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: 16.72). 06/2006; 130(6):1643-51. DOI: 10.1053/j.gastro.2006.02.008
Source: PubMed


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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    • "Meta-analyses have demonstrated that TIPS was more efficient in preventing rebleeding but it was more frequently followed by episodes of encephalopathy, and survival was not different between groups [59, 79, 80] (Table 5). TIPS has also been compared with surgical shunts or oesophageal transaction [81–83], but results are difficult to interpret because all the patients were good operative risks, and the studies were performed before the introduction of PTFE-coated stents. Therefore, TIPS is not recommended as a first-line therapy for secondary prophylaxis of variceal bleeding. "
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    ABSTRACT: The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.
    07/2012; 2012(5):167868. DOI:10.1155/2012/167868
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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 · 11.34 Impact Factor
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