Distal splenorenal shunt versus transjugular intrahepatic portal systematic shunt for variceal bleeding: a randomized trial.
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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ABSTRACT: Emergency treatment of bleeding esophageal varices (BEV) in cirrhotic patients is of prime importance because of the high mortality rate surrounding the episode of acute bleeding. Nevertheless, there is a paucity of randomized controlled trials of emergency surgical therapy and no reports of the costs of any of the widely used forms of emergency treatment. The important issue of direct costs of care was examined in a randomized controlled trial that compared endoscopic sclerotherapy (EST) to emergency portacaval shunt (EPCS). Two hundred eleven unselected consecutive patients with ultimately biopsy-proven cirrhosis and endoscopically proven acute BEV were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic workup was completed, and EST or EPCS was initiated within 8 h. Criteria for failure of EST or EPCS were clearly defined, and crossover rescue treatment was applied, when primary therapy failed. Ninety-six percent of patients underwent more than 10 years follow-up, or until death. Complete charges for all aspects of care were obtained continuously for more than 10 years. Direct charges for all aspects of care were significantly lower in patients treated by EPCS than in patients treated by emergency EST followed by long-term repetitive sclerotherapy. Charges per patient, per year of treatment, and per year in each child's risk class were significantly lower in patients randomized to EPCS. Charges in patients who failed endoscopic sclerotherapy and underwent a rescue portacaval shunt were significantly higher than the charges in both the unshunted sclerotherapy patients and the patients randomized to EPCS. This result was particularly noteworthy given the widespread practice of using surgical portacaval shunt as rescue treatment only when all other forms of therapy have failed. In this randomized controlled trial of emergency treatment of acute BEV, EPCS was significantly superior to EST with regard to direct costs of care as reflected in charges for care as well as in survival rate, control of bleeding, and incidence of portal-systemic encephalopathy. These results provide support for the use of EPCS as a first line of emergency treatment of BEV in cirrhosis.Journal of Gastrointestinal Surgery 01/2011; 15(1):38-47. · 2.36 Impact Factor
Article: Upper gastrointestinal bleeding[Show abstract] [Hide abstract]
ABSTRACT: CommentaryUpper GI bleeding is one of the most important therapeutic areas in gastroenterology. Many of the cases fall under the category of an emergency situation and thus require urgent endoscopic intervention. In this review, Dr Loren Laine provides updated information about the epidemiology, the clinical presentation, and therapeutic interventions in various GI bleeding scenarios. In addition, Dr Laine provides a critical review of some of the diagnostic and therapeutic approaches that are commonly pursued despite their very low yield. Lastly, Dr Laine emphasizes, in his review, the importance of combining endoscopic and medical therapeutic interventions in patients who present with upper-GI bleeding.– Ronnie Fass, MD, EditorClinical Update. 01/2007;
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ABSTRACT: Die chirurgische portokavale Shuntanlage muss, neben der mittlerweile etablierten TIPSS (transjugulären intrahepatischen portosystemischen Shunt)-Anlage, noch immer als ein mögliches Verfahren zur portomesenterialen Dekompression von Patienten, bei denen die medikamentöse und endoskopische Therapie ausgeschöpft ist und eine Lebertransplantation nicht zwingend indiziert ist, angesehen werden. Dies gilt für die Rezidivblutungsprophylaxe von Ösophagusvarizen bei Patienten mit einer kompensierten Leberfunktion, wenn beispielsweise eine extrahepatische Pfortaderthrombose oder eine prognostisch günstige CHILD-A-Zirrhose zugrunde liegt. Die endoskopische Notfalltherapie stellt die empfohlene Behandlung des akuten Blutungsereignisses dar. Aktuelle randomisierte Studien lenken die Aufmerksamkeit aber auch immer wieder auf den notfallmäßig angelegten chirurgischen portokavalen Shunt. Ebenso stellt der chirurgische portokavale Shunt eine geeignete Therapiealternative zum TIPSS oder der Lebertransplantation bei akutem Budd-Chiari-Syndrom oder der „veno-occlusive disease“ dar. Der vorliegende Artikel soll aktualisiert die Möglichkeiten der portokavalen Shuntchirurgie aufführen und anhand von Studien den berechtigten Stellenwert dieser Chirurgie belegen. Portosystemic shunt surgery in addition to transjugular intrahepatic portosystemic shunt (TIPS) insertion must still be regarded as a current treatment option for portomesenteric decompression in patients with pharmacological and endoscopic treatment failure, where liver transplantation is not imminent. This applies to secondary prophylaxis of rebleeding from varices in patients with well preserved liver function, e.g. liver cirrhosis CHILD A or extrahepatic portal vein thrombosis. Even if emergency endoscopy represents the treatment of choice in the acute bleeding situation, latest data from San Diego on emergency portacaval shunt surgery are encouraging. Likewise, portacaval shunt procedures can be an attractive alternative to TIPS or liver transplantation for acute Budd-Chiari syndrome or veno-occlusive disease. This article is an update on the systematics and methodology of portacaval shunt surgery, emphasizing the significance of this treatment option based on latest studies. SchlüsselwörterPortale Hypertension–Varizenblutung–Shuntchirurgie–Pfortaderthrombose–Hypersplenismus KeywordsPortal hypertension–Varices bleeding–Shunt surgery–Portal vein thrombosis–HypersplenismDer Chirurg 01/2011; 82(10):898-905. · 0.52 Impact Factor