Tips: Good for the liver, but what about the heart?

SELECTED SUMMARIES

August 1994

patients had been subjected to prior sclerotherapy. However, the authors of the present study should have defined the term “failure of more precisely.

sclerotherapy” controlled

by repeat

Does recurrent

sclerotherapy

All in all, this is a well-designed tion and should

bleeding

constitute

that is easily

failure?

study that provides

pave the way for further

useful informa-

experience VIVEK

with TIPS.

report of a prospective

M.D.

of reports

that discuss

shunt

or duplex

be responsible found

probof the

These different approaches may in part

sonography.

for differences

In our experience,

in the incidence

follow-up

It allows

of stenosis and occlusion

Duplex

sonography

by interpolation sis of shunt

before rebleeding

criteria

the report, patients,

its effect on cardiac and systemic

are lacking.

failure

was diagnosed

by duplex

rebled.

who did not meet the criteria of shunt

In the 2 1 patients lishment

and/or

with shunr

of the shunt

sonographic

diagnosis. most of them

size and appearance “Asymptomatic” reappearance

terology

1993; 104:A985)

confirm

these data

with

(>50%

after

meaning

reestab-

shunt

between

in respect

harmful

of the varices

partly

to

was performed

anymore.

Thus,

diagnosed

the less, to exclude

TIPS

monary

artery

on

there

is

by duplex unnecessary

The authors attempted (while

the patients

revision

M.D.

TIPS: GOOD FOR THE LIVER, BUT WHAT ABOUT THE HEART?

search Center,

Dennison

A,

Surgery

Paul Brousse Hospital,

Ma&no

W, Eyraud

and Liver Transplant Villejuif,

9 men

cirrhosis.

There

with a mean

had cirrhosis secondary

anesthesiaj,

to

before TIPS

30 minutes

later. Two of the 12 patients

values for heart rate, systemic CO, and CI were normal,

and portal-atria1

gradients

The mean portal pressure of 15. Thirty

after

died during patients.

arterial

whereas

were elevated

pressure, the portal

as expected.

was 26 mm Hg with a portal-atria1

minutes

after TIPS, there was a signih-

increase

in PAP from

cant increase in cardiac preload, namic

complications

authors

note, however,

preexisting

there was no evidence

cardiac or pulmonary

The data at 1 month which

had increased

this signifi-

there were no acute hemody-

from TIPS in this small series. As the

had decreased

of any significant

disease in these patients.

was of considerable

interest.

The portal

from a mean of 26 to 21 mm

after TIPS, was now 14 mm Hg. The CO

to a mean of 12 L/m (CI = 7.4). The PAP and

however,

the pre-TIPS

had decreased

to levels that were lower than

values. There was a modest in the systemic

there was a decrease

in the CI and the decrease that after 1 month,

D,

adjustment

in which

Re-

pulmonary

circulation

jugular intrahepatic portosystemic shunt worsens the hyperdynamic circulatory state of the cirrhotic patient: preliminary

from 7.7 to 9.9 Li

min, whereas the CI went from 4.5 to 5.7. lIespite

tance. There was no obvious

France). Trans-

16 to 21 mm Hg and WPAP

from 11 to 16 mm Hg. The CO increased

appeared D,

and

included

so the study is based on the 10 surviving

WPAP,

expected,

Castaing

studied

to obtain measurements

were under

TIPS, and 1 month

but no change

D,

(CO),

and portal-

viral hepatitis.

WPAP,

Bismuth H (Hepato-Billiary

The patients

output

all of whom had biopsy-proven

Hg immediately

ROSSLE,

patients

the right atria1

pressure

gradient.

pressure,

MARTIN

cardiac

and 3 women,

endoscopic

before radiological

of hemody-

artery pressure (PAP), wedged pul(WPAP),

atria1 pressure

in patients

is recommended

included

index (CI), as well as the portal

(e.g.,

of TIPS

IS performed.

Azoulay

pressure

or liver failure),

reestablishment encephalopathy

is rare

had co be

in our experience,

insufficiency,

None

that

The

to study a number

in a small series of 12 consecutive

nying

or not. It does not

the symptoms

who

cant increase in RAP from 8 to 12 mm Hg with an accompa-

We cannot

depending

artery

The measurements

pressure

insufficiency

this constellation

insufficiency),

because

shunt

that

disease

16 days before he died.

namic parameters

PAP,

its duplex

with stenosis.

undertook

coronary

The present

by the death from

undergoing

The pre-TIPS

had recurrence

shunt

with

procedure

authors subsequently

the month,

(P < 0.001).

and no bleeding,

in 2 of 11 patients

embolization

a risk of heparic

evaluation

rebled

of a patient a TIPS

gradient

occlusion,

and rebleeding.

and somerimes

insufficiency

immediately

ar all. We found

are not present

sonography,

none of the 62

with a high risk of rebleeding

of the shunt

a close relation

in 31

of varices, was found by Sanyal et al. (Gastroen-

simultaneous

[reared

insufficiency

in

of the varices.

without

revision

sonography

All but one of these patients

shunt

of patients

of shunt

flow velocity)

was performed

of varices,

whether

portal

sono-

As mentioned

In contrast,

failure

underwent

hemodynamics.

France, was occasioned

age of 45 years. Eight of the patients

clear duplex

insufficiency

shunt

reduction

that

for shunt

and 10 of these patients

patients

(<5%

opinion

diagno-

en-

available on

were 3 grade A, 7 grade B, and 2 grade C patients

occurs.

bleeding

of hepatic

but there is very little information

cardiac

in most patients

pressure,

the procedure,

pressure (RAP), pulmonary

at

devel-

Thus, in many patients,

can be established

We do nor share Dr. Gumaste’s graphic

In addition,

can be anticipated

of the early findings.

failure

function

data on shunt function,

on its location.

or occlusion

is of crucial

of shunt

as it is with angiography.

quantitative

and information

of stenosis

sonography

monitoring

is not limited

also provides

degree of stenosis, opment

with duplex

noninvasive

any time, and its frequency

with

is a major

reevaluation

in the literature.

importance.

afford

of the shunt

by radiological

its effect on portal

There is also some data on I-year survival after

heart

and occlusion

can be made

por-

cephalopathy.

stated

stenosis

intrahepatic

there have been a number

varices, and the development

report from Villejuif,

correctly,

1994; 19: 129- 132

of the transjugular

shunt (TIPS) procedure,

Reply. We enjoyed reading Dr. Gumaste’s accurare summary of our report and his balanced commentary on TIPS. As Dr. Gumaste lem. Its diagnosis

Hepatology

tosystemic

from esophageal

V. GUMASTE,

study.

(January). Since the introduction

593

arterial

increase in pulse rate pressure.

in the systemic correlation

between

in the portal-atria1

As would be vascular

resis-

the increase gradient.

It

there was a form of hemodynamic

there was less blood sequestered and more delivered

in the

to the periphery

in

consequence of the increase in CO. What cannot be determined from this study is what this implies for splanchnic hemodynamics.

594

SELECTED

Comment. namic

There

problems

relatively

GASTRDENTEROLOGY

SUMMARIES

have been

after

small.

TIPS,

scattered

reports

although

In a recent

series

of 100 patients

reported

(N Engl J Med 1994;330:165-207X

year-old

man, developed

reported

a considerably

surements

Doppler

be expected,

times the control not change,

study,

techniques

relatively

the portal

the authors

of the portal

blood

is somewhat

little information

any type of surgically Clichy,

the diameter surprising.

shunt,

France (Gastroenterology

proximately

2% of patients

pulmonary appear

hypertension.

factor

Surg 1979; 190:523-534) but not after distal

Forum

1976;27:370,

ported

conflicting

difficult

splenorenal

Anesth postsurgical

it is to extrapolate

The TIPS procedure, anesthesia

this

which

used in the present

in the return

to the right

in pulmonary

pressure,

decreases.

data

vessels, including tion about

CO increases

the splanchnic

eral, and splanchnic

that exists is to a considerable which

variety

the velocity

of drugs,

Gastroenterol (Hepatology

such

as glucagon,

and

1986;6:1248-1251),

from an intensive

care unit

apt to have

been administered are not likely

with

patients

develop

procedure

the diameter

at hand.

that

and

large

amounts

of the term “gradient.

are

not deter-

relatively

failure

few

after a TIPS are of no

in pressure

It was thought

between

although

this was only

alcoholic

cirrhosis.

Patients

ence that

It was found,

from esophageal

varices

is 12 mm Hg or greater.

whether

the so-called

procedure bleeding TIPS,

bleeding

well established

from esophageal

the change

the explanation.

There

portal-atrial

can or should

of the portal in patients

gradient

be interpreted varices

tends

in this portal-atria1

however,

to

and free hepatic

with other forms of chronic

do not always fit this pattern. gradient

the wedged

understood

to be an approximation

pressure,

the use

concerning

was initially

with

liver disease

through

rarely occurs

experi-

unless

this

is no clear understanding that

exists after a TIPS

in the same manner. to decrease gradient

to establish

performed values

at least

Dr. Sweeting

hemodynamics

however,

at 1 month

we think

of blood

it remains

dure has been postponed

3 patients

The PAP were

lower

by the decrease

of

by the reviewer.

that the decompression this phenomenon.

26 more patients period.

have been

A TIPS proce-

because of a CO of I6 L/min

have presented

after TIPS. A complete

systemic

report

soon. We fully agree that further

this area. In particular,

we need to establish

increased

syndrome

hyperdynamic

that

proposed

follow-up

in one patient

Furthermore,

out by patients

did not reach statistical

to be proven

of our report,

Pre-TIPS

syndrome).

bed via the TIPS prevents

for our study with a longer

rupture. as pointed

implied

is a sound hypothesis

in

TIPS was

to levels

this decrease

The sequestration

be submitted

in our patients failure,

for cirrhotic

degree of hyperdynamic

values; however,

However,

add normal

M.D.

several issues. The

were normal,

we would

had decreased

resistance

the

for his interesting

but feel we must address

10 days after the last variceal

peripheral

when

G. SWEETING,

is that TIPS was performed

a certain

WPAP

are available,

to determine

For the cases of sclerotherapy

for systemic

and pulmonary

techniques

hemody-

of this study will

studies

are needed

the consequences

on a subsequent

in

of an

liver transplanta-

tion.

of fluid

in hemodynamics

gradient”

first point

situations.

ac-

and portal blood flow. Only when

like to thank

on our report,

elective

it is totally

these procedures

DANIEL AZOULAY,

M.D.

homeostasis.

is simply

of interpretation

” “Hepatic

mean the difference vein pressure.

problem

We would

namic complications

consequence. There is an additional

Reply.

older more

appropriate.

comments

J

portal

before

JOSEPH

pre-TIPS.

coming

such agents

of reliable

heart

volume

in patients

of cardiac

the appropriate

technique of bleeding

we understand

undergoing

will it be possible

is truly

A

nitrates

to alter

The fact that

changes

of splanchnic

Since the submission

(Stand

patients

many

to these variables

overt signs of congestive

does not mean

that

with

measurements

available

of the

flow volume.

vasopressin

means

changes

patients

brought

high rate of complica-

that

determination

and, when

of the splanchnic

periph-

extent based on Dopp-

in which

along

the information

no informa-

p blockers

to be in a state

TIPS does when added

minable

this

it mandatory

that

have, at minimum,

significance.

resistance

pulmonary,

have been shown

At the very least,

The relatively

hemodynamic

appear

hemodynamics

than pre-TIPS

to the increase

peripheral

secretin,

should

and

increase

of blood in peripheral

of the flow to determine

replacement What

a short-term

on measuring

1986;21:1029-1038X

vein velocity. directly

depends

It would

(i.e., showing

the general

after any type of shunt procedure.

ler technology,

the associated

Dr. Sweeting;

situation.

without

cardiac,

The information vessel and

re-

it clear how

bed. There is virtually

hemodynamics

(Surg

have

making

whereas

among

(Ann

reports

side of the heart. In addition

the overall correlations

did not

Reichle

Other

This would imply some sequestration

60 years of age) make

about

to be a useful

in the management

found that ap-

in CO after mesocaval

imposes

hypertension.

this data is accumulated

to the post-TIPS

study,

than

It appears

acceptance

points

changes

(e.g., more than 40% encephalopathy

TIPS procedure

shunt

can be performed

to portal

tions, however,

after

of a surgical

findings,

rapid

No. 2

of patients,

about the hemodynamic

by the TIPS procedure. is obtaining

from

1982;61:185-186)

shunt

is

had coexisting

shunts.

Analg

there

hypertension

an increase

that

changes

for this association.

reported

(2.5

based on a small number

TIPS. A report

1991; 100:520-528)

The presence

about

cepted.

vein did

Unfortunately,

including

with portal

to be a determining

shunts

markedly

of the portal

about overall hemodynamic

created

flow before

hemodynamics.

although

out how little is understood

secondary

which (or he-

also made mea-

blood flow increased

level), although

which

an 84-

in the portal-atrial

and after TIPS but did not assess cardiac or pulmonary As would

from

only 1 patient,

decrease

than in the Clichy

using

to be

heart failure after TIPS. In that study, greater

This study,

hemody-

appears

Freiborg

patic) gradient

of acute

the incidence

Vol. 107,

De Cicco M, Panarello G, Fantin D, VeronesiA, Pinto A, Zagone/ V, Monfardini S, Testa V (Clinical Leukemia

Units

Riferimento

after a successful of

and Division

Oncologico,

a Carattere cancer

nutritional

Italy).

di Ricovero

di

e Cura

nutrition

effects

1993;17:513-518

and

Centro

Parenteral

chemotherapy:

JPEN

Nephrology, Oncology,

Nazionale

Aviano,

receiving

status.

Nutrition,

of Medical

Istituto

Scientifico,

patients

on toxicity

in and

(November-De-

cember). De

Cicco

(TPN)

might

therapy

Although

may be only part

NUTRITIONAL SUPPORT: FIXING NITROGEN, FIXING PATIENTS

with

et al. postulated be efficacious

in patients various

lymphoma, at least

with

cancers and bladder

two

identical

that

total

in reducing cancer.

(small

cell

cancer) courses

They lung

parenteral

nutrition

the toxicities identified cancer,

who were

50 patients non-Hodgkin’s

scheduled

of chemotherapy.

of chemo-

to receive

Using

a ran-