Distal Splenorenal Shunt Versus Transjugular Intrahepatic Portal Systematic Shunt for Variceal Bleeding: A Randomized Trial

Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
Gastroenterology (Impact Factor: 13.93). 06/2006; 130(6):1643-51. DOI: 10.1053/j.gastro.2006.02.008
Source: PubMed

ABSTRACT Variceal bleeding refractory to medical treatment with beta-blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts (TIPS). This prospective randomized trial tested the hypothesis that patients receiving distal splenorenal shunts (DSRS) would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding.
A prospective randomized controlled clinical trial at 5 centers was conducted. One hundred forty patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding were randomized to DSRS or TIPS. Protocol and event follow-up for 2-8 years (mean, 46 +/- 26 months) for primary end points of variceal bleeding and encephalopathy and secondary end points of death, ascites, thrombosis and stenosis, liver function, need for transplant, quality of life, and cost were evaluated.
There was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P = .29) or first encephalopathy event (DSRS, 50%; TIPS, 50%). Survival at 2 and 5 years (DSRS, 81% and 62%; TIPS, 88% and 61%, respectively) were not significantly different (P = .87). Thrombosis, stenosis, and reintervention rates (DSRS, 11%; TIPS, 82%) were significantly (P < .001) higher in the TIPS group. Ascites, need for transplant, quality of life, and costs were not significantly different.
DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child-Pugh class A and B patients. Reintervention is significantly greater for TIPS compared with DSRS. Because both procedures have equivalent outcomes, the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed.

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    • "Given the fact that the patient was only thirty-seven years old and had minimal medical comorbidities, surgical shunting was deemed to be more appropriate than TIPS. This was based on the fact that although both surgical shunting and TIPS provide significant portal decompression, TIPS is associated with a higher incidence of variceal rebleeding and dysfunction (e.g., stenosis, thrombosis, and occlusion) with reintervention rates of 48– 82% compared with 6.3–11% for surgical shunts [17] [18]. These high reintervention rates offset the initial cost-savings of a TIPS procedure and require close long-term surveillance to monitor for signs of TIPS failure [19] "
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    ABSTRACT: Nodular regenerative hyperplasia (NRH) is an uncommon condition, but an important cause of noncirrhotic intrahepatic portal hypertension (NCIPH), characterized by micronodules of regenerative hepatocytes throughout the liver without intervening fibrous septae. Herein, we present a case of a thirty-seven-year-old female with systemic lupus erythematosus (SLE) who was discovered to have significant esophageal varices on endoscopy for dyspepsia. Her labs revealed a slight elevation in the alkaline phosphatase and mild thrombocytopenia. Abdominal MRI revealed seven focal hepatic masses, splenomegaly, no ascites, and a patent portal vein. Ultrasound-guided core biopsy was reported as focal nodular hyperplasia. However, her varices persisted despite treatment with beta-blockers and four additional upper endoscopies with banding. She was subsequently referred for a surgical opinion. At that time, given her history of SLE, azathioprine use, and portal hypertension, suspicion for NRH was raised. Given her normal synthetic function and lack of parenchymal liver disease, the patient was offered surgical shunting. During shunt surgery, a liver wedge biopsy was also performed and this confirmed NRH. An upper endoscopy six weeks after shunting verified complete resolution of varices. Currently, fifteen months after surgery duplex ultrasonography demonstrates shunt patency and the patient is without recurrence of her portal hypertension.
    Case Reports in Medicine 08/2012; 2012:965304. DOI:10.1155/2012/965304
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    • "The main limitation of the study by Dr. Boyer and colleagues, however, is that TIPS was performed using bare stent [8] "
    Journal of Hepatology 04/2008; 48(3):387-90. DOI:10.1016/j.jhep.2007.12.009 · 10.40 Impact Factor
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    ABSTRACT: Preamble These recommendations provide a data-supported ap-proach. They are based on the following: (1) formal re-view and analysis of recently published world literature on the topic (Medline search); (2) The American College of Physicians' Manual for Assessing Health Practices and De-signing Practice Guideline 1 ; (3) policy guidelines, includ-ing the American Association for the Study of Liver Diseases' Policy Statement on Development and use of Practice Guidelines and the American Gastroenterologi-cal Associations' Policy Statement on the Use of Medical Practice Guidelines 2 ; and (4) the authors' years of experi-ence in the care of patients with portal hypertension and use of TIPS in the management of these disorders. These recommendations are fully endorsed by the AASLD and the Society for Interventional Radiology. Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventative aspects of care. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific rec-ommendations are based on relevant published information. In an attempt to characterize the quality of evidence support-ing recommendations, the Practice Guidelines Committee of the American Association for the Study of Liver Diseases requires a grade to be assigned and reported with each rec-ommendation (Table 1).
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