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Commins N, Subhaharan D, Kurup R, Wickremeratne T, Mitchell J, Elmes J, Braund A, Funakoshi N, Langton J, Leschke P, O'Beirne J. Indications and outcomes of transjugular intrahepatic portosystemic shunt insertion in two regional Australian hepatology centres. Intern Med J 2024. [PMID: 38654627 DOI: 10.1111/imj.16384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/13/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is an important therapy for complications of portal hypertension but remains underutilised in regional settings. AIMS The aim of this study is to explore the demographics, indications, outcomes and complications in patients undergoing TIPS in two regional hepatology centres. METHODS Retrospective analysis was undertaken of all patients undergoing TIPS at two regional centres between January 2017 and March 2023. The primary outcome measures were efficacy and complications of TIPS. Patient demographics (such as age, baseline liver severity scores and aetiology of liver disease) and indications for TIPS are detailed. RESULTS Forty-eight patients underwent TIPS. Median age was 56 years (interquartile range (IQR): 46-65). The most common indications for TIPS were refractory ascites (n = 17) and failure of secondary prophylaxis of variceal bleeding (n = 13). Cumulative survival at 3 months and 1 year was 93% and 77% respectively. There was no significant difference in outcomes based on TIPS indication. The median number of paracenteses in patients undergoing TIPS for refractory ascites 1 year pre- and post-TIPS were 10 (IQR: 4.5-16) and 2 (IQR: 0-4) respectively (P < 0.001). There were no procedure-related deaths. Inpatient management of liver disease complications had a mean cost of $32 874.67 (SEM: 7779) in 1 year pre-TIPS compared with $12 304.70 (SEM: 3531.1) in 1 year post-TIPS (P < 0.001). CONCLUSIONS TIPS is a safe and effective treatment to reduce complications of portal hypertension and can be performed successfully in the regional setting.
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Affiliation(s)
- Natalie Commins
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Deloshaan Subhaharan
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- Department of Hepatology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Rajiv Kurup
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Tehara Wickremeratne
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Jonathan Mitchell
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Julie Elmes
- Department of Hepatology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Alicia Braund
- Department of Hepatology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Natalie Funakoshi
- Department of Hepatology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Jonathan Langton
- Department of Interventional Radiology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Paul Leschke
- Department of Interventional Radiology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - James O'Beirne
- Department of Hepatology, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
- University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
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Khatib S, Sabobeh T, Ahmed M, Abdalla K, Algeo E. Incarcerated Umbilical Hernia Following Therapeutic Paracentesis in a Cirrhotic Patient. Cureus 2022; 14:e23851. [PMID: 35530876 PMCID: PMC9071239 DOI: 10.7759/cureus.23851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/05/2022] Open
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3
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McDaniel C, Bell R, Farha N, Vozzo C, Bullen J, Rosen M, Romero-Marrero C, Partovi S, Kapoor B. Risk of hernia-related complications after transjugular intrahepatic portosystemic shunt creation in patients with pre-existing ventral abdominal hernias: 15-year experience at a quaternary medical center. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000876. [PMID: 35318192 PMCID: PMC8943763 DOI: 10.1136/bmjgast-2022-000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/16/2022] [Indexed: 11/12/2022] Open
Abstract
Objective Transjugular intrahepatic portosystemic shunt (TIPS) placement is used to treat the sequelae of portal hypertension, including refractory variceal bleeding, ascites and hepatic hydrothorax. However, hernia-related complications such as incarceration and small bowel obstruction can occur after TIPS placement in patients with pre-existing hernias. The aim of this study was to determine the incidence of hernia complications in the first year after TIPS placement and to identify patient characteristics leading to an increased risk of these complications. Design This retrospective analysis included patients with pre-existing abdominal hernias who underwent primary TIPS placement with covered stents at our institution between 2004 and 2018. The 1-year hernia complication rate and the average time to complications were documented. Using a Wilcoxon rank-sum test, the characteristics of patients who developed hernia-related complications versus the characteristics of those without complications were compared. Results A total of 167 patients with pre-existing asymptomatic abdominal hernias were included in the analysis. The most common reason for TIPS placement was refractory ascites (80.6%). A total of 36 patients (21.6%) developed hernia-related complications after TIPS placement, including 20 patients with acute complications and 16 with non-acute complications. The mean time to presentation of hernia-related complications was 66 days. Patients who developed hernia-related complications were more likely than those without complications to have liver cirrhosis secondary to alcohol consumption (p=0.049), although this association was no longer significant after multivariate analysis. Conclusion Within 1 year after TIPS placement, approximately 20% of patients with pre-existing hernias develop hernia-related complications, typically within the first 2 months after the procedure. Patients with pre-existing hernia undergoing TIPS placement should be educated regarding the signs and symptoms of hernia-related complications, including incarceration and small bowel obstruction.
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Affiliation(s)
- Charles McDaniel
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ruth Bell
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Natalie Farha
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Catherine Vozzo
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer Bullen
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Rosen
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Sasan Partovi
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio, USA
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Keshava SN, Moses V, Sharma A, Ahmed M, Narayanan S, Padmanabhan A, Goel A, Zachariah U, Eapen C. Technical and Medium-Term Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt with Fluoroscopy and Additional Trans-abdominal Ultrasound Guidance. Indian J Radiol Imaging 2021; 31:858-866. [PMID: 35136497 PMCID: PMC8817814 DOI: 10.1055/s-0041-1735928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Abstract
Background and Objective The aim of the study is to evaluate the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) performed with additional transabdominal ultrasound guidance.
Material and Methods Patients who underwent TIPS between January 2004 to January 2020 in our center were studied. Technical, hemodynamic, angiographic, and clinical outcome were recorded up to 1 year of follow-up.
Results TIPS was attempted in 162 patients (median [range] age 37[3–69] years; 105 were males and 57 were females; Etiology: Budd-Chiari syndrome [BCS] 91, cirrhosis 65, symptomatic acute portal venous thrombosis [PVT] 3, veno-occlusive disease [VOD] 2, congenital portosystemic shunt [CPSS] 1) during the study period. Indication for TIPS was refractory ascites in 135 patients (BCS 86, cirrhosis 49) and variceal bleed in 21 patients (BCS 5, cirrhosis 16). Technical success was seen in 161 of the 162 (99.4%) patients. The tract was created from hepatic vein in 55 patients and inferior vena cava (IVC) in 106 patients. Complications within 1 week post TIPS were seen in 29 of the 162 (18%) patients, of whom one developed unexplained arrhythmia and hypotension and died. Of the patients with available follow-up, clinical success was noted in 120 (81%), while 14 (9%) patients had partial nonresponse and six (4%) had complete nonresponse. Eight (5%) patients died during the follow-up period.
Conclusion The technical success of TIPS creation with additional transabdominal ultrasound guidance is very high with low peri-procedural complication rate. It has enabled the inclusion of a wider spectrum of cases like acute PVT and obliterated hepatic veins which were otherwise considered contraindications.
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Affiliation(s)
- Shyamkumar N. Keshava
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vinu Moses
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anand Sharma
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Munawwar Ahmed
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sathya Narayanan
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Aswin Padmanabhan
- Department of Interventional Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Uday Zachariah
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - C.E. Eapen
- Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India
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Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1014-1048. [PMID: 33942342 DOI: 10.1002/hep.31884] [Citation(s) in RCA: 294] [Impact Index Per Article: 98.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, and Center for Liver Investigation Fostering discovEryUniversity of WashingtonSeattleWA
| | - Paulo Angeli
- Unit of Hepatic Emergencies and Liver TransplantationDepartment of MedicineDIMEDUniversity of PadovaPaduaItaly
| | - Guadalupe Garcia-Tsao
- Department of Internal MedicineSection of Digestive DiseasesYale UniversityNew HavenCT.,VA-CT Healthcare SystemWest HavenCT
| | - Pere Ginès
- Liver Unit, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i SunyerUniversity of BarcelonaBarcelonaSpain.,Centro de Investigación Biomèdica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Simon C Ling
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Mitra K Nadim
- Division of NephrologyUniversity of Southern CaliforniaLos AngelesCA
| | - Florence Wong
- Division of Gastroenterology and HepatologyUniversity Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford UniversityPalo AltoCA
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Young S, Larson L, Bermudez J, Mohei H, Rostambeigi N, Golzarian J, Mahgoub A. Evaluation of the frequency and factors predictive of hernia incarceration following transjugular intrahepatic portosystemic shunt placement. Clin Radiol 2021; 76:287-293. [PMID: 33549300 DOI: 10.1016/j.crad.2020.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 12/30/2020] [Indexed: 02/07/2023]
Abstract
AIM To examine the frequency and predictive factors for bowel incarceration following transjugular intrahepatic portosystemic shunts (TIPS) placement to treat refractory cirrhosis-induced ascites. MATERIALS AND METHODS Ninety-nine patients with known hernias at the time of TIPS placement were identified. Their electronic medical records were reviewed and pertinent pre-procedural, procedural, and outcome variables were recorded. Patients were divided between those that suffered incarceration (study group) and a control group of those with a hernia who did not suffer incarceration. RESULTS Twelve of the 99 patients (12.1%) suffered hernia incarceration, of which seven (7.1%) suffered incarceration in the first 90 days. One patient who suffered incarceration ultimately died from complications of the incarceration. When comparing all patients who suffered incarceration to controls, incarceration patients were found to have significantly higher albumin levels (mean 3.13 versus 2.73, p=0.02). When just considering those who had incarcerations in the first 90 days to controls, incarceration patients were less likely to have improvement in their ascites (p=0.04). CONCLUSIONS Incarcerated hernias occur frequently after TIPS placement and can lead to significant morbidity and mortality. Clinicians should be aware of this complication and counsel patients on presenting symptoms prior to placement.
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Affiliation(s)
- S Young
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA.
| | - L Larson
- Department of Medicine, Division of Gastroenterology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA
| | - J Bermudez
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA
| | - H Mohei
- Department of Medicine, Division of Gastroenterology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA
| | - N Rostambeigi
- Department of Radiology, Division of Interventional Radiology, Washington University, 5110 S Kingshighway Blvd, St Louis, MO 63110, USA
| | - J Golzarian
- Department of Radiology, Division of Interventional Radiology, University of Minnesota, 420 Delaware ST SE, Minneapolis, MN 55455, USA
| | - A Mahgoub
- Department of Medicine, Division of Gastroenterology, Baylor Scott and White, 3410 Worth St, Ste 860, Dallas, TX 75246, USA
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Guo C, Liu Q, Wang Y, Li J. Umbilical Hernia Repair in Cirrhotic Patients With Ascites: A Systemic Review of Literature. Surg Laparosc Endosc Percutan Tech 2020; 31:356-362. [PMID: 33347087 DOI: 10.1097/sle.0000000000000891] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 10/05/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Umbilical hernia is a common abdominal complication in cirrhotic patients. The incidence of umbilical hernias can be up to 20% in the presence of ascites. However, there is no consensus regarding the optimal management of umbilical hernias in cirrhotic patients. The purpose of this study is to review the management of umbilical hernias in cirrhotic patients with ascites. METHODS A search of the available literature in English since 1980 was performed using PubMed, the Cochrane Library, and a search of relevant journals and reference lists. The search terms included "umbilical hernia," "ascites," "cirrhosis," and any derivatives of these terms, and the literature search identified all the relevant publications. RESULTS Thirty-three relevant articles published in the language of English were identified. Fourteen studies involved the management of refractory ascites in cirrhotic patients. Twenty-four studies included cirrhotic patients receiving elective or emergency surgery. Because of much lower morbidity and mortality in elective surgery than in emergency surgery, many authors advocated early elective repair of uncomplicated umbilical hernias in cirrhotic patients. Of these, 2 studies described laparoscopic umbilical hernioplasty, with a significant lower morbidity and hernia recurrence than open repair. Fifteen studies described the use of prosthetic mesh umbilical hernia repair in cirrhotic patients, which was associated with minimal wound-related morbidity and markedly lower recurrences. CONCLUSIONS Our results indicate that early elective repair of uncomplicated umbilical hernias is recommended in cirrhotic patients with tolerable hepatic functional reserve or when the expected time for liver transplantation is >3 months. Umbilical hernias are supposed to be corrected in the process of liver transplantation, provided that patients could have a better prospect to be transplanted within 3 months. Control of ascites is a crucial part to successful outcomes of umbilical hernia repair. Large volume paracentesis, concomitant peritoneovenous shunting with herniorrhaphy and transjugular intrahepatic portosystemic shunting can be applied to control refractory ascites. Emergency repair of umbilical hernias is indicated in cirrhotic patients with ascites when complications develop.
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Affiliation(s)
| | | | - Yong Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Junsheng Li
- Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing
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Khodarahmi I, Shahid MU, Contractor S. Incarceration of umbilical hernia: a rare complication of large volume paracentesis. J Radiol Case Rep 2015; 9:20-5. [PMID: 26629305 DOI: 10.3941/jrcr.v9i9.2614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We present two cases of umbilical hernia incarceration following large volume paracentesis (LVP) in patients with cirrhotic ascites. Both patients became symptomatic within 48 hours after the LVP. Although being rare, given the significantly higher mortality rate of cirrhotic patients undergoing emergent herniorrhaphy, this complication of LVP is potentially serious. Therefore, it is recommended that patients be examined closely for the presence of umbilical hernias before removal of ascitic fluid and an attempt should be made for external reduction of easily reducible hernias, if a hernia is present.
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Affiliation(s)
- Iman Khodarahmi
- Department of Radiology, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Muhammad Usman Shahid
- Department of Radiology, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Sohail Contractor
- Department of Radiology, Rutgers, The State University of New Jersey, Newark, NJ, USA
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Umbilical paracentesis for incarcerated umbilical hernia in patients with end-stage liver disease. Hernia 2015; 20:531-3. [DOI: 10.1007/s10029-015-1421-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 08/14/2015] [Indexed: 01/27/2023]
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Suhocki PV, Lungren MP, Kapoor B, Kim CY. Transjugular intrahepatic portosystemic shunt complications: prevention and management. Semin Intervent Radiol 2015; 32:123-32. [PMID: 26038620 DOI: 10.1055/s-0035-1549376] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) insertion has been well established as an effective treatment in the management of sequelae of portal hypertension. There are a wide variety of complications that can be encountered, such as hemorrhage, encephalopathy, TIPS dysfunction, and liver failure. This review article summarizes various approaches to preventing and managing these complications.
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Affiliation(s)
- Paul V Suhocki
- Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, North Carolina
| | - Matthew P Lungren
- Department of Radiology, Stanford University Medical Center, Palo Alto, California
| | - Baljendra Kapoor
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charles Y Kim
- Division of Vascular and Interventional Radiology, Duke University Medical Center, Durham, North Carolina
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Im GY, Lubezky N, Facciuto ME, Schiano TD. Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk. Clin Liver Dis 2014; 18:477-505. [PMID: 24679507 DOI: 10.1016/j.cld.2014.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.
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Affiliation(s)
- Gene Y Im
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Nir Lubezky
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Marcelo E Facciuto
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA
| | - Thomas D Schiano
- Icahn School of Medicine at Mount Sinai, The Mount Sinai Medical Center, Recanati/Miller Transplantation Institute, One Gustave Levy Place, Box 1104, New York, NY 10029-6574, USA.
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Smith MT, Rase B, Woods A, Trotter J, Gipson M, Kondo K, Ray C, Durham J. Risk of hernia incarceration following transjugular intrahepatic portosystemic shunt placement. J Vasc Interv Radiol 2013; 25:58-62. [PMID: 24269791 DOI: 10.1016/j.jvir.2013.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 09/04/2013] [Accepted: 09/05/2013] [Indexed: 01/28/2023] Open
Abstract
PURPOSE Hernia complications after creation of a transjugular intrahepatic portosystemic shunt (TIPS) have been reported, although the incidence of this complication is unknown. This study was designed to determine the incidence, morbidity, and outcome of hernia complications in patients with preexisting abdominal or inguinal hernias after TIPS creation. MATERIALS AND METHODS The medical records of 244 consecutive patients undergoing TIPS creation between 1999 and 2007 at a single institution were reviewed. The study population was 57 patients (23%) with a preprocedural abdominal or inguinal hernia. The investigated outcome was small bowel obstruction or postprocedural incarceration of a preexisting hernia. Demographic and procedural variables were evaluated for an associated increased risk of hernia complications. RESULTS Hernia complications developed in 25% of patients (14 of 57) after TIPS creation at a mean presentation of 62 days (range, 2-588 d). Thirteen complications (93%) required emergent surgery, of which four (29%) required bowel resection for necrosis. There were no resulting deaths. Ninety-eight percent of patients with a hernia complication had the procedure to treat refractory ascites. The indication of refractory ascites was significantly associated with the risk of a hernia complication (P = .002). CONCLUSIONS A 25% incidence of hernia complications following TIPS creation in patients being treated for refractory ascites is higher than expected; emergent surgery is required in most cases. Further investigation to formulate a plan for elective management is warranted.
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Affiliation(s)
- Mitchell T Smith
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045.
| | - Benjamin Rase
- Department of Radiology, University of Colorado School of Medicine, Denver, Colorado
| | - Alyn Woods
- Department of Radiology, David Grant Medical Center, Travis AFB, California
| | - James Trotter
- Liver Transplantation Center, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Matt Gipson
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
| | - Kimi Kondo
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
| | - Charles Ray
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
| | - Janette Durham
- Department of Radiology, Division of Interventional Radiology, University of Colorado Denver, 12700 E. 19th Ave, Room P15-1205, Aurora, CO 80045
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13
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Russell KW, Mone MC, Scaife CL. Umbilical paracentesis for acute hernia reduction in cirrhotic patients. BMJ Case Rep 2013; 2013:bcr-2013-201304. [PMID: 24132449 DOI: 10.1136/bcr-2013-201304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Emergent repair of umbilical hernias in cirrhotic patients is associated with a high risk for morbidity and mortality. We propose a new technique, umbilical paracentesis, for reduction of incarcerated hernias in the patient with ascites. Under ultrasound guidance, removal of ascitic fluid from the umbilical hernia sac can reduce the local pressure and thereby allow for easy hernia reduction, thus avoiding the need for an emergent operation.
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Affiliation(s)
- Katie W Russell
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
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14
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Acute abdomen secondary to incarcerated umbilical hernia after treatment of massive cirrhotic ascites. Case Reports Hepatol 2013; 2013:948172. [PMID: 25374722 PMCID: PMC4208442 DOI: 10.1155/2013/948172] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 02/14/2013] [Indexed: 11/18/2022] Open
Abstract
Umbilical herniation is common in patients with liver cirrhosis and ascites. Rarely, they suffer from incarceration and strangulation of the umbilical hernia after treatment of ascites. We report 3 cases of umbilical hernia incarceration following removal of massive ascites with different treatment modalities. Physicians managing this group of patients should be aware of this rare and potentially fatal complication.
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15
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Incarceration of umbilical hernia after radiological insertion of a Denver peritoneovenous shunt. Jpn J Radiol 2012. [DOI: 10.1007/s11604-012-0161-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Umbilical hernia (UH) is the most frequent abdominal wall complication of ascites in cirrhotic patients. Treatment to control ascites, which mainly consists of repeated paracentesis or transjugular intrahepatic portosystemic shunt (TIPS), is mandatory; otherwise the risk of hernia recurrence is very high. Nowadays, surgical portosystemic shunts are rarely performed. Classically, hernia repair was offered only to patients with symptomatic UH, but presently, even if the hernia is minimally symptomatic, there is tendency to perform elective repair to avoid emergency surgery for complications associated with very high mortality and morbidity rates (rupture and strangulation). If liver transplantation is indicated, treatment of UH can be performed simultaneously, unless the hernia is highly symptomatic or complicated or if the waiting time on the transplantation list is long. During repair, necrotic skin tissue should be excised; the use of prosthetic material (if the defect is large) is possible with a low risk of infection as long as ascites is sterile. The advantage of laparoscopic repair of large UH is to avoid any skin incision (precluding ascitic fluid leak) and avoid exposing prosthetic mesh to necrotic infected tissue. If the defect is small, UH repair can be performed under local anesthesia.
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Garcia-Tsao G. Transjugular intrahepatic portosystemic shunt in the management of refractory ascites. Semin Intervent Radiol 2011; 22:278-86. [PMID: 21326706 DOI: 10.1055/s-2005-925554] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this article is to describe the pathophysiological basis for the use of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and refractory ascites, the short- and long-term hemodynamic, biochemical, and hormonal changes after TIPS, and the results of controlled trials of TIPS in cirrhotic patients with refractory ascites. TIPS placement is associated with normalization of sinusoidal pressure and a significant improvement in urinary sodium excretion that correlates with suppression of plasma renin activity (indicative of an improvement in effective arterial blood volume). Although effective in preventing the recurrence of ascites, the efficacy of TIPS is offset by an increase in the incidence of severe hepatic encephalopathy, a high incidence of shunt dysfunction, and a higher cost without an overall survival benefit, which should be reevaluated in light of polytetrafluoroethylene-covered stents. TIPS placement is currently indicated in seleceted cirrhotic patients with refractory ascites who require more than two to three large-volume paracenteses per month.
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Affiliation(s)
- Guadalupe Garcia-Tsao
- Professor of Medicine, Yale University School of Medicine, and VA-CT Healthcare System, New Haven, Connecticut
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Eker HH, van Ramshorst GH, de Goede B, Tilanus HW, Metselaar HJ, de Man RA, Lange JF, Kazemier G. A prospective study on elective umbilical hernia repair in patients with liver cirrhosis and ascites. Surgery 2011; 150:542-6. [PMID: 21621237 DOI: 10.1016/j.surg.2011.02.026] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 02/17/2011] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients with both cirrhosis and ascites have a 20% risk of developing umbilical hernia. A retrospective study from our center comparing conservative management of umbilical hernia with elective repair in these patients showed a significant risk of mortality as a result of hernia incarceration in conservatively treated patients. The goal of this study was to assess the safety and efficacy of elective umbilical hernia repair in these patients prospectively. METHODS Patients with liver cirrhosis and ascites presenting with an umbilical hernia were included in this study. For all patients, the expected time to liver transplantation was more than 3 months, and they did not have a patent umbilical vein in the hernia sac. The following data were collected prospectively for all patients: Child-Pugh-Turcotte (CPT) classification, model for end-stage liver disease (MELD) score, kidney failure, cardiovascular comorbidity, operation-related complications, and duration of hospital stay. Mortality rates were registered in hospital records and verified in government records during follow-up. Mortality rates were registered in hospital records and verified in government records during follow-up. On completion of the study, a retrospective survey was performed to search for any patients who met the study inclusion criteria but were left out of the study cohort. RESULTS In total, 30 patients (25 males) underwent operation at a mean age of 58 years (standard deviation [SD] ± 9 years). Of these 30 patients, 6 were classified as CPT grade A (20%), 19 (63%) as grade B, and 5 (17%) as grade C. The patients' median MELD score was 12 (interquartile range [IQR], 8-16). In 10 (33%) of the 30 patients hernia repair was performed with mesh. The median duration of hospital stay was 3 days (IQR, 2-4). None of the patients were admitted to the intensive care unit. Postoperative complications included pneumonia and decompensation of cirrhosis (1 case each,) resulting in prolonged hospital stay for those 2 patients. After a median follow-up period of 25 months (IQR, 14-34), 2 (7%) of the 30 patients died; neither of the deaths were attributable to the umbilical hernia repair. A total of 2 patients suffered recurrence. CONCLUSION Elective umbilical hernia repair is safe and the preferred approach in cirrhotic patients with ascites.
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Affiliation(s)
- Hasan H Eker
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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Abstract
The most common complications of umbilical hernias in patients with cirrhosis and ascites include leakage, ulceration, rupture and incarceration. If such a complication is present, there is a high mortality rate after surgical repair. Elective repair is the most effective choice, as it prevents complications with a lower mortality. However, the control of ascites before and/or after repair is mandatory but may not always be possible with diuretics and paracentesis. Portal decompression by transjugular intrahepatic portosystemic shunt (TIPS) with better control of ascites may allow these patients to undergo surgery. Patients with cirrhosis and umbilical hernias should be referred for consideration of an elective surgical repair with mesh, preferably after optimal management of ascites. There should be a low threshold for placement of a TIPS to facilitate surgery and reduce the chance of severe recurrence of ascites. If surgery is contraindicated, a TIPS must be considered for control of ascites.
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Andraus W, Sepulveda A, Pinheiro RSN, Teixeira AR, D'Albuquerque LAC. Management of uncommon hernias in cirrhotic patients. Transplant Proc 2010; 42:1724-8. [PMID: 20620510 DOI: 10.1016/j.transproceed.2010.02.090] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 01/17/2010] [Accepted: 02/26/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Abdominal hernias are a common disease among cirrhotic patients, because of malnutrition and persistently high intra-abdominal pressure due to ascites. When tense ascites is present, life-threatening complications are likely to occur. In such cases, the morbidity and mortality rates are high. OBJECTIVE We describe 3 cirrhotic patients with rare complicated hernias that needed surgical repair. We discuss optimal timing for surgical approaches and the necessity of ascites control before surgery, as well as the technical details of the procedures. METHOD Review of hospital charts of selected rare cases of herniae in cirrhotic patients. CONCLUSION Elective surgical approaches can treat even uncommon hernias in cirrhotic patients with good results.
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Affiliation(s)
- W Andraus
- Department of Gastroenterology, Sao Paulo University School of Medicine, Sao Paulo, Brazil
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21
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Marsman HA, Heisterkamp J, Halm JA, Tilanus HW, Metselaar HJ, Kazemier G. Management in patients with liver cirrhosis and an umbilical hernia. Surgery 2007; 142:372-5. [PMID: 17723889 DOI: 10.1016/j.surg.2007.05.006] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2006] [Revised: 05/02/2007] [Accepted: 05/03/2007] [Indexed: 12/20/2022]
Abstract
BACKGROUND Optimal management in patients with umbilical hernias and liver cirrhosis with ascites is still under debate. The objective of this study was to compare the outcome in our series of operative versus conservative treatment of these patients. METHODS In the period between 1990 and 2004, 34 patients with an umbilical hernia combined with liver cirrhosis and ascites were identified from our hospital database. In 17 patients, treatment consisted of elective hernia repair, and 13 were managed conservatively. Four patients underwent hernia repair during liver transplantation. RESULTS Elective hernia repair was successful without complications and recurrence in 12 out of 17 patients. Complications occurred in 3 of these 17 patients, consisting of wound-related problems and recurrence in 4 out 17. Success rate of the initial conservative management was only 23%; hospital admittance for incarcerations occurred in 10 of 13 patients, of which 6 required hernia repair in an emergency setting. Two patients of the initially conservative managed group died from complications of the umbilical hernia. In the 4 patients that underwent hernia correction during liver transplantation, no complications occurred and 1 patient had a recurrence. CONCLUSIONS Conservative management of umbilical hernias in patients with liver cirrhosis and ascites leads to a high rate of incarcerations with subsequent hernia repair in an emergency setting, whereas elective repair can be performed with less morbidity and is therefore advocated.
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Mallavarapu RK, Grimsley EW. Incarcerated umbilical hernia after transjugular intrahepatic portosystemic shunt procedure for refractory ascites. Clin Gastroenterol Hepatol 2007; 5:A26. [PMID: 17825762 DOI: 10.1016/j.cgh.2007.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ravi K Mallavarapu
- Department of Internal Medicine, Mercer University School of Medicine, Macon, Georgia, USA
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Montgomery A, Ferral H, Vasan R, Postoak DW. MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures. Cardiovasc Intervent Radiol 2005; 28:307-12. [PMID: 15886944 DOI: 10.1007/s00270-004-0145-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To Evaluate the MELD score as a predictor of 30-day mortality in patients undergoing elective TIPS procedures. METHODS This was a retrospective, IRB-approved study. The medical records of all patients who underwent a TIPS procedure between May 1, 1999 and June 1, 2003 in a single institution were reviewed. Patients who underwent elective TIPS were selected. Elective TIPS was performed in 119 patients with a mean age of 55.1 (+/- 9.6) years. The MELD and Child-Pugh scores before TIPS, etiology of cirrhosis, portosystemic gradients before and after TIPS, procedure time, and procedural complications were obtained from the medical records. The MELD and Child-Pugh scores before TIPS were compared between the survivor group (SG) and the early death (EDG) group. The early death rate was calculated for MELD score subgroups (1-10, 11-17, 18-24, and >24). Data were analyzed using the Fisher exact test, chi-square test and independent-sample t-test. A p value of less than 0.05 was considered significant. RESULTS Technical success rate was 100%. The early death rate was 10.9% (13/119). The mean MELD scores before TIPS were 19.4 (+/- 5.9) (EDG) and 14 (+/- 4.2) (SG) (p = 0.025). The early death rate was highest in the pre-TIPS MELD > 24 subgroup. The Child-Pugh scores were 9.0 (+/- 1.6) (SG) and 9.8 +/- 1.06 (EDG) (p = 0.08). The mean portosystemic gradients before TIPS were 20.5 (+/- 7.7) mmHg (EDG) and 22.7 (+/- 7.3) (SG) (p > 1) and the mean portosystemic gradients after TIPS were 6.5 (+/- 3.5) (EDG) and 6.9 (+/- 2.4) (SG) (p > 1). The mean procedural times were 95.6 (+/- 8.4) min (EDG) and 89.2 (+/- 7.5) min (SG) (p > 1). No early death was attributed to a fatal complication during TIPS. CONCLUSION The MELD score is useful in identifying patients at a higher risk of early death after an elective TIPS. On th basis of our results, we do not endorse elective TIPS in patients with MELD scores > 24.
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Affiliation(s)
- Aaron Montgomery
- Section of Cardiovascular and Special interventions, Department of Radiology, The University of Texas Health Sciences Center at San Antonio, Mail code 7880, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
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Sarit C, Eliezer A, Mizrahi S. Minimally invasive repair of recurrent strangulated umbilical hernia in cirrhotic patient with refractory ascites. Liver Transpl 2003; 9:621-2. [PMID: 12783405 DOI: 10.1053/jlts.2003.50078] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To repair a recurrent strangulated umbilical hernia in a cirrhotic patient with refractory ascites, we used a minimally invasive procedure. The laparoscopic repair included a release of the incarcerated small bowel loop and secure of a dual Gortex mesh onto the fascial rim. Our satisfactory long-term results should encourage surgeons to adapt this surgical approach.
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Affiliation(s)
- Cohen Sarit
- Department of Surgery A, Soroka University Medical Center, The Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
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