Tips: To be or not to be?

1994;107:591-597

GASTROENTEROLGGY

SELECTED SUMMARI.ES Henry J. Binder, M.D. Selected Summaries Editor YaleUniversity School of Medicine New Haven, Connecticut 06520-8019

STAFF OF CONTRIBUTORS Kim E. Barrett, San Diego, CA Grace H. Elta, Ann Arbor, Ml Greg Fitz, Durham, NC Lawrence S. Friedman, Boston, MA Vivek V. Gumaste, New York, NY Lynn Hornsby-Lewis, New York, NY Cyrus Kapadia, New Haven, CT

TIPS:

Ronald L. Koretz, Sylmar, CA William M. Lee, Dallas, TX Thomas A. Miller, Houston, TX Ravinder K. Mittal, Adelaide, South Australia Linda Rabeneck, Houston, TX Anil K. Rustgi, Boston, MA

TO BE OR NOT TO BE?

Mitchell Konrad Fergus Joseph Richard Jacques

needle track was dilated formed.

Finally,

R&e M, Haag K, Oh A, SellingevM, Noldge G, Peramu J.-M.,

Johnson

and Johnson,

Bwgw E, Blum U, Gabejmunn A, HauensteinK, Ianger M, Gerok W

expanded

(Medizinische

adjusted

Universitatsklinik

versitatsklinik,

Freiburg,

and the Radiologische

Germany;

and the Hopital

Secours, Metz, France). The transjugular temic

stent-shunt

procedure

de Bon-

intrahepatic

for variceal

Uni-

bleeding.

N Engl J

evaluating

questions

a new

regarding

temic stem-shunt, hemorrhage

A transjugular

the

sclerotherapy

electively,

basis. Ninety-two

noma,

were excluded

or stenosis

cirrhosis

portosysofvariceal

shunt (TIPS) was

with cirrhosis.

whereas

Hepatic procedure

Ninety

10 were managed

of these patients

on

underwent

hepatic

from the study

hepatitis

by the Number

was assessed Connection

carci-

The cause of cirrhosis in 19, primary

from 18 to 84 years (mean, encephalopathy

to

if they had portal hepatocellular

of the celiac trunk.

in 68, chronic

tal State test. Patients

to achieve a portal

infused

for 12 hours

biliary

in 9 patients.

seconds.

Patients

were discharged

ined 1 month intervals

during

measurements,

Lactulose

Patients

test and the Mini-Men-

through

The procedure

or pethedine.

this catheter vein. A

gradient

measured.

The

sonography,

at 3-month

blood chemistry

encephalopathy

were

in all patients.

up for 3-36

pressure

months

2

successful

in a dramatic

by >50%.

The

portal

(mean

‘-+ SD;

in 93%

of 100

blood

reduction

increased

to

rate of 7.7 & 4.8 cm/s, and

flow also increased

to 1900

It 800 from

500 mL/min.

Complications Six patients hemorrhage,

in the early phase were noted in 15 patients.

had intraperitoneal and three of a stent

hemorrhage,

had hematoma

into the pulmonary

four had biliary

of the liver capsule. artery was noted

but did not result in any climcal with bleeding,

had disseminated

and died. Another

patient

intravascular

had recurrent

which ceased after the coagulopathy rate of hepatic

medical therapy.

symptoms.

it ceased spontaneously

two. One patient

The

in the portal

flow velocity

5.2 cm/s from a preshunt

the portal 800

was technically

and resulted

the patients to

guidewire was introduced through the needle, and the catheter was advanced into the portal vein. The needle was then removed and the portal venous pressure

of

and exam-

thereafter

of hepatic

was continued

were followed

two patients

of the portal

once a

to avoid early thrombosis

12 + 6).

of these 23 patients,

branches

received

(0.3 mL of fraxiparine)

which a duplex

approach.

one of the main

thromboplastin

1 week after treatment

and assessment

before treatment

A needle was then introduced

of < 12

the patients

later; they were examined

After sonographic localization of the portal bifurcation, the right hepatic vein was catheterized through the transjugular to puncture

gradient

the partial

Subsequently,

for 1 month

Migration

facilitate catheterization of the hepatic vein. Patients were premeditated with midazolam

was

week, 5 - 15,000 U of heparin were

day subcutaneously

1- 3 days before the paracentesis

and

mm. The final diameter

to prolong heparin

57 4 13 years).

with ascites underwent

P308M;

was inserted

venous pressure

low-molecular-weight

19.7 t

encephalopathy,

of 8-12

(Palmaz-stent

Germany)

per-

mm Hg.

patients

failure.

in 3, cystic fibrosis in 1, and unknown

Age ranged

to a diameter

performed.

(mean, 4 lr 3 sessions) and had been referred

vein thrombosis, was alcohol

intrahepatic

patients

their unit because of treatment Patients

and is it

to answer these

for the treatment

portosystemic

stent

Norderstedt,

and angiography

the stent.

hypertension.

intrahepatic

were treated

important

are is it effective

transjugular

a new technique

in 100 consecutive

an emergency

the most

et al. have attempted

caused by portal

attempted patients

technique,

that need to be answered

safe. In this study, R&e questions

an expandable

time to 40-50

Med 1994;330:165-171.

When

with a balloon

In the first postoperative

portosys-

L. Schubert, Richmond, VA Schulze-Delrieu, Iowa City, IA Shanahan, WrIton, Cork, Ireland G. Sweeting, New York, NY C. Thirlby, Seattle, WA Van Dam, Boston, MA

in all but coagulation

episodes of hemobilia,

was treated.

encephalopathy

to 25% (23 patients) the encephalopathy

Of the remaining

in Of

increased

from

after treatment. was controlled

seven patients,

10% In 16 with

the encepha-

lopathy progressed to hepatic failure and death in three. Hepatic encephalopathy was noted during the first 3 months of placement of the stent.

592

SELECTED

Thirty-three

patients 31

(10). Of these varices,

whereas

remained

GASTROENTEROLOGY

SUMMARIES

had either

patients,

(21)

stenosis

10 (11%)

21 did not. Ninety-two

free of variceal bleeding

or occlusion

had rebleeding percent

at 6 months

from

gency

died. Three of 10 patients

basis died within

and 82% at 1

hepatic

treated

on an emer-

30 days of treatment.

died of a procedure-related

One patient

cause. Late deaths

failure in six patients

were caused by

criteria,

the survival

rates were lOO%, 86%,

and

was associated

47 of 53 patients not detected

(85%).

1993; 104:A941,

with a reduction

After

3 months,

in ascites in

severe ascites was

in any patient.

was detected

higher

(56%-73%).

ent modalities

that

used to diagnose

In patients

with

cirrhosis

resistance

to flow in the hepatic

the portal

veins.

circulation

The portal

sinusoids

system

system is transmitted

of veins. The mucosa of portal

leads to hypertension

anastomoses

that

to these points,

of the stomach

and systemic

anastomosis.

with

can produce

serious

and esophagus

of variceal

bleeding

in

the systemic in pressure

resulting

Dilatation

in

in dilatation

is the significance

21 did not. The majority

insufficiency,

The authors

hemorrhage,

of cirrhosis

has a mortality

in

which

of the liver. Each

of approximately

50%

Variceal balloon

bleeding

may be controlled

tamponade,

indirectly

vein by pharmacological caval

shunt.

limelight

therapy

result

tract.

However,

because

the tract shunt

in dogs.

balloon

creation

of a portois in the

resistance

on itself.

overcame

were coaxial

the first to

catheters,

to maintain

the patency

of the hepatic

Palmaz

of

parenchyma

et al. (Am J Roentgen01

this problem

by using

used for intra-arterial

an expandable

purposes)

to keep the

open.

Several groups,

including

the present

the efficacy of TIPS. The technical 93%. This is similar 1992; 16:88A,

Radiology feasible

Furthermore, was 8%

up period

a mean follow-up There

incidence hepatic Despite

at

1 year was

and shunt

the significanr

18%.

died

Sanyal

in controlling the rebleeding

et al. (Hepatology a follow-

1993; 187:413-

100 patients

during

associated

occlusion.

New hepatic

in this study. encephalopathy

incidence

with

develops

TIPS: hepatic encephalopathy

This is similar

present with

in the La Berge study. within

study,

TIPS include

hematoma

within

of hepatic

encephalopathy,

with

in their

large

13%

study

(Radiology

to be no procedure-related TIPS ranges

from 9% to 50% In the

rate was 15%. Complications

noted

hemorrhage, transient

biliary

oliguric

hemorrhage,

renal

infarction

2 hours of the procedure

(Radiology

failure,

occurred

and

in one

1993; 187:413-

420). Compared superior

with

surgical

procedure.

bleeding be similar

with

both

Hepatology

722,

Gastroenterology

TIPS

is approximately

shunts

(World under

surgical

portosystemic

procedures

J Surg local

from

1985;201:712mortality

10% with

Further

TIPS can be per-

is a simpler

procedure

a

for endo-

sclerotherapy at bedside.

by sclerotherapy

53%

is widely Active

N Engl J Med (Hepatology

N Engl J Med

variceal

in up to 90%

bleeding

1989;9:274-277, controlled

But this

by repeat

sclerother-

of cases (Ann Surg 1981; 194:521-530, Therefore,

it is only

Rossle et al. need to be commended study

(Radiology

Hepatol-

in a small

that TIPS would for “hitting

head” because they have chosen exactly this population

ranging Lancet

1989;321:857-862).

can be effectively

bleed-

of patients

1989;321:857-862).

has a high rate of recurrent

who have failed sclerotherapy

major

than

available,

1985;5:580-583).

In the other

with surgical

be hard to see TIPS as a replacement

sclerotherapy

bleeding

Surg Early the

to

1986; 91:802-

Endoscopic

1993;342:391-394),

1993;342:391-394,

patients

and

1988;8: appears

shunt.

it would

to

Hepatology

with

1984;8:722-732).

anesthesia

to be a

in controlling

encephalopathy Ann

easy, and can be performed

31%

shunt

(Gastroenterology

3% compared

sclerotherapy.

Endoscopic

TIPS appears

1985;88:424-429).

ing can be controlled (Lancet

of hepatic

1988;8:1475-1481,

formed

However,

shunt,

as a surgical

1986;91:802-809,

and the incidence

809,

simple,

portocaval

It is as effective

(Gastroenterology

1475-1481),

ogy

it is

was

myocardial

deThe

is

1992; 16:88A).

intraperitoneal

A subendocardial

In the other

Hepatology

of the liver capsule,

infection.

6 of 9 patients

of 3%. One patient

appeared

the complication

bleeding

stenosis.

mortality

rate with

vari-

the data available, 1993; 104:A941),

correlation;

cause.

1993; 187:413-420,

apy in the majority

the first 3 months.

There

dilata-

of the varices?

and recurrent

mortality

30-day

The complication

en-

to the 14%

the

1993; 187:413-420). deaths.

recurrent

of 4.7 months.

usually

TIPS,

developed

found recurrent

From

1 of 7 without

of a procedure-related

involving

that TIPS

rate of 5% during

in 19% of their

problems

in 16% of patients of new hepatic

modality

La Berge et al. (Radiology

period

encephalopathy

(Hepatology

suggesting

At 6 months,

a rebleeding

bleeding

are two major

cephalopathy veloped

to be an effective

documented

recurrent

study was

with

Rossle et al. noted a 30-day study

scopic

by this study.

of 4.5 months.

420) found

have reported

1993; 187:413-420),

it appears and

to evaluate

procedure.

as indicated

1992; 16:88A)

one, have tried

success rate in the present

to what other groups

is a technically bleeding,

to be a more direct compared

insuffi-

by balloon

in one study (Gastroenterology

there appeared

cryo-

were used to create the porto-

it was difficult

collapse

(normally

Initially,

catheters

the natural

1985; 145:821-825)

rate

in the portal

techniques

1969;92:1112-1114)

a TIPS operation

systemic

tract

by radiological

or

shunt

stenosis.

stenosis

rebled

after the patient

1993; 104:A985) insufficiency

between

with shunt

in obliteration

the relation

bleeding

were therefore

Were these persistent

of the stenosis

with

patient

and distended

these tracts

metal

the pressure

means, or by the surgical

performed

et al. (Radiology

perform probes,

by decreasing

by sclerotherapy

at present.

Rosch

made

TIPS

directly

occlusions

or angiography.

Of the 31

variceal

state that all patients

Did correction

not clear. However,

may be

and the lack of clear

insufficiency?

of shunt

ces in only 2 of 11 patients

(Radiology

(N Engl J Med 1994;330:208-209).

shunt

varices or were these varices that reoccurred or thrombolytic

that used angi-

insufficiency

10 had recurrent

ciency had varices on endoscopy

tion

in 33%

(Gastroenterology

could be because of the differ-

of this

whereas

is one of the sites

of veins here result

gastrointestinal

is by far the most serious complication episode

an increased

at several areas in the body and an increase

the portal

varices

of the liver,

of shunt

this problem

with shunt

insufficiency?

sonography

studies

stenosis.

patients

shunt

encephalopathy

1993; 104:A985)

These differences

Sanyal et al. (Gastroenterology

Comment.

by duplex

Two other

the incidence

to define shunt

of hepatic

No. 2

therapy.

Gastroenterology

indicated

What

episodes

in this study.

ography

criteria

most

by medical

insufficiency

asymptomatic!

73% for Child’s A, B, and C, respectively. The treatment

to note that

of the patients

and heart failure in one patient.

The l-year survival rate was 85%. When classified according to Child’s

Shunt

of patients

year. Ten patients

encouraging

can be well controlled

Vol. 107,

subset

of

have a role.

the nail on the for their study.

1993; 187:413-420),

only 32

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.