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TIPS on Portal Hypertension for Surgeons

TIPS on Portal Hypertension. . TIPS on Portal Hypertension. VARICEAL BLEEDING Resuscitation. Treat hemorrhagic shockCrystalloid (Limited)Platelets (Rarely)Red Cells FFPGoal: Tissue PerfusionMonitor: Urine OutputCaveat: Do NOT overload. TIPS on Portal Hypertension. VARICEAL BLEEDING Initial Treatment.

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TIPS on Portal Hypertension for Surgeons

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    1. 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 of Texas Medical School - Houston

    2. TIPS on Portal Hypertension

    3. TIPS on Portal Hypertension VARICEAL BLEEDING Resuscitation Treat hemorrhagic shock Crystalloid (Limited) Platelets (Rarely) Red Cells + FFP Goal: Tissue Perfusion Monitor: Urine Output Caveat: Do NOT overload

    4. TIPS on Portal Hypertension VARICEAL BLEEDING Initial Treatment Continue Tx hemorrhagic shock IV therapy Sandostatin® INITIATE WHEN Dx SUSPECTED!!!

    5. TIPS on Portal Hypertension VARICEAL BLEEDING Diagnosis 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

    6. TIPS on Portal Hypertension VARICEAL BLEEDING Initial Therapy Continue I.V. Sandostatin® Endoscopic Therapy Sengstaaken-Blakemore tube TIPS Emergency operation

    7. TIPS on Portal Hypertension VARICEAL BLEEDING Supportive Therapy Correct coagulopathy FFP, vitamin K, +/- platelets Pulmonary Other infection Encephalopathy Nutrition

    8. TIPS on Portal Hypertension VARICEAL BLEEDING Evaluation Child class History Hepatitis profile Angiography Transplant evaluation

    9. TIPS on Portal Hypertension Child-Pugh Classification

    10. TIPS on Portal Hypertension VARICEAL BLEEDING Definitive Therapy Rationale: 67% rebleed Most rebleed < 6 weeks Definitive Tx during initial stay

    11. TIPS on Portal Hypertension VARICEAL BLEEDING Definitive Therapy Medical Endoscopic Surgical Radiological

    12. TIPS on Portal Hypertension VARICEAL BLEEDING Medical Therapy Beta blockade ? bleeding by ? cardiac output Goal: 25% ? in heart rate Reduces # bleeding episodes Does not reduce mortality Use as adjunct

    13. TIPS on Portal Hypertension Endoscopic Banding Occludes venous channels Multiple sessions + surveillance >60% rebleed 1/3 fail treatment ? complications vs scleroTx = / ? efficacy vs scleroTx ENDOSCOPIC Tx OF CHOICE

    14. TIPS on Portal Hypertension Endoscopic Banding

    15. TIPS on Portal Hypertension VARICEAL BLEEDING SURGICAL OPTIONS Total Shunt Selective Shunt Partial Shunt Non-Shunt

    16. TIPS on Portal Hypertension Total Shunts

    17. TIPS on Portal Hypertension Total Shunt Results Prevent rebleed > 90% Thrombosis with graft Encephalopathy rate 40%

    18. TIPS on Portal Hypertension Selective Shunts Goals: Prevent variceal bleeding and encephalopathy Mechanism: Decompress Varices Maintain Portal Perfusion Maintain Portal Hypertension Key: Decompress only gastrosplenic compartment

    19. TIPS on Portal Hypertension Distal Splenorenal Shunt

    20. TIPS on Portal Hypertension DSRS vs Total Shunts Six randomized trials in N.A. Mean follow-up 39 mos (1-8 yrs)

    21. TIPS on Portal Hypertension Partial Shunts Ease of portocaval Limited portal diversion Maintain some liver perfusion Short, straight PTFE graft

    22. TIPS on Portal Hypertension Partial Shunts

    23. TIPS on Portal Hypertension Partial Shunts

    24. TIPS on Portal Hypertension Non-Shunt Operations Options Esophageal transection Variceal ligation Devascularize +/- splenectomy Very limited role

    25. TIPS on Portal Hypertension Liver 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

    26. TIPS on Portal Hypertension TIPS Transjugular Intrahepatic Portocaval Shunt

    27. TIPS on Portal Hypertension TIPS

    28. TIPS on Portal Hypertension TIPS Technically feasible Complications 9 - 50% Infection Intraperitoneal Bleeding Congestive Failure Subcapsular Hematoma Acute Renal Failure Hemobilia Mortality (30 day) 3 - 13%

    29. TIPS on Portal Hypertension Problems With TIPS Encephalopathy minimum 15% Occlusion 33 - 73% @ one year Rebleeding 18% @ one year (1) 19% @ 4.7 months (3)

    30. TIPS on Portal Hypertension The Role For Tips Refractory bleeding Bridge to transplant Child C (all or only “D?Z” ?) ??? refractory ascites Relative contraindication: Poor f/u

    31. Special Cases of Portal Hypertension

    32. TIPS on Portal Hypertension Splenic Vein Thrombosis Etiology: Pancreatitis - Acute or Chronic Pancreatic Carcinoma Hallmark: Isolated Gastric Varices Treatment: Splenectomy (if bleeding)

    33. TIPS on Portal Hypertension Portal Vein Thrombosis Etiology: Congenital - “Cavernous Transformation” Hallmark: Normal Liver Function W/ Varices Treatment: Endo Tx OR DSRS

    34. TIPS on Portal Hypertension Budd-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

    35. TIPS on Portal Hypertension Budd-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

    36. TIPS on Portal Hypertension Some Take Home Points Child A better than Child C Start Sandostatin when Dx suspected ß blockade ? bleeding by ? C.O Banding safer than scleroTx TIPS: Encephalopathy & occlusion rate

    37. TIPS on Portal Hypertension Some Take Home Points Selective shunt: ?? encephalopathy SV Thrombosis: Presentation & Tx Budd-Chiari: Classic triad Transplant for liver failure

    38. TIPS on Portal Hypertension

    39. TIPS on Portal Hypertension

    40. TIPS on Portal Hypertension Portal Hypertension Etiology PRE-HEPATIC Portal Vein or Splenic Vein Thrombosis INTRA-HEPATIC Cirrhosis (ETOH, Hepatitis, Other Toxins) POST-HEPATIC Budd-Chiari

    41. TIPS on Portal Hypertension Complications of Portal Hypertension Ascites Encephalopathy Variceal bleeding Initial management Evaluation Definitive therapy Special cases

    42. TIPS on Portal Hypertension Encephalopathy Etiology: ? Nitrogen compounds Induced by: Infection Dehydration Constipation Blood in gut No test is diagnostic Therapy: Hydrate Cleanse gut ? protein Find and treat cause

    43. TIPS on Portal Hypertension Ascites Origin: Sinusoidal pressure > colloid oncotic pressure Induced by: Physiologic Stress IV Fluids Complications: Spontaneous Bacterial Peritonitis “Hepatorenal Syndrome”

    44. TIPS on Portal Hypertension Control of Ascites Sodium / Water Restriction Spironolactone Loop Diuretic Large Volume Paracentesis Peritoneal-Venous Shunt (?) TIPS

    45. TIPS on Portal Hypertension VARICEAL BLEEDING General Approach Resuscitation Initial treatment Support Evaluation Definitive therapy

    46. TIPS on Portal Hypertension Vasopressin 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

    47. TIPS on Portal Hypertension 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

    48. TIPS on Portal Hypertension Portal Vein Anatomy

    49. TIPS on Portal Hypertension Portal Vein Collaterals Five principle routes for portosystemic collaterals Listed here in increasing order of surgical importanceFive principle routes for portosystemic collaterals Listed here in increasing order of surgical importance

    50. TIPS on Portal Hypertension VARICEAL BLEEDING Sclerotherapy Intra- or Para- Variceal Occludes venous channels Multiple sessions + surveillance >60% rebleed 1/3 fail treatment 30% complication rate

    51. TIPS on Portal Hypertension Endoscopic Sclerotherapy

    52. TIPS on Portal Hypertension Complications of ScleroTx LOCAL Ulceration Stricture Perforation SYSTEMIC Fever Pneumonitis CNS

    53. TIPS on Portal Hypertension Total Shunts Divert most (all?) portal flow Options Portocaval Shunt (E-S or S-S; +/- Graft) Interposition Shunt Central Splenorenal Shunt

    54. TIPS on Portal Hypertension TIPS

    55. TIPS on Portal Hypertension Child’s Classification

    56. TIPS on Portal Hypertension SclTx vs TIPS

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