Transjugular intrahepatic portosystemic stent shunt (TIPSS) modification in the management of post-TIPSS refractory hepatic encephalopathy.

Abstract

BACKGROUND:

Post-transjugular intrahepatic portosystemic stent shunt (TIPSS) hepatic encephalopathy (HE) can occur in up to one third of patients. In 5%, this can be refractory to optimal medical treatment and may require shunt modification. The efficacy of shunt modification has been poorly studied.

AIMS:

To evaluate the efficacy of and natural history following TIPSS modification for treatment of refractory HE.

METHODS:

From a dedicated database, we selected and further studied patients who had TIPSS modification for refractory HE.

RESULTS:

Over a 14 year period, of 733 TIPSS insertions, 211(29%) patients developed HE post-TIPSS. In 38 patients, shunt modification (reduction (n = 9) and occlusion (n = 29)) was performed for refractory HE. Indications for TIPSS were: variceal bleeding (n = 32), refractory ascites (n = 5), and other (n = 1). Child's grades A, B, and C were noted in 11%, 47%, and 42% of cases, respectively. HE improved in 58% of patients and remained unchanged or worsened in 42%, with similar results for occlusions and reductions. Following shunt modification, variceal bleeding recurred in three patients and ascites in three. Twenty five patients have died (liver related in 15) at a median duration of 10.2 months. Three patients died due to procedure related complications following shunt occlusions (mesenteric infarction (n = 2) and septicaemia (n = 1)). Median survival of patients whose HE did not improve following shunt modification was 79 days compared with 278 days in patients whose did (p<0.05). No variables independently predicted response to shunt modification.

CONCLUSIONS:

TIPSS modification is a useful option for patients with refractory HE following TIPSS insertion. Due to the significant risk of iatrogenic complications with shunt occlusions, shunt reduction is a safer and preferred option.

• Authors: N Kochar, D Tripathi, H Ireland, D N Redhead, P C Hayes
• Journal: Gut (Gut) Vol. 55 Issue 11 Pg. 1617-23 (Nov 2006) ISSN: 0017-5749 [Print] England
• PMID: 16571635 (Publication Type: Evaluation Study, Journal Article)

Topics

• Adult
• Aged
• Aged, 80 and over
• Ascites (surgery)
• Epidemiologic Methods
• Esophageal and Gastric Varices (surgery)
• Female
• Gastrointestinal Hemorrhage (surgery)
• Hepatic Encephalopathy (etiology)
• Humans
• Male
• Middle Aged
• Portasystemic Shunt, Transjugular Intrahepatic (adverse effects, methods)
• Recurrence
• Severity of Illness Index
• Stents
• Treatment Outcome