Michel Lafortune

Predictors of clinical response to transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with refractory ascites

Objective:Transjugular intrahepatic portosystemic shunt (TIPS) is used increasingly as a treatment for refractory ascites. The aim of the present study was to determine the prognostic value of different parameters in predicting a favorable evolution following TIPS in a cohort of 53 cirrhotic patients without organic renal disease and with refractory ascites.Methods:Patients were classified as good responders if they survived more than 6 months, without severe chronic hepatic encephalopathy and with good control of ascites. The prognostic value for a good outcome was evaluated using age, creatinine clearance, plasma renin activity, plasma aldosterone, and Pugh score.Results:Good control of ascites was obtained in 90%. The cumulative survival rate was 54% at 6 months, 48% at 1 yr, and 39% at 2 yr. The vast majority of patients died of complications of hepatic insufficiency. Severe chronic hepatic encephalopathy developed in 26%. Overall, a good clinical response was observed in 47%. Creatinine clearance was identified as the only pre-TIPS factor to be significantly and independently associated with a good clinical response to TIPS for refractory ascites. A good clinical response was observed in 57% of patients with a creatinine clearance >36 ml/min compared to 9% of those with a clearance <36 ml/min p < 0.01. This cutoff point in creatinine clearance had a sensitivity of 96% and a specificity of 36%; positive predictive and negative predictive values were 57% and 90%, respectively.Conclusions:TIPS might be useful for the treatment of refractory ascites in cirrhotic patients without severe renal function impairment. However, the TIPS usefulness still has to be demonstrated compared to large volume paracentesis or Leveen shunt. In patients with poor renal function or with liver failure after TIPS, liver transplantation should be considered.

Power Doppler sonography: basic principles and clinical applications in children

Power Doppler sonography is a new technique that displays the strength of the Doppler signal in color, rather than the speed and direction information. It has three times the sensitivity of conventional color Doppler for detection of flow and is particularly useful for small vessels and those with low-velocity flow. Power Doppler sonography shows potential for detecting areas of ischemia in the kidney, brain, and prepubertal testis and for demonstrating hyperemia in areas of inflammation. Its increased sensitivity to motion and flash artifact, however, limits its application in children. Power Doppler is useful as an adjunct to conventional color and pulsed Doppler sonography.

Relationship between pre-TIPS liver perfusion by the portal vein and the incidence of post-TIPS chronic hepatic encephalopathy

OBJECTIVE:In the present study we evaluated the predictive value of pretransjugular intrahepatic portosystemic shunt (TIPS) portal perfusion as assessed by Doppler ultrasonography for the onset of chronic encephalopathy after TIPS.METHODS:A total of 231 cirrhotic patients were followed-up prospectively after TIPS placement. The pattern of intrahepatic portal flow was assessed before TIPS. Patients were divided into two groups according to Doppler findings. Group 1 comprised patients with prograde portal flow (n = 200), whereas group 2 comprised those with loss of portal perfusion (hepatofugal or back-and-forth flow or portal vein thrombosis; n = 31). The presence of chronic encephalopathy during a median follow-up of 32 months was prospectively recorded. The prognostic value of the following parameters for the onset of chronic recurrent encephalopathy after TIPS was evaluated: age, presence of encephalopathy before TIPS, alcoholism, Pugh score, and loss of portal perfusion before TIPS. The independent prognostic value of each variable was tested with a multiple logistic regression analysis.RESULTS:The two groups were comparable in terms of age, incidence of prior episodes of hepatic encephalopathy, and portacaval gradient before and after the procedure; however, liver failure was more severe in patients in group 2 (Pugh score: 9.2 ± 1.9 vs 10.3 ± 1.7). The 3-yr survival was identical for both groups; 25% of the 200 patients in group 1 developed chronic encephalopathy as compared to 6% of the 31 patients in group 2 (p = 0.03). Multiple logistic regression analysis demonstrated that loss of portal perfusion and age >65 yr were the only independent predictors of the onset of post-TIPS chronic encephalopathy (odds ratios 0.24 and 1.98, respectively).CONCLUSIONS:Cirrhotic patients with loss of portal perfusion before TIPS were protected against post-TIPS chronic hepatic encephalopathy despite a more severe liver dysfunction at baseline. The only other independent predictive factor for the onset of this complication was age.

The Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Portal Hypertension: Current Status

The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.

A Microcomputer‐based Stimulator for Clinical and Experimental Investigations in Cardiac Electrophysiology*

A cardiac stimulator is described which combines the ease of operation required in clinical investigations, particularly endocavitary studies of cardiac arrhythmias, and the versatility needed in a research context. This instrument uses a microcomputer to control two independent opticully‐isolated Stimulation ports which can be addressed either independently or jointly to stimulate at two different sites. The main software module operates as a cascade of ten real time pulse generators with individually presettable parameters: amplitude, duration, period, initial delay, periodic and cyclic modifiers, triggering mode, etc, A simple interactive procedure allows the operator to define a stimulation protocol either by accessing the generator structure directly, or by calling any of five preprogrammed stimulation protocols. With this combination, the instrument can provide a large variety of pulse patterns. The operator can intervene at any lime during stimulation to change parameter values or modify the pulse pattern. Concurrently with stimulation, the instrument generates time‐codes to help relate car‐dine responses recorded on paper chart and magnetic tope, and reference them to specific events. The instrument can be readily expanded by the addition of parallel microprocessor modules; other real time tasks such as acquisition and processing of cardiac responses can thus be incorporated.

Non-surgical treatment of a congenital splenic cyst

A congenital splenic cyst in a 5.5 year old girl was aspirated under ultrasonographic guidance and injected with 150 mg Tetracycline (intended for IV use). Septation and gradual resorption of the cyst occurred during the following weeks, leaving small residual cysts which have remained stable for the last 12 months. Splenectomy and its possible complications were avoided.

Chest tube drainage under radiological guidance for pleural effusion and pneumothorax in a tertiary care university teaching hospital: Review of 51 cases

BACKGROUND Chest tube drainage under radiological guidance has been used with increasing frequency as a treatment option for pleural effusions and pneumothoraxes. OBJECTIVE To evaluate the safety and usefulness of pleural drainage under radiological guidance for pleural effusion and pneumothorax in a tertiary care university teaching hospital. METHODS A retrospective study of cases of chest tube placement under radiological guidance over a 12-month period in a university hospital. RESULTS Fifty-one percutaneous pigtail catheter drainage cases were reviewed (30 patients). Forty-six (90%) chest tubes were inserted as a first-line treatment. The overall success rate of radiological drainage was 88%. Specific success rates were 92%, 85% and 91% for loculated pleural effusion, pneumothorax and empyema, respectively. The complications were few and minor. CONCLUSIONS Pigtail catheter insertion under radiological guidance is a useful procedure for the treatment of sterile pleural effusion, empyema and pneumothorax. This technique can be used as a first-line procedure in the majority of cases.

Umbilical hemorrhage from a cutaneous varix treated by transjugular intrahepatic portosystemic shunt (TIPS)

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Successful reversal of chronic incapacitating post-TIPS encephalopathy by balloon occlusion of the stent

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a new technique allowing decompression of the portal system without the need for abdominal surgery or general anesthetic. This promising procedure appears safe, and is being evaluated in the context of life threatening uncontrollable variceal hemorrhage as well as ascites refractory to medical treatment. Following TIPS, portal flow diversion is associated with hepatic encephalopathy in up to 25% of patients. This is most often mild and treatable but may become uncontrollable, incapacitating and even life threatening in up to 3 to 5% of cases. The authors present two patients in whom such life threatening encephalopathy and stupor was reversed by transjugular balloon occlusion of the TIPS.

Deep Doppler in the Liver Vasculature

The widespread availability of duplex Doppler instruments that combine high-quality ultrasound imaging with spectral and color pulsed Doppler at ultrasonic frequencies suitable for abdominal scanning has brought several exciting new areas of clinical diagnosis into view. These include the assessment of blood flow in the vasculature of the liver and splanchnic veins in a variety of pathologic conditions. It has become apparent that there are numerous circumstances in which the addition of information related to blood flow can complement the role of conventional abdominal ultrasound imaging.1,2 The Doppler sonographer of the abdomen must therefore be capable of interpreting the Doppler spectrum under a relatively wide range of hemodynamic circumstances: it is perhaps because of the varied objectives of the Doppler technique in the abdomen that there are so few firm guidelines for its use. A critical appreciation of the basic principles and limitations of the Doppler method applied to the splanchnic circulation is an essential prerequisite for its successful clinical use.