Transjugular intrahepatic portosystemic shunt vs. small-diameter prosthetic H-graft portacaval shunt: extended follow-up of an expanded randomized prospective trial.

We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a "bridge to transplantation." All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child's class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt (P < 0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) (P < 0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS (P < 0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding.

Immediate and long-term portal hemodynamic consequences of small-diameter H-graft portacaval shunt.

BACKGROUND: Effective hepatic blood flow is thought to play a critical role in outcome following portal decompressive procedures. We have shown previously that hepatic arterialization occurs soon after shunting, preserving nutrient flow, but the remote effects of shunting are unknown. The purpose of this study was to determine the effect of small-diameter prosthetic H-graft portacaval shunt (HGPCS) on effective hepatic blood flow (EHF) and portal pressures 1 year from shunt placement. METHODS: Patients undergoing 8-mm HGPCS had effective hepatic blood flow determined using low-dose galactose clearance preoperatively, postoperatively, and at 1 year postshunt. Portal blood flow, pressures, and portal vein/inferior vena cava pressure gradients were determined intraoperatively before and after shunt placement and at 1 year. RESULTS: Twenty patients undergoing shunting had flows measured. All patients had significant reductions in portal vein/inferior vena cava pressure gradients while effective hepatic flow was maintained immediately postoperatively. At 1 year following shunting, effective hepatic blood flow was significantly lower than both pre- and postoperative rates of flow while portal pressures and gradients were significantly increased. Albumin, cholesterol, and PT were improved at 1 year while total bilirubin was slightly worse. Nineteen of 20 patients are still alive with average follow-up of 26 +/- 10.3 months. Four patients were encephalopathic preop, 5 postop, and none chronically. CONCLUSIONS: Recollateralization of varices and progression of cirrhosis may account for the observed reductions in EHF at 1 year. Regardless of the cause, diminution of EHF at 1 year is well compensated as demonstrated by minimal encephalopathy and ascites, improved hepatic function reflected in blood chemistry profiles, and good survival.

Small-diameter H-graft portacaval shunt reduces portal flow yet maintains effective hepatic blood flow.

Small-diameter H-graft portacaval shunts (HGPCSs) effectively treat bleeding varices due to cirrhosis, although the effects of such shunts on hepatic blood flow are not well established. Proponents of HGPCS believe that portal flow diverted through the shunt is regained through increased hepatic arterial inflow while others argue that this flow is never recovered; resulting in compromised nutrient flow. In this study, we sought to determine the effects of HGPCS on effective hepatic and portal blood flow. Patients undergoing HGPCS had portal pressures and flow (via color-flow Doppler ultrasound) measured intraoperatively before and after placement of HGPCS. Effective hepatic blood flow was determined utilizing low-dose galactose clearance 1 day preoperatively and 5 days postoperatively. Over a 7-year period, 64 patients (42 male and 22 female), average age 54 +/- 13.6 years (SD), were studied. Cirrhosis was due to alcohol in 37 patients, hepatitis in 9, alcohol and hepatitis in 5, and assorted other causes in 13. Child's class was A in 11 patients, B in 35, and C in 18. Both portal flow and pressures decreased significantly postoperatively (15 +/- 14.2 to 10 +/- 15.1 mL/min [P < 0.05] and 29 +/- 13.0 to 18 + 6.2 mm/Hg [P < 0.05]), whereas effective hepatic blood flow decreased insignificantly (1441 +/- 1719 to 1332 +/- 863 mL/min). Small-diameter HGPCS significantly reduce portal pressures and portal blood flow while maintaining effective hepatic flow. These findings suggest that hepatic arterialization occurs as early as 5 days after shunting and thus support the application of HGPCS.

Small-diameter prosthetic H-graft portacaval shunt: definitive therapy for variceal bleeding.

Partial portal decompression has become a popular option in the treatment of complicated portal hypertension. This study was undertaken to report long-term follow-up after partial portal decompression obtained utilizing 8 mm prosthetic H-graft portacaval shunts. A total of 110 consecutive patients underwent H-graft portacaval shunting through a protocol that detailed care and studies from 1988 to 1996. Prospective follow-up recorded efficacy of partial portal decompression, shunt patency, morbidity of shunting, and survival. Seventy males and 40 females, whose average age was 54 +/-12.7 years (standard deviation), underwent shunting. Cirrhosis was due to alcohol abuse in 64%. Fourteen percent were in Child's class A, 55% in Child's class B, and 31% in Child's class C. Shunts were undertaken as emergencies in 20%, urgently in 13%, and electively in 67%. Shunting decreased portal pressure in all patients (30 +/-5.3 Hg to 19.9 -/+5.5 mm Hg; P <0.001). Early and late thrombosis was 6.4% and 3.6%, respectively. Late rebleeding occurred in 5.4%. Perioperative (30-day) mortality was 11.8%, and was highest for patients in Child's class C. Three-year survival was 53%. Five-year survival was 41%. Partial portal decompression is achieved with H-graft portacaval shunting. Rebleeding, shunt occlusion, and encephalopathy are uncommon. In this series of unselected older patients with alcoholic cirrhosis, 5-year survival after H-graft portacaval shunting was greater than 40% with minimal intervention.

Transjugular intrahepatic portosystemic shunt versus H-graft portacaval shunt in the management of bleeding varices: a cost-benefit analysis.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is popular in treating portal hypertension because of its perceived efficacy and cost benefits, although it has never been compared with surgical shunting in a cost-benefit analysis. This study was undertaken to determine the cost benefit of TIPS versus small-diameter prosthetic H-graft portacaval shunt (HGPCS). METHODS: Cost of care was determined in 80 patients prospectively randomized to receive TIPS or HGPCS as definitive treatment for bleeding varices, beginning with shunt placement and including subsequent admissions for complications or follow-up related to shunting. RESULTS: Patients were similar in age, gender, severity of illness/liver dysfunction, and urgency of shunting. After TIPS or HGPCS, variceal rehemorrhage (8 versus O, respectively; p = 0.03), shunt occlusion (13 versus 4; p = 0.03), shunt revision (16 versus 4; p < 0.005), and shunt failure (18 versus 10; p = 0.10) were compared; all were more common after TIPS. Through the index admission, TIPS cost $48,188 +/- $43,355 whereas HGPCS cost $61,552 +/- $47,615. With follow-up, TIPS cost $69,276 +/- $52,712 and HGPCS cost $66,034 +/- $49,118. CONCLUSIONS: Early cost of TIPS was less than, though not different from, cost of HGPCS. With follow-up, costs after TIPS mounted. The initially lower cost of TIPS is offset by higher rates of subsequent occlusion and rehemorrhage.

Body composition and source of weight loss after bariatric surgery.

BACKGROUND: Little is known about the composition and source of weight loss after bariatric surgery for morbid obesity. PURPOSE: This study was undertaken to determine changes in weight, body mass index (BMI), lean body weight (LBW), fat weight (FW) and left ventricular cardiac mass (LVM) following vertical banded gastroplasty (VBG). METHODS: After VBG for morbid obesity, 26 women and four men (mean age = 39.1 years) were weighed and had body composition analysis undertaken at intervals. Thirteen patients underwent echocardiography preoperatively and 1 year postoperatively to determine change in LVM and LVM index. RESULTS: Over 12 months there was significant weight loss for all weight parameters examined (p < 0.05). Fat weight loss was most significant; total weight loss and reduction of BMI were significant but less so than fat loss (Wilcoxon's signed ranks test). LBW loss had the smallest contribution to weight loss (p < 0.0001). There was a significant loss of LVM and posterior cardiac wall thickness (p < 0.05). CONCLUSIONS: VBG can lead to loss of lean body weight and left ventricular mass, and more dramatically, fat weight, body weight, and BMI. Cardiac mass and lean body mass are preferentially conserved relative to body fat with weight loss after VBG.

Differential effects on portal and effective hepatic blood flow. A comparison between transjugular intrahepatic portasystemic shunt and small-diameter H-graft portacaval shunt.

OBJECTIVE: This study was undertaken to determine the effects of transjugular intrahepatic portasystemic shunt (TIPS) and small-diameter prosthetic H-graft portacaval shunt (HGPCS) on portal and effective hepatic blood flow. SUMMARY BACKGROUND DATA: Mortality after TIPS is higher than after HGPCS for bleeding varices. This higher mortality is because of hepatic failure, possibly a result of excessive diminution of hepatic blood flow. METHODS: Forty patients randomized prospectively to undergo TIPS or HGPCS had effective hepatic blood flow determined 1 day preshunt and 5 days postshunt using low-dose galactose clearance. Portal blood flow was determined using color-flow Doppler ultrasound. RESULTS: Treatment groups were similar in age, gender, and Child's class. Each procedure significantly reduced portal pressures and portasystemic pressure gradients. Portal flow after TIPS increased (21 mL/second +/- 11.9 to 31 mL/second +/- 16.9, p < 0.05), whereas it remained unchanged after HGPCS (26 mL/second +/- 27.7 to 14 mL/second +/- 41.1, p = n.s.). Effective hepatic blood flow was diminished significantly after TIPS (1684 mL/minute +/- 2161 to 676 mL/minute +/- 451, p < 0.05) and was unaffected by HGPCS (1901 mL/ minute +/- 1818 to 1662 mL/minute +/- 1035, p = n.s.). CONCLUSIONS: Both TIPS and HGPCS achieved significant reductions in portal vein pressure gradients. Portal flow increased after TIPS, although most portal flow was diverted through the shunt. Effective hepatic flow is reduced significantly after TIPS but well preserved after HGPCS. Hepatic decompensation and mortality after TIPS may be because, at least in part, of reductions in nutrient hepatic flow.

Peritoneovenous shunts in patients with intractable ascites: palliation at what price?

Intractable ascites carries great morbidity by affecting appetite, mobility, and quality of life. Peritoneovenous shunts (PVSs) are utilized to abate intractable ascites, although long-term efficacy is unestablished. Thirty male and 18 female cirrhotics, 55 +/- 12 (standard deviation) years of age, failed multiple large-volume paracenteses and diuretic therapy before undergoing PVS. Data were collected until death or the present time. Nine patients (19%) are alive and palliated, four with working shunts [average follow-up (ave. f/u), 30 months] and five without shunts (ave. f/u, 19 months). Thirty-two (67%) patients died: 18 palliated with functional shunts (survival time, 4.4 +/- 5.7 months), 8 unpalliated with dysfunctional shunts (ave. f/u, 3.9 +/- 4.5 months), 4 unpalliated with shunts removed (ave. f/u 5.5 +/- 4.7 months), and 2 with unknown shunt function at death. Function was lost to occlusion in 26 patients, infection in 9, and ligation for disseminated intravascular coagulation in 3. Thirteen patients underwent 18 shunt replacements. At death/present time, 22 (46%) patients were palliated with functioning shunts. Seven patients were lost to follow-up. PVSs provide palliation for intractable ascites short term, but commonly occlude within 1 year. Despite palliation, complications with PVSs are high, and survival is limited.

Does the direction of portal blood flow determine outcome with small-diameter prosthetic H-graft portacaval shunt?

BACKGROUND: Partial portal decompression, as attained by small-diameter prosthetic H-graft portacaval shunting, continues to gain popularity because of favorable outcomes. This study was undertaken to determine whether the direction of preshunt or postshunt portal blood flow or reversal in the direction of portal flow occurred with shunting effect outcome after small-diameter prosthetic H-graft portacaval shunt. METHODS: In 56 consecutive patients the direction of portal flow was determined before and after shunting. The direction of portal blood flow before and after shunting and changes in the direction of portal flow that occur with shunting were correlated with 30-day and 1-year survival, as well as with the rate of postshunt encephalopathy. RESULTS: Portal pressures significantly decreased in all with shunting. Whether or not stratified by Child's classification, neither the preshunt nor postshunt direction of portal flow affected 30-day or 1-year survival or incidence of encephalopathy. Eleven patients (significant at p < 0.001, fisher's exact test) had reversal of portal blood flow with shunting without an increase in 30-day or 1-year survival or incidence of encephalopathy. CONCLUSIONS: Small-diameter prosthetic H-graft portacaval shunts significantly reduce portal pressure and lead to reversal of portal flow in significant numbers. Significant hepatic dysfunction is uncommon after shunting. Neither the direction of preshunt or postshunt portal blood flow nor the reversal of portal blood flow with shunting has an effect on clinical outcome after small-diameter prosthetic H-graft portacaval shunt.

Outcome following bariatric surgery in super versus morbidly obese patients: does weight matter?

BACKGROUND: Numerous investigators have attempted to identify prognostic indicators for successful outcome following bariatric surgery. The purpose of this study was to determine whether degree of obesity affects outcome in super obese [>225% ideal body weight (IBW)] versus morbidly obese patients (160-225% IBW) undergoing gastric restrictive/bypass procedures. METHODS: Since 1984, 157 patients underwent either gastric bypass or vertical banded gastroplasty. Super obese (78) and morbidly obese (79) patients were followed prospectively, documenting outcome and complications. RESULTS: Super obese patients reached maximum weight loss 3 years following bariatric surgery, exhibiting a decrease in body mass index (BMI) from 61 to 39 kg/m2 and an average loss of 42% excess body weight (EBW). Morbidly obese patients had a decrease in BMI from 44 to 31 kg/m2 and carried 39% EBW at 1 year. After their respective nadirs, each group began to regain the lost weight with the super obese exhibiting a current BMI of 45 kg/m2 (61% EBW) versus 34 kg/m2 (52% EBW) in the morbidly obese at 72 months cumulative follow-up. Currently, loss of 50% or more of EBW occurred in 53% of super obese patients versus 72% of morbidly obese (P < 0.01). Twenty-six percent of super obese patients returned to within 50% of ideal body weight (IBW) while 71% of morbidly obese were able to reach this goal (P < 0.01). Co-morbidities and complications related to surgery were similar in each group. CONCLUSIONS: Super obese patients have a greater absolute weight loss after bariatric surgery than do morbidly obese patients. Using commonly utilized measures of success based on weight, morbidly obese patients tend to have better outcomes following bariatric surgery.

A prospective trial of transjugular intrahepatic portasystemic stent shunts versus small-diameter prosthetic H-graft portacaval shunts in the treatment of bleeding varices.

OBJECTIVE: The authors compare transjugular intrahepatic portasystemic stent shunts (TIPS) to small-diameter prosthetic H-graft portacaval shunts (HGPCS). SUMMARY BACKGROUND DATA: Transjugular intrahepatic portasystemic stent shunts have been embraced as a first-line therapy in the treatment of bleeding varices due to portal hypertension, although they have not been compared to operatively placed shunts in a prospective trial. METHODS: In 1993, the authors began a prospective, randomized trial to compare TIPS with HGPCSs. All patients had bleeding varices and had failed nonoperative management. Shunting was undertaken as definitive therapy in all. Failure of shunting was defined as an inability to accomplish shunting despite repeated attempts, unexpected liver failure leading to transplantation, irreversible shunt occlusion, major variceal rehemorrhage, or death. Mortality and failure rates were analyzed at 30 days (early) and after 30 days (late) using Fischer's exact test. RESULTS: There were 35 patients in each group, with no difference in age, gender, Child's class, etiology of cirrhosis, urgency of shunting, or incidence of ascites or encephalopathy between groups. In two patients, TIPS could not be placed despite repeated attempts. Transjugular intrahepatic portasystemic stent shunts reduced portal pressures from 32 +/- 7.5 mmHg (standard deviation) to 25 +/- 7.5 mmHg (p < 0.01), whereas HGPCS reduced them from 30 +/- 4.6 mmHg to 19 +/- 5.3 mmHg (p < 0.01; paired Student's test). Irreversible occlusion occurred in three patients after placement of TIPS. Total failure rate after TIPS placement was 57%; after HGPCS placement, it was 26% (p < 0.02). CONCLUSIONS: Both TIPS and HGPCS reduced portal pressure. Placement of TIPS resulted in more deaths, more rebleeding, and more than twice the treatment failures. Mortality and failure rates promote the application of HGPCS over TIPS.

The effect of small-diameter H-graft portacaval shunts on portal blood flow.

BACKGROUND: Small-diameter prosthetic H-graft portacaval shunts have been shown to promote preservation of total hepatic blood flow relative to large-diameter H-graft shunts. Nonetheless, specific changes in portal hemodynamics occurring with small-diameter H-graft shunting are unknown. This study was undertaken to evaluate changes in portal flow that occur with these shunts. METHODS: Portal vein and inferior vena cava (IVC) blood flow were determined intraoperatively in 36 consecutive adults before and after prosthetic H-graft portacaval shunting using color-flow Doppler ultrasound. Postshunt measurements were made immediately cephalad and caudad to the shunt. Comparisons were undertaken using a paired Student's t-test with 95% confidence. RESULTS: Portal pressures decreased in all (P < 0.001), but never to normal. Postshunt portal flow cephalad and caudad to the shunt were not different from preshunt flow (P = 0.09, P = 0.28, respectively), although they were different from each other (P = 0.004). Postshunt IVC flow cephalad to the shunt was greater than caudad IVC flow (P = 0.004) and greater than preshunt IVC flow (P < 0.001), reflecting high flow through the shunt into the IVC. CONCLUSIONS: Small-diameter prosthetic H-graft portacaval shunts divert a significant amount of blood from the portal vein and significantly decrease portal pressures. The decreases in portal pressures with shunting are significant whereas changes in portal blood flow into the liver are not. These findings help explain the low incidence of variceal rebleeding and hepatic dysfunction after these shunts.

The effect of partial portal decompression on portal blood flow and effective hepatic blood flow in man: a prospective study.

With the advent of transjugular intrahepatic porta-systemic stent shunt and the wider application of the surgically placed small diameter prosthetic H-graft portacaval shunt (HGPCS), partial portal decompression in the treatment of portal hypertension has received increased attention. The clinical results supporting the use of partial portal decompression are its low incidence of variceal rehemorrhage due to decreased portal pressures and its low rate of hepatic failure, possibly due to maintenance of blood flow to the liver. Surprisingly, nothing is known about changes in portal hemodynamics and effective hepatic blood flow following partial portal decompression. To prospectively evaluate changes in portal hemodynamics and effective hepatic blood flow brought about by partial portal decompression, the following were determined in seven patients undergoing HGPCS: intraoperative pre- and postshunt portal vein pressures and portal vein-inferior vena cava pressure gradients, intraoperative pre- and postshunt portal vein flow, and pre- and postoperative effective hepatic blood flow. With HGPCS, portal vein pressures and portal vein-inferior vena cava pressure gradients decreased significantly, although portal pressures remained above normal. In contrast to the significant decreases in portal pressures, portal vein blood flow and effective hepatic blood flow do not decrease significantly. Changes in portal vein pressures and portal vein-inferior vena cava pressure gradients are great when compared to changes in portal vein flow and effective hepatic blood flow. Reduction of portal hypertension with concomitant maintenance of hepatic blood flow may explain why hepatic dysfunction is avoided following partial portal decompression.

Bioavailability of fluconazole in surgical intensive care unit patients: a study comparing routes of administration.

OBJECTIVE: Anticandidal therapy is commonly used in the surgical intensive care unit (SICU). Unfortunately, it is expensive because it is generally given intravenously, as acute trauma and abdominal surgery are often accompanied by impaired gastrointestinal function. We compared the systemic availability of fluconazole given enterally or intravenously in trauma and surgery SICU patients to determine the reliability of enteral administration. METHODS: Nine adult trauma (Injury Severity Score (> or = 18) and nine adult abdominal surgery SICU patients were randomized to receive fluconazole 100 mg via the intravenous (IV) or enteral route. Patients with a bilirubin > 4.0 mg/dL or creatinine clearance < 60 mL/min were excluded. Enteral fluconazole was crushed, dissolved, and flushed through a nasogastric or feeding tube. Eleven serial blood samples were drawn over 72 hours. Area under the curve (AUC), elimination rate constant (Ke), and terminal half-life (T1/2) were determined and compared (t test). Relative bioavailability was estimated (AUC(enteral)/AUCIV). RESULTS: Peak concentrations occurred within 2 hours after enteral dosing and 15 minutes after IV dosing. The relative bioavailability was 77%. Weight, AUC, Ke, and T1/2 did not differ between enteral and IV dosing. CONCLUSIONS: Fluconazole is significantly absorbed when crushed, dissolved, and given via a nasogastric or feeding tube in SICU patients. Nonsignificant trends toward lower systemic availability with enteral administration can be overcome with slightly higher doses. Since enteral administration of fluconazole costs 10% of fluconazole given intravenously, more liberal use of enteral administration offers tremendous savings. Such savings moderate the cost concerns of antifungal therapy.

Direction or reversal of preshunt portal blood flow as determinants of outcome up to 1 year after small-diameter prosthetic H-graft portacaval shunt.

Partial portal decompression (PPD) is gaining popularity in the treatment of portal hypertension. We have achieved PPD in over 80 patients by utilizing an 8-mm prosthetic H-graft portacaval shunt (HGPCS). We have been pleased with the infrequency of encephalopathy and liver failure after shunting. While maintenance of portal blood flow would presumably play a role in outcome after shunting, changes in portal hemodynamic occurring within the first year after shunting are generally unknown. In 31 patients (Child's class 6% A, 61% B, 32% C) of an average age of 55 +/- 13.3 (SD) years undergoing HGPCS, clinical outcome was prospectively evaluated relative to the direction of portal blood flow determined before and after shunting and at 1 year after shunting using color-flow Doppler ultrasound. Preshunt hepatopetal flow reversed in 2/29 (7%) patients with shunting and in an additional 5/27 (18%) patients by 1 year after shunting. Death (due to alcoholism in 1, old age in 1) and encephalopathy (Child's class A = 1, B = 2, C = 1) were uncommon by 1 year after shunting. Eighty-one percent had excellent outcome (alive without encephalopathy or rebleeding) at 1 year. Though preshunt hepatopetal flow is generally maintained postshunt and after one year, maintenance of hepatopetal flow does not ensure an excellent outcome and reversal of hepatopetal flow does not pre-dispose to a suboptimal outcome. Outcome up to 1 year after HGPCS is not determined by direction or reversal of portal blood flow.