasoumy B. Safety and feasibility of transjugular intrahepatic portosystemic shunt in elderly patients with liver cirrhosis and refractory ascites. PLoS One 2020; 15:e0235199. [PMID: 32584874 PMCID: PMC7316253 DOI: 10.1371/journal.pone.0235199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/10/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND & AIMS The management of patients with refractory ascites (RA) is challenging, particularly at higher age. Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for RA, but safety data in elderly patients are rare. Our aim was to evaluate the safety and feasibility of TIPS in elderly patients with RA. METHODS Overall, 160 consecutive cirrhotic patients receiving a TIPS for RA at Hannover Medical School between 2012 and 2018 were considered for this retrospective analysis. Periinterventional complications such as acute-on-chronic liver failure (ACLF) as well as survival were compared between patients <65 and ≥65 years. Propensity score matching was conducted to match elderly TIPS patients and patients treated with paracentesis. RESULTS A number of 53 out of the 160 patients were ≥65 years (33%). Periinterventional course in those ≥65 years appeared to be slightly more complicated than in <65 years as reflected by a significantly longer hospital stay (p = 0.030) and more ACLF-episodes (21% vs. 9%; p = 0.044). 28-day mortality was similar between both groups (p = 0.350), whereas survival of the younger patients was significantly higher at 90 days (p = 0.029) and numerically higher at 1 year (p = 0.171). In the multivariate analysis age ≥65 years remained an independent predictor for 90-day mortality (HR: 2.58; p = 0.028), while it was not associated with 28-day and 1-year survival. Importantly, after matching for potential confounders 1-year survival was similar in elderly patients if treated with TIPS or paracentesis (p = 0.419). CONCLUSIONS TIPS placement in elderly patients with RA appears to be slightly more complicated compared to younger individuals, but overall feasible and at least not inferior to paracentesis.
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Affiliation(s)
- Lena Stockhoff
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marie Schultalbers
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Tammo L. Tergast
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Svetlana Gerbel
- Centre for Information Management (ZIMt), Hannover Medical School, Hannover, Germany
| | - Timo C. Meine
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), c/o CRC Hannover, Hannover, Germany
- German Centre for Infection Research (Deutsches Zentrum für Infektions-forschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
| | - Nicolas Simon
- Centre for Information Management (ZIMt), Hannover Medical School, Hannover, Germany
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), c/o CRC Hannover, Hannover, Germany
- German Centre for Infection Research (Deutsches Zentrum für Infektions-forschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
| | - Bernhard C. Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Benjamin Maasoumy
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), c/o CRC Hannover, Hannover, Germany
- German Centre for Infection Research (Deutsches Zentrum für Infektions-forschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany
- * E-mail:
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172
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Santos S, Dantas E, Veloso Gomes F, Luz JH, Vasco Costa N, Bilhim T, Calinas F, Martins A, Coimbra É. Retrospective Study of Transjugular Intrahepatic Portosystemic Shunt Placement for Cirrhotic Portal Hypertension. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:5-12. [PMID: 33564700 DOI: 10.1159/000507894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/13/2020] [Indexed: 12/14/2022]
Abstract
Background and Aims Transjugular intrahepatic portosystemic shunt (TIPS) is used for decompressing clinically significant portal hypertension. The aims of this study were to evaluate clinical outcomes and adverse events associated with this procedure. Methods Retrospective single-center study including 78 patients submitted to TIPS placement between January 2015 and November 2018. Follow-up data were missing in 27 patients, and finally 51 patients were included in the study sample. Data collected from individual registries included demographics, comorbidities, laboratory results, complications, and clinical results according to the indication. Results Average pre-TIPS portosystemic pressure gradient decreased from 18.1 ± 5 to 6 ± 3 mm Hg after TIPS placement. Indications for TIPS were refractory ascites (63%, n = 49), recurrent or uncontrolled variceal bleeding (36%, n = 28), and Budd-Chiari syndrome (1.3%, n = 1). TIPS-related adverse events occurred in 29/51 (56.8%) patients, with hepatic encephalopathy (HE) in 21 (41%) patients, sepsis in 3, liver failure in 2, hemolytic anemia in 1, acute pulmonary edema in 1, and capsular perforation in 1 patient. Mean follow-up was 15.7 ± 15 months. First-month mortality was 11.7% (n = 6) (sepsis, n = 3; acute liver failure, n = 2; and recurrence of variceal bleeding, n = 1) and was significantly higher for patients with Child-Pugh >9 points (p = 0.01), model of end-stage liver disease (MELD) scores >19 (p = 0.02), and for patients with a history of HE before the procedure (p = 0.001). Older age (p = 0.006) and higher levels of creatinine (p = 0.008) were significantly higher in patients developing HE after TIPS. Ascites persisted in 21.2% (7/33 patients) and was more frequent in patients with lower baseline albumin levels (p = 0.003). Recurrent variceal bleeding occurred in 22% (n = 4/18 patients) and was more frequent in patients with lower baseline hemoglobin levels (p = 0.03). Conclusion TIPS is effective in up to 80% of patients presenting with variceal bleeding or refractory ascites. Careful patient selection based on age and HE history may reduce adverse events after TIPS.
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Affiliation(s)
- Sara Santos
- Gastroenterology and Hepatology Department, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Eduardo Dantas
- Gastroenterology and Hepatology Department, Centro Hospitalar de Setúbal, Setúbal, Portugal
| | - Filipe Veloso Gomes
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - José Hugo Luz
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Nuno Vasco Costa
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Tiago Bilhim
- NOVA Medical School, Lisbon, Portugal.,Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Filipe Calinas
- Gastroenterology and Hepatology Department, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Américo Martins
- Surgery Department, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
| | - Élia Coimbra
- Interventional Radiology Unit, Curry Cabral Hospital, Centro Hospitalar Universitário de Lisboa Central (CHULC), Lisbon, Portugal
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Mistry M, Fiske J, Chaudhry T, Cross TJ, Mehta S, Ballal K, Diwakar P, Chambers J, Smith PJ. Halting the haematochezia. Frontline Gastroenterol 2020; 12:232-234. [PMID: 33912335 PMCID: PMC8040502 DOI: 10.1136/flgastro-2020-101495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/01/2020] [Accepted: 05/06/2020] [Indexed: 02/04/2023] Open
Abstract
An elderly gentleman with primary sclerosing cholangitis (PSC) was admitted with rectal bleeding, shown on flexible sigmoidoscopy to be arising from rectal varices, which bled despite endoscopic therapy with histoacryl glue. Therapeutic options were limited with surgery and transjugular intrahepatic portosystemic shunt deemed too high risk, and endovascular embolisation through interventional radiology was sought. Coil-assisted retrograde transvenous obliteration was used to good effect. This rare approach has advantages over balloon occlusion, avoiding long indwelling balloon time and risk of rupture or infection, as well as time efficiency.
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Affiliation(s)
- Meera Mistry
- Department of Gastroenterology and Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Joseph Fiske
- Department of Gastroenterology and Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Tehreem Chaudhry
- Department of Gastroenterology and Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Timothy J Cross
- Department of Gastroenterology and Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Shemin Mehta
- Department of Radiology, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, Liverpool, UK
| | - Khaled Ballal
- Department of Radiology, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, Liverpool, UK
| | - Previn Diwakar
- Department of Radiology, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, Liverpool, UK
| | - James Chambers
- Department of Radiology, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, Liverpool, UK
| | - Philip J Smith
- Department of Gastroenterology and Hepatology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
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