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S K Mathur MS,FACS Sr.Consultant Surgeon Surgical Gastroenterology HPB Surgery & Liver Transplantation Wockhardt Hospitals
(Associated Hospital of Harvard Medical International)
Options for elective treatment of portal hypertension in cirrhotic patients in the transplantation era.
Bismuth H, Adam R, Mathur S, Sherlock D. Am J Surg. 1990 Jul;160(1):105-10. Hepatobiliary Surgery and Liver Transplant Unit, Paul Brousse Hospital, Villejuif, France.
We propose that initial bleeding be controlled by endoscopic sclerotherapy, Grade A patients appear to be managed best by a reduced-size portacaval shunt (RPS) Grade B patients can be managed by either sclerotherapy, RPS, or OLT, depending upon individual circumstances. Grade C patients are best managed by liver transplantation
1983
Year
1950
1980
1990
2000
Spina et al 1990
60
72
66
EVS 542
Mathur SK
542
45%
14%
39%
EHPVO 236
NCPF
87
8 Budd-Chiari
*Personal series
Clinical Manifestations
Variceal bleeding Ascitis Liver cell failure Cirrhosis
Non-Cirrhotic portal hypertension Symptomatic Splenomegaly Hypersplenism Growth retardation EHPVO Biliary Obstruction Menorrhagia
Splenectomy : curative
Baveno Am J Gastroenterol Hepatol 1988 J Gastro 1989 Consensus 96 Gv with Mathurs Sarins
GOV1 GOV2
OV Type1 Type2
IGV1
Isolated GV Type1
IGV2
Long-term results of endoscopic Histoacryl injection sclerotherapy for gastric variceal bleeding: a 10-year experience
Akahoshi T et al. Surgery. 2002 Jan; 131(1 Suppl): S176-81.
n=52 , active bleeding 32 and recent bleeding 20 mean Follw-up : 28.1 months RESULTS: Initial hemostasis was 96.2%. (no bleeding occurred for 48 hours after sclerotherapy) Cumulative non-bleeding rates at : 1 5 10 years 64.7% 52.7% 48.2%
CONCLUSIONS:
Histoacryl injection sclerotherapy is highly effective for the treatment of bleeding gastric varices but the rate of recurrent bleeding is so high that further methods or devices still need to be developed in order to prevent gastric variceal rebleeding.
Post Shunt
Rebleed 2%
EHPVO:Portal Biliopathy
Bile duct abnormalities: 85 100% Symptomatic: 1%
ERCP
MRCP
MRCP
O.V.
Fundal G.V.
MRCP+MR ANGIOGRAPHY
Large calculi in Rt hep duct, CHD and prox CBD with marked IHBR diln. CBD prominent but N. E/o EHPVO with portal cavernoma with hepatopetal and hepatofugal collaterals and splenomegaly.
patients
TIPS
TIPS
Case # 5
Distal-spleno-renal shunt
Splenic vein
SHUNT
Renal vein
TIPS Vs Surgery
Evidence based Medicine :
U.S. Preventive Services Task Force for ranking evidence about the effectiveness of treatments : Level I: Evidence obtained from at least one properly designed randomized controlled trial. Level II-1: Evidence obtained from well-designed controlled trials without randomization. Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
Ten years' follow-up of 472 patients following TIPSS insertion at a single centre Procedure-related mortality : 1.2%. Rebleed: 13.7% (within 2 years of TIPS) (principally from gastric and ectopic varices) Shunt patency rates: need for reinterventions - Primary 45.4% & 26.0% at 1 and 2 years
- Secondary assisted patency rate was 72.2%.
TIPS: PTFE covered V/s Uncoverd Stents long-term results of a randomized multicentre study
N = 80 (follow-up for 2 yrs) TIPS Stent Covered Uncovered Primary patency 76% 36% (P=0.001) Rebleed 10% 29% (P<0.05) Encephalopathy 33% 49% (P<0.05) Probability of survival 58% 45% (NS) (2 years)
Bureau C et al Liver Int. 2007 Aug;27:742-7.
Distal splenorenal shunt versus TIPS for variceal bleeding : a randomised trial
73 DSRS & 67 TIPS (Child Pugh A and B patients) Follow-up: 2-8yrs (mean46+/-26 months) DSRS and TIPS similar in efficacy in the control of refractory variceal bleeding
(rebleeding DSRS, 5.5%; TIPS, 10.5%; P = .29)
H-Graft Portacaval Shunts Versus TIPS H-Graft Portacaval Shunts VersusWith TIPS Ten-Year Follow-up of a Randomized Trial Ten-Year Follow-up Predicted Survivals Comparison to of a Randomized Trial Rosemurgy AS et al, to Predicted Survivals With ComparisonAnn Surg. 2005; 241: 238246. .
TIPS 66 HGPCS 66 10(15%) 13(20%) (Post procedure) Child-Pugh C 70% 84% Rebleed: 20(30%) 5(7.6%) Shunt stenosis 32(48.5%) 7(10.6%) significantly higher after TIPS (P <0.001) Encephalopathy: 30% 10%
Rosemurgy AS et al, Ann Surg. 2005; 241: 238246
N=132 Mortality
H-Graft Portacaval Shunts Versus TIPS Ten-Year Follow-up of a Randomized Trial With Comparison to Predicted Survivals TIPS (N = 66) HGPCS (N = 66) Through 24 months, actual survival was superior after HGPCS v/s TIPS (P = 0.04). Survival at 5 to 10 years was superior after HGPCS compared with TIPS for : - Child's class A and B (P = 0.07) - MELD scores less than 13 (P = 0.04)
Rosemurgy AS et al, Ann Surg. 2005; 241: 238246.
Portal Hypertension
"Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.
Randomized trial of emergency endoscopic sclerotherapy versus emergency portacaval shunt for acutely bleeding esophageal varices in cirrhosis. Orloff MJ J Am Coll Surg. 2009 July
BACKGROUND: The mortality rate of bleeding esophageal varices in cirrhosis is highest during the period of acute bleeding. This is a report of a randomized trial that compared endoscopic sclerotherapy (EST) with emergency portacaval shunt (EPCS) in cirrhotic patients with acute variceal hemorrhage. STUDY DESIGN: A total of 211 unselected consecutive patients with cirrhosis and acutely bleeding esophageal varices who required at least 2 U of blood transfusion were randomized to EST (n=106) or EPCS (n=105). Diagnostic workup was completed within 6 hours and EST or EPCS was initiated within 8 hours of initial contact. Longterm EST was performed according to a deliberate schedule. Ninety-six percent of patients underwent more than 10 years of followup, or until death. RESULTS: The percent of patients in Child's risk classes were A, 27.5; B, 45.0; and C, 27.5. EST achieved permanent control of bleeding in only 20% of patients; EPCS permanently controlled bleeding in every patient (p< or =0.001). Requirement for blood transfusions was greater in the EST group than in the EPCS patients. Compared with EST, survival after EPCS was significantly higher at all time intervals and in all Child's classes (p< or =0.001). Recurrent episodes of portal-systemic encephalopathy developed in 35% of EST patients and 15% of EPCS patients (p< or =0.01). CONCLUSIONS: EPCS permanently stopped variceal bleeding, rarely became occluded, was accomplished with a low incidence of portal-systemic encephalopathy, and compared with EST, produced greater longterm survival. The widespread practice of using surgical procedures mainly as salvage for failure of endoscopic therapy is not supported by the results of this trial (clinicaltrials.gov #NCT00690027).
22 19 2 7 3 2
80
6%
12%
8%
6%
5%
% 10
8 6 4 2 0
Rebleed
Enceph
Choice of Surgery
Timing : Emergency vs elective
Experience of surgeon with shunt surgery Portal venous anatomy Indication for surgery Site of bleed
Distal-spleno-renal shunt