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Prognostic Factors With the Use of the Transjugular Intrahepatic Portosystemic Shunt for Bleeding Varices

Prognostic Factors With the Use of the Transjugular Intrahepatic Portosystemic Shunt for Bleeding... Abstract Objectives: To evaluate the outcome of patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure for bleeding esophageal varices and to outline the factors affecting outcome. Design: Uncontrolled, nonrandomized, retrospective study. Setting: A 320-bed university-associated urban emergency adult hospital. Patients: Thirty-three patients undergoing TIPS procedures for bleeding esophageal varices with at least 18 months of follow-up. Five patients (15%) had Child class B disease and 28 (85%) had Child class C disease. The mean transfusion requirements were 12.6 U of red blood cells, 18 U of fresh-frozen plasma, and 7 U of platelets. The mean portosystemic gradients before and after the initial TIPS procedure were 18 and 7 mm Hg, respectively. Outcome Measures: The incidence, time and causes of death, and recurrent variceal hemorrhage were correlated with various clinical and laboratory factors. Results: By 18 months after the TIPS procedure, 16 patients (48%) died of rebleeding or hepatic failure. Subsequent upper gastrointestinal tract bleeding occurred in 14 patients (42%). Of 8 in whom occlusion or stenosis of the TIPS was promptly corrected, all 8 survived. Of 6 in whom occlusion or stenosis of the TIPS was not corrected, 5(83%) died. Laboratory values (mean±SD) predictive of death before 18 months (compared with those of patients alive at 18 months) included a low initial serum albumin level (22 ±4 vs 29 ±5 g/L;P<.001), an increased initial total bilirubin level (68±75 vs 34±20 μmol/L [4.0±4.4 vs 2.0±1.2 mg/dL]; P=.001), and an elevated prothrombin time after attempts at correction (18.0±3.4 vs 14.6±1.2 seconds; P<.001). Conclusions: The TIPS procedure in patients with Child class C alcoholic cirrhosis was associated with a high incidence of death or rebleeding within 18 months. Prompt correction of TIPS abnormalities in patients with rebleeding increased survival. The albumin, bilirubin, and prothrombin time values obtained before performance of the TIPS procedure were predictive of outcome.Arch Surg. 1997;132:626-631 References 1. Rossle M, Ritcher GM, Noldge G, et al. Performance of an intrahepatic portacaval shunt (PCS) using a catheter technique: a case report . Hepatology . 1988:8:1348. 2. LaBerge JM, Sombert KA, Lake JR, et al. Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients . Gastroenterology . 1995;108:1143-1155.Crossref 3. Rossle M, Haag K, Och A, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding . N Engl J Med . 1994;330:165-171.Crossref 4. Martin M, Zajko AB, Orons PD, et al. Transjugular intrahepatic portosystemic shunt in the management of variceal bleeding: indications and clinical results . Surgery . 1993;114:719-727. 5. Helton WAS, Belshaw A, Althaus S, Park S, Coldwell D, Johansen K. Critical appraisal of the angiographic portacaval shunt (TIPS) . Am J Surg . 1993;165: 566-571.Crossref 6. Freedman AM, Sanyal AJ, Tisnado J, et al. Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review . Radiographics . 1993; 13:1185-1210.Crossref 7. Lind CD, Malisch TW, Chong WK, et al. Incidence of shunt occlusion or stenosis following transjugular intrahepatic portosystemic shunt placement . Gastroenterology . 1994;106:1277-1283. 8. Hausegger KA, Sternthal HM, Klein GE, Kariac R, Stauber R, Zenker G. Transjugular intrahepatic portosystemic shunt: angiographic follow-up and secondary interventions . Radiology . 1994;191:171-181.Crossref 9. LaBerge JM, Ring EJ, Gordon RL, et al. Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients . Radiology . 1993;187:413-420.Crossref 10. Burroughs AK, McCormick PA. Prevention of variceal rebleeding . Gastroenterol Clin North Am . 1992;21:119-147. 11. Graham DY, Smith TL. The course of patients after variceal hemorrhage . Gastroenterology . 1991;80:800-809. 12. Richter GM, Noeldge G, Palmer JC, et al. Transjugular intrahepatic portacaval stent shunt: preliminary clinical results . Radiology . 1990;174:1027-1030.Crossref 13. Ring EJ, Lake JR, Roberts JP, et al. Using transjugular intrahepatic portosystemic shunts to control variceal bleeding before liver transplantation . Ann Intern Med . 1992;116:304-309.Crossref 14. Spina GP, Santambrogio R, Opocher E, et al. Distal splenorenal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding: first stage of a randomized, controlled trial . Ann Surg . 1990;211:178-186.Crossref 15. Westaby D, Poison RJ, Gimson AES, Hayes PC, Hayllar K, Williams R. A controlled trial of oral propranolol compared with injection sclerotherapy for the long-term management of variceal bleeding . Hepatology . 1990;11:353-359.Crossref 16. Cello CG III, Grendell JH, Crass RA, Trunkey DD, Cobb EE, Heilbron DC. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and variceal hemorrhage . N Engl J Med . 1984;311:1589-1594.Crossref 17. Cello JP, Grendell JH, Crass RA, et al. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage . N Engl J Med . 1987;316:11-16.Crossref 18. Orloff MJ, Orloff MS, Rambotti M, Girard B. Is portal-systemic shunt worthwhile in Child's class C cirrhosis? long-term results of emergency shunt in 94 patients with bleeding varices . Ann Surg . 1992;216:256-268.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Prognostic Factors With the Use of the Transjugular Intrahepatic Portosystemic Shunt for Bleeding Varices

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Publisher
American Medical Association
Copyright
Copyright © 1997 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1997.01430300068014
Publisher site
See Article on Publisher Site

Abstract

Abstract Objectives: To evaluate the outcome of patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure for bleeding esophageal varices and to outline the factors affecting outcome. Design: Uncontrolled, nonrandomized, retrospective study. Setting: A 320-bed university-associated urban emergency adult hospital. Patients: Thirty-three patients undergoing TIPS procedures for bleeding esophageal varices with at least 18 months of follow-up. Five patients (15%) had Child class B disease and 28 (85%) had Child class C disease. The mean transfusion requirements were 12.6 U of red blood cells, 18 U of fresh-frozen plasma, and 7 U of platelets. The mean portosystemic gradients before and after the initial TIPS procedure were 18 and 7 mm Hg, respectively. Outcome Measures: The incidence, time and causes of death, and recurrent variceal hemorrhage were correlated with various clinical and laboratory factors. Results: By 18 months after the TIPS procedure, 16 patients (48%) died of rebleeding or hepatic failure. Subsequent upper gastrointestinal tract bleeding occurred in 14 patients (42%). Of 8 in whom occlusion or stenosis of the TIPS was promptly corrected, all 8 survived. Of 6 in whom occlusion or stenosis of the TIPS was not corrected, 5(83%) died. Laboratory values (mean±SD) predictive of death before 18 months (compared with those of patients alive at 18 months) included a low initial serum albumin level (22 ±4 vs 29 ±5 g/L;P<.001), an increased initial total bilirubin level (68±75 vs 34±20 μmol/L [4.0±4.4 vs 2.0±1.2 mg/dL]; P=.001), and an elevated prothrombin time after attempts at correction (18.0±3.4 vs 14.6±1.2 seconds; P<.001). Conclusions: The TIPS procedure in patients with Child class C alcoholic cirrhosis was associated with a high incidence of death or rebleeding within 18 months. Prompt correction of TIPS abnormalities in patients with rebleeding increased survival. The albumin, bilirubin, and prothrombin time values obtained before performance of the TIPS procedure were predictive of outcome.Arch Surg. 1997;132:626-631 References 1. Rossle M, Ritcher GM, Noldge G, et al. Performance of an intrahepatic portacaval shunt (PCS) using a catheter technique: a case report . Hepatology . 1988:8:1348. 2. LaBerge JM, Sombert KA, Lake JR, et al. Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients . Gastroenterology . 1995;108:1143-1155.Crossref 3. Rossle M, Haag K, Och A, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding . N Engl J Med . 1994;330:165-171.Crossref 4. Martin M, Zajko AB, Orons PD, et al. Transjugular intrahepatic portosystemic shunt in the management of variceal bleeding: indications and clinical results . Surgery . 1993;114:719-727. 5. Helton WAS, Belshaw A, Althaus S, Park S, Coldwell D, Johansen K. Critical appraisal of the angiographic portacaval shunt (TIPS) . Am J Surg . 1993;165: 566-571.Crossref 6. Freedman AM, Sanyal AJ, Tisnado J, et al. Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review . Radiographics . 1993; 13:1185-1210.Crossref 7. Lind CD, Malisch TW, Chong WK, et al. Incidence of shunt occlusion or stenosis following transjugular intrahepatic portosystemic shunt placement . Gastroenterology . 1994;106:1277-1283. 8. Hausegger KA, Sternthal HM, Klein GE, Kariac R, Stauber R, Zenker G. Transjugular intrahepatic portosystemic shunt: angiographic follow-up and secondary interventions . Radiology . 1994;191:171-181.Crossref 9. LaBerge JM, Ring EJ, Gordon RL, et al. Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients . Radiology . 1993;187:413-420.Crossref 10. Burroughs AK, McCormick PA. Prevention of variceal rebleeding . Gastroenterol Clin North Am . 1992;21:119-147. 11. Graham DY, Smith TL. The course of patients after variceal hemorrhage . Gastroenterology . 1991;80:800-809. 12. Richter GM, Noeldge G, Palmer JC, et al. Transjugular intrahepatic portacaval stent shunt: preliminary clinical results . Radiology . 1990;174:1027-1030.Crossref 13. Ring EJ, Lake JR, Roberts JP, et al. Using transjugular intrahepatic portosystemic shunts to control variceal bleeding before liver transplantation . Ann Intern Med . 1992;116:304-309.Crossref 14. Spina GP, Santambrogio R, Opocher E, et al. Distal splenorenal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding: first stage of a randomized, controlled trial . Ann Surg . 1990;211:178-186.Crossref 15. Westaby D, Poison RJ, Gimson AES, Hayes PC, Hayllar K, Williams R. A controlled trial of oral propranolol compared with injection sclerotherapy for the long-term management of variceal bleeding . Hepatology . 1990;11:353-359.Crossref 16. Cello CG III, Grendell JH, Crass RA, Trunkey DD, Cobb EE, Heilbron DC. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and variceal hemorrhage . N Engl J Med . 1984;311:1589-1594.Crossref 17. Cello JP, Grendell JH, Crass RA, et al. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage . N Engl J Med . 1987;316:11-16.Crossref 18. Orloff MJ, Orloff MS, Rambotti M, Girard B. Is portal-systemic shunt worthwhile in Child's class C cirrhosis? long-term results of emergency shunt in 94 patients with bleeding varices . Ann Surg . 1992;216:256-268.Crossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Jun 1, 1997

References

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