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

TIPS TIPS on on

Portal Hypertension for Portal Hypertension for SurgeonsSurgeons

John R. Potts, III, M.D., F.A.C.S.Program Director in Surgery

Assistant Dean Graduate Medical EducationUniversity of Texas Medical School - Houston

TIPS on Portal Hypertension


VARICEAL BLEEDING

ResuscitationResuscitation

• Treat hemorrhagic shock

Crystalloid (Limited)

Platelets (Rarely)

Red Cells + FFP

• Goal: Tissue Perfusion

• Monitor: Urine Output

• Caveat: Do NOT overload


VARICEAL BLEEDINGVARICEAL BLEEDING

Initial TreatmentInitial Treatment

• Continue Tx hemorrhagic shock

• IV therapy

Sandostatin®

INITIATE WHEN Dx SUSPECTED!!!


VARICEAL BLEEDINGVARICEAL BLEEDING DiagnosisDiagnosis

• 50% UGI bleeds not variceal

(MW Tear, Gastritis, Gastric/Duodenal Ulcer)

• Early endoscopy mandatory

• Variceal bleeding Dx’d:

Active bleeding

Stigmata

Varices and NO other source

TIPS on Portal HypertensionVARICEAL BLEEDING

Initial TherapyInitial Therapy

• Continue I.V. Sandostatin®

• Endoscopic Therapy

• Sengstaaken-Blakemore tube

• TIPS

• Emergency operation


VARICEAL BLEEDING

Supportive TherapySupportive Therapy

• Correct coagulopathy

FFP, vitamin K, +/- platelets

• Pulmonary

• Other infection

• Encephalopathy

• Nutrition



EvaluationEvaluation

• Child class

• History

• Hepatitis profile

• Angiography

• Transplant evaluation


Child-Pugh ClassificationChild-Pugh Classification

Points

1 2 3

Bilirubin (mg/dL) < 2 2 – 3 > 3

Albumin (g/dL) > 3.5 2.8 – 3.5 < 2.8

Prothrombin time (seconds ↑) 1 – 3 4 – 6 > 6

Ascites None Slight Moderate

Encephalopathy None Minimal Advanced

Grade A, 5-6 points; Grade B, 7-9 points; Grade C, 10-15 points



Definitive TherapyDefinitive Therapy

• Rationale: 67% rebleed

• Most rebleed < 6 weeks

• Definitive Tx during initial stay



Definitive TherapyDefinitive Therapy

• Medical

• Endoscopic

• Surgical

• Radiological


VARICEAL BLEEDING

Medical TherapyMedical Therapy

• Beta blockade

bleeding by cardiac output

Goal: 25% in heart rate

Reduces # bleeding episodes

Does not reduce mortality

Use as adjunct


Endoscopic BandingEndoscopic Banding

• Occludes venous channels

• Multiple sessions + surveillance

• >60% rebleed

• 1/3 fail treatment

complications vs scleroTx

• = / efficacy vs scleroTx

• ENDOSCOPIC Tx OF CHOICE


Endoscopic BandingEndoscopic Banding



SURGICAL OPTIONSSURGICAL OPTIONS

• Total Shunt

• Selective Shunt

• Partial Shunt

• Non-Shunt


Total ShuntsTotal ShuntsEnd to Side Portocaval Side to Side Portocaval

Interposition Shunts Central Splenorenal


Total Shunt ResultsTotal Shunt Results

• Prevent rebleed > 90%

• Thrombosis with graft

• Encephalopathy rate 40%


Selective ShuntsSelective Shunts

• Goals:

Prevent variceal bleeding and encephalopathy

• Mechanism:

Decompress Varices

Maintain Portal Perfusion

Maintain Portal Hypertension

• Key:

Decompress only gastrosplenic compartment


Distal Splenorenal ShuntDistal Splenorenal Shunt


DSRS vs Total ShuntsDSRS vs Total Shunts

• Six randomized trials in N.A.

• Mean follow-up 39 mos (1-8 yrs)

OP MORT

LATE MORT

SHUNT OCC

ENCEPH

DSRS% 10.9 24.2 7.3 19.8

TOTAL% 8.3 34.7 9.0 34.4


Partial ShuntsPartial Shunts

• Ease of portocaval

• Limited portal diversion

• Maintain some liver perfusion

• Short, straight PTFE graft


Partial ShuntsPartial Shunts

Sarfeh Ann Surg 200:706,1986


8mm (n=14)

16mm (n=16)

p Value

SURVIVAL

11

12

n.s.

SHUNT THROMBOSIS

0

0

n.s.

VARICEAL BLEEDING

0

0

n.s

HEPATOPEDAL FLOW

13

0

<0.0001

SHUNT GRADIENT

16 +/-5

6 +/-3

<0.001

COMA

0

5

0.002

Partial ShuntsPartial ShuntsRandomized trial in ETOH cirrhotics

Follow-up @ 20 +/- 11 mos


Non-Shunt OperationsNon-Shunt Operations

• Options

Esophageal transection

Variceal ligation

Devascularize +/- splenectomy

• Very limited role


Liver TransplantLiver Transplant

• Indicated for liver failure

Not for variceal bleeding

• Number > 3,500/yr in U.S.

• 20,000 potential recipients in U.S.

• 5,000 listed for transplant

• 24% die on waiting list


TIPSTIPSTTransjugular ransjugular IIntrahepatic ntrahepatic PPortocaval ortocaval SShunthunt


TIPSTIPS


TIPSTIPS

• Technically feasible

• Complications 9 - 50%

Infection Intraperitoneal Bleeding

Congestive Failure Subcapsular Hematoma

Acute Renal Failure Hemobilia

• Mortality (30 day) 3 - 13%

(1) Rossie NEJM 1994;330:165, (2) Rosch Hepatology 1992;16:884, (3) LaBerge Radiology 1993;187:913.


Problems With TIPSProblems With TIPS

• Encephalopathy minimum 15%

• Occlusion 33 - 73% @ one year

• Rebleeding

18% @ one year (1)

19% @ 4.7 months (3)

(1) Rossie NEJM 1994;330:165, (2) Rosch Hepatology 1992;16:884, (3) LaBerge Radiology 1993;187:913.


The Role ForThe Role For TipsTips

• Refractory bleeding

• Bridge to transplant

• Child C

(all or only “DZ” ?)

• ??? refractory ascites

• Relative contraindication: Poor f/u

Special Cases of Portal Hypertension


Splenic Vein ThrombosisSplenic Vein Thrombosis

• Etiology: Pancreatitis - Acute or Chronic

Pancreatic Carcinoma

• Hallmark:

Isolated Gastric Varices

• Treatment:

Splenectomy (if bleeding)


Portal Vein ThrombosisPortal Vein Thrombosis

Etiology:

Congenital - “Cavernous Transformation”

Hallmark:

Normal Liver Function W/ Varices

Treatment:

Endo Tx OR DSRS


Budd-Chiari SyndromeBudd-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


Budd-Chiari SyndromeBudd-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


Some Take Home PointsSome Take Home Points

• Child A better than Child C

• Start Sandostatin when Dx suspected

• β blockade bleeding by C.O

• Banding safer than scleroTx

• TIPS: Encephalopathy & occlusion rate


Some Take Home PointsSome Take Home Points

Selective shunt: encephalopathy

SV Thrombosis: Presentation & Tx

Budd-Chiari: Classic triad

Transplant for liver failure



TIPS on Portal HypertensionPortal Hypertension

EtiologyEtiology

• PRE-HEPATIC

Portal Vein or Splenic Vein Thrombosis

• INTRA-HEPATIC

Cirrhosis (ETOH, Hepatitis, Other Toxins)

• POST-HEPATIC

Budd-Chiari


Complications of Portal Complications of Portal HypertensionHypertension

• Ascites

• Encephalopathy

• Variceal bleeding

– Initial management

– Evaluation

– Definitive therapy

– Special cases


EncephalopathyEncephalopathy

• Etiology: ? Nitrogen compounds

• Induced by:

Infection Dehydration

Constipation Blood in gut

• No test is diagnostic

• Therapy:

Hydrate Cleanse gut

↓ protein Find and treat cause


AscitesAscites• Origin:

Sinusoidal pressure > colloid oncotic pressure

• Induced by:

Physiologic Stress

IV Fluids

• Complications:

Spontaneous Bacterial Peritonitis

“Hepatorenal Syndrome”


Control of AscitesControl of Ascites

• Sodium / Water Restriction

• Spironolactone

• Loop Diuretic

• Large Volume Paracentesis

• Peritoneal-Venous Shunt

• (?) TIPS


VARICEAL BLEEDINGVARICEAL BLEEDING General ApproachGeneral Approach

• Resuscitation

• Initial treatment

• Support

• Evaluation

• Definitive therapy


VasopressinVasopressin

• 8-Arginine Vasopressin (ADH)• Intense constriction (all beds)

+’s Mesenteric Flow Portal Pressure Stops Bleeding in >80%

-’s Peripheral Ischemia Myocardial Ischemia

• NTG ’s adverse effects


Sandostatin®Sandostatin®

• Long acting STS analogue

+’s Mesenteric Flow

Portal Pressure

Stops bleeding in > 85%

Good as VP but side effects

-’s Cost

• DRUG OF CHOICE


Portal Vein AnatomyPortal Vein Anatomy


Portal Vein CollateralsPortal Vein Collaterals

Five Principle Routes

Veins of Retzius

Umbilical Vein

Hemorrhoids

Adhesions

Esophageal Varices


VARICEAL BLEEDING

SclerotherapySclerotherapy

• Intra- or Para- Variceal

• Occludes venous channels

• Multiple sessions + surveillance

• >60% rebleed

• 1/3 fail treatment

• 30% complication rate


Endoscopic SclerotherapyEndoscopic Sclerotherapy

Intravariceal Paravariceal


Complications of ScleroTxComplications of ScleroTx

LOCAL

Ulceration

Stricture

Perforation

SYSTEMIC

Fever

Pneumonitis

CNS


Total ShuntsTotal Shunts

• Divert most (all?) portal flow

• Options

Portocaval Shunt (E-S or S-S; +/-

Graft)

Interposition Shunt

Central Splenorenal Shunt


TIPSTIPS


Child’s ClassificationChild’s Classification

A B C

Bilirubin < 2 2 – 3 > 3

Albumin > 3.5 2.8 – 3.5 < 2.8

Ascites None Controlled Uncontrolled

Enceph None Minimal Advanced

Nutrition Excellent Good Poor


SclTx SclTx vs vs TIPSTIPS

Five Randomized Trials - 360 patients

Mean Follow-up 15 mos (1-36)

* p < 0.05 in all but one study ** p < 0.05 in all studies*** n.s. in all but one study where survival w/ SclTx

REBLEED* ENCEPH** SURVIV***

SCLTX 37% 8% 88%

TIPS 17% 32% 81%

Documents

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