Kamarjit Mangat

Good clinical outcomes following transjugular intrahepatic portosystemic stent-shunts in Budd-Chiari syndrome.

There have been encouraging reports on transjugular intrahepatic portosystemic stent‐shunt (TIPSS) for Budd–Chiari syndrome (BCS). Long‐term data are lacking.

The role of Transjugular Intrahepatic Portosystemic Stent‐Shunt (TIPSS) in the management of variceal hemorrhage

Variceal bleeding in cirrhosis represents a lethal complication of their disease. In the last 20 years, management of AVH has improved greatly with reduction in mortality from 43% in 1980 to 15% in 2000.

A case‐controlled study of the safety and efficacy of transjugular intrahepatic portosystemic shunts after liver transplantation

The role of transjugular intrahepatic portosystemic shunt (TIPS) insertion in managing the complications of portal hypertension is well established, but its utility in patients who have previously undergone liver transplantation is not well documented. Twenty‐two orthotopic liver transplantation (OLT) patients and 44 nontransplant patients (matched controls) who underwent TIPS were analyzed. In the OLT patients, the TIPS procedure was performed at a median of 44.8 months (range = 0.3‐143 months) after transplantation. Eight (36.4%) had variceal bleeding, and 14 (63.6%) had refractory ascites. The underlying liver disease was cholestatic in 10 (45.4%) and viral in 4 (18.2%). The mean pre‐TIPS Model for End‐Stage Liver Disease (MELD) score was 13.4 ± 5.1. There were no significant differences in age, sex, indication, etiology, or MELD score with respect to the control group. The mean initial portal pressure gradients (PPGs) were similar in the 2 groups (21.0 versus 22.4 mm Hg for the OLT patients and controls, respectively), but the final PPG was lower in the control group (9.9 versus 6.9 mm Hg, P < 0.05). The rates of both technical success and clinical success were higher in the control group versus the OLT group [95.5% versus 68.2% (P < 0.05) and 93.2% versus 77.2% (P < 0.05), respectively]. The rates of complications and post‐TIPS encephalopathy were similar in the 2 groups, and there was a trend toward increased rates of shunt insufficiency in the OLT group. The mortality rate of the patients with a pre‐TIPS MELD score > 15 was significantly higher in the OLT group [hazard ratio (HR) = 4.32, 95% confidence interval (CI) = 1.45‐12.88, P < 0.05], but the mortality rates of the patients with a pre‐TIPS MELD score < 15 were similar in the 2 groups. In the OLT group, the predictors of increased mortality were the pre‐TIPS MELD score (HR = 1.161, 95% CI = 1.036‐1.305, P < 0.05) and pre‐TIPS MELD scores > 15 (HR = 5.846, 95% CI = 1.754‐19.485, P < 0.05). In conclusion, TIPS insertion is feasible in transplant recipients, although its efficacy is lower in these patients versus control patients. Outcomes are poor for OLT recipients with a pre‐TIPS MELD score > 15. Liver Transpl 17:771‐778, 2011.

Embolization of Bleeding Stomal Varices by Direct Percutaneous Approach

Stomal varices can occur in patients with stoma in the presence of portal hypertension. Suture ligation, sclerotherapy, angiographic embolization, stoma revision, beta blockade, portosystemic shunt, and liver transplantation have been described as therapeutic options for bleeding stomal varices. We report the case of a 21-year-old patient with primary sclerosing cholangitis and colectomy with ileostomy for ulcerative colitis, where stomal variceal bleeding was successfully treated by direct percutaneous embolization. We consider percutaneous embolization to be an effective way of treating acute stomal bleeding in decompensated patients while awaiting decisions regarding shunt procedures or liver transplantation.

Long-term outcomes following percutaneous hepatic vein recanalization for Budd–Chiari syndrome

A proportion of patients with Budd–Chiari Syndrome (BCS) associated with stenosis or short occlusion of the hepatic vein (HV) or upper inferior vena cava (IVC) can be treated with recanalization by percutaneous venoplasty ± HV stent insertion. We studied the long‐term outcomes of this approach.

Hepatic and splenic trauma

The spleen and liver are two organs commonly injured in various forms of abdominal trauma. Their relative size, relatively fixed positions, and abundant vascular supply make them prone both to injury and potential sources of catastrophic haemorrhage. With the evolution of computed tomography (CT), there has been a paradigm shift in the management of such injuries from operative to non-operative means. Advances in imaging techniques have also enabled clinicians to observe such patients for development of complications, and when appropriate, utilise the repertoire of interventional radiology techniques available. This review aims to summarise the epidemiology of splenic and hepatic trauma, the mechanisms of trauma and the classifications used in describing these injuries. The role of commonly used imaging modalities, namely ultrasound and CT, both in the acute setting and in observation of these patients for delayed complications is described, and finally a brief description of the current management strategies of such injuries is given.

A case-control study of transjugular intrahepatic portosystemic stent shunts for patients admitted to intensive care following variceal bleeding.

Introduction Variceal bleeding has a 6-week mortality of 20%. Recent evidence suggests that early covered transjugular intrahepatic portosystemic stent shunts (TIPSS) can improve outcomes following a variceal bleed in selected patients. We aim to assess the outcomes following the insertion of covered TIPSS in a real-life intensive care setting. Materials and methods This is a retrospective matched cohort study of all patients referred for TIPSS with variceal bleeding admitted to intensive care (2007–2009). Patients were matched with others admitted to intensive therapy unit following a variceal bleed but did not proceed to TIPSS. All TIPSS procedures were carried out using polytetrafluoroethylene-covered stents. Results Thirty-eight patients [mean age 55.2 years; mean model for end-stage liver disease (MELD)=14.0; and median follow-up 458 days] were assessed. Nineteen underwent TIPSS and were well matched to the controls. All patients received terlipressin and antibiotics and 86% had active bleeding at endoscopy. Indication for TIPSS was salvage therapy (47%), rebleeding after day 5 (11%) and as secondary prophylaxis (42%). There was 34% all-cause inpatient mortality. The TIPSS group had lower mortality than the non-TIPSS group at 6 weeks (10.5 vs. 47.4%, P<0.05) that persisted at 1 year (21.1 vs. 52.6%, P<0.05). Multivariate analysis indicated MELD [HR 1.131, 95% confidence interval (CI) 1.018–1.257] and TIPSS (HR 0.301, 95% CI 0.091–0.995) as significant predictors of mortality (P<0.05). TIPSS was found to significantly reduce the incidence of failure to control bleeding and rebleeding (HR 0.120, 95% CI 0.015–0.978, P<0.05). Conclusion Patients with recent severe variceal bleeding admitted to intensive care have significantly better outcomes following covered TIPSS insertion. These findings should be validated in randomized-controlled trials.

Imaging in abdominal trauma

Abdominal trauma is increasing and although penetrating wounds are also on the increase, blunt trauma remains more common. The cornerstone of management is accurate diagnosis and the advent of high-quality rapid CT scanning has revolutionised the treatment of serious abdominal injury. It has allowed the introduction of selective non-operative management which is applicable to many low- and intermediate-grade injuries, whereas application of interventional radiology can avert laparotomy in higher grade injuries. This review examines the pathophysiology of the commonest forms of abdominal injury and uses a series of cases to illustrate the impact of modern radiology in management.

Commentary: TIPSS for Budd-Chiari syndrome - authors' reply

gle-handedly by two experienced physicians, cases had been carefully selected (only 68 of the 104 patients actually underwent TIPSS) and all patients were maintained on full anticoagulation throughout. It would have been helpful to know what criteria were used for patient selection to generalise these findings, and whether the improved survival was a function of effective anticoagulation. Owing to the lack of randomised controlled evidence and the relative rarity of BCS, the management of BCS will likely continue to be based on expert opinions and local expertise. In general, recanalisation attempts are advocated as the first line, and TIPSS as the rescue step when the former is unsuitable or ineffective. While angioplasty is common in Asia and surgical shunts are favoured in certain US centres, 6 TIPSS has become increasingly popular in Europe. 7 Given the feasibility, safety, efficacy profile and excellent long-term survival, the authors add to the growing body of evidence regarding the importance of TIPSS as a viable option for Budd-Chiari syndrome. ACKNOWLEDGEMENT Declaration of personal and funding interests: None.