TIPS IN MANAGMENT OF PORTAL HYPERTENSION

BYPROF/ GOUDA ELABBAN

EGYPT

TIPS:A NEW METHOD IN MANAGEMENT OF O.V.

BY

GOUDA ELLABBAN GEN. SURGERY

Many treatments have evolved over the last 30 years for controlling U.G.I.T. Bleeding.

• Variceal bleeding continues to be a major cause of mortality in cirrhotic patient.

• Immediate control of bleeding can be achieved in 90% of patients by balloon tamponade, drug therapy, sclerotherapy, band ligation or surgery. Gouda Ellabban 20/06/03

• There is a high rate of rebleeding after sclerotherapy and drug therapy.

• The high rate of morbidity and mortality coupled with the evolution of OLT have greatly reduced the indications for surgical shunt

• Transplant is the ultimate treatment for complicated portal hypertension but is impractical in emerg. setting ,and it may be unnecessary in patients with mild liver disease, also the waiting time for OLT candidates has been increased because of the limited dooner and continuous expansion of indications of OLT

Gouda Ellabban 20/06/03

The current therapeutic options for treatment of refractory ascites are far

from ideal and associated with significant morbidity

TIPS is a safe method in the management of complicated portal hypertension.

• TIPS is a new therapeutic procedure that enables the decompression of the portal pressure, which performed via a percutaneous approach.

• TIPS my become the procedure of choice in the treatment of portal hypertension or to be used as a bridge to OLT.

Gouda Ellabban 20/06/03

History of TIPS

•1969, Roch et al. reported creation of shunt between the portal and hepatic veins percutaneously.

• 1971, they used silastic tubing.

•1977, Reich et al. Used a 9- mm cryoprobe to create a large tract though the hepatic parenchyma.

Gouda Ellabban 20/06/03

• 1979, Gutierrez used angioplasty balloon to create shunt experimentally.

• 1982, Colapinto reported the first clinical use of TIPS.

• 1985, Palmaz began using metallic stents for TIPS.

Gouda Ellabban 20/06/03

Indication for TIPS

• Acute variceal bleeding.• Recurrent variceal bleeding.• Refractory ascites.• Hepatic hydrothorax.• Budd- Chiari syndrome.• Hepatopulmonary syndrome.

Gouda Ellabban 20/06/03

Contraindications of TIPS

•uncorrectable coagulopathy.•Grade three or four encephalopathy.•Multi organ failure and sepsis in patients with terminal bleeding.

•Polycystic liver.•Right sided heart failure with elevated CVP.

•Hepatic neoplasm.Gouda Ellabban 20/06/03

TECHNIQUE OF TIPS

• preprocedural evaluation.

• Anesthesia.

• venous access.

• Alternative venous access.

• Portal venous puncture.Gouda Ellabban 20/06/03

• Catheterizing the hepatic vein.

• Tract dilatation.

• Stent deployment.

• Stent dilatation.

• Postprocedural management.

• Follow up.Gouda Ellabban 20/06/03

Venous access through I.J.vein

Isertention of the sheath into the hepatic vein

Puncture of the portal vein

Advancement of the guide wire into the portal vein

Balloon dilatation of shunt tract

Placement of the stent

TIPS : COMPLICATIONS

• Complications related specifically to TIPS procedure.

• Complications related to puncture site.

• Complications related to portosystemic shunting.

• Complications related to transhepatic portal venous canulation and dilatation.

Gouda Ellabban 20/06/03

• Complications related to stenting and the stent.

• Complications related to infection.

Gouda Ellabban 20/06/03

ILLUSTRATED CASES

Venography shows right hepatic vein

Portography of the portal vein

Balloon dilatation with constriction at the hepatic vein

Complete dilatation of the hepatic parenchyma

Deployment of the stent

SUMMARY &CONCLUSION

• TIPS is an effective method in reducing portal pressure & P.S.G. that can be used in the management of complications of portal

hypertension

• TIPS is very effective in the management of uncontrolled variceal bleeding and refractory ascites.

• TIPS is a bridge to LOTx as it is not compromising transplantation

Gouda Ellabban 20/06/03

•

TIPS is a temporary procedure with good short term results, which needs close follow up for early detection of shunt insufficiency.

TIPS improves the life style in symptomatic patients who are not candidate for LOTx

Gouda Ellabban 20/06/03

RECOMMENDATION

• Using TIPS in the management of uncontrolled variceal bleeding when other lines are not suitable especially severely ill patients.

• TIPS is recommended to be used as a first choice in patients with refractory ascites.

Gouda Ellabban 20/06/03

TIPS is recommended for patients with portal hypertension candidate for liver transplantation .

• Follow up by Doppler ultrasound and venography is essential for early detection of shunt dysfunction.

• Other researches are necessary to determine the mechanism responsible for shunt dysfunction, which represents the main limitation of TIPS.

Gouda Ellabban 20/06/03

رب لله الحمد أن دعوانا وأخرالعالمين