Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial

BACKGROUND & AIMS

The first studies comparing covered stents (CS) and bare stents (BS) to achieve Transjugular Intrahepatic Portosystemic Shunt (TIPS) were in favor of CS, but only one randomized study has been performed. Our aim was to compare the primary patency of TIPS performed with CS and BS.

METHODS

The study was planned as a multicenter, pragmatic (with centers different in size and experience), randomized, single-blinded (with blinding of patients only), parallel group trial. The primary endpoint was TIPS dysfunction defined as either a portocaval gradient ⩾12mmHg, or a stent lumen stenosis ⩾50%. A transjugular angiography with portosystemic pressure gradient measurement was scheduled every 6months after TIPS insertion.

RESULTS

137 patients were randomized: 66 to receive CS, and 71 BS. Patients who were found to have a hepato-cellular carcinoma, or whose procedure was cancelled were excluded, giving a sample of 129 patients (62 vs. 67). Median follow-up for CS and BS were 23.6 and 21.8months, respectively. Compared to BS, the risk of TIPS dysfunction with CS was 0.60 95% CI [0.38-0.96], (p=0.032). The 2-year rate of shunt dysfunction was 44.0% for CS vs. 63.6% for BS. Early post TIPS complications (22.4% vs. 34.9%), risk of hepatic encephalopathy (0.89 [0.53-1.49]) and 2-year survival (70% vs. 67.5%) did not differ in the two groups. The 2-year cost/patient was 20k€ [15.9-27.5] for CS vs. 23.4k€ [18-37] for BS (p=0.52).

CONCLUSIONS

CS provided a significant 39% reduction in dysfunction compared to BS. We did not observe any significant difference with regard to hepatic encephalopathy or death.

Predictive factors of alcohol relapse after orthotopic liver transplantation for alcoholic liver disease

OBJECTIVES

The objective of this prospective study was to determine whether sociological and/or alcohol-related behavioral factors could be predictive of relapse after orthotopic liver transplantation for alcoholic liver disease.

METHODS

Fifty-five liver-transplanted patients out of a series of 120 alcoholic cirrhotic patients were enrolled in a randomized prospective study. This study was initially designed to compare the 2 year survival in intent-to-transplant patients versus in-intent-to-use conventional treatment patients. For all patients, an identical questionnaire was completed at inclusion, and every 3 months for 5 years to collect data on alcohol-related behavior factors.

RESULTS

Fifty-one patients fulfilled the criteria for the study. The mean follow-up was 35.7 months (range: 1-86). Rate of alcohol relapse was 11% at one year and 30% at 2 years. Alcohol intake above 140 g a week was declared by 11% and 22% of patients at one and 2 years, respectively. The only variable leading to a significantly lower rate of relapse was abstinence for 6 months or more before liver transplantation (23% vs 79%, P=0.0003). This variable was also significant for patients whose alcohol intake was greater than 140 g per week (P=0.003) (adjusted relative risk=5.5; 95%CI=1.3-24.5; P=0.02). Multivariate analysis (Cox model) showed that abstinence for 6 months or more before liver transplantation was the unique predictive variable.

CONCLUSION

In this prospective study of 51 patients transplanted for alcoholic liver disease, abstinence before liver transplantation was the only predictive factor of alcohol relapse after liver transplantation.

Garlic, onion and cereal fibre as protective factors for breast cancer: a French case-control study

The role of diet on breast cancer risk was investigated in a case-control study of 345 patients diagnosed with primary breast carcinoma between 1986 and 1989 in the north-east of France (Lorraine). For each case, one control was matched for age (+/-3 years) and socio-economic status. The dietary history questionnaire consisted of a self-administered food frequency questionnaire, a 6-day food diary and an energy expenditure record. It also elicited personal characteristics and medical history. While taking into account total caloric intake and established risk factors, breast cancer risk was shown to decrease as consumption of fibre (p value for trend = 0.03), and garlic and onions (p value for trend <10(-6)) increased. This study also supports the epidemiologic evidence that saturated fat intake and breast cancer risk are associated in post-menopausal women (p value for trend = 0.03). Conversely, it suggests that unsaturated fat intake could lower the risk in the same subgroup (p value for trend = 0.03). Our findings on protective factors of breast cancer could induce effective preventive measures and warrant further experimental investigations to isolate specific subfractions.

Alcoholic calories, red wine consumption and breast cancer among premenopausal women

The role of alcohol consumption (alcoholic calories, alcoholic beverages) on breast cancer risk was investigated in a case-control study of 154 premenopausal female patients diagnosed with primary breast carcinoma. For each case, one control was matched for age (+/- 3 years) and socio-economic status. The survey was carried out in Northeastern France (Lorraine) between 1986 and 1989. While taking into account total caloric intakes and various breast cancer factors, breast cancer risk was shown to increase as consumption of alcohol increased (p value for trend = 0.007). A significant relative risk (RR = 2.69; 95% CI: 1.40-5.17) was shown above 60 kcal per day (approximately 9 g of alcohol per day). Breast cancer risk appeared to be restricted to red wine consumption among these premenopausal women, for monthly consumption (p value for trend = 0.003) as well as for duration of consumption (p value for trend = 0.01). A relative risk of 3.96 (95% CI: 1.59-9.84) was found for a monthly consumption higher than 4 liters per month. This reinforces the notion of a particular sensitivity of young women to breast cancer in relation to alcohol consumption.

[Digestive involvement in dystrophic bullous epidermolysis. Presentation of 2 cases and review of the literature]

Congenital epidermolysis bullosa is an inherited disorder characterized by an anomaly of joint structures between epidermis and dermis. This anomaly involves different malpighian epithelium and particularly in the digestive chorioepithelial junction. Digestive and oropharyngeal manifestations include bullae, erosions and ulcerations that heal by fibrosis, leading to retraction and stenosis. We report two cases of esophageal stenosis, the first one in a young patient with a congenital epidermolysis bullosa of Hallopeau-Siemens and the second one, in a young woman with a Pasini variant. In the first case, the esophageal stenosis was treated by careful dilation. In the second case, the endoscopy induced hemorragic bullae and septicemia, which were treated with antibiotics and total parenteral nutrition.

The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding

BACKGROUND

Transjugular placement of an intrahepatic stent is a new technique to establish a portosystemic shunt for treatment of portal hypertension. A puncture needle is advanced in a catheter through the inferior vena cava into a hepatic vein; then an intrahepatic branch of the portal vein is punctured and an expandable stent of metallic mesh is implanted to establish the shunt.

METHODS

We attempted the stent-shunt procedure in 100 of 112 consecutive patients with variceal bleeding due to cirrhosis, who were then followed for a mean (+/- SD) of 12 +/- 6 months. Of the 100 patients, 22 had Child-Pugh class C cirrhosis, 10 were treated on an emergency basis, and 68 had alcoholic cirrhosis. The shunt was established with use of Palmaz stents expanded to 8 to 12 mm in diameter.

RESULTS

Technical success was achieved in 93 percent of the patients. The mean (+/- SD) time for the procedure was 1.2 +/- 0.3 hours. The shunt reduced the portal venous pressure gradient by 57 percent. Major complications were hemorrhage (intraabdominal bleeding in six patients, biliary bleeding in four, and bleeding in the liver capsule in three) and migration of the stent into the pulmonary artery (in two patients). At follow-up, stenosis of the shunt was evident in 21 patients and occlusion in 10 patients; 10 of these 31 patients had variceal rebleeding. Stenoses and occlusions of the shunt were all treated successfully by redilation, thrombolysis, or implantation of an additional stent. Hepatic encephalopathy (stages I to III) developed in 25 percent of the patients. The proportion of patients with shunts who remained free of variceal rebleeding was 92 percent at six months and 82 percent at one year. The 30-day mortality was 3 percent. The cumulative one-year survival was 85 percent.

CONCLUSIONS

These results suggest that the transjugular placement of an intrahepatic portosystemic stent is an effective and safe treatment for variceal hemorrhage in patients with portal hypertension due to cirrhosis.

[Intrahepatic portacaval anastomosis by the transjugular approach. Use of the Palmaz endoprosthesis]

This new, non-operative procedure has been devised to create an intrahepatic shunt between a main portal branch and the right hepatic vein. First, the portal bifurcation is located by sagittal sonography and its position is marked on the skin. Then one of the main portal branches is punctured from the right hepatic vein by the transjugular route, and the puncture tract is expanded by balloon dilatation. This channel is kept open by placement of one or several Palmaz stents. Ten cirrhotic patients (age range: 60-84 years) unfit for surgical portocaval shunting and presenting with recurrent variceal bleeding after sclerotherapy were successfully treated by this method without any related death. During a 1 to 8 months follow-up, 9 of the 10 shunts have remained perfectly patent, but more time is required to determine the place of this method for secondary management of cirrhotic variceal bleeding.

[Peri-rectal infectious cellulitis with septicemia of anal origin. Suppository on trial]

Rectal route with local or general effects, is an interesting possibility of treatment. Easy use and rapid absorption are two major advantages. But this therapeutic modality is not riskless. We report a case of septicemia with peri-rectal cellulitis which was generated by two ano-rectal ulcerations after using Trophires suppositories. The infection was favoured by local application of cortisone. Our original observation, with ano-rectal ulcerations and short use of suppository, confirms the idea of short-term treatment stopped in case of unwanted symptom.

[Modelling the transjugular intrahepatic portosystemic shunt using a metal prosthesis: requirements of the stent]

Non-operative percutaneous treatment of portal hypertension as ultima ratio therapy in liver cirrhosis has now been established in 16 cases. After transjugular puncture of a main branch of the portal vein via a liver vein, recollapse of the parenchymal track after predilation was prevented by implantation of a Palmaz stent. This type of stent enables remodelling of the individual length of the parenchymal track in the liver by overlapping placement of several stents. In our experience the Palmaz stent seems to be very efficient in keeping the shunt patent. First, its smooth inner surface after dilation guarantees laminar flow within the stent as a precondition for homogeneous endothelialization of the inner surface. Second, overlapping placement of the stents allows precise covering of the individual length of the shunt. Third shunt diameters can be established by using different sized balloons. The range is 7-10 mm. Fourth this type of stent has a high degree of resistance to eccentric or concentric compression by the surrounding tissue.