Control Of Variceal Bleeding Research Articles

Effects of transjugular intrahepatic portosystemic shunt on abdominal muscle mass in patients with decompensated cirrhosis

Sarcopenia is a common finding in patients with decompensated cirrhosis without effective therapy. We aimed to examine whether a transjugular portosystemic shunt (TIPS) could improve the abdominal muscle mass assessed by cross-sectional images in patients with decompensated cirrhosis and to investigate the association of imaging-defined sarcopenia with the prognosis of such patients. In this retrospective observational study, we enrolled 25 Decompensated cirrhosis patients aged >20 who received TIPS for the control of variceal bleeding or refractory ascites between April 2008 and April 2021. All of them underwent preoperative computed tomography or magnetic resonance imaging, which was used to determine psoas muscle (PM) and paraspinal muscle (PS) indices at the third lumbar vertebra. First, we compared baseline muscle mass with muscle mass at 6 and 12 months after TIPS placement and analyzed PM- and PS-defined sarcopenia to predict mortality. Among 25 patients, 20 (80.0%) and 12 (48.0%) had PM- and PS-defined sarcopenia, respectively, at baseline. In total, 16 and 8 patients were followed up for 6 and 12 months, respectively. All imaging-based muscle measurements performed 12 months after TIPS placement were significantly greater than the baseline measurements (all p<0.05). Unlike patients with PS-defined sarcopenia (p=0.529), patients with PM-defined sarcopenia had poorer survival than did patients without (p=0.036). PM mass in patients with decompensated cirrhosis may increase by 6 or 12 months after TIPS placement and imply a better prognosis. Patients with preoperative PM-defined sarcopenia may suggest poorer survival.

The Portosystemic Shunt for the Control of Variceal Bleeding in Cirrhotic Patients: Past and Present.

Based on an experience of more than 50 years in the treatment of portal hypertension (PHT), the authors review and analyze the evolution of the surgical portocaval shunt (PCS). We would like to provide an insight into the past of PCS, in order to compare it with the current state of the treatment of PHT complications. As a landmark of the past, we shall present statistics of more than 500 cases of PHT operated between 1968 and 1983. From this group, 238 patients underwent surgical portocaval shunting during a fifteen-year period. The behavior of the portal hemodynamics following PCS was studied and the postoperative decrease in portal pressure (PP), as well as the residual PP, were recorded. The portal manometric determinations were made by electronic recordings using the Hellige device and direct intraoperative recordings through the catheterization of a ramus in the portal area. The results of PCS are superposable, in terms of hemodynamic efficiency, with those of the intrahepatic shunt (TIPS—transjugular intrahepatic portosystemic shunt). The authors discuss the current place of PCS, in obvious decline in comparison with the situation 50 years ago. The current methods of controlling variceal bleeding represent obvious progress. PCS remains with very limited indications, in specific situations when the other therapeutic methods have failed or are not recommended.

Efficacy of Octreotide Versus Terlipressin along with Endoscopic Variceal Ligation (EVL) in Preventing Re-bleeding and Mortality in Acute Bleeding Esophageal Varices in Cirrhosis: A Randomized Prospective Study

Background: Octreotide and terlipressin are two pharmacologic drugs used as an adjuvant therapy in the treatment of acute esophageal variceal bleeding. Large enough clinical trial data is not available, in comparing the efficacy of octreotide versus terlipressin as an adjunct to EVL for control of variceal bleed. Still, there is a scarcity of data on which is the better efficient drug amongst terlipress in and octreotide to control 5 days rebleeding.&#x0D; Aim: To compare efficacy of octreotide versus terlipressin in preventing the 6 weeks mortality (primary outcome) and 5 days rebleeding (secondary outcome) in cases of acute esophageal variceal bleeding.&#x0D; Method: All the patients of cirrhosis of liver presenting with upper gastrointestinal bleeding admitted in the Medicine Intensive Care Unit(MICU) at Acharya Vinoba Bhave Rural Hospital (AVBRH) will be enrolled. In this Randomized Prospective study ,patients presenting with acute esophageal variceal bleed, after diagnostic endoscopy during a period of one year (august 2020 to july 2021) will be randomised into two group by simple randomisation with chits: Group A will receive Terlipressin while Group B will receive Octreotide for 5 days combined with esophageal variceal ligation. These two groups will be compared in terms of hemodynamic effects, child pugh score, MELD (Model for End stage Liver Disease) score to predict 6 weeks mortality as primary outcome and 5 day treatment failure as secondary outcome according to Bavino VI consensus statement.&#x0D; Expected results: From our study we are anticipating that both octreotide and terlipressin will be equally efficacious in controlling the EVB when given along with EVL therapy and also there will be no difference in both the drugs in preventing 6 weeks mortality and 5 days rebleeding.&#x0D; Conclusion: There will be no significant difference between Terlipressin and Octreotide in preventing 6 week mortality and 5 day rebleeding in bleeding esophageal varices when given along with EVL therapy.

Surgical Shunt Procedures in Childhood Portal Hypertension: A Review Article

Normal portal pressure is between 0 and 10 mmHg and the pressure in the portal vein is slightly higher than that of the pressure in the inferior vena cava [1]. Portal Hypertension (PH) is usually defined as either a hepatice venous pressure gradient greater than 5mmHg or hepatic venous wedge pressure greater than 10mmHg [2]. It is usually encountered as a complication arising from chronic liver disease and cirrhosis. Common presentation of PH in children include catastrophic variceal hemorrhage usually from esophagus. Other common clinical features of PH include splenomegaly, hypersplenism, ascites, encephalopathy, and hepatopulmonary syndrome and portopulmonary hypertension. It has been reported that up to 15% of children with PH ultimately require shunt surgery [2]. Traditionally shunt surgery was a treatment option for children in whom control of variceal bleeding failed however; it was associated with relatively high rate of anastomotic stricture or thrombosis [1]. Nowadays it has also been reported that as the experience in vascular and transplant surgery together with microsurgical techniques have improved good success rates can be achieved even in small children [1]. In this review article, it is aimed to review the surgical treatment options in children with PH with special regard to shunt procedures under the light of relevant literature.

Sa1264 USUAL VS MODIFIED EBL TECHNIQUE IN ACUTE VARICEAL BLEEDING

Endoscopic band ligation (EBL) is used for variceal bleeding control, despite improvements in therapy, the mortality related to variceal hemorrhage remains high. Other authors recommend initiate banding in the most distal portion of the esophagus near the GE junction (usual technique). However, some experts suggest targeting bleeding stigmata (white clot) first (modified technique). To our knowledge, there are no comparative studies between EBL approaches. This study was aimed to compare the bleeding events during the endoscopy between two EBL techniques procedures in patients with bleeding stigmata. Objectives: Compare bleeding rates, band dislodgments, and endotracheal tube placements (ETP) during endoscopic procedures with two different approaches. This was an observational ambispective, single-center study. We enrolled consecutive patients (>18 y) managed from December 2016 to September 2019, with bleeding stigmata or active bleeding assessed with upper endoscopy in our institution. We defined bleeding events during the endoscopy if they occurred after the passage of the scope by the stigma or the esophagus, this was unequivocally seen on video. A total of 98 patients were included, 57 (58.2%) patients were treated with the usual technique and 41 (41.8%) with the modified approach, 26 women, and 72 men were included, with an average of 52.3 years. The most frequent etiology was alcohol (58.2%) and 25.5% of the procedures were performed under ET. The usual technique was used in 58.2% of the patients and the modified one in 41.8%. Regarding the primary objective, a difference of 14.3% and 2.0% was found (p = 0.012). Only one band dislodgment was recorded. We observed 7 ETP with the usual and only 1 with the modified technique. Less bleeding and orotracheal intubations were found during endoscopic procedures with the modified technique. This study suggests that initiation of banding of the culprit lesion is safe and improves visualization in terms of less bleeding events during endoscopy.

Safety and efficacy of transjugular intrahepatic portosystemic shunt combined with palliative treatment in patients with hepatocellular carcinoma.

BACKGROUNDThere is a close relationship between cirrhosis and hepatocellular carcinoma (HCC). Transjugular intrahepatic portosystemic shunt (TIPS) has good clinical effect in treating the complication of portal hypertension. However, because of the risk of postoperative liver failure, severe complications, and low survival rate for HCC, TIPS is contraindicated in patients with portal hypertension and liver cancer. We studied a large cohort of patients with cirrhosis and HCC who underwent TIPS for recurrent variceal bleeding and/or ascites.AIMTo assess the safety, efficacy, and survival rate in patients with HCC who underwent TIPS.METHODSGroup A comprised 217 patients with HCC and portal hypertension who underwent the TIPS procedure between 1999 and 2014. After TIPS deployment, these patients received palliative treatment for HCC. Group B comprised a cohort of 136 HCC patients with portal hypertension who did not undergo TIPS placement. Group B received palliative treatment for HCC plus medical therapy for portal hypertension. The clinical outcomes and survival rate were assessed.RESULTSIn Group A, the primary technical success rate was 97.69% for TIPS placement, and no severe procedure-related complications of TIPS placement were reported. The control of variceal bleeding (VB) within 1 mo did not differ significantly between the groups (P = 0.261). Absorption of refractory ascites within 1 mo, recurrence of VB, and recurrence of refractory ascites differed significantly between the groups (P = 0.017, 0.023, and 0.009, respectively). By comparison, the rate of hepatic encephalopathy in Group B was lower than that in Group A (P = 0.036). The 1-, 2-, 3-, 4-, and 5-year survival rates were significantly different between Groups A and B (χ2 = 12.227, P = 0.018; χ2 = 12.457, P = 0.014; χ2 = 26.490, P = 0.013; χ2 = 21.956, P = 0.009, and χ2 = 24.596, P = 0.006, respectively). The mean survival time was 43.7 mo in Group A and 31.8 mo in Group B. Median survival time was 50.0 mo in Group A and 33.0 mo in Group B. Mean and median survival differed significantly between the two groups (P = 0.000, χ2 = 35.605, log-rank test). The mortality rate from VB in Group A was low than that in Group B (P = 0.006), but the rates of hepatic tumor, hepatic failure, and multiorgan failure did not differ significantly between the two groups (P = 0.173, 0.246 and 0.257, respectively).CONCLUSIONTIPS combined with palliative treatment is safe and effective for portal hypertension in patients with HCC.

The SAGES flexible endoscopy course for fellows: a worthwhile investment in furthering surgical endoscopy.

The SAGES flexible endoscopy course for minimally invasive surgery (MIS) fellows improves confidence and skills in performing gastrointestinal (GI) endoscopy. This study evaluated the long-term retention of these confidence levels and investigated how fellows changed practices within their fellowships due to the course. Participating MIS fellows completed surveys 6months after the course. Respondents rated their confidence to independently perform 16 endoscopic procedures (1 = not at all; 5 = very), barriers to use of endoscopy, and current uses of endoscopy. Respondents also noted participation in additional skills courses and status of fundamentals of endoscopic surgery (FES) certification. Comparisons of responses from the immediate post-course survey to the 6-month follow-up survey were examined. McNemar and paired t tests were used for analyses. 23 of 57 (40%) course participants returned to the 6-month survey. No major barriers to endoscopy use were identified. Fellows reported less competition with GI providers as a barrier to practice compared to their original post-course expectations (50% vs. 86%, p < 0.01). In addition, confidence was maintained in performing the majority of the 16 endoscopic procedures, although fellows reported significant decreases in confidence in independently performing snare polypectomy (- 26%; p < 0.05), control of variceal bleeding (- 39%; p < 0.05), colonic stenting (- 48%; p < 0.01), BARRX (- 40%; p < 0.05), and TIF (- 31%; p < 0.05). Fewer fellows used the GI suite to manage surgical problems than was anticipated post course (26% vs. 74%, p < 0.01). Fellows who passed FES noted no significant loss of independence, changes in use, or barriers to use. 18% made additional partnerships with industry after the course. 41% stated flexible endoscopy has influenced their post-fellowship job choice. The SAGES flexible endoscopy course for MIS fellows results in long-term practice changes with participating fellows maintaining confidence to perform the majority of taught endoscopic procedures 6months later. Additionally, fellows experienced no major barriers to implementing endoscopy into practice.

Retrospective analysis of Devascularisation with/without Splenectomy for control of Variceal bleed following failure of Endotherapy/Pharmacotherapy

Retrospective analysis of Devascularisation with/without Splenectomy for control of Variceal bleed following failure of Endotherapy/Pharmacotherapy

Spectrum of upper gastrointestinal bleed in children

Aims and Objectives: To study the etiology, occurrence and pattern of upper gastrointestinal haemorrhage and investigations this would aid in the early diagnosis and management of children with upper gastrointestinal haemorrhage. Methods: This study was conducted over two years on 50 children below 12 years of age who presented with upper gastrointestinal bleeding, at a tertiary care hospital. All the cases were analysed by taking a detailed history and examination. An oesophagogastroduodenoscopy was done in indicated cases. The patients were treated according to standard guidelines and were followed up for a period of two year. Bleeding control was assessed during follow up based on check scopy findings. Results: The majority of children who presented with upper gastrointestinal bleedwere in the age group of 6-10 years with male predominance with male to female ratio being 1.3:1. EHPVO was the most common cause. Among 15 cases of EHPVO, 12 required endoscopic interventions, with recurrent bleed in 3 patients (25%). Oesophageal varices were the commonest finding seen on endoscopy. Of the 14 patients (66.6%) who followed for check scopy, 78.5 % showed no bleed on follow up and 21.5% showed small varices not requiring any intervention. The mortality was 26% (13) in patients with UGIB. Patients who had an underlying hepatic failure and septicaemia had higher mortality as compared to other patients. Conclusion: The outcome of children with EHPVO depends on the control of bleeding. Sclerotherapy and banding are effective in long-term variceal bleeding control. EHPVO was associated with better outcome inpatients with UGIB.

Therapeutic Endoscopy for the Control of Nonvariceal Upper Gastrointestinal Bleeding in Children: A Case Series.

Gastrointestinal bleeding is one of the most common indications for urgent endoscopy in the pediatric setting. The majority of these procedures are performed for control of variceal bleeding, with few performed for nonvariceal upper gastrointestinal (NVUGI) bleeding. The data on therapeutic endoscopy for NVUGI are sparse. The aims of our study were to review our experience with NVUGI bleeding, describe technical aspects and outcomes of therapeutic endoscopy, and determine gastroenterology fellows' training opportunities according to the national training guidelines. We performed a retrospective review of endoscopy database (Endoworks, Olympus Inc, Center Valley, PA) from January 2009 to December 2014. The search used the following keywords: bleeding, hematemesis, melena, injection, epinephrine, cautery, clip, and argon plasma coagulation. The collected data included demographics, description of bleeding lesion and medical/endoscopic therapy, rate of rebleeding, relevant laboratories, physical examination, and need for transfusion and surgery. The study was approved by the institutional review board. During the study period 12,737 upper endoscopies (esophagogastroduodenoscopies) were performed. A total of 15 patients underwent 17 esophagogastroduodenoscopies that required therapeutic intervention to control bleeding (1:750 procedures). The mean ± standard deviation (median) age of patients who required endoscopic intervention was 11.6 ± 6.0 years (14.0 years). Seven out of 17 patients received dual therapy to control the bleeding lesions. All but 3 patients received medical therapy with intravenous proton pump inhibitor, and 3 received octreotide infusions. Six of the patients experienced rebleeding (40%), with 4 out of 6 initially only receiving single modality therapy. Two of these patients eventually required surgical intervention to control bleeding and both patients presented with bleeding duodenal ulcers. There were no cases of aspiration, perforation, or deaths. There were a total of 24 fellows trained in our program during the study period. Less than 1 therapeutic endoscopy per fellow for NVUGI bleeding was performed. NVUGI bleeding requiring therapeutic endoscopic intervention is rare in pediatrics. A high rate (40%) of rebleeding was noted with a large proportion (66%) of patients receiving single modality therapy. Two patients required surgical intervention to control bleeding and both presented with bleeding duodenal ulcers. An insufficient number of therapeutic procedures is available for adequate fellow training requiring supplemental simulator and hands-on animal model, or adult endoscopy unit training.

PS013 - Early use of Tips and Outcomes in Patients with Cirrhosis and Acute Esophageal Varlceal Bleeding: Analysis of the U.S. Nationwide Inpatient Sample Database, 2000-2010

Methods: The nationwide inpatient sample (NIS) database was queried to identify patients with EVB from 2000 to 2010. Only patients with decompensated liver disease by Baveno V classification were included in our analyses because early TIPS is recommended in patients at high-risk of further bleeding and death despite endoscopic and medical therapy. The primary outcome measure was in-hospital death, and secondary outcomes were rebleeding, hepatic encephalopathy, sepsis, and length of hospital stay. Early TIPS was defined by placement within 3 days of hospitalization for acute EVB after one EGD with endoscopic therapy. Rescue TIPS was defined by 2 or more EGDs with endoscopic therapy or one EGD plus a nonendoscopic intervention for control of variceal bleeding (balloon tamponade, interventional radiology or surgery) prior to TIPS. Secular trends in age-adjusted mortality were characterized using Poisson regression models.

Early Use of TIPS and Outcomes in Patients With Cirrhosis and Acute Esophageal Variceal Bleeding: Analysis of the U.S. Nationwide Inpatient Sample (NIS) Database, 2000-2010: ACG Fellows-In-Training Award

Introduction: Recent evidence suggest that TIPS placement as primary therapy within 72 hours after esophageal variceal bleeding (EVB) in patients with high risk of treatment failure is associated with decreased recurrent bleeding and improved survival. The purpose of this study was to investigate the impact of early TIPS on outcomes of patients with EVB. Methods: The NIS database was queried to identify patients with EVB from 2000 to 2010. Only patients with decompensated liver disease by Baveno V classification were included in our analyses because early TIPS is recommended in patients at high-risk of further bleeding and death despite endoscopic and medical therapy. The primary outcome measure was in-hospital death, and secondary outcomes were rebleeding, hepatic encephalopathy, sepsis, and length of hospital stay. Early TIPS was defined by placement within 3 days of hospitalization for acute EVB after one EGD with endoscopic therapy. Rescue TIPS was defined by 2 or more EGDs with endoscopic therapy or one EGD plus a non-endoscopic intervention for control of variceal bleeding (balloon tamponade, interventional radiology or surgery) prior to TIPS. Secular trends in age-adjusted mortality were characterized using Poisson regression models. Results: The study included 142,539 patients (68.2% males) with a discharge diagnosis of EVB. The median age was 55 (IQR 40-60) years. From 2000 to 2010, the age-adjusted in-hospital mortality rate decreased 37.2 % from 656 per 100 000 to 412 per 100 000 (p < 0.01). Utilization of TIPS (Early and Rescue) significantly increased over the study period (0.22 % to 0.70 %, p < 0.01 and 1.1 % to 6.1%, p < 0.01 respectively). Poisson regression analysis showed a significant inverse association of TIPS utilization and the mortality rate ratio of EVB from 2000 to 2010 (RR 0.88; 95% CI 0.83-0.92). Early TIPS had a lower rate of in-hospital death compared to No TIPS and Rescue TIPS, (1.5 % vs 5.6 %; p < 0.01 and 1.5 % vs 8.1; p< 0.01, respectively). Table 1 summarizes the results of the multivariable analysis.Table 1: Multivariable Logistic Regression Analysis for Outcomes with Early TIPS vs. No TIPS or Rescue TIPS in Patients with Cirrhosis and Acute Esophageal Variceal BleedingConclusion: A significant inpatient mortality improvement in EVB among decompensated cirrhotics in the U.S. was seen from 2000 to 2010. In addition, TIPS was increasingly utilized during this time period. The early use of TIPS as a primary treatment was associated with significant short-term reductions in rebleeding and mortality without a significant increase in encephalopathy or sepsis in “real-world” U.S. clinical practice. The Nationwide Inpatient Sample database is the largest publically available all-payer inpatient database in the United States and contains more than 8 million hospital stays per year from more than 1000 hospitals. These data can be taken as outcomes representative of the country as a whole.

Three‐day versus five‐day somatostatin infusion combination with endoscopic variceal ligation in the prevention of early rebleeding following acute variceal hemorrhage: A randomized controlled trial

Combined pharmacological and endoscopic therapy is recommended for initial treatment of acute variceal bleeding (AVB). The optimal duration of therapy with a vasoactive agent is not well established. The aim of this study was to compare the efficacy and safety of 3-day and 5-day somatostatin treatment in the prevention of early rebleeding after endoscopic variceal ligation (EVL). In a double-blind, prospective trial, cirrhotic patients with AVB who underwent EVL were randomly assigned to receive a continuous infusion of somatostatin for either 3 days or 5 days. A total of 95 patients were enrolled; 50 patients in the 3-day group and 45 patients in the 5-day group after initial hemostasis by combination therapy with somatostatin and EVL. Both groups were comparable in terms of baseline data. Very early and early rebleeding within 5 days and 42 days occurred in one and three patient (2%, 6%) in the 3-day group and three and two patients (6.67%, 4.45%) in the 5-day group (P = 0.342, 0.735), respectively. Overall, eight patients died (three from variceal rebleeding and five from causes other than variceal bleed); four (8%) in the 3-day group and four (8.89%) in the 5-day group (P = 0.876). Multivariate analysis revealed that none of the factors was a predictor of rebleeding. No serious side-effects and complications were observed. A 3-day course of somatostatin is as effective as a 5-day course for the control of variceal bleeding and prevention of early rebleeding when used as combination therapy with EVL.

Radiological interventions in portal hypertension.

The role of radiologists in the management of portal hypertension (PHT) had been confined to its diagnosis and treatment planning. However, with the advancements in the field of interventional radiology various minimally invasive techniques have been evolved for the management of portal hypertension and its complications such as recanalisation techniques, shunt creation and variceal bleeding control. Thus, with these technical advances, there is shift in the role of radiologist from diagnosis to management of portal hypertension. In this review, we discuss the nuances of various radiological interventions available for the treatment of portal hypertension.

The first Egyptian experience using new self-expandable metal stents in acute esophageal variceal bleeding: Pilot study

Background/Aim:Balloon tamponade has been widely available in emergency situations of acute variceal bleeding. To lessen the complications of Balloon tamponade, a new special type of stent for exclusive use in acute variceal bleeding has been developed. This study aims to investigate the effectiveness and safety of the new self-expandable metal stents (SEMS) in the initial control of acute variceal bleeding. We also hypothesized that using SEMS can bridge the acute bleeding episode converting endoscopic management by sclerotherapy or band ligation to an elective procedure.Patients and Methods:Twenty patients with acute variceal bleeding were included in the study and 16 of them were allocated to receive stent treatment.Results:Stent deployment was successful in 15 of 16 patients (93.75%). Technical errors were reported in 3 (18.75%) patients. Initial control of variceal bleeding was reported in 14 (out of 16) (87.5%) patients. The mean duration of the procedure was 10 (±6) min. Mortality was reported in 4 (25.0%) patients.Conclusion:SEMS is a safe and effective mean to control acute variceal bleeding.

Tu1644 Results of Endoscopic Cyanoacrylate Injection for the Treatment of Esophageal Variceal Hemorrhage in Child-Pugh C Patients

Despite the recognized efficacy of elastic band ligation for the treatment of variceal bleeding, the results of endoscopic treatment in Child-Pugh C patients remain poor. A recent randomized controlled trial (RCT) proved that the early use of TIPS was related to less rebleeding rate and higher survival rate in decompensated (Child-Pugh scores from 9-13 points) cirrhotic patients (Garcia-Pagán et al,NEJM 2010:362:25). Ten years ago our group postulated that Child-Pugh C patients with variceal bleeding could benefit from glue injection. In a RCT involving 36 pts we proved the superiority of the endoscopic injection of glue (N-2-Butyl-Cyanoacrylate) for the bleeding control in Child-Pugh C pts compared to conventional sclerotherapy (Maluf-Filho et al.,Endoscopy 2001;33:421). We recognize that RCTs create an artificial environment which might overestimate the results of the intervention group. For the last ten years we have been treating Child-Pugh C pts by the endoscopic injection of cyanoacrylate for the control of variceal bleeding and we wanted to reassess the efficacy of the this treatment in that group of patients.

Terlipressin: An Asset for Hepatologists!

Terlipressin: An Asset for Hepatologists!

Simvastatin effects on portal‐systemic collaterals of portal hypertensive rats

Portal-systemic collateral vascular resistance and vasoconstrictor responsiveness are crucial in portal hypertension and variceal bleeding control. Statins enhance vasodilators production, but their influence on collaterals is unknown. This study aimed to survey the effect of simvastatin on collaterals. Partially portal vein-ligated rats received oral simvastatin (20 mg/kg/day) or distilled water from -2 to +7 day of ligation. After hemodynamic measurements on the eighth postoperative day, baseline perfusion pressure (i.e. an index of collateral vascular resistance) and arginine vasopressin (AVP, 0.1 nM-0.1 microM) responsiveness were evaluated with an in situ perfusion model for collateral vascular beds. RT-PCR of endothelial NO synthase (eNOS), inducible NOS (iNOS), cyclooxygenase-1 (COX-1), COX-2, thromboxane A(2) synthase (TXA(2)-S) and prostacyclin synthase genes was performed in parallel groups for splenorenal shunt (SRS), the most prominent intra-abdominal collateral vessel. To determine the acute effects of simvastatin, collateral AVP response was assessed with vehicle or simvastatin. SRS RT-PCR of eNOS, iNOS, COX-1, COX-2 and TXA(2)-S, and measurements of perfusate nitrite/nitrate, 6-keto-PGF1(alpha) and TXB(2) levels were performed in parallel groups without AVP. Acute simvastatin administration enhanced SRS eNOS expression and elevated perfusate nitrite/nitrate and 6-keto-PGF1(alpha) concentrations. Chronic simvastatin treatment reduced baseline collateral vascular resistance and portal pressure and enhanced SRS eNOS, COX-2 and TXA(2)-S mRNA expression. Neither acute nor chronic simvastatin administration influenced collateral AVP responsiveness. Simvastatin reduces portal-systemic collateral vascular resistance and portal pressure in portal hypertensive rats. This may be related to the enhanced portal-systemic collateral vascular NO and prostacyclin activities.

Control of variceal bleeding in a patient with severe haemophilia A and factor VIII inhibitors using a transjugular intrahepatic portosystemic shunt

Control of variceal bleeding in a patient with severe haemophilia A and factor VIII inhibitors using a transjugular intrahepatic portosystemic shunt

A Single-Institution Review of Portosystemic Shunts in Children: An Ongoing Discussion

Purpose. Review the safety and long-term success with portosystemic shunts in children at a single institution. Methods. An IRB-approved, retrospective chart review of all children ages 19 and undergoing surgical portosystemic shunt from January 1990–September 2008. Results. Ten patients were identified, 8 females and 2 males, with a mean age of 15 years (range 5–19 years). Primary diagnoses were congenital hepatic fibrosis (5), hepatic vein thrombosis (2), portal vein thrombosis (2), and cystic fibrosis (1). Primary indications were repeated variceal bleeding (6), symptomatic hypersplenism (2), and significant liver dysfunction (2). Procedures performed were distal splenorenal bypass (4), side-to-side portocaval shunt (3), proximal splenorenal shunt (2), and an interposition H-graft portocaval shunt (1). There was no perioperative mortality and only minor morbidity. Seventy percent of patients had improvement of their symptoms. Eighty percent of shunts remained patent. Two were occluded at a median follow-up of 50 months (range 0.5–13.16 years). Two patients underwent subsequent liver transplantation. Two patients died at 0.5 and 12.8 years postoperatively, one from multisystem failure with cystic fibrosis and one from post-operative transplant complications. Conclusions. The need for portosystemic shunts in children is rare. However, in the era of liver transplantation, portosystemic shunts in selected patients with well-preserved liver function remains important. We conclude that portosystemic shunts are safe and efficacious in the control of variceal hemorrhage and symptoms related to hypersplenism.