TIPS on Portal Hypertension for Surgeons

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TIPS on Portal Hypertension for Surgeons

• John R. Potts, III, M.D., F.A.C.S.
• Program Director in Surgery
• Assistant Dean Graduate Medical Education
• University of Texas Medical School - Houston

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VARICEAL BLEEDINGResuscitation

• Treat hemorrhagic shock
• Crystalloid (Limited)
• Platelets (Rarely)
• Red Cells FFP
• Goal Tissue Perfusion
• Monitor Urine Output
• Caveat Do NOT overload

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VARICEAL BLEEDINGInitial Treatment

• Continue Tx hemorrhagic shock
• IV therapy
• Sandostatin
• INITIATE WHEN Dx SUSPECTED!!!

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VARICEAL BLEEDING Diagnosis

• 50 UGI bleeds not variceal
• (MW Tear, Gastritis, Gastric/Duodenal Ulcer)
• Early endoscopy mandatory
• Variceal bleeding Dxd
• Active bleeding
• Stigmata
• Varices and NO other source

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VARICEAL BLEEDINGInitial Therapy

• Continue I.V. Sandostatin
• Endoscopic Therapy
• Sengstaaken-Blakemore tube
• TIPS
• Emergency operation

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VARICEAL BLEEDINGSupportive Therapy

• Correct coagulopathy
• FFP, vitamin K, /- platelets
• Pulmonary
• Other infection
• Encephalopathy
• Nutrition

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VARICEAL BLEEDINGEvaluation

• Child class
• History
• Hepatitis profile
• Angiography
• Transplant evaluation

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Child-Pugh Classification
Grade A, 5-6 points Grade B, 7-9 points Grade
C, 10-15 points
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VARICEAL BLEEDINGDefinitive Therapy

• Rationale 67 rebleed
• Most rebleed lt 6 weeks
• Definitive Tx during initial stay

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VARICEAL BLEEDINGDefinitive Therapy

• Medical
• Endoscopic
• Surgical
• Radiological

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VARICEAL BLEEDINGMedical Therapy

• Beta blockade
• ? bleeding by ? cardiac output
• Goal 25 ? in heart rate
• Reduces bleeding episodes
• Does not reduce mortality
• Use as adjunct

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Endoscopic Banding

• Occludes venous channels
• Multiple sessions surveillance
• gt60 rebleed
• 1/3 fail treatment
• ? complications vs scleroTx
• / ? efficacy vs scleroTx
• ENDOSCOPIC Tx OF CHOICE

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Endoscopic Banding
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VARICEAL BLEEDINGSURGICAL OPTIONS

• Total Shunt
• Selective Shunt
• Partial Shunt
• Non-Shunt

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Total Shunts
End to Side Portocaval
Side to Side Portocaval
Interposition Shunts
Central Splenorenal
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Total Shunt Results

• Prevent rebleed gt 90
• Thrombosis with graft
• Encephalopathy rate 40

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Selective Shunts

• Goals
• Prevent variceal bleeding and encephalopathy
• Mechanism
• Decompress Varices
• Maintain Portal Perfusion
• Maintain Portal Hypertension
• Key
• Decompress only gastrosplenic compartment

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Distal Splenorenal Shunt
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DSRS vs Total Shunts

• Six randomized trials in N.A.
• Mean follow-up 39 mos (1-8 yrs)

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Partial Shunts

• Ease of portocaval
• Limited portal diversion
• Maintain some liver perfusion
• Short, straight PTFE graft

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Partial Shunts
Sarfeh Ann Surg 200706,1986
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Partial Shunts
Randomized trial in ETOH cirrhotics Follow-up _at_
20 /- 11 mos
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Non-Shunt Operations

• Options
• Esophageal transection
• Variceal ligation
• Devascularize /- splenectomy
• Very limited role

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Liver Transplant

• Indicated for liver failure
• Not for variceal bleeding
• Number ? gt 3,500/yr in U.S.
• 20,000 potential recipients in U.S.
• 5,000 listed for transplant
• 24 die on waiting list

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TIPSTransjugular Intrahepatic Portocaval Shunt
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TIPS
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TIPS

• Technically feasible
• Complications 9 - 50
• Infection
  Intraperitoneal Bleeding
• Congestive Failure Subcapsular Hematoma
• Acute Renal Failure Hemobilia
• Mortality (30 day) 3 - 13

(1) Rossie NEJM 1994330165, (2) Rosch
Hepatology 199216884, (3) LaBerge Radiology
1993187913.
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Problems With TIPS

• Encephalopathy minimum 15
• Occlusion 33 - 73 _at_ one year
• Rebleeding
• 18 _at_ one year (1)
• 19 _at_ 4.7 months (3)

(1) Rossie NEJM 1994330165, (2) Rosch
Hepatology 199216884, (3) LaBerge Radiology
1993187913.
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The Role For Tips

• Refractory bleeding
• Bridge to transplant
• Child C
• (all or only D?Z ?)
• ??? refractory ascites
• Relative contraindication Poor f/u

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Special Cases of Portal Hypertension
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Splenic Vein Thrombosis

• Etiology
• Pancreatitis - Acute or Chronic
• Pancreatic Carcinoma
• Hallmark
• Isolated Gastric Varices
• Treatment
• Splenectomy (if bleeding)

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Portal Vein Thrombosis

• Etiology
• Congenital - Cavernous Transformation
• Hallmark
• Normal Liver Function W/ Varices
• Treatment
• Endo Tx OR DSRS

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Budd-Chiari Syndrome

• Etiology
• Hypercoagulable Estrogens, XRT, Myeloprolif,
  PNH
• IVC Occlusion RA Myxoma, Pericarditis, Membrane
• Liver Mass
• High Dose ChemoTx
• Presentation Classic Triad
• Abdominal Pain
• Ascites
• Hepatomegaly

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Budd-Chiari Syndrome

• Diagnosis
• U/S, CT, Angio
• Treatment
• NOT a static disease
• If NO necrosis ? Symptomatic Tx
• If necrosis ? Shunt (PCS or MAS) or Transplant

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Some Take Home Points

• Child A better than Child C
• Start Sandostatin when Dx suspected
• ß blockade ? bleeding by ? C.O
• Banding safer than scleroTx
• TIPS Encephalopathy occlusion rate

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Some Take Home Points

• Selective shunt ?? encephalopathy
• SV Thrombosis Presentation Tx
• Budd-Chiari Classic triad
• Transplant for liver failure

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Portal HypertensionEtiology

• PRE-HEPATIC
• Portal Vein or Splenic Vein Thrombosis
• INTRA-HEPATIC
• Cirrhosis (ETOH, Hepatitis, Other Toxins)
• POST-HEPATIC
• Budd-Chiari

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Complications of Portal Hypertension

• Ascites
• Encephalopathy
• Variceal bleeding
• Initial management
• Evaluation
• Definitive therapy
• Special cases

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Encephalopathy

• Etiology ? Nitrogen compounds
• Induced by
• Infection Dehydration
• Constipation Blood in gut
• No test is diagnostic
• Therapy
• Hydrate Cleanse gut
• ? protein Find and treat cause

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Ascites

• Origin
• Sinusoidal pressure gt colloid oncotic pressure
• Induced by
• Physiologic Stress
• IV Fluids
• Complications
• Spontaneous Bacterial Peritonitis
• Hepatorenal Syndrome

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Control of Ascites

• Sodium / Water Restriction
• Spironolactone
• Loop Diuretic
• Large Volume Paracentesis
• Peritoneal-Venous Shunt
• (?) TIPS

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VARICEAL BLEEDING General Approach

• Resuscitation
• Initial treatment
• Support
• Evaluation
• Definitive therapy

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Vasopressin

• 8-Arginine Vasopressin (ADH)
• Intense constriction (all beds)
• s ? Mesenteric Flow
• ? Portal Pressure
• Stops Bleeding in gt80
• -s Peripheral Ischemia
• Myocardial Ischemia
• NTG ?s adverse effects

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Sandostatin

• Long acting STS analogue
• s ? Mesenteric Flow
• ? Portal Pressure
• Stops bleeding in gt 85
• Good as VP but ? side effects
• -s Cost
• DRUG OF CHOICE

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Portal Vein Anatomy
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Portal Vein Collaterals
Five Principle Routes Veins of
Retzius Umbilical Vein Hemorrhoids Adhesions E
sophageal Varices
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VARICEAL BLEEDING Sclerotherapy

• Intra- or Para- Variceal
• Occludes venous channels
• Multiple sessions surveillance
• gt60 rebleed
• 1/3 fail treatment
• 30 complication rate

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Endoscopic Sclerotherapy
Intravariceal
Paravariceal
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Complications of ScleroTx

• LOCAL
• Ulceration
• Stricture
• Perforation

• SYSTEMIC
• Fever
• Pneumonitis
• CNS

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Total Shunts

• Divert most (all?) portal flow
• Options
• Portocaval Shunt (E-S or S-S /- Graft)
• Interposition Shunt
• Central Splenorenal Shunt

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TIPS
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Childs Classification
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SclTx vs TIPS
Five Randomized Trials - 360 patients Mean
Follow-up 15 mos (1-36)
p lt 0.05 in all but one study p lt
0.05 in all studies n.s. in all but one study
where survival ? w/ SclTx