TIPSS 10 years on.
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Esophageal and Gastric Varices↗
Biomedical subjects
D N Redhead
Publications and source records attributed to D N Redhead.
Laparoscopy with laparoscopic ultrasonography in the TNM staging of pancreatic carcinoma.
A prospective study was performed comparing laparoscopy with laparoscopic ultrasonography (LapUS), transabdominal ultrasonography (USS), computed tomography (CT), and selective visceral angiography with portal phase venography (SVA) for the assessment of resectability in 50 patients with pancreatic or periampullary cancer. The results were stratified by TNM stages. Tumor unresectability was demonstrated in 36 patients (72%). The sensitivity of LapUS for demonstrating the index lesion was 96%. Laparoscopic ultrasonography failed to predict factors precluding resection by T stage in six patients, and there were no significant differences in the ability of any modality to predict local resectability (predictive value 58-73%). Laparoscopic ultrasonography did not overestimate T stage and was significantly more specific for assessing unresectability compared with USS (100% vs. 64%, p<0.05) and CT (100% vs. 47%, p<0.005). No imaging investigation was able to assess the N stage accurately. Metastases were confirmed in 16 patients (32%), with LapUS proving significantly more sensitive than USS (94% vs. 29%, p<0.001) and CT (94% vs. 33%, p<0.005). The addition of LapUS to the laparoscopic examination did not change the M stage in any patient, as all metastases were superficially located. Laparoscopy with LapUS was the most reliable method for assessing overall tumour resectability and was significantly more predictive than CT (97% vs. 79%, p<0.005). These results confirm that laparoscopy is indispensable for detecting occult intraabdominal metastases. LapUS reliably predicts tumor unresectability, offsetting the tendency of USS and CT to overestimate T stage. Methods of accurate N staging remain elusive, and the use of routine SVA is not justified.
Adult↗
Cytolysis following chemoembolization for hepatocellular carcinoma.
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Carcinoma, Hepatocellular↗
Direct measurement of post-prandial portal haemodynamics in cirrhotic patients with a transjugular intrahepatic portosystemic stent-shunt.
OBJECTIVE: Portal haemodynamics vary in response to eating and other stimuli, but any increase in portal venous pressure (PVP) in cirrhotic patients may be a risk factor for variceal bleeding. We directly assessed post-prandial splanchnic haemodynamics in cirrhotic patients with a transjugular intrahepatic portosystemic stent-shunt (TIPSS) in situ. METHODS: A thermodilution catheter was inserted via the patent TIPSS into the portal vein in 12 cirrhotic patients. PVP,portal venous flow (PVF) (thermodilution method), portal vascular resistance (PVR), porto-atrial pressure gradient (PPG), heart rate, mean arterial pressure (MAP) and right atrial pressure (RAP) were measured. A 505 kcal meal was given and all haemodynamic measurements were repeated at 15 min intervals for 60 min. RESULTS: Following the meal, there was a significant rise in PVP from 11.2 +/- 1.5 to 14.0 +/- 1.9 mmHg at 15 min, and 14.0 +/- 1.8 mmHg at 30 min (P < 0.001); in PPG from 9.5 +/- 1.4 to 12.7 +/- 2.2 mmHg at 15 min and 12.7 +/- 2.1 mmHg at 30 min (P < 0.005); and in PVF from 1110.2 +/- 141.1 to 1543.2 +/- 227.6 ml/min at 30 min (P < 0.01). PVR feil from 0.08 +/- 0.01 to 0.05 +/- 0.01 RU at 30 min (P < 0.05). Heart rate increased from 77 +/- 4.1 to 80.5 +/- 5.4 bpm at 15 min (p < 0.05), but MAP and RAP remained unchanged. CONCLUSION: In cirrhotic patients with TIPSS, significant changes in portal haemodynamics occur at 15-30 min following a meal, with minimal effect on systemic haemodynamics. This model offers a new technique to directly assess the causes for and possible treatments of post-prandial splanchnic hyperaemia in cirrhosis.
Blood Pressure↗
Acute effects of transjugular intrahepatic portosystemic stent-shunt (TIPSS) procedure on renal blood flow and cardiopulmonary hemodynamics in cirrhosis.
OBJECTIVE: An acute increase in portal pressure is associated with an immediate reduction in renal blood flow. It has been suggested that this supports the presence of an hepatorenal reflex. In this study, we used TIPSS placement as a model to investigate the effect of an acute reduction in portal pressure on renal blood flow and cardiopulmonary hemodynamic parameters. METHODS: Eleven cirrhotic patients were studied during elective TIPSS placement for variceal hemorrhage (n = 9) or refractory ascites (n = 2). Unilateral renal blood flow (RBF) was measured before and at 5, 15, 30, 45, and 60 min after shunt insertion. Heart rate (HR), mean arterial pressure (MAP), right atrial pressure (RAP), mean pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and systemic vascular resistance (SVR) were also measured before and 30 min after TIPSS placement. RESULTS: Despite significant increases in CO (p = 0.001), RAP (p < 0.001), PAP (p < 0.001), and PCWP (p = 0.001), and a fall in SVR (p = 0.003), no change was observed in RBF, HR, or MAP after TIPSS placement. The fall in the portoatrial pressure gradient correlated only with the rise in CO (p < 0.05) and the drop in SVR (p < 0.05). CONCLUSION: Despite the fall in portal pressure and the systemic hemodynamic changes caused by TIPSS placement, there is no immediate effect on RBF. Any improvement in renal function after TIPSS procedure does not appear to be due to an acute increase in RBF.
Blood Pressure↗
A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices.
The aim of this study was to compare transjugular intrahepatic portosystemic stent-shunt (TIPSS) with variceal band ligation (VBL) in the secondary prophylaxis of esophageal variceal hemorrhage in patients with cirrhosis. Fifty-eight patients with cirrhosis who presented with the first episode of esophageal variceal hemorrhage were randomized to TIPSS (31) or VBL (27), 24 hours after control of bleeding. Shunt function was assessed after 1 month and then at 6 monthly intervals thereafter. VBL was performed weekly until variceal eradication, and then at 3 months, 6 months, and yearly thereafter. Mean follow-up in the TIPSS group was 15.7 (+/-10.2) months; in the VBL group, it was 16.8 (+/-10.9) months. Results for rebleeding and mortality were analyzed on an intention-to-treat basis and using the Kaplan-Meier method. The frequency and the severity of variceal rebleeding was significantly lower in the TIPSS group (9.8%), compared with the VBL group (51.9%) (P < .0006). Although mortality rates were not significantly different, 8 of the patients who rebled in the VBL group required TIPSS therapy for uncontrolled bleeding. No significant differences were found in the frequency of other complications such as encephalopathy and sepsis. Patients in the VBL group required significantly greater time in the intensive care unit during the period of this study (<0.03). The total direct cost of treatment incurred was pound sterling 1,373 ($2,200) per patient, the cost being less in the patients treated with TIPSS compared with VBL. The results of this study show that TIPSS is superior to VBL for the secondary prophylaxis of variceal hemorrhage in patients with cirrhosis.
Adolescent↗
Shunt insufficiency after transjugular intrahepatic portosystemic stent-shunt: the whens, whys, hows and what should we do about it?
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Clinical Protocols↗
Elevation of intracranial pressure following transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage.
Increased intracranial pressure and cerebral oedema in patients with chronic liver disease is rare and is more typical of acute liver failure. Transjugular intrahepatic portosystemic stent-shunt is being increasingly used in the management of uncontrolled variceal haemorrhage in patients with cirrhosis. In our institution, a total of 160 patients has undergone transjugular intrahepatic porto-systemic stent-shunt for variceal haemorrhage; 56 of these procedures were emergencies for uncontrolled variceal haemorrhage. Four of these 56 patients developed features of acute liver failure, with marked deterioration in liver function tests and elevated intracranial pressure. This unusual but important complication of transjugular intrahepatic portosystemic stent-shunt has not been reported in the literature previously, and may have important consequences both for clinical practice and in the provision of further clues to understanding the pathogenesis of increased intracranial pressure in patients with liver diseases.
Adult↗
A comparison between gastric and oesophageal variceal haemorrhage treated with transjugular intrahepatic portosystemic stent shunt (TIPSS).
BACKGROUND: Transjugular intrahepatic portosystemic stent-shunts (TIPSS) are becoming widely used in the management of oesophageal variceal haemorrhage (OVH). Their place in the treatment of gastric variceal haemorrhage (GVH), a condition with a traditionally poor prognosis, remains unclear. The aims of our study were to compare portal haemodynamics and patient outcome in patients undergoing TIPSS for either GVH or OVH. PATIENTS AND METHODS: 106 consecutive patients undergoing TIPSS at our institution for either GVH (32 patients) or OVH (74 patients) were studied. The groups were similar with regard to patient age, aetiology and severity of liver disease and number of procedures carried out as an emergency (34.4% vs. 36.5%). Episodes of shunt insufficiency, rebleeding, encephalopathy and other clinical sequela were recorded. Mean follow-up was similar in both patient groups (14.2 vs. 12.1 months). RESULTS: Baseline portocaval pressure gradient was lower in patients with GVH compared with those with OVH (13.0+/-0.9 mmHg vs. 19.0+/-0.6 mmHg) (P < 0.001). Rates of variceal rebleeding, encephalopathy and shunt insufficiency during follow-up were similar in both groups and there was no difference in survival. CONCLUSION: Patients with GVH had markedly lower portocaval pressure gradients than those with OVH, but shunt and clinical complications and survival were similar during follow-up. TIPSS appears to be an effective treatment for GVH and should be compared with endoscopic or surgical techniques in controlled trials.
Esophageal and Gastric Varices↗
Review article: update on the role of transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of complications of portal hypertension.
In the 8 years since its introduction into clinical practice, initial enthusiasm for the transjugular intrahepatic portosystemic stent-shunt (TIPSS) has been tempered by a more critical appraisal of its role in the management of portal hypertension. TIPSS has established its role as a rescue procedure for variceal haemorrhage uncontrolled by endoscopic means and as a treatment for ectopic or recurrent variceal bleeding. Randomized trials comparing TIPSS with endoscopic methods in the secondary prophylaxis of oesophageal variceal haemorrhage have shown reduced rebleeding after TIPSS but no effect on survival. Its exact role in this situation awaits further assessment, including quality of life and cost analyses, and consideration of the current limited availability of the technique. Experience of TIPSS in patients with refractory ascites or hepatorenal syndrome has been disappointing. Little data currently exist, but results of further randomized studies comparing TIPSS with paracentesis for refractory ascites are awaited. Ideally these should be multicentre studies, and should include quality of life data for this poor prognostic group. Development of shunt insufficiency remains a major problem and occurs in approximately 50% patients at 1 year. The need for continued shunt surveillance by Doppler sonography and direct portography is the major limitation of TIPSS, but hopefully the development of covered stents will address this problem.
Ascites↗
Reduction in renal blood flow following acute increase in the portal pressure: evidence for the existence of a hepatorenal reflex in man?
BACKGROUND: To investigate the relation between changes in portal haemodynamics and renal blood flow (RBF) in patients with cirrhosis. PATIENTS/METHODS: Twenty patients with cirrhosis and transjugular intrahepatic portosystemic stent-shunts were divided into two groups which were well matched. At routine portography, either changes in unilateral RBF (group I) or changes in cardiac output (group II) before and after shunt occlusion were studied. Blood was obtained from the renal and systemic circulations for the measurement of neurohumoral factors before and after shunt occlusion in group I patients. RESULTS: After shunt occlusion, there was a progressive reduction in unilateral RBF from a mean (SD) of 289 (32) to 155 (25) (-43.5%) (p < 0.001). These changes correlated significantly with the changes in the portal atrial gradient (p < 0.001). There was no significant change in heart rate, mean arterial pressure and right atrial pressure. No significant changes were found in the concentrations of the various neurohumoral factors measured. There was a less notable but significant reduction in the cardiac output (-10.9%) (p = 0.02) unaccompanied by significant reduction in the pulmonary capillary wedge pressure or mean arterial pressure. CONCLUSIONS: These results suggest the existence of hepatorenal reflex in man which is important in the regulation of RBF, although other mechanisms may also be contributory.
Female↗
Transhepatic venous angioplasty and stenting: a treatment option in bleeding from gastric varices secondary to pancreatic carcinoma.
We present a case of recurrent variceal bleeding due to subtotal occlusion of the splenoportal junction by a pancreatic carcinoma. This was effectively treated by transhepatic venous angioplasty and stenting.
Adenocarcinoma↗
Transjugular intrahepatic portosystemic stent-shunt (TIPSS) occlusion and the role of biliary venous fistulae.
BACKGROUND/AIM: The aim of this study was to assess the pathology and pathogenic mechanisms involved in the occlusion of transjugular intrahepatic portosystemic stent-shunts. METHODS: Thirty-four patients with transjugular intrahepatic portosystemic stent-shunt who had at least two portographic assessments of shunt function were the subjects of this study. The contents of any shunt demonstrating > 70% stenosis were biopsied before balloon dilatation. Further assessment was made of 10 livers obtained at either post mortem (8) or at liver transplantation (2). Cholangiography was performed in these explanted livers, which were then perfused and fixed with formaldehyde. The shunts were dissected out, sectioned, opened and the contents and the surrounding liver examined macroscopically, histopathologically and immunohistochemically. RESULTS: Fourteen patients with TIPSS developed shunt stenosis. In eight patients the stenosis was greater than 70% and significant re-stenosis occurred in all at repeat portography. Three of these patients who were managed by insertion of new shunts showed no further shunt-related problems, whereas the five who were treated solely by dilatation developed further re-stenosis. Organising thrombus was found in all eight patients and bile was incorporated in the thrombus in four. Biliary epithelium was found in two. Four of the ten explanted livers showed evidence of shunt stenosis, of which three were severe and one was mild (< 70%). The occluding material in patients with severe stenosis was composed of organising thrombus containing bile and a granulomatous inflammatory response. This was associated with a transected bile duct, and the degree of stenosis was related closely to the size of the bile duct transected. The shunts free of bile showed no stenosis. CONCLUSIONS: The results of this study suggest that transection of a major bile duct and bile leak play an important role in the stenosis and occlusion of the intraparenchymal portion of transjugular intrahepatic portosystemic stent-shunt. This has important implications for patient management and stent design.
Biliary Fistula↗
Clinical response after transjugular intrahepatic portosystemic stent shunt insertion for refractory ascites in cirrhosis.
BACKGROUND: Transjugular intrahepatic portosystemic stent shunts (TIPSS) have been used successfully to reduce portal pressure in the context of variceal haemorrhage. Recent interest has focused on the possible use of TIPSS to manage refractory ascites. AIM: To study the effect of TIPSS insertion in 18 patients with refractory ascites. RESULTS: Response rates were 33.3%, 50%, 33.3% and 26.7% at 1 week, 4 weeks, 3 months and 6 months, respectively. Overall mortality was 50% with a new or worsening encephalopathy rate also of 50%. Patients with lower serum bilirubin and serum creatinine prior to TIPSS insertion had greater response at 1 and 4 weeks, respectively. There was no improvement in either liver or renal function after TIPSS insertion by standard laboratory tests, although serum sodium increased in the responders after 1 month. CONCLUSION: TIPSS improves refractory ascites in only a minority of patients, and is associated with high encephalopathy and mortality rates.
Ascites↗
Differing actions of the acute administration of propranolol and isosorbide-5-mononitrate on the portal circulation.
BACKGROUND: The aim of this study was to clarify the actions of propranolol and isosorbide-5-mononitrate upon the portal circulation. METHODS: Portal haemodynamics were assessed in 16 patients with transjugular intrahepatic portosystemic stent shunts. A reverse thermodilution catheter was positioned in the portal vein, and portal vein pressure and portal vein flow were measured directly. The effects of propranolol 80 mg and isosorbide-5-mononitrate 20 mg over 1 h were determined independently. RESULTS: This demonstrated that propranolol reduced both portal pressure gradient (7.7 +/- 2.3 to 5.5 +/- 2.1 mmHg, P < 0.01) and portal vein flow (925 +/- 123 to 597 +/- 99 mL/min, P = 0.01) significantly, implying a reduction in splanchnic inflow as its main effect. In contrast, isosorbide-5-mononitrate tended to increase portal vein flow (814 +/- 186 to 911 +/- 211 mL/min; P = 0.06) whilst reducing portal pressure significantly (108 +/- 12 to 92 +/- 10 mmHg P = 0.014). This suggests a fall in intrahepatic resistance and provides no evidence for baroreceptor-mediated reflex splanchnic vasoconstriction. CONCLUSIONS: These drugs act upon different variables contributing to portal hypertension and so they may have a powerful synergistic effect in combination. Direct measurement of portal vein flow is a valuable method for assessing the pharmacological modulation of portal venous inflow.
Blood Pressure↗
Massive ascitic fluid loss after liver transplantation.
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Ascitic Fluid↗
Prospective evaluation of haematological alterations following the transjugular intrahepatic portosystemic stent-shunt (TIPSS).
BACKGROUND: TIPSS is effective in reducing portal hypertension and provides access to the portal system for direct pressure measurements. OBJECTIVE: To assess the incidence and severity of haemolysis and its course following TIPSS, and also to assess changes in spleen size and any relationship to changes in the platelet and white cell count and haemoglobin concentration. DESIGN: A prospective study. MATERIALS AND METHODS: Twenty-three patients undergoing TIPSS with a mean follow-up of 8 months (SE 1.2) were studied. Male-female ratio was 13:10 and the mean age was 53.6 years (SE 1.7). Full blood count, reticulocyte count, serum haptoglobin, urinary haemosiderin, examination of the peripheral blood smear and spleen size (ultrasonography) were measured prior to and 3, 7 and 30 days after TIPSS and 6-monthly thereafter. RESULTS: Seven patients (30.4%) developed haemolysis, which was clinically significant in three (13%). This settled spontaneously within 2 weeks of TIPSS. Portal pressure gradient was reduced from a mean of 21.9 (SE 1.6) to 9.5 (SE 1) mmHg (P < 0.001) and did not change significantly thereafter. Haemoglobin concentration improved significantly from a mean of 89 (SE 16) to 113 (SE 19) g/l (P < 0.05) after TIPSS. Significant changes in spleen size and platelet count occurred, with a reduction in the former from 16.9 (SE 1.1) to 13.7 cm (SE 2.4) (P < 0.01) and an increase in the latter from 85.9 (SE 8.4) to 135.3 x 10(9)/l (SE 16.8) (P < 0.01). No significant correlations were found between the changes in the portal pressure gradient, spleen size and platelet count. There was no significant change in the white cell count. CONCLUSION: Transient significant haemolysis occurs in about 13% of patients following TIPSS. TIPSS is useful for reducing splenomegaly and improving thrombocytopenia and haemoglobin. There is no correlation between the changes in portal pressure gradient, spleen size and platelet count.
Anemia, Hemolytic↗
Mechanisms of changes in renal handling of sodium following transjugular intrahepatic portal systemic stent-shunt (TIPSS).
BACKGROUND AND AIMS: Transjugular intrahepatic portosystemic stent-shunt (TIPSS) reduces the portal pressure gradient and leads to better control of ascites. The aim of this study was to evaluate (1) changes in renal handling of sodium following TIPSS and (2) the mechanism of these changes. DESIGN: Prospective study. SETTING: Tertiary referral centre for liver diseases. METHODS: Eighteen patients with ascites undergoing TIPSS for recurrent variceal haemorrhage (16) (3 or more hospital admissions because of variceal haemorrhage whilst being treated endoscopically) or refractory ascites (2) were studied. Urinary sodium (UNa), creatinine clearance (CrCl), plasma renin activity (PRA), atrial natriuretic peptide (ANP), cyclic guanosine monophosphate (cGMP), Angiotensin II (AII) and lithium clearance (LiCl) were measured before and 3 months after TIPSS when portography was performed and the portal pressure gradient (PPG) also measured. All patients were haemodynamically stable and had received no diuretics for at least 1 week before blood sampling. RESULTS: Improvement in ascites was achieved in all patients in whom TIPSS was inserted successfully (reduction in PPG to < 12 mmHg). PPG was reduced from a mean of 19 (+/-6) to 8.8 (+/-3.4) mmHg (P < 0.001). Urinary sodium and creatinine clearance improved significantly following TIPSS (P < 0.001, P < 0.001, respectively). PRA, All, cGMP and LiCl were abnormal before TIPSS and improved significantly following TIPSS (P < 0.007, P < 0.001, P < 0.001 and P < 0.01, respectively). ANP was not significantly different from normal controls and did not change significantly following TIPSS. Changes in UNa did not correlate with the Pugh score or the change in PPG. CONCLUSION: The results of this study show that TIPSS is associated with significant improvement in UNa, CrCl, PRA, AII, cGMP and LiCl. The change in UNa following TIPSS was independent of the severity of underlying liver disease or the change in PPG.
Adult↗