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Soldner T, Bakke K, Savage S. Surgical Management of Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:301-316. [PMID: 38395485 DOI: 10.1016/j.giec.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
The use of surgery in managing upper gastrointestinal (GI) bleeding has rapidly diminished secondary to advances in our understanding of the pathologies that underlie upper GI bleeding, pharmaceutical treatments for peptic ulcer disease, and endoscopic procedures used to gain hemostasis. A surgeon must work collaboratively with gastroenterologist and interventional radiologist to determine when, and what kind of, surgery is appropriate for the patient with upper GI bleeding.
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Affiliation(s)
- Teresa Soldner
- Acute Care and Regional General Surgery, University of Wisconsin School of Medicine and Public Health, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Katherine Bakke
- Acute Care and Regional General Surgery, University of Wisconsin School of Medicine and Public Health, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Stephanie Savage
- Acute Care and Regional General Surgery, University of Wisconsin School of Medicine and Public Health, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA.
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Aslan A, Stevens C, Aldine AS, Mamilly A, De Alba L, Arevalo O, Ahuja C, Cuellar HH. The reproducibility of interventional radiology randomized controlled trials and external validation of a classification system. Diagn Interv Radiol 2023; 29:529-534. [PMID: 37070845 PMCID: PMC10679611 DOI: 10.4274/dir.2023.222052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/24/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE The fragility index (FI) measures the robustness of randomized controlled trials (RCTs). It complements the P value by taking into account the number of outcome events. In this study, the authors measured the FI for major interventional radiology RCTs. METHODS Interventional radiology RCTs published between January 2010 and December 2022 relating to trans-jugular intrahepatic portosystemic shunt, trans-arterial chemoembolization, needle biopsy, angiography, angioplasty, thrombolysis, and nephrostomy tube insertion were analyzed to measure the FI and robustness of the studies. RESULTS A total of 34 RCTs were included. The median FI of those studies was 4.5 (range 1-68). Seven trials (20.6%) had a number of patients lost to follow-up that was higher than their FI, and 15 (44.1%) had a FI of 1-3. CONCLUSION The median FI, and hence the reproducibility of interventional radiology RCTs, is low compared to other medical fields, with some having a FI of 1, which should be interrupted cautiously.
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Affiliation(s)
- Assala Aslan
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Christopher Stevens
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Amro Saad Aldine
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Ahmed Mamilly
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Luis De Alba
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Octavio Arevalo
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Chaitanya Ahuja
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Hugo H. Cuellar
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
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3
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The Portosystemic Shunt for the Control of Variceal Bleeding in Cirrhotic Patients: Past and Present. Can J Gastroenterol Hepatol 2022; 2022:1382556. [PMID: 36164663 PMCID: PMC9509272 DOI: 10.1155/2022/1382556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/11/2022] [Accepted: 08/20/2022] [Indexed: 11/21/2022] Open
Abstract
Based on an experience of more than 50 years in the treatment of portal hypertension (PHT), the authors review and analyze the evolution of the surgical portocaval shunt (PCS). We would like to provide an insight into the past of PCS, in order to compare it with the current state of the treatment of PHT complications. As a landmark of the past, we shall present statistics of more than 500 cases of PHT operated between 1968 and 1983. From this group, 238 patients underwent surgical portocaval shunting during a fifteen-year period. The behavior of the portal hemodynamics following PCS was studied and the postoperative decrease in portal pressure (PP), as well as the residual PP, were recorded. The portal manometric determinations were made by electronic recordings using the Hellige device and direct intraoperative recordings through the catheterization of a ramus in the portal area. The results of PCS are superposable, in terms of hemodynamic efficiency, with those of the intrahepatic shunt (TIPS-transjugular intrahepatic portosystemic shunt). The authors discuss the current place of PCS, in obvious decline in comparison with the situation 50 years ago. The current methods of controlling variceal bleeding represent obvious progress. PCS remains with very limited indications, in specific situations when the other therapeutic methods have failed or are not recommended.
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Roberts D, Best LM, Freeman SC, Sutton AJ, Cooper NJ, Arunan S, Begum T, Williams NR, Walshaw D, Milne EJ, Tapp M, Csenar M, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Treatment for bleeding oesophageal varices in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD013155. [PMID: 33837526 PMCID: PMC8094233 DOI: 10.1002/14651858.cd013155.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with liver cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed within about one to three years after diagnosis. Several different treatments are available, including, among others, endoscopic sclerotherapy, variceal band ligation, somatostatin analogues, vasopressin analogues, and balloon tamponade. However, there is uncertainty surrounding the individual and relative benefits and harms of these treatments. OBJECTIVES To compare the benefits and harms of different initial treatments for variceal bleeding from oesophageal varices in adults with decompensated liver cirrhosis, through a network meta-analysis; and to generate rankings of the different treatments for acute bleeding oesophageal varices, according to their benefits and harms. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until 17 December 2019, to identify randomised clinical trials (RCTs) in people with cirrhosis and acute bleeding from oesophageal varices. SELECTION CRITERIA We included only RCTs (irrespective of language, blinding, or status) in adults with cirrhosis and acutely bleeding oesophageal varices. We excluded RCTs in which participants had bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those in whom initial haemostasis was achieved before inclusion into the trial, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS software, using Bayesian methods, and calculated the differences in treatments using odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. We performed also the direct comparisons from RCTs using the same codes and the same technical details. MAIN RESULTS We included a total of 52 RCTs (4580 participants) in the review. Forty-eight trials (4042 participants) were included in one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those with and without a previous history of bleeding. We included outcomes assessed up to six weeks. All trials were at high risk of bias. A total of 19 interventions were compared in the trials (sclerotherapy, somatostatin analogues, vasopressin analogues, sclerotherapy plus somatostatin analogues, variceal band ligation, balloon tamponade, somatostatin analogues plus variceal band ligation, nitrates plus vasopressin analogues, no active intervention, sclerotherapy plus variceal band ligation, balloon tamponade plus sclerotherapy, balloon tamponade plus somatostatin analogues, balloon tamponade plus vasopressin analogues, variceal band ligation plus vasopressin analogues, balloon tamponade plus nitrates plus vasopressin analogues, balloon tamponade plus variceal band ligation, portocaval shunt, sclerotherapy plus transjugular intrahepatic portosystemic shunt (TIPS), and sclerotherapy plus vasopressin analogues). We have reported the effect estimates for the primary and secondary outcomes when there was evidence of differences between the interventions against the reference treatment of sclerotherapy, but reported the other results of the primary and secondary outcomes versus the reference treatment of sclerotherapy without the effect estimates when there was no evidence of differences in order to provide a concise summary of the results. Overall, 15.8% of the trial participants who received the reference treatment of sclerotherapy (chosen because this was the commonest treatment compared in the trials) died during the follow-up periods, which ranged from three days to six weeks. Based on moderate-certainty evidence, somatostatin analogues alone had higher mortality than sclerotherapy (OR 1.57, 95% CrI 1.04 to 2.41; network estimate; direct comparison: 4 trials; 353 participants) and vasopressin analogues alone had higher mortality than sclerotherapy (OR 1.70, 95% CrI 1.13 to 2.62; network estimate; direct comparison: 2 trials; 438 participants). None of the trials reported health-related quality of life. Based on low-certainty evidence, a higher proportion of people receiving balloon tamponade plus sclerotherapy had more serious adverse events than those receiving only sclerotherapy (OR 4.23, 95% CrI 1.22 to 17.80; direct estimate; 1 RCT; 60 participants). Based on moderate-certainty evidence, people receiving vasopressin analogues alone and those receiving variceal band ligation had fewer adverse events than those receiving only sclerotherapy (rate ratio 0.59, 95% CrI 0.35 to 0.96; network estimate; direct comparison: 1 RCT; 219 participants; and rate ratio 0.40, 95% CrI 0.21 to 0.74; network estimate; direct comparison: 1 RCT; 77 participants; respectively). Based on low-certainty evidence, the proportion of people who developed symptomatic rebleed was smaller in people who received sclerotherapy plus somatostatin analogues than those receiving only sclerotherapy (OR 0.21, 95% CrI 0.03 to 0.94; direct estimate; 1 RCT; 105 participants). The evidence suggests considerable uncertainty about the effect of the interventions in the remaining comparisons where sclerotherapy was the control intervention. AUTHORS' CONCLUSIONS Based on moderate-certainty evidence, somatostatin analogues alone and vasopressin analogues alone (with supportive therapy) probably result in increased mortality, compared to endoscopic sclerotherapy. Based on moderate-certainty evidence, vasopressin analogues alone and band ligation alone probably result in fewer adverse events compared to endoscopic sclerotherapy. Based on low-certainty evidence, balloon tamponade plus sclerotherapy may result in large increases in serious adverse events compared to sclerotherapy. Based on low-certainty evidence, sclerotherapy plus somatostatin analogues may result in large decreases in symptomatic rebleed compared to sclerotherapy. In the remaining comparisons, the evidence indicates considerable uncertainty about the effects of the interventions, compared to sclerotherapy.
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Affiliation(s)
- Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Dana Walshaw
- Acute Medicine, Barts and The London NHS Trust, London, UK
| | | | | | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Kumar R, Kerbert AJC, Sheikh MF, Roth N, Calvao JAF, Mesquita MD, Barreira AI, Gurm HS, Ramsahye K, Mookerjee RP, Yu D, Davies NH, Mehta G, Agarwal B, Patch D, Jalan R. Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding. J Hepatol 2021; 74:66-79. [PMID: 32561318 DOI: 10.1016/j.jhep.2020.06.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Failure to control oesophago-gastric variceal bleeding (OGVB) and acute-on-chronic liver failure (ACLF) are both important prognostic factors in cirrhosis. The aims of this study were to determine whether ACLF and its severity define the risk of death in OGVB and whether insertion of rescue transjugular intrahepatic shunt (TIPS) improves survival in patients with failure to control OGVB and ACLF. METHODS Data on 174 consecutive eligible patients, with failure to control OGVB between 2005 and 2015, were collected from a prospectively maintained intensive care unit registry. Rescue TIPS was defined as technically successful TIPS within 72 hours of presentation with failure to control OGVB. Cox-proportional hazards regression analyses were applied to explore the impact of ACLF and TIPS on survival in patients with failure to control OGVB. RESULTS Patients with ACLF (n = 119) were significantly older, had organ failures and higher white cell count than patients with acute decompensation (AD, n = 55). Mortality at 42-days and 1-year was significantly higher in patients with ACLF (47.9% and 61.3%) than in those with AD (9.1% and 12.7%, p <0.001), whereas there was no difference in the number of endoscopies and transfusion requirements between these groups. TIPS was inserted in 78 patients (AD 21 [38.2%]; ACLF 57 [47.8%]; p = 0.41). In ACLF, rescue TIPS insertion was an independent favourable prognostic factor for 42-day mortality. In contrast, rescue TIPS did not impact on the outcome of patients with AD. CONCLUSIONS This study shows that in patients with failure to control OGVB, the presence and severity of ACLF determines the risk of 42-day and 1-year mortality. Rescue TIPS is associated with improved survival in patients with ACLF. LAY SUMMARY Variceal bleeding that is not controlled by initial endoscopy is associated with high risk of death. The results of this study showed that in the occurrence of failure of the liver and other organs defines the risk of death. In these patients, insertion of a shunt inside the liver to drain the portal vein improves survival.
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Affiliation(s)
- Rahul Kumar
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Duke-NUS Academic Medical Centre, CGH Campus, Singapore
| | - Annarein J C Kerbert
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - M Faisal Sheikh
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Noam Roth
- Intensive Care Unit, Royal Free Hospital London NHS Foundation Trust, London, UK
| | - Joana A F Calvao
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Centro Hospital de Tras-os-Montes e Alto Douro, EPE, Portugal
| | - Monica D Mesquita
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Centro Hospital de Tras-os-Montes e Alto Douro, EPE, Portugal
| | - Ana I Barreira
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Centro Hospital de Tras-os-Montes e Alto Douro, EPE, Portugal
| | - Haqeeqat S Gurm
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Komal Ramsahye
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Rajeshwar P Mookerjee
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Dominic Yu
- Department of Radiology, Royal Free Hospital London NHS Foundation Trust, London, UK
| | - Neil H Davies
- Department of Radiology, Royal Free Hospital London NHS Foundation Trust, London, UK
| | - Gautam Mehta
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK
| | - Banwari Agarwal
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK; Intensive Care Unit, Royal Free Hospital London NHS Foundation Trust, London, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free London NHS Trust, London, UK
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Campus, London, UK.
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Pandhi MB, Kuei AJ, Lipnik AJ, Gaba RC. Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding. Semin Intervent Radiol 2020; 37:3-13. [PMID: 32139965 DOI: 10.1055/s-0039-3402015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.
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Affiliation(s)
- Mithil B Pandhi
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Kuei
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew J Lipnik
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, Chicago, Illinois.,Division of Interventional Radiology, University of Illinois at Chicago, Chicago, Illinois
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Mohan BP, Chandan S, Khan SR, Kotagiri R, Kassab LL, Olaiya B, Ponnada S, Ofosu A, Adler DG. Self-expanding metal stents versus TIPS in treatment of refractory bleeding esophageal varices: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E291-E300. [PMID: 32118103 PMCID: PMC7035032 DOI: 10.1055/a-1067-4563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/15/2019] [Indexed: 12/24/2022] Open
Abstract
Background and study aims Refractory and recurrent esophageal variceal (EV) bleeding can be life threatening. Self-expanding metal stents (SEMS) have been used as a "bridge" therapy. However, their role in the treatment protocol is not established due to paucity in data. Methods We searched multiple databases from inception through May 2019 to identify studies that reported on SEMS and TIPS in refractory EV hemorrhage. Our primary goals were to analyze and compare the pooled all-cause mortality, immediate bleeding control and rebleeding rates. Results Five hundred forty-seven patients from 21 studies were analyzed (SEMS: 12 studies, 176 patients; TIPS: 9 studies, 398 patients). The pooled rate of all-cause mortality with SEMS was 43.6 % (95 % CI 28.6-59.8, I 2 = 38) and with TIPS was 27.9 % (95 % CI 16.3-43.6, I 2 = 91). The pooled rate of immediate bleeding control with SEMS was 84.5 % (95 % CI 74-91.2, I 2 = 40) and with TIPS was 97.9 % (95 % CI 87.7-99.7, I 2 = 0). The pooled rate of rebleeding with SEMS was 19.4 % (95 % CI 11.9-30.4, I 2 = 32) and with TIPS was 8.8 % (95 % CI 4.8-15.7, I 2 = 40). Conclusion Use of SEMS in refractory EV hemorrhage demonstrates acceptable immediate bleeding control with good technical success rate. Mortality and rebleeding rates were lesser with TIPS, however, its superiority and/ or inferiority cannot be validated due to limitations in the comparison methodology.
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Affiliation(s)
- Babu P. Mohan
- Internal Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, United States
| | - Saurabh Chandan
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Shahab R. Khan
- Internal Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, United States
| | - Rajesh Kotagiri
- Internal Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, United States
| | - Lena L. Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Babatunde Olaiya
- Internal Medicine, Marshfield Medical Center, Marshfield, Wisconsin, United States
| | - Suresh Ponnada
- Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, United States
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Brooklyn, New York, United States
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
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Ibadov RA, Babadzhanov AK, Irmatov SK, Gizatulina NR, Ibragimov SK, Ruziboev SA. [Standardization of intensive therapy tactics for acute hepatic insufficiency in patients with liver cirrhosis after portosystem shunting]. Khirurgiia (Mosk) 2019:61-67. [PMID: 30113595 DOI: 10.17116/hirurgia2018861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Here we analyze efficiency of the algorithm for intensive therapy of acute hepatic insufficiency in patients with cirrhosis after portosystemic shunting, based on the experience of the Republican Specialized Scientific and Practical Medical Center of Surgery named after academician V.V. Vakhidov and considering recommendations of the world's leading hepatology schools. MATERIAL AND METHODS Algorithm efficiency was analyzed based on the results of portosystemic shunting of 556 patients with cirrhosis and acute liver insufficiency. Treatment effectiveness was assessed by presence and severity of postoperative complications, such as hepatic insufficiency and hepatic encephalopathy. Initial decompensation of liver cirrhosis significantly increases the risk of postoperative complications of portosystemic shunting due to edematous ascites syndrome - liver insufficiency (13.5% vs 6.9% in patients without ascites p≥0.05) and hepatic encephalopathy (64.9% vs. 51,7%, respectively, p≥0.05). In group of patients with preoperative ascites syndrome mortality rate was 3.8% (10 patients) and in the group without ascites - 2.3% (6 patients). The main cause of early postoperative lethality was anastomotic thrombosis development with recurrence of bleeding from esophagus and stomach varicose veins. To reduce the risk of postoperative complications and lethality, a therapeutic-tactical algorithm was developed which was effective in combination with a complex of conservative and biophysical methods of treatment and aimed at eliminating the 'resolving factors' of their developmen. RESULTS One of the most important components of this algorithm is pharmacotherapy with hepatoprotective drugs use in patients with liver cirrhosis in the postoperative period to maintain liver functional state. Considering the antihypoxic, detoxifying and antioxidant properties of active components of remaxol and revealed positive effect of its use in patients (decrease in bilirubin level, increase in albumin fraction of total blood protein and decrease in activity of ALAT and ASAT in 2 times), this drug can be recommended for inclusion in the postoperative pathogenetic standard therapy in this category of patients.
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Affiliation(s)
- R A Ibadov
- Repulican specialized scientific and practical medical center of surgery named after academician V. Vakhidov 700115, Tashkent, ul. Farhad 10, Uzbekistan
| | - A Kh Babadzhanov
- Repulican specialized scientific and practical medical center of surgery named after academician V. Vakhidov 700115, Tashkent, ul. Farhad 10, Uzbekistan
| | - S Kh Irmatov
- Repulican specialized scientific and practical medical center of surgery named after academician V. Vakhidov 700115, Tashkent, ul. Farhad 10, Uzbekistan
| | - N R Gizatulina
- Repulican specialized scientific and practical medical center of surgery named after academician V. Vakhidov 700115, Tashkent, ul. Farhad 10, Uzbekistan
| | - S Kn Ibragimov
- Repulican specialized scientific and practical medical center of surgery named after academician V. Vakhidov 700115, Tashkent, ul. Farhad 10, Uzbekistan
| | - S A Ruziboev
- Samarkand State Medical Institute, Samarkand, ul. Amir Temur, 18, Uzbekistan
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9
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Brand M, Prodehl L, Ede CJ. Surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt for variceal haemorrhage in people with cirrhosis. Cochrane Database Syst Rev 2018; 10:CD001023. [PMID: 30378107 PMCID: PMC6516991 DOI: 10.1002/14651858.cd001023.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Variceal haemorrhage that is refractory or recurs after pharmacologic and endoscopic therapy requires a portal decompression shunt (either surgical shunts or radiologic shunt, transjugular intrahepatic portosystemic shunt (TIPS)). TIPS has become the shunt of choice; however, is it the preferred option? This review assesses evidence for the comparisons of surgical portosystemic shunts versus TIPS for variceal haemorrhage in people with cirrhotic portal hypertension. OBJECTIVES To assess the benefits and harms of surgical portosystemic shunts versus transjugular intrahepatic portosystemic shunt (TIPS) for treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, LILACS, Science Citation Index Expanded, and Conference Proceedings Citation Index - Science. We also searched on-line trial registries, reference lists of relevant articles, and proceedings of relevant associations for trials that met the inclusion criteria for this review (date of search 8 March 2018). SELECTION CRITERIA Randomised clinical trials comparing surgical portosystemic shunts versus TIPS for the treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials and extracted data using methodological standards expected by Cochrane. We assessed risk of bias according to domains and risk of random errors with Trial Sequential Analysis (TSA). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We found four randomised clinical trials including 496 adult participants diagnosed with variceal haemorrhage due to cirrhotic portal hypertension. The overall risk of bias in all the trials was judged at high risk. All the trials were conducted in the United States of America (USA). Two of the trials randomised participants to selective surgical shunts versus TIPS. The other two trials randomised participants to non-selective surgical shunts versus TIPS. The diagnosis of liver cirrhosis was by clinical and laboratory findings. We are uncertain whether there is a difference in all-cause mortality at 30 days between surgical portosystemic shunts compared with TIPS (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.44 to 1.99; participants = 496; studies = 4). We are uncertain whether there is a difference in encephalopathy between surgical shunts compared with TIPS (RR 0.56, 95% CI 0.27 to 1.16; participants = 496; studies = 4). We found evidence suggesting an increase in the occurrence of the following harms in the TIPS group compared with surgical shunts: all-cause mortality at five years (RR 0.61, 95% CI 0.42 to 0.90; participants = 496; studies = 4); variceal rebleeding (RR 0.18, 95% CI 0.07 to 0.49; participants = 496; studies = 4); reinterventions (RR 0.13, 95% CI 0.06 to 0.28; participants = 496; studies = 4); and shunt occlusion (RR 0.14, 95% CI 0.04 to 0.51; participants = 496; studies = 4). We could not perform an analysis of health-related quality of life but available evidence appear to suggest improved health-related quality of life in people who received surgical shunt compared with TIPS. We downgraded the certainty of the evidence for all-cause mortality at 30 days and five years, irreversible shunt occlusion, and encephalopathy to very low because of high risk of bias (due to lack of blinding); inconsistency (due to heterogeneity); imprecision (due to small sample sizes of the individual trials and few events); and publication bias (few trials reporting outcomes). We downgraded the certainty of the evidence for variceal rebleeding and reintervention to very low because of high risk of bias (due to lack of blinding); imprecision (due to small sample sizes of the individual trials and few events); and publication bias (few trials reporting outcomes). The small sample sizes and few events did not allow us to produce meaningful trial sequential monitoring boundaries, suggesting plausible random errors in our estimates. AUTHORS' CONCLUSIONS We found evidence suggesting that surgical portosystemic shunts may have benefit over TIPS for treatment of refractory or recurrent variceal haemorrhage in people with cirrhotic portal hypertension. Given the very low-certainty of the available evidence and risks of random errors in our analyses, we have very little confidence in our review findings.
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Affiliation(s)
- Martin Brand
- University of PretoriaDepartment of SurgeryPretoriaSouth Africa0001
| | - Leanne Prodehl
- University of the WitwatersrandDepartment of Surgery1 Jubilee RoadJohannesburgGautengSouth Africa2192
| | - Chikwendu J Ede
- University of the WitwatersrandDepartment of Surgery1 Jubilee RoadJohannesburgGautengSouth Africa2192
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Bucsics T, Schoder M, Goeschl N, Schwabl P, Mandorfer M, Diermayr M, Feldner M, Riedl F, Bauer D, Angermayr B, Cejna M, Ferlitsch A, Sieghart W, Trauner M, Peck-Radosavljevic M, Karner J, Karnel F, Reiberger T. Re-bleeding rates and survival after early transjugular intrahepatic portosystemic shunt (TIPS) in clinical practice. Dig Liver Dis 2017; 49:1360-1367. [PMID: 28869158 DOI: 10.1016/j.dld.2017.08.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/19/2017] [Accepted: 08/01/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early implantation (<72h) of a transjugular intrahepatic portosystemic shunt (TIPS) after acute variceal bleeding (AVB) improves survival in highly selected patients. METHODS We retrospectively assessed bleeding control and survival of unselected cirrhotic patients undergoing early TIPS implantation within 72h. We compared the outcomes to patients meeting early TIPS criteria but receiving late TIPS within 3-28days after AVB and endoscopic/medical treatment. RESULTS Forty-nine patients were included. Mean MELD was 14.4 (±4.4). Thirteen patients (26.5%) presented characteristics that were exclusion criteria in previous early TIPS trials (age>75, CPS>13, HCC>Milan, previous beta-blocker/band-ligation, renal insufficiency). Bare metal and PTFE-covered stents were used in n=32 (65.3%) and n=17 (34.7%) patients, respectively, and showed similar early re-bleeding rates (9.9% vs. 7.1%; p=0.6905) and bleeding-related mortality (25.0% vs. 23.5%; p=0.9906). However, overall re-bleeding rate was lower with PTFE-TIPS (7.7% vs. 64.2%; p=0.0044) over a median follow-up of 18.5 months with a tendency towards improved survival (median 70.5 vs. 13.8 months; p=0.204). Additional 68 patients meeting stringent criteria but receiving late TIPS also showed a favorable bleeding-related mortality (8.8%), which was not achieved in similar n=34 patients by a medical/endoscopic strategy with bleeding-related mortality of 35.7%. CONCLUSIONS An early TIPS strategy using covered stents and implementation of 'stringent criteria' results in a favorable outcome in patients with acute variceal bleeding.
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Affiliation(s)
- Theresa Bucsics
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maria Schoder
- Dept. of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Nicolas Goeschl
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Magdalena Diermayr
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maria Feldner
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Florian Riedl
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Angermayr
- Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Manfred Cejna
- Dept. of Radiology, Landeskrankenhaus Feldkirch, Austria
| | - Arnulf Ferlitsch
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Sieghart
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Josef Karner
- Dept. of Surgery, Kaiser-Franz-Josef Hospital, Vienna, Austria
| | - Franz Karnel
- Dept. of Radiology, Kaiser-Franz-Josef Hospital, Vienna, Austria
| | - Thomas Reiberger
- Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr 2017; 129:135-158. [PMID: 29063233 PMCID: PMC5674135 DOI: 10.1007/s00508-017-1262-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
The Billroth III guidelines were developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on 18 February 2017 in Vienna. Based on international guidelines and considering recent landmark studies, the Billroth III recommendations aim to help physicians in guiding diagnostic and therapeutic strategies in patients with portal hypertension.
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12
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Haq I, Tripathi D. Recent advances in the management of variceal bleeding. Gastroenterol Rep (Oxf) 2017; 5:113-126. [PMID: 28533909 PMCID: PMC5421505 DOI: 10.1093/gastro/gox007] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 12/12/2022] Open
Abstract
Acute haemorrhage from ruptured gastroesophageal varices is perhaps the most serious consequence of uncontrolled portal hypertension in cirrhotic patients. It represents a medical emergency and is associated with a high morbidity and mortality. In those who survive the initial bleeding event, the risks of further bleeding and other decompensated events remain high. The past 30 years have seen a slow evolution of management strategies that have greatly improved the chances of surviving a variceal haemorrhage. Liver cirrhosis is a multi-staged pathological process and we are moving away from a one-size-fits-all therapeutic approach. Instead there is an increasing recognition that a more nuanced approach will yield optimal survival for patients. This approach seeks to risk stratify patients according to their disease stage. The exact type and timing of treatment offered can then be varied to suit individual patients. At the same time, the toolbox of available therapy is expanding and there is a continual stream of emerging evidence to support the use of endoscopic and pharmacological therapies. In this review, we present a summary of the treatment options for a variety of different clinical scenarios and for when there is failure to control bleeding. We have conducted a detailed literature review and presented up-to-date evidence from either primary randomized-controlled trials or meta-analyses that support current treatment algorithms.
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Affiliation(s)
- Ihteshamul Haq
- Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - Dhiraj Tripathi
- Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
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Outcomes of surgical shunts and transjugular intrahepatic portasystemic stent shunts for complicated portal hypertension. Br J Surg 2017; 104:443-451. [DOI: 10.1002/bjs.10431] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 10/09/2016] [Accepted: 10/15/2016] [Indexed: 12/14/2022]
Abstract
Abstract
Background
Transjugular intrahepatic portasystemic stent shunt (TIPSS), instead of surgical shunt, has become the standard treatment for patients with complicated portal hypertension. This study compared outcomes in patients who underwent TIPSS or surgical shunting for complicated portal hypertension.
Methods
This was a retrospective study of all consecutive patients who received portasystemic shunts from 1994 to 2014 at a single institution. Patients who underwent surgical shunting were compared with those who had a TIPSS procedure following one-to-one propensity score matching. The primary study endpoints were overall survival and shunt failure, defined as major variceal rebleeding, relapse of refractory ascites, irreversible shunt occlusion, liver failure requiring liver transplantation, or death.
Results
A total of 471 patients received either a surgical shunt or TIPSS. Of these, 334 consecutive patients with cirrhosis who underwent elective surgical shunting (34) or TIPSS (300) for repeated variceal bleeding or refractory ascites were evaluated. Propensity score matching yielded 31 pairs of patients. There were no between-group differences in morbidity and 30-day mortality rates. However, shunt failure was less frequent after surgical shunting than TIPSS (6 of 31 versus 16 of 31; P = 0·016). The 5-year shunt failure-free survival (77 versus 15 per cent; P = 0·008) and overall survival (93 versus 42 per cent; P = 0·037) rates were higher for patients with surgical shunts. Multivariable analysis revealed that a Model for End-Stage Liver Disease (MELD) score exceeding14 and TIPSS were independently associated with shunt failure. In patients with MELD scores of 14 or less, the 5-year overall survival rate remained higher after surgical shunting than TIPSS (100 versus 40 per cent; P < 0·001).
Conclusion
Surgical shunting achieved better results than TIPSS in patients with complicated portal hypertension and low MELD scores.
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Portal Hypertension Over the Last 25 Years: Where Did It Go? J Am Coll Surg 2016; 222:1164-70. [PMID: 27234633 DOI: 10.1016/j.jamcollsurg.2016.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 01/04/2016] [Accepted: 02/16/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Portal hypertension has seemingly vanished from surgery; this study was undertaken to determine where it has gone. STUDY DESIGN Data from the Agency for Health Care Administration for 33,166,201 hospital inpatients in Florida for the periods 1988 to 1992, 1998 to 2002, and 2008 to 2012 were analyzed. RESULTS Admissions with a diagnosis of portal hypertension dramatically increased: 5,473 patients from 1988 to 1992, 7,366 patients from 1998 to 2002, and 36,554 patients from 2008 to 2012. Endoscopic treatment of esophageal varices also dramatically increased. The number of decompressive shunts placed nominally increased, but application of endoscopic therapy increased significantly faster than the application of decompressive shunts (p < 0.0001). The percentage of patients who underwent shunting dramatically and significantly decreased (p < 0.0001), and surgeons undertook proportionally fewer shunts (42% in 1992 to 4% in 2012; p < 0.0001). For patients with a diagnosis of portal hypertension, in-hospital mortality progressively decreased, from 9% in 1988 to 1992 to 3% in 2008 to 2012 (p < 0.0001). CONCLUSIONS In the state of Florida, over 25 years, there has been a 7-fold increase in the number of patients admitted with a diagnosis of portal hypertension, with a 65% reduction of in-hospital mortality. Application of endoscopic treatment of varices has increased dramatically. Decompressive shunts are applied to an ever-decreasing percentage of patients, and when applied, are now routinely undertaken by nonsurgeons. Therefore, portal hypertension has disappeared from the purview of surgery and has migrated toward the world of medical and endoscopic therapy, probably never to return.
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Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW, Olliff SP, Hudson M, Christie JM. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 64:1680-704. [PMID: 25887380 PMCID: PMC4680175 DOI: 10.1136/gutjnl-2015-309262] [Citation(s) in RCA: 357] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 03/17/2015] [Indexed: 12/12/2022]
Abstract
These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London, London, UK
| | - Charles Millson
- Gastrointestinal and Liver Services, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Homoyon Mehrzad
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Austin
- Department of Gastroenterology, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - James W Ferguson
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon P Olliff
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Hudson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - John M Christie
- Department of Gastroenterology, Royal Devon and Exeter Hospital, Devon, UK
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Huang L, Yu QS, Zhang Q, Liu JD, Wang Z. Transjugular intrahepatic portosystemic shunt versus surgical shunting in the management of portal hypertension. Chin Med J (Engl) 2015; 128:826-34. [PMID: 25758281 PMCID: PMC4833991 DOI: 10.4103/0366-6999.152676] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: The purpose of this article was to clarify the optimal management concerning transjugular intrahepatic portosystemic shunts (TIPSs) and surgical shunting in treating portal hypertension. Methods: All databases, including CBM, CNKI, WFPD, Medline, EMBASE, PubMed and Cochrane up to February 2014, were searched for randomized controlled trials (RCTs) comparing TIPS with surgical shunting. Four RCTs, which were extracted by two independent investigators and were evaluated in postoperative complications, mortality, 2- and 5-year survival, hospital stay, operating time and hospitalization charges. Results: The morbidity in variceal rehemorrhage was significantly higher in TIPS than in surgical shunts (odds ratio [OR] = 7.45, 95% confidence interval[CI]: (3.93–14.15), P < 0.00001), the same outcomes were seen in shunt stenosis (OR = 20.01, 95% CI: (6.67–59.99), P < 0.000001) and in hepatic encephalopathy (OR = 2.50, 95% CI: (1.63–3.84), P < 0.0001). Significantly better 2-year survival (OR = 0.66; 95% CI: (0.44–0.98), P = 0.04) and 5-year survival (OR = 0.44; 95% CI: (0.30–0.66), P < 0.00001) were seen in patients undergoing surgical shunting compared with TIPS. Conclusions: Compared with TIPS, postoperative complications and survival after surgical shunting were superior for patients with portal hypertension. Application of surgical shunting was recommended for patients rather than TIPS.
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Affiliation(s)
- Long Huang
- Department of No. 1 Surgery, Anhui Chinese Medical Research Institute of Surgery, The First Hospital Affiliated to Anhui Chinese Medical University, Hefei, Anhui 230031, China
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Orloff MJ, Hye RJ, Wheeler HO, Isenberg JI, Haynes KS, Vaida F, Girard B, Orloff KJ. Randomized trials of endoscopic therapy and transjugular intrahepatic portosystemic shunt versus portacaval shunt for emergency and elective treatment of bleeding gastric varices in cirrhosis. Surgery 2015; 157:1028-45. [PMID: 25957003 PMCID: PMC6370460 DOI: 10.1016/j.surg.2014.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 11/14/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Bleeding esophageal varices has been studied extensively, but bleeding gastric varices (BGV) has received much less investigation. However, BGV has been reported in ≤ 30% of patients with acute variceal bleeding. In our studies of 1,836 bleeding cirrhotics, 12.7% were bleeding from gastric varices. BGV mortality rate of 45-55% has been reported. The BGV literature has mainly involved retrospective case reports, often with short-term follow-up. OBJECTIVE We sought to describe the results of a prospective, randomized, controlled trial (RCT) in unselected, consecutive patients with BGV comparing endoscopic therapy (ET) with portacaval shunt (PCS; n = 518), and later comparing emergency transjugular intrahepatic portosystemic shunt (TIPS) with emergency portacaval shunt (EPCS; n = 70). DESIGN, SETTING, AND PARTICIPANTS Initially, our RCT involved 518 patients with BGV comparing ET with direct PCS regarding control of bleeding, mortality rate, and disability. When entry of patients ended, the RCT was expanded to compare emergency TIPS with EPCS (n = 70). This RCT of BGV was separate from our other RCTs of bleeding esophageal varices. INTERVENTIONS Initially, ET was compared with PCS. In the second part of our RCT, emergency TIPS was compared with emergency PCS (EPCS). MAIN OUTCOME MEASURES Outcomes were survival, control of bleeding, portal-systemic encephalopathy (PSE), quality of life, and direct costs of care. In the RCT of ET versus PCS, 28 and 30%, respectively, were in Child class C. In the expanded RCT of TIPS versus EPCS, 40 and 41%, respectively, were in Child class C. Permanent control of BGV was achieved in 97-100% of patients treated by emergency or elective PCS, compared with 27-29% by ET. TIPS was even less effective, achieving long-term control of BGV in only 6%. Survival rates after PCS were greater at all time intervals and in all Child classes (P < .001). Repeated episodes of PSE occurred in 50% of TIPS patients, 16-17% treated by ET, and 8-11% treated by PCS. Shunt stenosis or occlusion occurred in 67% of TIPS patients, in contrast with 0-2% of PCS patients. CONCLUSION These results support the conclusion that PCS is uniformly effective, whereas ET and TIPS are not very effective.
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA.
| | - Robert J Hye
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA
| | - Henry O Wheeler
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego Medical Center, San Diego, CA
| | - Jon I Isenberg
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego Medical Center, San Diego, CA
| | - Kevin S Haynes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego Medical Center, San Diego, CA
| | - Florin Vaida
- Department of Family and Preventive Medicine/Biostatistics and Bioinformatics, University of California, San Diego Medical Center, San Diego, CA
| | - Barbara Girard
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA
| | - Karen J Orloff
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA
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Peck-Radosavljevic M, Angeli P, Cordoba J, Farges O, Valla D. Managing complications in cirrhotic patients. United European Gastroenterol J 2015; 3:80-94. [PMID: 25653862 DOI: 10.1177/2050640614560452] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/21/2014] [Indexed: 12/13/2022] Open
Abstract
Liver cirrhosis is a serious and potentially life-threatening condition. This life-threatening condition usually arises from complications of cirrhosis. While variceal bleeding is the most acute and probably best studied, several other complications of liver cirrhosis are more insidious in their onset but nevertheless more important for the long-term management and outcome of these patients. This review summarizes the topics discussed during the UEG-EASL Hepatology postgraduate course of the United European Gastroenterology Week 2013 and discusses emergency surgical conditions in cirrhotic patients, the management of hepatic encephalopathy, ascites and hepatorenal syndrome, coagulation disorders, and liver cancer.
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Affiliation(s)
| | - Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine, University of Padova, Italy
| | - Juan Cordoba
- Liver Unit, Hospital Valld'Hebron, Barcelona, Spain
| | - Oliver Farges
- Department of HPB surgery HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
| | - Dominique Valla
- Service d'Hépatologie, HôpitalBeaujon, AP-HP, Université Paris-Diderot, Clichy-la-Garenne, France
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Abstract
Percutaneous interventions for portal hypertension have been available since the 1990s. Over time, improved technology-including covered stent grafts-and clinical understanding has expanded the available procedures for percutaneous portal decompression. While transjugular intrahepatic portosystemic shunt creation is the most commonly cited percutaneous intervention, direct intrahepatic portocaval shunt and percutaneous mesocaval shunt creation are important alternatives with specific advantages and applications. This article reviews contemporary, minimally invasive interventional approaches to percutaneous portosystemic shunt creation in terms of procedure rationale, patient selection, interventional technique, and technical outcomes.
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Affiliation(s)
- Leigh C Casadaban
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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Parvinian A, Gaba RC. Outcomes of TIPS for Treatment of Gastroesophageal Variceal Hemorrhage. Semin Intervent Radiol 2014; 31:252-7. [PMID: 25177086 DOI: 10.1055/s-0034-1382793] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Variceal hemorrhage is a life-threatening complication of cirrhosis that requires a multidisciplinary approach to management. The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a minimally invasive image-guided intervention used for secondary prevention of bleeding and as salvage therapy in acute hemorrhage. This review focuses on the role of TIPS in the setting of variceal hemorrhage, with emphasis on the pathophysiology and conventional management of variceal hemorrhage, current and emerging indications for TIPS creation, TIPS clinical outcomes, and the role of adjuvant embolotherapy.
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Affiliation(s)
- Ahmad Parvinian
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Ron C Gaba
- Division of Interventional Radiology, Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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Gur I, Diggs BS, Orloff SL. Surgical portosystemic shunts in the era of TIPS and liver transplantation are still relevant. HPB (Oxford) 2014; 16:481-93. [PMID: 23961811 PMCID: PMC4008167 DOI: 10.1111/hpb.12163] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 06/10/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The surgical portosystemic shunts (PSS) are a time-proven modality for treating portal hypertension. Recently, in the era of liver transplantation and the transjugular intrahepatic portosystemic shunts (TIPS), use of the PSS has declined. OBJECTIVES This study was conducted to evaluate changes in practice, referral patterns, and short- and longterm outcomes of the use of the surgical PSS before and after the introduction of the Model for End-stage Liver Disease (MELD). METHODS A retrospective analysis of 47 patients undergoing PSS between 1996 and 2011 in a single university hospital was conducted. RESULTS Subgroups of patients with cirrhosis (53%), Budd-Chiari syndrome (13%), portal vein thrombosis (PVT) (26%), and other pathologies (9%) differed significantly with respect to shunt type, Child-Pugh class, MELD score and perioperative mortality. Perioperative mortality at 60 days was 15%. Five-year survival was 68% (median: 70 months); 5-year shunt patency was 97%. Survival was best in patients with PVT and worst in those with Budd-Chiari syndrome compared to other subgroups. Patency was better in the subgroups of patients with cirrhosis and other pathologies compared with the PVT subgroup. Substantial changes in referral patterns coincided with the adoption of the MELD in 2002, with decreases in the incidence of cirrhosis and variceal bleeding, and increases in non-cirrhotics and hypercoagulopathy. CONCLUSIONS Although the spectrum of diseases benefiting from surgical PSS has changed, surgical shunts continue to constitute an important addition to the surgical armamentarium. Selected subgroups with variceal bleeding in well-compensated cirrhosis and PVT benefit from the excellent longterm patency offered by the surgical PSS.
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Affiliation(s)
- Ilia Gur
- Division of Surgical Oncology, Oregon Health and Science UniversityPortland, OR, USA,Correspondence Ilia Gur, General Surgery, Sutter Gould Medical Foundation, 2545 W. Hammer Lane, STE 2200, Stockton, CA, 95209 USA. Tel: +209 941 0127. Fax: + 209 951 2438.
| | - Brian S Diggs
- Division of General Surgery, Oregon Health and Science UniversityPortland, OR, USA
| | - Susan L Orloff
- Division of Abdominal Organ Transplant, Oregon Health and Science UniversityPortland, OR, USA
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Zabicki B, Ricke J, Dudeck O, Pech M. CT-assisted transfemoral intrahepatic portosystemic shunt in a long duration follow-up: A case report. Pol J Radiol 2014; 79:39-41. [PMID: 24596585 PMCID: PMC3940701 DOI: 10.12659/pjr.889841] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/12/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension may be considered as a rescue therapy in case of recurrent variceal bleeding or failure of endoscopic management. CASE REPORTS We present a case of a patient with massive gastroesophageal variceal bleeding refractory to numerous endoscopic treatments in which TIPS was considered in an attempt to decrease the risk of potentially fatal rebleeding. Standard TIPS procedure was not feasible due to altered anatomy of the liver resulting from right hemidiaphragmatic paresis. Computed Tomography (CT) fluoroscopic guidance was utilized for direct percutaneous puncture of the left hepatic and left portal vein with subsequent guidewire snaring to perform portosystemic shunting via femoral access. Since the procedure, no recurrent variceal bleeding was reported and the shunt remained patent at a 3-year follow-up. Although stent fracture with fragment migration was observed. CONCLUSIONS Significant variation in liver anatomy does not preclude the creation of nonsurgical portosystemic shunt. In these cases, combined percutaneous and endovascular technique may be utilized.
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Affiliation(s)
- Bartosz Zabicki
- Department of Radiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Jens Ricke
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany
| | - Oliver Dudeck
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany
| | - Maciej Pech
- Department of Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany
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Klarik Z, Toth E, Kiss F, Miko I, Furka I, Nemeth N. A modified microsurgical model for end-to-side selective portacaval shunt in the rat: intraoperative microcirculatory investigations. Acta Cir Bras 2013; 28:625-31. [DOI: 10.1590/s0102-86502013000900001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 08/22/2013] [Indexed: 01/13/2023] Open
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Moran DE, Bennett AE, Sheiman RG. Diagnostic radiology of transjugular intrahepatic portosystemic shunts. Semin Ultrasound CT MR 2013; 34:352-64. [PMID: 23895907 DOI: 10.1053/j.sult.2013.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Transjugular intrahepatic portosystemic shunts (TIPS) are an effective method for treating the complications of portal hypertension. Specific indications for TIPS include secondary prevention of variceal bleeding and refractory ascites. The purpose of this review is to summarize the role of diagnostic radiology in the creation and assessment of TIPS, to highlight the complications that can occur post-TIPS, and to critically evaluate the literature regarding ultrasound evaluation of TIPS.
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Affiliation(s)
- Deirdre E Moran
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA.
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