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Taslakian B, Faraj W, Khalife M, Al-Kutoubi A, El-Merhi F, Saade C, Hallal A, Haydar A. Assessment of surgical portosystemic shunts and associated complications: The diagnostic and therapeutic role of radiologists. Eur J Radiol 2015; 84:1525-1539. [PMID: 25963504 DOI: 10.1016/j.ejrad.2015.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 04/16/2015] [Accepted: 04/21/2015] [Indexed: 02/07/2023]
Abstract
Surgical portosystemic shunting, the formation of a vascular connection between the portal and systemic venous circulation, has been used as a treatment to reduce portal venous pressure. Although the use of portosystemic shunt surgery in the management of portal hypertension has declined during the past decade in favour of alternative therapies, and subsequently surgeons and radiologists became less familiar with the procedure, it remains a well-established treatment. Knowledge of different types of surgical portosystemic shunts, their pathophysiology and complications will help radiologists improve communication with surgeons and enhance their understanding of the diagnostic and therapeutic role of radiology in the assessment and management of these shunts. Optimal assessment of the shunt is essential to determine its patency and allow timely intervention. Both non-invasive and invasive imaging modalities complement each other in the evaluation of surgical portosystemic shunts. Interventional radiology plays an important role in the management of complications, such as shunt thrombosis and stenosis. This article describes the various types of surgical portosystemic shunts, explains the anatomy and pathophysiology of these shunts, illustrates the pearls and pitfalls of different imaging modalities in the assessment of these shunts and demonstrates the role of radiologists in the interventional management of complications.
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Affiliation(s)
- Bedros Taslakian
- Department of Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020-PO Box: 11-0236, Beirut, Lebanon.
| | - Walid Faraj
- Department of General Surgery, American University of Beirut Medical Center, Riad El-Solh 1107 2020-PO Box: 11-0236, Beirut, Lebanon.
| | - Mohammad Khalife
- Department of General Surgery, American University of Beirut Medical Center, Riad El-Solh 1107 2020-PO Box: 11-0236, Beirut, Lebanon.
| | - Aghiad Al-Kutoubi
- Department of Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020-PO Box: 11-0236, Beirut, Lebanon.
| | - Fadi El-Merhi
- Department of Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020-PO Box: 11-0236, Beirut, Lebanon.
| | - Charbel Saade
- Department of Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020-PO Box: 11-0236, Beirut, Lebanon.
| | - Ali Hallal
- Department of General Surgery, American University of Beirut Medical Center, Riad El-Solh 1107 2020-PO Box: 11-0236, Beirut, Lebanon.
| | - Ali Haydar
- Department of Radiology, American University of Beirut Medical Center, Riad El-Solh 1107 2020-PO Box: 11-0236, Beirut, Lebanon.
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Portal-systemic encephalopathy in a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt treatment of acutely bleeding esophageal varices in cirrhosis. Ann Surg 2011; 250:598-610. [PMID: 19730244 DOI: 10.1097/sla.0b013e3181b73126] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND In patients with cirrhosis and bleeding esophageal varices, there is a widespread belief that control of bleeding by portal-systemic shunts is compromised by a high incidence of shunt-related portal-systemic encephalopathy (PSE). This important issue was examined by a randomized controlled trial that compared emergency and long-term endoscopic sclerotherapy (EST) to emergency direct portacaval shunt (EPCS) in patients with cirrhosis and acute variceal hemorrhage. METHODS The study was a community-wide undertaking known as the San Diego Bleeding Esophageal Varices Study. A total of 211 unselected, consecutive patients with biopsy-proven cirrhosis and endoscopically proven, acutely bleeding esophageal varices that required at least 2 units of blood transfusion were randomized to EST (n = 106) or EPCS (n = 105). The diagnostic workup was completed in less than 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Long-term EST was performed according to a deliberate schedule over months. Criteria for failure of EST or EPCS were clearly defined and crossover rescue treatment was applied, whenever possible, when failure of primary therapy was declared. PSE was quantitated by a "blinded" senior faculty gastroenterologist. Four variously weighted components of PSE were graded on a scale of 0 to 4: (1) mental state, (2) asterixis, (3) number connection test, and (4) arterial blood ammonia. PSE was classified as recurrent if 2 or more episodes were documented. All patients (100%) had follow-up for more than 9.4 years or until death. RESULTS Child's risk classes in the EST and EPCS groups, respectively, were 25% and 30% in class A, 43% and 47% in class B, and 26% and 29% in class C. Mean time from onset of bleeding to EST or EPCS was less than 24 hours, and from study entry to EST or EPCS was 3.1 to 4.4 hours, respectively. EST achieved permanent control of bleeding in only 20% of patients, while EPCS permanently controlled bleeding in every patient (P ≤ 0.001). Survival following EPCS was 3.5 to 5 times greater than that of EST at 5, 10, and 15 years (P ≤ 0.001). The incidence of recurrent PSE following EST (35%) was more than twice the incidence following EPCS (15%) (P ≤ 0.001). EST patients had a total of 179 episodes of PSE and 146 PSE-related hospital admissions, compared with EPCS patients who had 94 episodes of PSE and 87 hospital admissions (P ≤ 0.001). Recurrent upper gastrointestinal bleeding, which was rare in the EPCS group, was a major causative factor of PSE in the EST patients. CONCLUSIONS In contrast to EST, EPCS permanently controlled variceal bleeding, resulted in significantly greater long-term survival, and was followed by a relatively low (15%) incidence of PSE. These results were facilitated by rigorous, frequent, and lifelong follow-up that included regular counseling on dietary protein restriction and abstinence from alcohol, and by long-term patency of the portacaval shunt in 98% of patients. Furthermore, these results call into question the practice of avoiding portacaval shunt because of fear of PSE, and thereby foregoing the lifesaving advantage achieved by surgical control of bleeding. (clinicaltrials.gov NCT00690027).
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Bittencourt PL, Farias AQ, Strauss E, Mattos AAD. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2010; 47:202-16. [PMID: 20721469 DOI: 10.1590/s0004-28032010000200017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 08/17/2009] [Indexed: 02/06/2023]
Abstract
In the last decades, several improvements in the management of variceal bleeding have resulted in a significant decrease in morbidity and mortality of patients with cirrhosis and bleeding varices. Progress in the multidisciplinary approach to these patients has led to a better management of this disease by critical care physicians, hepatologists, gastroenterologists, endoscopists, radiologists and surgeons. In this respect, the Brazilian Society of Hepatology has, recently, sponsored a consensus meeting in order to draw evidence-based recommendations on the management of these difficult-to-treat subjects. An organizing committee comprised of four people was elected by the Governing Board and was responsible to invite 27 researchers from distinct regions of the country to make a systematic review of the subject and to present topics related to variceal bleeding, including prevention, diagnosis, management and treatment, according to evidence-based medicine. After the meeting, all participants met together for discussion of the topics and the elaboration of the aforementioned recommendations. The organizing committee was responsible for writing the final document. The meeting was held at Salvador, May 6th, 2009 and the present manuscript is the summary of the systematic review that was presented during the meeting, organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.
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Abstract
Portal hypertension is a progressively debilitating complication of cirrhosis and a principal cause of mortality in patients who have hepatic decompensation. This article describes the classification system and pathophysiology of portal hypertension. It also discusses a practical approach to prevention of first variceal hemorrhage, general management of the acute bleeding episode, and secondary prophylaxis to prevent rebleeding. Pharmacologic, endoscopic, radiologic, and surgical modalities are all described in detail.
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Affiliation(s)
- David A Sass
- Division of Gastroenterology and Hepatology, Drexel University College of Medicine, 216 N. Broad Street, Feinstein Building, Suite 504, MS 1001, Philadelphia, PA 19102, USA.
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Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ. Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. J Am Coll Surg 2009; 209:25-40. [PMID: 19651060 PMCID: PMC6420230 DOI: 10.1016/j.jamcollsurg.2009.02.059] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 02/13/2009] [Accepted: 02/16/2009] [Indexed: 01/15/2023]
Abstract
BACKGROUND The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage. STUDY DESIGN A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death. RESULTS The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01). CONCLUSIONS EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027).
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Affiliation(s)
- Marshall J Orloff
- Department of Surgery, University of California, San Diego Medical Center, San Diego, CA 92103-8999, USA
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Orug T, Soonawalla ZF, Tekin K, Olliff SP, Buckels JAC, Mayer AD. Role of surgical portosystemic shunts in the era of interventional radiology and liver transplantation. Br J Surg 2004; 91:769-73. [PMID: 15164449 DOI: 10.1002/bjs.4526] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abstract
Background
In the present era of liver transplantation and transjugular intrahepatic portosystemic shunts, the role and choice of shunt surgery for portal hypertension was reviewed.
Methods
This retrospective study analysed the management of patients with portal hypertension in a tertiary liver transplant unit between June 1993 and May 2002. During this 9-year interval, 394 patients underwent endoscopic control of varices, 235 transjugular intrahepatic portosystemic shunts were inserted, 1142 liver transplants were performed, while only 29 patients needed a surgical portosystemic shunt.
Results
Twenty-nine shunt operations were performed in nine patients with cirrhosis, one patient with congenital hepatic fibrosis and 19 without parenchymal liver disease. There were 12 side-to-side lienorenal, nine mesocaval, three proximal lienorenal, two distal lienorenal, two portacaval and one mesoportal shunts. Encephalopathy was seen in five of 11 patients with a non-selective shunt, but did not occur after side-to-side or selective lienorenal shunt procedures. At a median follow-up of 42·5 months, one mesocaval shunt had thrombosed and one portacaval shunt had stenosed; both were successfully managed by percutaneous intervention. To date, six patients have died; two succumbed to postoperative complications, one of which was related to the shunt.
Conclusion
Patients with Budd–Chiari syndrome and cirrhosis can nearly always be managed by a combination of endoscopy, interventional radiology and liver transplantation. In the rare instances when these therapies fail in patients with cirrhosis, a side-to-side lienorenal shunt is a good option.
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Affiliation(s)
- T Orug
- Hepatobiliary and Liver Transplant Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, UK
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Zhu JB, Deng LQ, Wang SY. Effects of pituitrin and triglycyl-lysine-vasopressin on hepatic oxygen partial pressure in portal hypertensive rats. Shijie Huaren Xiaohua Zazhi 2003; 11:1172-1174. [DOI: 10.11569/wcjd.v11.i8.1172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To explore the different effects of pituitrin and triglycyl-lysine-vasopressin (tGLVP)on hepatic oxygen partial pressure (PhO2) while reducing the partial hypertension in portal hypertension rats.
METHODS The model of biliary cirrhosis was induced by ligating the choledochus. Forty rats were divided into two groups randomly: pp group (n = 20)and tGLVP group(n = 20). PP and tGLVP were slowly infused into the rats via portal vein respectively. The portal vein pressure and the oxygen partial pressure were obtained at the moment before administration and 5, 10, 15, 25, 30 minutes after administration.
RESULTS Portal venous pressure (PVP) was significantly lowered after infusion in two groups. There was no significant difference between the two groups (t = 0.39, P>0.05). PhO2 was significantly decreased in pp group after infusion (P<0.01), but not in tGLVP group (P<0.05).There was significant difference between the two groups in PhO2 after infusion (t = 9.19, P<0.01).
CONCLUSION PP caused a significant decrease both in portal pressure and PhO2. PVP was decreased by tGLVP, but PhO2 was not decreased significantly. tGLVP is considered to be better than PP in treatment of acute variceal hemorrhage.
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Affiliation(s)
- Jian-Bo Zhu
- Department of Gastroenterology, Affiliated Hospital of Medical College of Hubei Institute for Nationalities, Enshi 445000, Hubei Province, China
| | - Li-Qun Deng
- Department of Gastroenterology, Affiliated Hospital of Medical College of Hubei Institute for Nationalities, Enshi 445000, Hubei Province, China
| | - Si-Yuan Wang
- Department of Gastroenterology, Affiliated Hospital of Medical College of Hubei Institute for Nationalities, Enshi 445000, Hubei Province, China
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Vater Y, Dembo G, Levy A, Hunter C, Martay K. Adjunct drugs in liver transplantation. ACTA ACUST UNITED AC 2002. [DOI: 10.1053/sane.2002.34196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Abstract
AIM: To evaluate the clinical application of serial operations with preservation of spleen.
METHODS: Serial operations with preserving spleen were performed on 211 cases in our hospital from 1980 to 2000. The patient’s age ranged from 13 to 56 years, averaging 38 years. Diseases included splenic injury in 171 cases, portal hypertension in 9 cases, splenic cyst in 10 cases, and the lesion of pancreatic body and tail in 21 cases.
RESULTS: All the cases were cured, and 129 patients were followe dup from 3 mo to 3 years with the leukocyte phagocytosis test, detection of immunoglubin, CT, 99mTc scanning and ultrasonography. The results were satisfactory.
CONCLUSION: The operations with preserving spleen were safe, feasible, and worth of clinical application.
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Affiliation(s)
- H C Jiang
- Department of General Surgery, First Clinical Hospital, Harbin Medical University, Harbin 150001, China
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