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Hepatic sinusoidal obstruction syndrome (HSOS) is a vascular liver disease characterized by varying degrees of liver injury and portal hypertension. HSOS in China is mostly associated with the intake of pyrrolizidine alkaloids. The step-up approach with anticoagulant therapy and transjugular intrahepatic portosystemic shunt (TIPS) as the core treatment methods is the therapy currently recommended for this disease. Subcutaneous injection of low-molecular-weight heparin is the first choice for anticoagulant therapy, and oral warfarin can be used in combination or sequentially to enhance anticoagulation. Patients with no response to anticoagulant therapy can switch to TIPS. The Drum Tower Severity Score (DTSS) system can be used during treatment to evaluate the severity of the disease, in order to identify high-risk patients earlier and switch to TIPS in time, thereby improving the prognosis of patients.
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Gastroesophageal variceal bleeding is the life-threating complication of cirrhotic portal hypertension, and transjugular intrahepatic portosystemic shunt (TIPS) is an effective therapy for portal hypertension-related complications. TIPS can be used for the prevention of first-time bleeding in patients with recurrent or intractable ascites. TIPS should be performed as early as possible for patients at a high risk of acute variceal bleeding (Child-Pugh class C 7 points with active bleeding on endoscopy or hepatic venous pressure > 20 mmHg). TIPS is an effective salvage therapy for acute variceal bleeding with failure after standard treatment, and is also a second-line option for preventing variceal rebleeding.
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Objective:To explore the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of esophago-gastric variceal bleeding (EGVB) complicated with cavernous transformation of portal vein (CTPV).Methods:From January 1, 2015 to December 31, 2018, the clinical data of liver cirrhosis patients with EGVB and complicated with (CTPV group) or without (non-CTPV group) CTPV receiving TIPS at Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School were retrospectively analyzed. The success rate of operation, stent patency rate, recurrent bleeding rate, incidence and survival rate of hepatic encephalopathy of CTPV group and non-CTPV group were analyzed. Independent samples t test, Mann-Whitney U test and chi-square test were used for statistical analysis. Kaplan-Meier method was used for survival analysis. Results:A total of 37 liver cirrhosis patients with EGVB and CTPV receiving TIPS treatment were screened out, among which 10 patients (27.0%) failed the portal vein puncture during the TIPS and switched to endoscopic treatment, the success rate was 73.0%. A total of 460 liver cirrhosis patients with EGVB and non-CTPV received TIPS treatment, among which TIPS in 18 patients (3.9%) was failed, and the success rate was 96.1%. With 1∶2 ratio propensity matching, 54 patients were enrolled in non-CTPV group. In the CTPV group, after TIPS treatment, the average portal vein pressure decreased from (28.9±5.1) mmHg (1 mmHg=0.133 kPa) to (18.8±4.5) mmHg, and the difference was statistically significant ( t=7.122, P<0.01). The median follow-up time was 33 months(1 to 66 months). There were no significant differences between the CTPV group and the non-CTPV group in one-year of cumulative stent patency rate (75.0% vs. 86.8%), recurrent upper gastrointestinal bleeding rate of hepatic encephalopathy (21.0% vs. 10.0%), the incidence of hepatic encephalopathy (34.8% vs. 22.2%) and the survival rate (80.7% vs. 88.9%)(all P >0.05). Conclusion:TIPS is safe and effective in the treatment of liver cirrhosis patients with EGVB and CTPV, and does not increase the incidence of postoperative complications and long-term mortality.
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Objective:To investigate the changes of liver volume and liver function in patients with extensive hepatic vein occluded Budd-Chiari syndrome (BCS) treated with transjugular intrahepatic portosystem shunt (TIPS).Methods:The clinical data of 29 BCS patients from Affiliated Hospital of Xuzhou Medical University during March 2016 to June 2019 were retrospectively collected and analyzed. The BCS was caused by extensive hepatic vein occlusion and patients were treated with TIPS. Pre- and postoperative abdominal CT/MRI images were collected and analyzed, and hepatic volume was measured with 3D-reconstruction. The liver volume and liver function during before and post the surgery were also collected and analyzed with preoperative value.Results:Patients including 8 males and 21 females, aged (33.3±6.3) years, were enrolled in this study. TIPS was successfully performed in all patients, with a technical success rate 100%. No serious complications related to TIPS occurred. Patients were followed up for 12-33 months (median, 16 months). Compared with preoperative [(2 124.6±420.9) cm 3] , the hepatic volume of time points after operation [1 week: (1 926.3±372.3) cm 3; 3 months: (1 480.6±183.1) cm 3; 6 months: (1 461.9±153.0) cm 3; 12 months: (1 469.3±148.5) cm 3] were all significantly reduced, and the differences were statistically significant ( P<0.05). Compared with preoperative values, the hepatic function indexes at each time point after operation were significantly improved ( P<0.05). The complete remission rate of ascites was 96.4% (27/28), 100.0% (28/28) and 100.0% (28/28) at 3, 6 and 12 months, respectively. Conclusion:The extensive hepatic vein occlusive BCS patients were benefit from TIPS therapy. Six months after operation, the hepatic volume and the hepatic function returned to normal level.
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Sarcopenia is a common and insidious complication in patients with liver cirrhosis and is closely associated with the prognosis of patients with liver cirrhosis. Transjugular intrahepatic portosystemic shunt (TIPS) is an important method for the treatment of portal hypertension-related complications. More and more studies have shown that sarcopenia is associated with the prognosis of cirrhotic portal hypertension after TIPS. This article reviews the research on sarcopenia and its association with TIPS in China and globally, in order to explore the association between them and guide clinical treatment.
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Esophageal and gastric variceal bleeding (EGVB) is a serious complication of portal hypertension, and it is necessary to control the progression of esophageal and gastric varices in clinical practice and prevent and treat EGVB; however, the mortality rate associated with variceal rupture and bleeding remains high at present. As for clinical treatment, risk classification of patients should be performed based on clinical and hemodynamic features and individualized treatment should be adopted, taking into account the balance of "embolization, shunt, and perfusion" of portal hypertension, so as to improve the clinical outcome and prognosis of patients with liver cirrhosis.
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Globally, the population living with liver cirrhosis is growing. There is the largest number of cirrhosis patients in China throughout the world. Acute-on-chronic liver failure (ACLF) is a clinical syndrome of sudden hepatic decompensations such as variceal bleeding, spontaneous bacterial peritonitis, hepatic encephalopathy and hepatorenal syndrome seen in patients with liver cirrhosis. ACLF leads to poor quality of life and high mortality. Portal hypertension is not only a consequence of the development of cirrhosis, but also a secondary or even superimposed attack to the development of cirrhosis. It is necessary to early reduce intrahepatic resistance by transjugular intrahepatic portosystemic shunt and drugs to improve the prognosis.
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Liver cirrhosis is the end stage of various chronic liver diseases, and portal hypertension is a main complication of liver cirrhosis. In this pathological state, spontaneous portosystemic shunt (SPSS), as the collateral circulation of the portal venous system, has not attracted enough attention in terms of occurrence mechanism and clinical value. The analysis shows that although SPSS is a natural shunt channel, further studies are still needed to clarify whether it can be used as a decompression method for portal hypertension, and a deeper understanding of SPSS will provide important guiding significance for the diagnosis and treatment of portal hypertension.
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Liver cirrhosis is the end stage of various chronic liver diseases, and portal hypertension is a main complication of liver cirrhosis. In this pathological state, spontaneous portosystemic shunt (SPSS), as the collateral circulation of the portal venous system, has not attracted enough attention in terms of occurrence mechanism and clinical value. The analysis shows that although SPSS is a natural shunt channel, further studies are still needed to clarify whether it can be used as a decompression method for portal hypertension, and a deeper understanding of SPSS will provide important guiding significance for the diagnosis and treatment of portal hypertension.
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Hepatic encephalopathy (HE) is a common complication after transjugular intrahepatic portosystemic shunt (TIPS), and there are still no systematic strategies for prevention and treatment at present. Based on recent studies in China and foreign countries, this article analyzes and summarizes the risk factors for HE after TIPS and the advances in treatment and prevention. It is pointed out that early diagnosis and prevention of covert HE should be emphasized in further research, and it is important to standardize the prevention strategies for HE after TIPS.
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ObjectiveTo investigate the changes in gut microbiota after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients with mild hepatic encephalopathy (MHE) in different prognosis groups. MethodsA total of 28 MHE cirrhotic patients who were hospitalized and underwent TIPS in Xijing Hospital of Digestive Diseases from July 2016 to July 2017 were enrolled. Fecal samples and related clinical data were collected on days 1-3 before surgery and at 1 month after surgery. According to the prognosis after surgery, the patients were divided into none-hepatic encephalopathy (HE) group with 8 patients, MHE group with 12 patients, and overt hepatic encephalopathy (OHE) group with 8 patients. Fecal samples were analyzed by 16S rRNA sequencing to obtain the relative abundance of gut microbiota, and SPSS and R packages were used to analyze the biodiversity, postoperative changes, and differences in such changes of gut microbiota at the genus level between groups. The chi-square test was used for comparison of categorical data between groups; the Kruskal-Wallis H test was used for comparison of continuous data between three groups; the Bonferroni method was used for multiple comparisons of multiple samples; the Wilcoxon signed-rank test was used for comparison before and after surgery within each group. For microbiome beta-diversity analyses, a principal coordinate analysis (PCoA) was performed based on Bray-Curtis distance matrix, and the Adonis method (PerMANOVA) was used for comparison between groups. ResultsPCoA based on Bray-Curtis distance matrix showed that only the MHE group had a significant change in beta diversity after surgery (F=2.71, P=0.049). After surgery, the non-HE group had significant increases in the abundance of the native flora Dialister, Coprococcus, Ruminococcaceae_uncultured, Flavonifractor, and Clostridium_sensu_stricto_1 (Z=2.521, 2.1, 2.1, 2.1, and 1.96, all P＜0.05); the MHE group had significant reductions in the abundance of the harmful flora Granulicatella（Z=2.521,P=0.012）, Enterococcus（Z=2.51,P=0.012）, Streptococcus（Z=2.432,P=0.015）, and Rothia（Z=2.001,P=0.045） and significant increases in the abundance of Veillonella（Z=2.353,P=0.019） and Megasphaera（Z=1.955,P=0.05）; the OHE group only had a significant increase in the abundance of Veillonella after surgery (Z=2.38, P=0.017). There was a significant difference in the change in gut microbiota (postoperative abundance/preoperative abundance) between the non-HE group, the MHE group, and the OHE group ［2.00 (1.11-91.61) vs 1.21 (0.26-679) vs 0.09 (0.01-0.92), χ2=6.249, P=0.043］. ConclusionThere is a significant difference in the change in gut microbiota after TIPS between patients with different prognoses, and the increase in the abundance of native flora may have a certain influence on the remission of MHE.
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Chylous Ascites (CA) and chylothorax (CTx) are associated with obstruction, disruption or insufficiency of the lymphatic system. We report a 68-year-old male, with a history of alcoholic cirrhosis, who had recurrent events of CTx and CA. After a complete study, no other etiologies other than portal hypertension were found. Therapy with diuretics, nothing per mouth, parenteral feeding plus octreotide did not relieve symptoms. A transjugular intrahepatic portosystemic shunt (TIPS) was successfully placed and pleural effusion subsided. This case shows that CA and CTx can be caused by portal hypertension and they may subside employing a multimodal management strategy.
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ObjectiveTo investigate the clinical features and causes of death after transjugular intrahepatic portosystemic shunt (TIPS) in patients with hepatic sinus obstruction syndrome (HSOS), as well as the prevention and treatment measures to further improve the survival rate of such patients. MethodsA retrospective analysis was performed for 293 patients with HSOS who were admitted to Nanjing Drum Tower Hospital from January 2013 to December 2019, among whom 20 patients died after TIPS. General information, laboratory examination, and clinical treatment regimen were analyzed, and clinical indices and complications were compared at different stages of the disease. The paired t-test was used for comparison of normally distributed continuous data between groups, and the Wilcoxon rank-sum test was used for comparison of non-normally distributed continuous data between groups. ResultsThe mean survival time was 15.15±4.21 weeks for the 20 patients who died, among whom there were 15 male patients and 5 female patients, with a mean age of 67.60±7.01 years; there were 17 patients (85%) aged ≥60 years, and more than 90% of the patients had abdominal distention and oliguria. Among the 20 patients who died, 9 (45%) had chronic underlying diseases, and 5 (25%) had more than two underlying diseases. Portal venous pressure decreased from 21.67±5.15 mm Hg before surgery to 8.17±4.98 mm Hg after surgery (t=10.318,P＜0.05). The levels of total bilirubin, direct bilirubin, and D-dimer were significantly higher than the normal values before surgery, and there were significant increases in these levels on day 5 after surgery (Z=3.823,3.823,2.756, all P＜0.05); the hemoglobin level, platelet count, and creatinine level tended to decrease on day 5 after surgery (t=4.979,t=2.147,Z=-3.125, all P＜005). Three patients had hepatic encephalopathy before surgery, while 10 patients (50%) had hepatic encephalopathy after surgery. Causes of death included acute liver failure, infectious shock, and multiple organ failure syndrome (MODS). ConclusionThe possible risk factors for death after TIPS in HSOS patients include underlying diseases, high bilirubin, and complications such as hepatic encephalopathy and renal dysfunction. Causes of death mainly include acute liver failure and MODS. Ultrasound and laboratory markers should be reexamined during anticoagulation therapy to identify the patients with progression to severe diseases as early as possible, and in case of progressive deterioration of indices, TIPS should be selected as early as possible to improve the survival rate and prognosis of such patients. In addition, hemobilia should be observed during and after surgery, and intervention measures should be adopted in time to further reduce mortality rate.
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Objective: To investigate the value of CEUS in evaluating on the function of stent after TIPS in cirrhosis patients with portal hypertension. Methods: Totally 107 cirrhosis patients with portal hypertension who underwent TIPS were selected, and the function of stent were observed with CDFI and CEUS. Taken DSA results as golden standards, the diagnostic efficiency of CDFI and CEUS were evaluated and compared. Results: The sensitivity, specificity, positive predictive value and negative predictive value of CEUS in evaluation on function of stent after TIPS was 90.00% (9/10), 100% (16/16), 100% (9/9) and 94.12% (16/17), while of CDFI was 64.71% (11/17), 80.00% (68/85), 39.29% (11/28) and 91.89% (68/74), respectively. Taken DSA results as gold standards, AUC of CDFI and CEUS was 0.542 and 0.958 (P<0.01). Conclusion: CEUS has high sensitivity and specificity for judgment of stent function after TIPS, which can provide objective and accurate information for clinical practice.
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ObjectiveTo investigate the clinical value of indocyanine green retention rate at 15 minutes (ICG-R15), Child-Turcotte-Pugh (CTP) class, and Model for End-Stage Liver Disease (MELD) score in predicting post-transjugular intrahepatic portosystemic shunt (TIPS) hepatic encephalopathy (HE) in liver cancer patients with portal hypertension. MethodsA retrospective analysis was performed for the clinical data of 95 liver cancer patients with portal hypertension who underwent TIPS in Department of Interventional Therapy in Beijing Shijitan Hospital from January 2015 to June 2017, and according to the presence or absence of HE after TIPS, they were divided into HE group with 24 patients and non-HE group with 71 patients. ICG-R15, CTP class, and MELD score were determined for all patients before surgery. The t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test and the Fisher’s exact test were used for comparison of categorical data between two groups. Univariate and multivariate logistic regression analyses were used to investigate the risk factors for HE after TIPS, and the receiver operating characteristic (ROC) curve was used to analyze the value of ICG-R15, CTP class, and MELD score in predicting HE. ResultsThe incidence rate of HE was 25.2% (24/95) within 12 months after TIPS. The univariate analysis showed that stent location (P=0.021), ICG-R15 (P=0.005), and CTP class (P=0.040) were associated with HE after TIPS. The multivariate analysis showed that stent located in the right portal vein (OR=3.373, 95% CI: 2.346~5.103, P=0.010) and ICG-R15＞30% (OR=2.107, 95% CI: 1.331~3.212, P=0.036) were independent risk factors for HE after TIPS in liver cancer patients with portal hypertension. The ROC curve analysis showed that ICG-R15, MELD score, and CTP class had an area under the ROC curve of 0.659, 0.638, and 0.621, respectively, in predicting HE after TIPS. ConclusionICG-R15 has a certain clinical value in predicting HE after TIPS in liver cancer patients with portal hypertension.
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ObjectiveTo investigate the effect of intraoperative Viatorr stent implantation for shunting of blood flow in the left or right branch of the portal vein on the clinical outcome of patients with cirrhotic portal hypertension undergoing transjugular intrahepatic portosystemic shunt (TIPS). MethodsA retrospective analysis was performed for the clinical data of 120 patients with cirrhotic portal hypertension who underwent TIPS in The General Hospital of Western Theater Command from March 2016 to December 2019, and according to the target position of portal vein puncture determined by intraoperative angiography, the patients were divided into left branch group and right branch group. The two groups were compared in terms of the incidence rates of postoperative recurrence and bleeding, stent dysfunction, and hepatic encephalopathy (HE) and survival. The t-test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier curve was used to calculate rebleeding rate, stent patency rate, incidence rate of HE, and survival rate. ResultsThe surgical success rate was 100% for all 120 patients, with a short-term hemostasis rate of 100%. Among the 120 patients, 52 underwent shunting of the left branch of the portal vein and 68 underwent shunting of the right branch. There was a significant reduction in portal venous pressure after surgery (9.98±2.84 mm Hg vs 24.72±5.11 mm Hg, t=37.76, P＜0.01). The cumulative rebleeding rates at 12 and 24 months after surgery were 3.2% and 11.0%, respectively, and the cumulative incidence rates of HE at 3, 6, 12, and 24 months after surgery were 10.8%, 13.6%, 21.2%, and 24.5%, respectively. Among the 29 patients who experienced HE, 23 had grade Ⅰ-Ⅱ HE and 6 had grade Ⅲ HE. The cumulative incidence rates of stent dysfunction at 12 and 24 months after surgery were 7.1% and 21.4%, respectively. The cumulative survival rates at 12 and 24 months after surgery were 92.0% and 86.5%, respectively. As for comparison of the left branch group and the right branch group, there were no significant differences in postoperative stent patency rate, rebleeding rate, incidence rate of HE, and survival rate(all P＜0.05). ConclusionTIPS is a safe and effective method for the treatment of cirrhotic portal hypertension, and intraoperative Viatorr stent implantation, no matter for establishing the shunt of the left or right branch of the portal vein, will not affect the clinical outcome of patients.
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ObjectiveTo investigate the characteristics of flora microbiota before and after transjugular intrahepatic portosystemic shunt (TIPS) in patients with liver cirrhosis. MethodsA total of 18 patients with liver cirrhosis who were hospitalized and underwent TIPS in Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, from July 2018 to July 2019 were enrolled. Fecal samples were collected from 18 patients before surgery, 6 fecal samples were collected at 1 month after surgery, and 9 were collected at 3 months after surgery. The results of liver function and coagulation were collected before and after surgery. Fecal samples were analyzed by the 16S rRNA high-throughput sequencing method, and the DADA2 method recommended by QIIME2 was used in the bioinformatics analysis. The intestinal flora was analyzed in terms of the generated amplified characteristic sequence, and the multiple hypothesis tests of LEfSe, SPSS (Alpha analysis), PERMANOVA (Beta analysis), and Pheatmap were used for analysis. For normally distributed continuous data, intergroup comparison of parameters at different time points was made by a repeated measures analysis of variance. For non-normally distributed continuous data, intergroup comparison of parameters at different time points was made using a generalized estimating equation, and further pairwise comparison was made using the Bonferroni method. ResultsThere were significant differences in total bilirubin and total bile acid between groups before TIPS and during the three periods of time after TIPS (F=8.201 and 39.482, P=0.001 and P＜0.001). At 1 month after surgery, Beta diversity changes were observed in fecal samples (F=2.603, P=002), while there was no significant difference in Alpha diversity of the fecal samples between the three periods of time (P＞0.05). At the genus level, portal venous pressure before TIPS was negatively correlated with Bifidobacterium, Collinsella, and Ruminococcus (r=-0.35, -0.38, and -0.34, P=0.04, 0.02, and 0.04) and was positively correlated with Boletus (r=0.41, P=0.015). Other indices were also correlated with different components of the intestinal flora (P＜0.05). ConclusionThere is a correlation between clinical indices and intestinal flora before TIPS. The composition of intestinal flora changes after TIPS, with a significant difference at the genus level.
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Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive technique for the treatment of portal hypertension in liver cirrhosis. With the gradual maturity of TIPS technique and the continuous improvement of stent materials, the indications for TIPS are gradually expanded, the incidence rate of complications gradually decreases, and the treatment outcome is getting better and better. The impact of TIPS on the main organs of patients has attracted more and more attention in recent years, and this article reviews the effect of TIPS on the liver and the heart.
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Ohjective To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of sinusoidal obstruction syndrome (SOS) caused by gynura segetum.Methods The clinical data of 9 patients with SOS caused by gynura segetum (5 males and 4 females) who underwent TIPS were retrospectively analyzed from February 2017 to June 2018.The Child-Pugh scores were (9.5 ± 1.3) and the MELD scores were (12.5 ± 5.0).The success rates,complications and follow-up results were evaluated.Results TIPS was performed successfully in all the 9 patients.The portal venous pressure gradient dropped from (22.4 ± 2.7) mmHg to (10.4 ± 3.2) mmHg (P ＜ 0.05).There was no complication such as abdominal hemorrhage and biliary peritonitis.Nine patients were followed-up for 1 ～17months,mean 7.8 ± 6.0 months.One month after treatment,the Child-Pugh scores were (7.1 ± 1.8),compared with that of the preoperative scores,the difference was statistically significant (P ＜ 0.05).The MELD scores were (5.3 ± 4.6),compared with that of the preoperative scores,the difference was also statistically significant (P ＜ 0.05).At the end point of the follow-up,color Doppler ultrasound and portal CTA showed that the TIPS shunt was patent and hepatic congestion was relieved in all the 9 patients.All patients were alive.Conclusion TIPS was a safe and efficacious treatment for SOS caused by gynura segetum.
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Objective: To observe stent patency after TIPS with color Doppler and contrast-enhanced ultrasound, and to analyze the hemodynamic characteristics of the stent. Methods: Postoperative ultrasonographic data of 32 patients underwent TIPS were retrospectively analyzed. The patency of stent was evaluated using color Doppler and contrast-enhanced ultrasound (defined into grade 0-3), and the flow velocities of the portal vein site, middle site and hepatic vein site of the stent were measured. Stent patency after TIPS was analyzed and compared between different ultrasound techniques, and the flow velocities in different sites of stent were compared in stents with excellent patency (grade 3). Results: There was significantly statistical difference of stent patency between color Doppler ultrasound and contrast-enhanced ultrasound (Z=-3.589, P<0.001). Contrast-enhanced ultrasound showed mild stenosis of stents (grade 2) in 8 times examination, severe stenosis (grade 1) in 6 times examination and stent occlusion in 2 times examination, while color Doppler ultrasound showed excellent patency (grade 3). There was significantly statistical difference of blood flow velocities among the portal vein site ([71.52±36.84]cm/s), middle site ([94.35±39.94]cm/s) and hepatic vein site([99.83±32.63]cm/s) of the stent (F=22.617, P<0.001). Besides, the flow velocitie of middle site (P=0.001) and the hepatic vein site (P<0.001) were respectively higher than that of portal vein site through pairwise comparison. Conclusion: Color Doppler combined with contrast-enhanced ultrasound can improve the accuracy of the evaluation of stent patency after TIPS. Significant difference of flow velocities exist in different sites of the stent.