Surgical Portal Decompression Research Articles

Abstract No. 498 Trends in utilization and Medicare reimbursement for TIPS and open surgical portal decompression

To analyze trends in the number of minimally invasive TIPS (transjugular intrahepatic portosystemic shunt) vs. open surgical procedures performed for portal decompression in the Medicare population between 2009 and 2018 as well as the reimbursement rates for these procedures. Using the CPT Professional 2019 guidebook, 6 portosystemic decompression codes were identified: 1 for TIPS and 5 for open procedures. Medicare payments as well as the number of reimbursed procedures (allowed services) were selected for each code from the Centers for Medicare and Medicaid Services Part B National Summary Data Files between 2009 and 2018. All payments were adjusted for inflation to their respective 2018 prices. Four of the five open surgical codes were excluded from our analysis as they were performed < 10 times/year and were accordingly censored on the database. The total number of allowed services as well as payments per procedure were analyzed over time using linear regression. They were then compared between procedure types using tests for equality of slopes. Finally, TIPS cases as a proportion of total portosystemic decompressions were analyzed longitudinally via a chi-square test for trend. Significance in all analyses was defined as a 2-sided test with P < 0.05. The number of allowed TIPS procedures increased at a rate of 38.6 procedures/year between 2009 and 2018 (r2 = 0.67) while open procedures decreased at a rate of 2.8 procedures/year (r2 = 0.30) (P = 0.047). The reimbursements for TIPS decreased at a rate of $8.58 per year (r2 = 0.44) while the reimbursements for open procedures increased at a rate of $39.91 per year (r2 = 0.25) (P = 0.01). The number of TIPS cases as a proportion of total portosystemic decompressions increased from 95.0% in 2009 to 98.6% in 2018 (P < 0.001). In the Medicare population between 2009 and 2018, the number of TIPS procedures performed per year showed a positive trend while the number of open surgical procedures for portosystemic decompression demonstrated a slight negative trend. Payments for TIPS decreased while payments for the same open surgical procedures increased. Overall, TIPS was used at an increasing proportion of total portal decompression procedures over this time period, suggesting an increase in its availability or preference by physicians.

Management of portal cavernoma-associated cholangiopathy: Single-centre experience

Portal cavernoma associated cholangiopathy (PCC) is an uncommon disease in western countries. We describe our experience in seven patients with PCC, in particular the endoscopic management. We describe the mode of presentation, frequent symptoms and the outcome of different treatment modalities of patients with symptomatic PCC. Prospectively maintained database was reviewed at a large tertiary referral unit in London, UK. Data included therapeutic interventions, outcomes and complications. Seven patients with PCC were followed for a median of 87 months [interquartile range (IQR), 62-107.5]. Causes of EHPVO included (hypercoagulable status, n=2, peritoneal tuberculosis n=1, neonatal sepsis, n=1, idiopathic, n=3). Acute cholangitis constituted the most recurring complications in all patients during the disease course. Endoscopic intervention was deemed required in all patients for biliary decompression, with 5 out 7 patients managed with repeat endoscopic sessions, (total=23 ERCPs). Surgical portal decompression (meso-caval shunt) was successfully performed in one patient and another patient underwent liver transplantation for decompensated liver cirrhosis. When endoscopic intervention was indicated, a fully covered self expanding metal stent (FcSEMS) provided a longer "symptoms free" period when compared to plastic stent, 7.5 (IQR, 4.75-18.25) and 4 (IQR, 3.5-7) months respectively, P=0.03. Bile duct bleeding occurred in two patients during ERCP procedure, however none of the patients had spontaneous haemobilia. Both patients were successfully treated by FcSEMS. Acute cholangitis is a common presentation and recurrent complication during the disease course. Spontaneous haemobilia seems to be uncommon, however it is a significant potential hazard during endoscopic intervention. Insertion of FcSEMS may remodel choledochal varices and provide a longer "symptoms free" period compared to plastic stents.

Budd-chiari syndrome – outcomes of surgical portal decompression and liver transplantation

Introduction: Budd-Chiari syndrome (BCS) is characterised by hepatic venous outflow obstruction. We present the management outcomes of BCS patients. Methods: The records of 55 patients who presented with BCS between 2011 and 2017 to were retrospectively reviewed. Management plan was based on severity of symptoms, underlying liver function, level of outflow obstruction and patency of retrohepatic cava. Patients were accordingly managed by non-operative procedures, decompressive shunt surgery and liver transplantation. Results: The median age at presentation was 24.8 years(1-43 years). Seven patients had underlying haematological disorder.There were 35 male and 20 female patients. One patient presented with acute BCS. Nonsurgical Interventional procedures were done in 11 patients with Cavoplasty alone in 8, Hepatic venoplasty with RHV stenting in 2 and TIPS in 1 patient. Twenty nine patients underwent surgery for BCS. Surgical procedures performed were Liver transplantation in 15 patients (Living donor-13;Deceased donor-2),Portal decompression in 12 patients(Porto-caval shunt-5,Meso-caval shunt-7),Retro-caval cyst excision in 1 and Denver shunt in 1 patient. Morbidity in patients with transplantation included bile leak in 3, chyle leak in 2, MHV thrombosis in 1 patient and mortality rate was 0.6% (1/15). Median hospital stay was 24 days(11 - 182 days). Mean follow-up was 16 months. In patients with portal decompression, morbidity included chyle leak in 2 and shunt thrombosis in 1 patient and 1 death with mean follow-up of 10.3 months. Conclusion: Budd Chiari syndrome is a challenging clinical problem affecting young patients. Management should be tailored to the anatomy of the obstruction and underlying liver function.

Proximal spleno-renal shunt with retro-aortic left renal vein in a patient with extra-hepatic portal vein obstruction: first case report

BackgroundPresence of retro-aortic left renal vein poses special challenge in creating spleno-renal shunt potentially increasing the chance of shunt failure. The technical feasibility and successful outcome of splenectomy with proximal spleno-renal shunt (PSRS) with retro-aortic left renal vein is presented for the first time. The patient was treated for portal hypertension and hypersplenism due to idiopathic extra-hepatic portal vein obstruction.Case presentationA twenty year old male suffering from idiopathic extra-hepatic portal vein obstruction presented with bleeding esophageal varices, portal hypertensive gastropathy, asymptomatic portal biliopathy and symptomatic hypersplenism. As variceal bleeding did not respond to endoscopic and medical treatment, surgical portal decompression was planned. On preoperative contrast enhanced computed tomography retro-aortic left renal vein was detected. Splenectomy with proximal splenorenal shunt with retro-aortic left renal vein was successfully performed by using specific technical steps including adequate mobilisation of retro-aortic left renal vein and per-operative pressure studies. Perioperative course was uneventful and patient is doing well after 3 years of follow up.ConclusionsPSRS is feasible, safe and effective procedure when done with retro-aortic left renal vein for the treatment of portal hypertension related to extra-hepatic portal vein obstruction provided that attention is given to key technical considerations including pressure studies necessary to ensure effective shunt. Present case provides the first evidence that retro-aortic left renal vein can withstand the extra volume of blood flow through the proximal shunt with effective portal decompression so as to treat all the components of extra-hepatic portal vein obstruction without causing renal venous hypertension.

Portosystemic Shunts: Stable Utilization and Improved Outcomes, Two Decades After the Transjugular Intrahepatic Portosystemic Shunt

PurposeThe aim of this study was to assess national trends in utilization, demographics, hospital characteristics, and outcomes of patients undergoing surgical or percutaneous portal decompression since the introduction of transjugular intrahepatic portosystemic shunts (TIPS). MethodsA retrospective analysis of patients undergoing surgical portal decompression and TIPS procedures was conducted using Medicare Physician/Supplier Procedure Summary Master Files from January 2003 through December 2013 and National (Nationwide) Inpatient Sample data from 1993, 2003, and 2012. Utilization rates normalized to the annual number of Medicare enrollees, estimated means, and 95% confidence intervals were calculated. ResultsThe Medicare total annual utilization rate per million for all portosystemic decompression procedures decreased by 6.5% during the study period, from 15.3 in 2003 to 14.3 in 2013. TIPS utilization increased by 19.4% (from 10.3 to 12.3 per million), whereas open surgical shunt utilization decreased by 60.0% (from 5.0 to 2.0 per million). TIPS procedures represented 86% of all procedures in 2013. From 1993 to 2012, mean age increased slightly (from 53.0 to 55.5 years, P < .05). The percentage of procedures performed at teaching hospitals increased, whereas in-hospital mortality and length of stay decreased by 42% (P < .05) and 20% (P < .05), respectively. Of factors evaluated, the performance of procedures on an elective basis was the most influential on in-hospital mortality (P < .01, all years studied) and length of stay (P < .0001, all years studied). ConclusionsApproximately two decades after the introduction of TIPS, the utilization of all portal decompression procedures has remained relatively stable. The TIPS procedure represents the dominant portal decompression technique. In-hospital mortality and mean length of stay after decompression have decreased, partially because of the performance of procedures during elective admissions.

Balloon-occluded retrograde transvenous obliteration for intractable gastric variceal bleeding

Balloon-occluded retrograde transvenous obliteration (BRTO) is an interventional radiologic technique that obliterates gastric varices (GV) from draining veins under balloon occlusion. A 54-year-old man presented with Stage IV hepatocellular carcinoma and tumor thrombi in main portal vein. Intractable GV bleeding had no response to repeated endoscopic sclerotherapy and pharmacotherapy well. Additionally, his medical condition could not allow transjugular intrahepatic portosystemic shunt or surgical portal decompression. Due to spontaneous gastrorenal shunt proved with abdominal computed tomography, we conducted BRTO to prevent further bleeding. The immediate postprocedural venogram showed total occlusion of the gastrorenal shunt and no visualization of the GV. Follow-up endoscopy was performed at 1 month, 2 months, and 4 months after BRTO. It revealed shrinkage of gastric varices and no worsening of esophageal varices after 4 months of BRTO. The patient was free from repeated GV bleeding for 4 months. Our experience proved BRTO could be the other effective treatment for intractable GV bleeding.

Budd–Chiari Syndrome Revisited: 38 Years’ Experience with Surgical Portal Decompression

ObjectiveTen years ago, we reported our results with what remains as the largest clinical experience with surgical portal decompression for Budd–Chiari syndrome (BCS) in the West. Since then, our series has expanded to 77 patients, and there has been an explosion of interest in and publications about BCS. The objectives of this study are to assess the validity of our observations and conclusions regarding BCS reported 10 years ago by expansion of our series of patients and observations of outcomes over an additional decade of close follow-up. MethodsSeventy-seven patients with BCS were allocated to three groups: group I, 39 had hepatic vein occlusion alone, treated by side-to-side portacaval shunt (SSPCS); group II, 26 had inferior vena cava occlusion treated by mesoatrial shunt in eight and combined SSPCS and cavoatrial shunt (CAS) in 18; and group III, 12 had decompensated cirrhosis too late for portal decompression who were listed for liver transplantation (LT). An extensive diagnostic workup included angiography with pressure measurements and needle liver biopsy. Follow-up was 100%, lasting 5–38 years. ResultsIn group I, long-term survival is 95% with 36 free of ascites, leading lives of good quality 5–38 years post-SSPCS. In group II, mesoatrial shunt was discontinued after 1990 because of a high failure rate, but combined SSPCS-CAS has resulted in 100% survival for 5–25 years. In group III, six patients (50%) are alive and well for more than 5 years post-LT. Serial liver biopsies following portal decompression have shown long-term reversal of the lesions of BCS. ConclusionsLong-term survival following portal decompression of BCS in the West has not been equaled by any other form of therapy, medical or surgical. It is imperative to perform surgical portal decompression early in the course of BCS in order to avoid irreversible liver damage.

Budd-Chiari Syndrome Revisited: Thirty-Eight Years' Experience With Surgical Portal Decompression

Budd-Chiari Syndrome Revisited: Thirty-Eight Years' Experience With Surgical Portal Decompression

TIPS technique

Transjugular intrahepatic portosystemic shunts (TIPS) have become an accepted alternative to the conventional surgical portal decompression procedures for the management of complications related to portal hypertension. Though the precise technique of creating TIPS varies between institutions, the principle steps are similar. Selection of the hepatic vein is of critical importance, because each vein differs in its relationship to the main, right, and left portal veins. Targeting of the portal veins has been facilitated with the advent of wedged hepatic venography using carbon dioxide (CO2). After portal vein puncture, the hepatic parenchymal tract is dilated and bridged with a flexible metallic stent. With current techniques, TIPS can be established in more than 90% of patients. Minor modifications of this technique also allow for the successful creation of TIPS in patients with hepatic vein occlusion and portal vein occlusion. Transjugular intrahepatic portosystemic shunts (TIPS) have become an accepted alternative to the conventional surgical portal decompression procedures for the management of complications related to portal hypertension. Though the precise technique of creating TIPS varies between institutions, the principle steps are similar. Selection of the hepatic vein is of critical importance, because each vein differs in its relationship to the main, right, and left portal veins. Targeting of the portal veins has been facilitated with the advent of wedged hepatic venography using carbon dioxide (CO2). After portal vein puncture, the hepatic parenchymal tract is dilated and bridged with a flexible metallic stent. With current techniques, TIPS can be established in more than 90% of patients. Minor modifications of this technique also allow for the successful creation of TIPS in patients with hepatic vein occlusion and portal vein occlusion.

The transjugular intrahepatic portosystemic Stent-Shunt (TIPSS): Results of a pilot study

The new concept of TIPSS (Transjugular Intrahepatic Portosystemic Stent-Shunt) using the Palmaz iliac stent was successfully accomplished in 9 patients with severe portal hypertension (7 alcoholic, 2 postinfectious liver cirrhosis) and histories of multiple life-threatening upper GI bleeding. All patients were considered noncandidates for surgical portal decompression. An intrahepatic central connection was made transjugularly between the right hepatic vein and the right portal vein in 8 patients and the left portal vein in 1. The portosystemic gradient dropped from an average of 29 +/- 7.2 mmHg to 17.8 +/- 2.9 mmHg immediately after, and to 15.7 +/- 2.8 mmHg at the latest follow-up control after the procedure. Seven patients survived the procedure and progressed to Child's A stage during the observation period of 1-10 months (mean 5 months). One patient died as a direct complication from the procedure, and another patient 11 days after the procedure from a severe nosocomial infection. In none of the surviving patients has bleeding from varices recurred or encephalopathic coma developed. In one patient the shunt diameter was moderately increased by a routine PTA catheter to further decrease the portosystemic gradient (23 to 14 mmHg) 3 months after the primary procedure. Autopsy in the two patients who died demonstrated open stent-shunts with early neoendothelial incorporation.

Causes of Death Among Cirrhotic Patients Following Portal Decompression

One hundred and twenty-three proved cirrhotic patients were followed up until death, following surgical portal decompression. It was found that 42% died of causes that could not be directly blamed on the cirrhosis or results of the operation. Liver failure without bleeding caused 50 of the deaths, about a quarter during the first postoperative month. Seven deaths were due to variceal bleeding, and 12 followed bleeding from some other upper gastrointestinal lesion. Seven patients died of cerebral vascular accident. The frequencies of the various causes of death differed strikingly from those observed among 358 cirrhotic patients without shunts who were followed up until death during the same period.

Pulmonary hypertension associated with cirrhosis of the liver and with portacaval shunts.

Pulmonary hemodynamics were studied in 11 patients with hepatic cirrhosis who had undergone surgical portal decompression several years earlier. Four of the patients had both clinical and physiological evidence of pulmonary hypertension; two others had mild, subclinical pulmonary hypertension. Autopsy examination of two patients who had clinical evidence of pulmonary hypertension revealed thickening of the small pulmonary arteries and multiple small pulmonary emboli. Before the portosystemic venous anastomosis was created, all of the patients had had normal cardiorespiratory performance. These studies suggest that emboli from the portal vein may have been involved in the genesis of the pulmonary hypertension in these patients. The role of surgical portal decompression is unclear. Retrospective studies of 70 clinical records and of 17 autopsy protocols in a similar group of patients did not clarify the role of the surgical decompression in the genesis of the pulmonary hypertension.

Cirrhosis of the liver: fatalities following surgical portal decompression.

Cirrhosis of the liver: fatalities following surgical portal decompression.

Management of Ascites

Ascites refractory to medical therapy has been considered an indication for surgical portal decompression in a good-risk patient 1 or a grave prognostic sign otherwise. 2 Availability of potent diuretics with differing mechanisms of action has greatly reduced the number of patients who cannot be controlled by medical means. Although some patients fail to respond to current medical therapy, neither the frequency nor the mechanism for such failure has been documented. The present investigation was undertaken to ascertain the incidence and cause for refractoriness to popular diuretic regimens and to determine the significance of nonresponsiveness. The study consisted of an evaluation of the influence of thiazide derivatives, spironolactones, and adrenal steroids administered singly or in combination by a predetermined, randomized schedule to patients not responsive to sodium restriction and mercurial diuretics. Material and Methods Hospitalized patients with ascites secondary to cirrhosis were studied in the Clinical Research Center or a

Spontaneous decrease in portal pressure with clinical improvement in cirrhosis.

THERE is much to be learned regarding the natural history of portal hypertension in cirrhosis. This is a natural consequence of the lack of a technic for direct measurement of portal pressure and the relative difficulty of documenting the presence of esophageal varices. Increased reliance on surgical portal decompression for the control of esophageal hemorrhage focuses attention on the need for knowledge regarding spontaneous fluctuations in portal pressure that may be correlated with progression or improvement in the cirrhotic process.The possibility that portal hypertension, once developed, will decrease spontaneously has been suggested by reports of reduction in size or . . .

On the natural history of esophageal varices which are secondary to portal cirrhosis.

Excerpt Uncertainties regarding the natural behavior of esophageal varices continue to interfere with evaluation of cirrhotic patients for surgical portal decompression. Following perfection of ope...

The Fate of Esophageal Varices in Cirrhosis Following Surgical Portal Decompression

Success of surgical portal decompression in the treatment of esophageal varices secondary to cirrhosis must be measured largely in terms of prophy­ laxis against future hemorrhage. The thorough effectiveness of shunt opera­ tions in this regard among patients observed at this hospital has recently been reported. l The purely objective results of portal decompression, especially in its effect on esophageal varices themselves, are important, too, not only for theoretic reasons but also because the technical purpose of decompression of the portal system is to make varices disappear. 2 9 This report deals with the fate of varices in patients with cirrhosis, as judged by esophagoscopic measurement, following portacaval shunt and splenorenal shunt, and it compares the course of varices in cirrhotic patients with and without surgical shunt. MATERIAL AND METHODS Sixty-three patients, with cirrhosis proved in all cases by liver biopsy, have been followed by periodic esophagoscopic examinations for more than 11 weeks and as long as 63 months following surgical portal decompression for eso­ phageal varices (table 1). An end-to-side portacaval shunt had been made in 49 patients, and an end-to-side splenorenal shunt in 14 patients. The patients were Caucasian men, except for 13 women and 2 Negroes. At the time of operation the numbers of patients per age-decade, from the second decade through the seventh, were, respectively, 2, 19, 15, 19, 7, and 1. In addition to the preoperative esophagoscopic examinations, which averaged about 2 per patient, there were 182 esophagoscopic examinations to evaiuate the severity of varices following shunt. These evaluations were made at various postopera­ tive intervals, but the general plan was to carry out the examination after 1, 3, 6, and 9 months and at 6-month intervals thereafter. The actual times of examinations after the shunt are indicated in table 2. The control group consisted of 45 patients for whom shunt was recom­ mended but who refused operation or, in a few cases, whose referring doctors did not agree with the recommendation for shunt. All of these control patients were followed by esophagoscopy for at least 3 and as long as 51 months after