Axel Gebauer

Course of platelet counts in cirrhotic patients after implantation of a transjugular intrahepatic portosystemic shunt - a prospective, controlled study

BACKGROUND/AIMS The pathogenesis of thrombocytopenia associated with advanced liver disease is still controversial. To study the impact of portal decompression on this hematologic complication, we conducted a prospective, controlled study to compare the course of platelet counts in patients after implantation of a transjugular intrahepatic portosystemic shunt (TIPS) with matched controls without shunts. METHODS Fifty-five TIPS patients and 110 controls matched for age, sex, Child-Pugh class, etiology of liver disease and baseline platelet count were included, and followed for 1 year. Follow-up visits were scheduled after 1 month, after 3 months, and at 3-month intervals thereafter. RESULTS Nonparametric Mann-Whitney U-tests revealed significantly higher platelet counts for TIPS patients as compared to controls from the 1st through the 12th month (p<0.01). During the study period, the median platelet count of TIPS patients increased by 19.7%, from 104.0/nl (IR: 68.0) to 124.5/nl (IR: 41.0). In contrast, during the same period the median platelet count of controls decreased by 17.1%, from 102.5/nl (IR: 66.0) to 85.0/nl (IR: 67.5). In the group of cases with baseline platelet counts < or =100/nl, platelet counts had increased by at least 25% at month 12 in 65% of TIPS patients, but in only 5% of controls (p<0.001). However, normalization of platelet counts, i.e. > or =150/nl, was not achieved in any case. Neither the portosystemic pressure gradient after TIPS implantation, nor the percentage of portosystemic pressure gradient reduction during the procedure was predictive of platelet response. CONCLUSIONS TIPS implantation increases platelet counts significantly. However, portal hypertension is clearly not the only mechanism contributing to thrombocytopenia in advanced liver disease.

Clinical outcome two years after implantation of a transjugular intrahepatic portosystemic shunt for recurrent variceal bleeding

Objective: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a relatively new therapy for variceal bleeding. The aim of this study was to assess clinical course 2 years after TIPS procedure. Design: The study was designed as a prospective, uncontrolled cohort study. Methods: Forty‐six patients who underwent successful TIPS implantation were followed prospectively by clinical examinations, duplex sonography and portal venography. Mean follow‐up in surviving patients was 24.1 ±9.0 months. Results: The cumulative rate of survival was 80.4% at 1 year and 70.2% at 2 years. The cumulative rebleeding rate was 12.4% at 1 year and 21.3% at 2 years. The mortality rate of episodes of variceal rebleeding was 22.2%. Variceal rebleeding was associated with shunt abnormalities, and successful shunt revision resulted in control of the bleeding. The cumulative incidence of shunt stenosis or occlusion was 41.2% at 1 year and 54.9% at 2 years. Of those patients without shunt abnormalities after 1 year, 23.3% developed shunt stenosis or occlusion during the second year after TIPS procedure. Shunt revision was successful in 96.6% of cases. Secondary patency rate was 88.1% after 2 years. Conclusion: Successful TIPS implantation results in a low rate of morbidity and mortality from variceal rebleeding over 2 years. TIPS creation in combination with careful follow‐up examinations represents an effective long‐term treatment of recurrent variceal bleeding. Even in patients in whom no shunt abnormality is detected during the first year, routine duplex follow‐up examinations should be continued at 3‐month intervals.

Der transjuguläre intrahepatische porttosystemische Stent-Shunt “TIPSS”—erste Ergebnisse

ZusammenfassungDer transjuguläre intrahepatische portosystemische Stent-Shunt (“TIPSS”) ist eine neue, nichtoperative Methodezur Behandlung von Patienten mit Varizenblutungen. Ohne Laparotomie kann eine hämodynamisch den englumigen Interponatshunts entsprechende Verbindung zwischen einem Pfortaderhauptast und einer Lebervene etabliertund durch eine ballonexpandierbaren, Metallstent offengehalten werden. Die ersten Erfahrungen mit 3 Patienten in Wien werden berichtet. Bei 2 Patienten konnte der TIPSS erfolgreich und komplikationslos durchgeführt werden, beide sind im Follow-up (17 bzw. 3. Wochen) ohne Rezidivblutung. Beim 3. Patienten konnte wegen einer sehr kleinen Leber die Pfortader transjugulär nicht punktiert werden. Der TIPSS stellt eine Alternative zur frühzeitigen Lebertransplantation bei CHILD-B- und-C-Patienten mit schlechten Sklerotherapieergebnissen dar, möglicherweise in Zukunftauch zur Sklerotherapie im Stadium CHILD A nach Erstblutung.SummaryThe “Transjugular intrahepatic portosystemic stent-shunt” (“TIPSS”) is a new nonoperative method for the treatment of recurrent variceal bleedings in patients with portal hypertension Without a need for laporotomy an balloon-expandable sent is placed in an intrahepatic tract between a main portal branch and a hepatic vein. The first experiences with three patients in Vienna/Austria are reported. TIPSS were placed successfully and without complications in2 patients, both are without recurrent bleedings at a follow up of 17 and 3 weeks. In a third patient with a very small liver the portal vein could not be punctured. TIPSS is an potential alternative to shunt surgery in CHILD A patients and an early liver transplantation in CHILD B and C patients with poor results of endoscopic sclerotherapy.