Liver transplantation in patients with transjugular intrahepatic portosystemic shunts.

BACKGROUND: In patients with intractable oesophageal variceal bleeding, transjugular intrahepatic portosystemic shunts (TIPSS) are being used increasingly as a bridge to orthotopic liver transplantation (OLTx). There is little information in the literature concerning variations in the operative techniques of OLTx required because of the presence of TIPSS. METHODS: A retrospective review of patients treated by TIPSS prior to OLTx was undertaken. The aims were to assess the effectiveness of TIPSS in bridging patients to OLTx and to examine whether TIPSS influence the operative management of OLTx. RESULTS: Over a 4-year period eight adult patients underwent TIPSS insertion prior to OLTx in the Australian National Liver Transplant Unit (ANLTU). Transplantation was performed at a mean of 14.6 (0.3-53.8) months after TIPSS insertion. Prevention of major recurrent variceal haemorrhage prior to transplantation was achieved in six cases. In two patients the stents were predominantly intrahepatic and they did not interfere with OLTx. In five patients the stents extended into the portal vein, requiring removal during OLTx either by division of the stent with the recipient portal vein, followed by removal of the fractured stent wires from the portal veins (n = 3), or by 'endarterectomy' of the recipient portal vein, allowing removal of the intact stent (n = 2). In one case where the stent extended into the suprahepatic inferior vena cava, removal was achieved by traction without difficulty. All patients are alive at a mean of 24 (7-53) months post-transplant and none has portal vein abnormalities. When compared to 178 adult patients who had no TIPSS and underwent primary OLTx during the same study period, there was no difference in the length of operating time or the usage of blood products during OLTx. CONCLUSION: Transjugular intrahepatic portosystemic shunts offer a bridge to OLTx by providing effective control of variceal haemorrhage. In the present series TIPSS did not increase surgical morbidity or mortality, but emphasis is placed upon the need for optimal TIPSS placement within the liver to facilitate subsequent OLTx.

Pyogenic liver abscess: a review of 10 years' experience in management.

BACKGROUND: Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. METHODS: Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. RESULTS: Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. CONCLUSION: Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.

Type III and type IV endoleak: toward a complete definition of blood flow in the sac after endoluminal AAA repair.

In this document the authors continue to refine their seminal categorization of endoleak, a major complication of endovascular aneurysm repair. In addition to type I (related to the graft device itself) and type II (retrograde flow from collateral branches) endoleak, they propose two new categories: endoleak due to fabric tears, graft disconnection, or disintegration would be classified type III, and flow through the graft presumed to be associated with graft wall "porosity" would be categorized as type IV endoleak.

Isolated limb infusion with cytotoxic agents: a simple alternative to isolated limb perfusion.

Isolated limb perfusion (ILP) with cytotoxic agents is an effective but complex procedure. Isolated limb infusion (ILI) has been developed as a simpler alternative. Catheters are inserted percutaneously into the axial artery and vein of the affected limb and a pneumatic tourniquet is inflated proximally. Cytotoxic agents are then infused through the arterial catheter and circulated with a syringe for 15 to 20 minutes. Progressive hypoxia occurs, but normothermia is maintained. To date, 175 ILIs have been performed: 164 for melanoma and 11 for other tumours. Results obtained are similar to those obtained by conventional ILP. Morbidity is low and treatment of frail and elderly patients who would not tolerate ILP is possible. An elective double ILI protocol can be used to obtain the additional benefits of fractionated chemotherapy. The possibility of increasing ILI response rates by using other drugs and drug combinations and by multiple fractionated dosing is being investigated.

Ureteric injury at Burch colposuspension. 4 case reports and literature review.

The Burch colposuspension operation is an accepted and effective technique for the correction of genuine stress incontinence. It is, however, associated with a number of well-recognized complications. Ureteric injury at the time of colposuspension is a potentially severe, if uncommon, complication of this procedure with legal ramifications for the surgeon as well as health risks for the patient. To date, only 19 cases have been described in the literature. This paper highlights 4 cases of this injury occurring amongst the patients of 1 urogynaecologist (2) and gives an incidence for its occurrence as well as discussing the aetiology and management of this complication.

Results of endoluminal grafting of abdominal aortic aneurysms are dependent on aneurysm morphology.

The aim of this prospective study was to analyze the outcome of elective endoluminal grafting in patients with various morphologies of abdominal aortic aneurysms (AAA). Between May 1992 and May 1994, endoluminal repair of AAA was undertaken in 40 patients. After detailed imaging by means of CT scanning and arteriography, aneurysms were classified into one of two types according to the following criteria: type I (suitable for transfemoral implantation of a straight tube graft), AAA with a proximal neck (2 cm or longer), a distal neck (1.5 cm or longer), and an iliac artery diameter of 8 mm or greater (N = 19); or type II (requiring tapered aortoiliac or bifurcated grafts or access through an iliac approach), AAA that did not fit the type I criteria (N = 21). Radiographic guidance was used to pass the aortic endografts (38 Dacron and 2 PTFE) via a delivery sheath introduced through the femoral or iliac arteries into the aorta. The configuration of the aortic endografts was tubular in 26 patients, tapered aortoiliac in 11, and bifurcated in three. Successful endoluminal repair was achieved in 17 (89%) of 19 patients with type I AAA and in 15 (71%) of 21 patients with type II AAA. All failed endoluminal repairs proceeded to successful open repair, and there were no deaths during the period of hospitalization for the operation. The mean operative time and mean hospital stay were shorter in patients with type I AAA compared to patients with type II AAA. The incidence of postoperative complications was 37% in type I endoluminal repairs compared to 71% in type II endoluminal repairs. There was one cardiac death (procedure related) within 30 days, and there were three late deaths (one cardiac, one from liver failure in a type II AAA repair, and one from a ruptured esophagus in a type I repair). These preliminary results suggest that there is a better outcome in transfemoral endoluminal tube graft repair of aneurysms conforming to type I criteria compared to endoluminal repair of the more complex type II AAA.

Historic control comparison of outcome for matched groups of patients undergoing endoluminal versus open repair of abdominal aortic aneurysms.

PURPOSE: Currently no randomized studies show the relative morbidity and mortality of the open and endoluminal methods of abdominal aortic aneurysm (AAA) repair. The aim of this study was to analyze the outcome of two matched groups of patients with AAA, one undergoing open repair and the other undergoing endoluminal repair. METHODS: Two groups of patients who had undergone repair of AAA by open technique (group 1) or by endoluminal methods (group 2) were compared. A historic control cohort of 27 patients was selected from 56 consecutive patients who underwent open repair of AAA between January 1991 and February 1992. Patients considered unsuitable for the endoluminal method on the basis of computed tomography and aortography were excluded (n=29). Between May 1992 and November 1994 prospective data were recorded for 62 consecutive patients who underwent endoluminal repair by tube or bifurcated endografts. Twenty-eight patients who had been specifically referred for endoluminal AAA repairs because of preexisting severe medical comorbidities were excluded. Six of the endoluminal cases had failure, requiring conversion to open operation, and were excluded for separate analysis, leaving 28 patients in group 2. Patients in both groups were thus fit and suitable for either open or endoluminal repair and were comparable in relation to age, sex, risk factors, dimensions, and form of AAA. RESULTS: The mean values for operation time, blood loss, intensive care stay, and hospital stay for group 1 and group 2 were 2.6 versus 3.1 hours, 1422 versus 873 ml,* 1.8 versus 0.7 days,* and 12.4 versus 11.1 days, respectively (*p<0.05). Local/vascular complications occurred in 15% of patients in group 1 compared with 25% in group 2 (p=0.55), whereas remote/systemic complications occurred in 37% and 29%, respectively (p=0.3). Five of 28 patients in the endoluminal group had complications requiring early operative repair (n=3) or late revision (n=2). When comparison was made on an intention-to-treat basis (with failed procedures included), the incidence of local/vascular complications was significantly greater for endoluminal repair (p=0.047). CONCLUSIONS: The incidence of systemic/remote complications was similar for the two groups in spite of significantly less blood loss and shorter intensive care unit stay with endoluminal repair. The incidence of local/vascular complications had a tendency to be higher for endoluminal compared with standard open method (and was significantly greater if failed procedures were included). In this early experience with prototype devices, patients who were medically suitable for open surgical procedures did not derive benefit from the less invasive endoluminal technique with respect to duration of operation, length of hospital stay, or perioperative morbidity and mortality. On the other hand, because they also did not have worse outcome, a randomized study is now justified in this group.

Biliary strictures after liver transplantation: clinical picture, correlates and outcomes.

We retrospectively examined 154 adults to ascertain the frequency, site of and pre-disposing factors for biliary strictures after liver transplantation, as well as their management and clinical outcome. Twenty patients (12.5%) were identified with biliary strictures; 16 were non-anastomotic and four were anastomotic strictures. The median time from transplantation to stricture diagnosis was 17 weeks (range 3-366). Of the 16 non-anastomotic strictures, six were intrahepatic, eight hilar and two extrahepatic (donor bile duct). A control group (n = 32) of patients transplanted immediately before and after index cases was used to examine for correlates in patients with non-anastomotic strictures. At the time of diagnosis in the non-anastomotic index cases, there was a higher incidence of: (i) biliary sludge (63 vs 0%; P < 0.001); and (ii) clinical cholangitis (75 vs 0%; P < 0.001) compared with controls. Primary sclerosing cholangitis was more often the diagnosis in index patients with non-anastomotic strictures compared with controls (31 vs 9%; P < 0.05). There were no differences between index patients and controls (non-anastomotic group) in ABO blood group non-identity, cold allograft ischaemia time, use of OKT3 (murine monoclonal antibody to CD3) and hepatic artery thrombosis. Of 15 patients treated with balloon dilatation, seven required stent insertion although none have required surgery. As determined by liver function tests, there was evidence of persisting graft dysfunction in index patients compared with controls (SAP 381 vs 112 U/L, P < 0.001; GGT 529 vs 80 U/L, P < 0.001), but there was no difference in survival during a median follow-up time of 16 months (range: 3-48 months) from stricture diagnosis. In conclusion, biliary strictures tend to occur within 6 months of transplantation and are an important cause of ongoing graft dysfunction. Non-anastomotic strictures were more common in patients requiring transplantation for primary sclerosing cholangitis.

A prospective study of changes in morphology and dimensions of abdominal aortic aneurysms following endoluminal repair: a preliminary report.

PURPOSE: The aim of this prospective study was to analyze early changes in morphology and dimensions of abdominal aortic aneurysms (AAA) following endoluminal repair. METHODS: Forty-two of 62 patients undergoing endoluminal repair of AAAs between May 1992 and November 1994 were potentially available for follow-up at 6 months or longer after operation. After excluding patients with failed endoluminal repairs, patients who died within 6 months of operation, and patients with anastomotic aneurysms, a study group of 30 patients remained. Contrast-enhanced computed tomography (CE-CT) was performed preoperatively, within 10 days of operation, and at 6 and 12 months postprocedure. Based on the postoperative CE-CT findings, patients were divided into two groups: those with no extravasation of contrast into the aneurysmal sac (group I; n = 26), and those in which there was contrast extravasation ("leak") into the aneurysmal sac (group II; n = 4). RESULTS: The mean maximum diameters of AAAs in group I diminished progressively at 6 and 12 months, while those in group II increased. Twenty-three (88%) patients in group I had decreased diameter of AAA, while all patients in group II had progressive increase in AAA diameter. Patients who had an increase in AAA diameter had a significantly higher incidence of leak compared with those who had a decrease in diameter (p = 0.001). CONCLUSIONS: The majority of AAAs in which the sac has been excluded from the general circulation diminish in size following successful endoluminal repair. An increase in size occurs in those AAAs in which a communication exists between the aortic lumen and the sac. These results suggest that successfully excluded AAAs that continue to increase in size should be suspected of having an undetected leak.

Early experience with the Sydney and EVT prostheses for endoluminal treatment of abdominal aortic aneurysms.

PURPOSE: The aim of this study was to report early experiences with the Sydney and Endovascular Technologies (EVT) prostheses for the treatment of abdominal aortic aneurysms (AAA) deemed suitable for endoluminal tube graft repair. METHODS: Consecutive endoluminal tube graft repairs were analyzed over the first 12 months in which the Sydney and EVT prostheses were used. Patients eligible for the EVT prosthesis had type I AAAs: a proximal neck length > or = 2 cm, a distal cuff length > or = 1.5 cm, and nontortuous iliac arteries > or = 8 mm. Selection criteria for the Sydney device were more liberal and included AAAs that had distal cuffs < 1.5 cm. During the study period, 28 of 91 patients evaluated for AAA repair were thus selected for endoluminal grafting: 18 patients received the Sydney endograft and 10 the EVT device. Medical comorbidities were present in slightly less than one third of patients in both groups. Contrast-enhanced computerized tomography (CT) was performed preoperatively, within 10 days of operation, and at 6 and 12 months postprocedure. RESULTS: All endografts were successfully deployed in both groups. Postprocedural CT scans revealed incomplete aneurysm exclusion in four patients with the Sydney endograft. Subsequent deployment of a second endograft sealed these "leaks" in two cases; the other two were converted to open repair (89% clinical success). No leaks were seen with the EVT device. Local/vascular complications occurred in 33% of the Sydney group compared with 20% for the EVT device (p = 0.001); systemic sequelae were more common in the EVT group (30% versus 17% in the Sydney cohort, p = 0.002). There were no deaths within 30 days; three late deaths were not procedure related. CONCLUSION: AAAs that are suitable for endoluminal tube graft repair may be treated with a high rate of initial success with either the Sydney or EVT prostheses. More liberal selection criteria may increase the likelihood of local/vascular complications.

Surgical management of complications following endoluminal grafting of abdominal aortic aneurysms.

OBJECTIVE: The aim of this study was to report the outcome of endoluminal grafting of abdominal aortic aneurysms (AAA) with special reference to complications. METHODS: Between May 1992 and August 1994 endoluminal repair of aneurysms was undertaken in 61 patients. In 53 the aneurysm was aortic and these are the basis of this report. In patients with AAA all procedures were elective and were performed in the operating room with the patient draped for an open repair in the event of failed endoluminal repair. The configuration of the endografts was tubular 36, tapered aortoiliac/aortofemoral 12 and bifurcated 5. Radiographic guidance was used to pass the endografts into the aorta via a delivery sheath introduced through the femoral or iliac arteries. RESULTS: Successful endoluminal repair of AAA was achieved in 43 of 53(81%) patients. In the remaining 10 patients, endoluminal repair was abandoned in favour of an open repair. There were 17(32%) local/vascular and 13(25%) systemic/remote remote complications. The sum of these complications occurring in successful endoluminal repairs and those complications leading to failure of endoluminal repair was 40(75%). There were two cardiac deaths within 30 days in patients undergoing endoluminal repair (both procedure related) and four late deaths (unrelated to aneurysm repair). Three of the late deaths were in patients undergoing endoluminal repair and one endoluminal converted to open repair. CONCLUSION: Endoluminal repair of AAA in our experience has a low perioperative (< 30 days) mortality rate (3.7%) but a high morbidity rate (75%). It is recommended that complications be classified into three groups: systemic/remote and local/vascular (following successful endoluminal repair) plus those complications leading to failure of endoluminal repair. The first group is composed of medical complications while the latter two groups comprise those surgical complications directly related to the endoluminal technique.

Early outcome and intermediate follow-up of vascular stents in the femoral and popliteal arteries without long-term anticoagulation.

PURPOSE: The role of arterial stenting in the treatment of femoral and popliteal arterial disease is controversial and has been hampered by recommendations for patients to be given anticoagulants (oral warfarin) for several months or more. This study was undertaken to evaluate the immediate and midterm outcomes of vascular stents implanted percutaneously in the femoral and popliteal arteries, without long-term anticoagulation. METHODS: Over a 3-year period, 32 patients admitted to a vascular surgery service had arterial stents implanted in the femoral (n = 22) or popliteal (n = 10) artery for the following indications: recurrent stenosis after angioplasty (n = 13), suboptimal result after angioplasty of occluded (n = 12) or calcified stenotic arteries (n = 2), percutaneous transluminal angioplasty-induced thrombosis or dissection (n = 5). Access to the artery was gained by percutaneous insertion of a hemostatic sheath into the ipsilateral common femoral artery. Systemic heparin was given at the time of stent insertion, and patients were prescribed daily low-dose aspirin. RESULTS: Successful stent implantation was achieved in 31 of the 32 patients. Acute thrombosis (< 30 days) occurred in two patients. There was no incidence of false aneurysm formation, acute leg ischemia, or vessel perforation. All patients were monitored by Doppler scanning index and duplex scanning within 24 hours, and thereafter at 3- to 6-month intervals. The mean ankle-brachial systolic pressure index improved from 0.60 (before treatment) to 0.88 (3 to 6 months after stenting). Stent occlusion has occurred in six patients; two stents were successfully salvaged with urokinase infusion. In follow-up to date (range 3 to 33 months) the primary patency rate by life-table analysis was 75% at 18 months, whereas the secondary patency rate was 89% at the same interval. Restenosis (> 50% lumen diameter) was detected by duplex ultrasonography in seven of 25 patent stents (28%) at a mean interval of 9.5 months (range 4 to 15 months); of these, four patients remained clinically symptom-free despite the ultrasound findings. CONCLUSIONS: We conclude that vascular stents can be implanted into the femoropopliteal arteries with few complications and with acceptable early and intermediate patency rates, without the need for long-term anticoagulation. Restenosis is not prevented by stents, and the main value of stenting at this site appears to be in salvaging acute complications of percutaneous transluminal angioplasty, or to correct suboptimal results after recanalization of occluded arteries.

Endoluminal repair of abdominal aortic aneurysms.

OBJECTIVE: To review the outcome of endoluminal repair of abdominal aortic aneurysm. PATIENTS: Twelve patients with abdominal aortic aneurysms (mean diameter, 5 cm; range, 4.4-7.8 cm) were selected according to strict criteria relating to the morphology of the aneurysm and iliac arteries. The aneurysms all had a proximal neck between the renal arteries and the aneurysm and a distal neck between the aneurysm and the bifurcation of the aorta. The iliac arteries were not tortuous and were 8 mm or greater in diameter. INTERVENTION: The aneurysm was repaired with a graft stent device introduced into the aorta via a sheath in the femoral artery. RESULTS: Successful endoluminal repair was achieved in 10 of 12 patients (83%). The two patients in whom the endoluminal repair was abandoned were treated by standard open repair. All patients have since had an aortogram and duplex ultrasound examination to confirm exclusion of the aneurysm from the general circulation (mean period of follow-up, seven months). There have been no deaths. CONCLUSION: Abdominal aortic aneurysms conforming to strict morphological criteria can be treated safely and successfully by this minimally invasive endoluminal method.

A new nonstented balloon-expandable graft for straight or bifurcated endoluminal bypass.

PURPOSE: The aim of this study was to determine the feasibility of endoluminal grafting of aneurysms using a new design of nonstented endograft. METHODS: Initial studies were undertaken in bench models and by implantation of endografts into animal vessels. Between May 1992 and June 1994, endoluminal repair of aneurysms was undertaken in 47 patients (44 male, 3 female). A new balloon-expandable endoluminal graft was developed and has now been studied in 25 of these 47 cases. This graft does not require adjunctive use of a vascular stent because of its unique construction, which incorporates metallic implants (graft attachment device or "GAD") into the graft material. The design is applicable to endovascular grafting of occlusive arterial disease, as well as aneurysms. All patients were investigated by duplex scan, calibrated angiogram, and angio-CT scan and then allocated into groups that we defined according to the following criteria: group I, considered suitable for transfemoral implantation of a straight tube graft (n = 12); group II, unsuitable for transfemoral tube graft because of short neck of aneurysm, absent distal neck, or diseased iliac arteries (n = 10); and group III, peripheral aneurysms (n = 3). All patients were followed by clinical examination, duplex scan, and CT scan, with selective use of angiography. RESULTS: Intraluminal deployment of the graft was achieved in all 25 patients; however, 3 patients from group II subsequently required conversion to open procedures because of the following complications: (1) partial graft thrombosis resulting from inadvertent omission of systemic anticoagulation during deployment (n = 1); and (2) unsuccessful deployment of the contralateral limb of a bifurcated graft in the iliac artery (n = 2). Successful endoluminal repair was achieved in 100% of patients in groups I and III, compared to 70% in group II. CONCLUSIONS: These preliminary results (in a series of high-risk patients) have demonstrated that endoluminal abdominal aortic aneurysms repair with this graft can be achieved reliably and with low morbidity in patients who fulfill the selection criteria (group I) and in peripheral aneurysms (group III) but the results were less satisfactory in aneurysms that do not have a good proximal or distal neck or in patients with diseased iliac arteries (group II). Further modification of the bifurcated version in this graft design, together with improvements in access techniques and graft materials, is required for successful endoluminal grafting in a wider range of patients.

Endoluminal grafting of abdominal aortic aneurysms: causes of failure and their prevention.

PURPOSE: The aim of this study was to analyze the causes of failure of endoluminal grafting for abdominal aortic aneurysms (AAA) and to put forward proposals for preventing these failures. METHODS: Since May 1992, endoluminal repair of aneurysms was undertaken in 47 patients. Forty-three of these patients had AAAs and are the basis of this study. All procedures were nonurgent and were performed in the operating room with the patient draped for an open repair in the event of failed endoluminal repair. Radiographic guidance was used to pass the endografts into the aorta via a delivery sheath introduced through the femoral or iliac arteries. The configuration of the endografts was tubular (n = 28), tapered aortoiliac/aortofemoral (n = 11), and bifurcated (n = 4). RESULTS: Successful endoluminal repair was achieved in 34 of 43 (79%) patients. The remaining nine were terminated in favor of an open repair. The causes of failure were problems with access (2), balloon malfunction (1), stent dislodgment (3), graft thrombosis (1), and inability to deploy the contralateral limb of a bifurcated graft (2). All failed endoluminal repairs proceeded to successful open repair. There was no perioperative mortality in patients undergoing endoluminal repair or in those whose endoluminal repair was converted to open operation. CONCLUSIONS: The failures of endoluminal grafting have been analyzed. Methods of avoiding access problems, balloon malfunction, and stent dislodgment have been defined and recommendations made.

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) for variceal haemorrhage: initial results in 28 patients.

BACKGROUND: Endoscopic sclerotherapy is an effective form of treatment of bleeding varices in patients with cirrhosis. However, the mortality in patients who rebleed is high. Recently, transjugular intrahepatic portosystemic stent-shunt (TIPSS) has been developed as an alternative to surgical shunt formation in patients who have failed sclerotherapy. AIM: To review the early experience with TIPSS at a teaching hospital. METHODS: Twenty-eight patients underwent TIPSS on 30 occasions between September 1991 and June 1993 for bleeding oesophageal or gastric varices. The majority had alcoholic liver disease. RESULTS: TIPSS was performed successfully in all patients. Immediate control of bleeding was achieved, but one patient rebled within 24 hours. Complications related to the procedure occurred in 30%, but no patient died from these. Thirty-day mortality was 11% (three of 28), two patients dying from progressive liver failure and one from sepsis. A further three patients died from six weeks to two months following TIPSS, due to liver failure in one, spontaneous bacterial peritonitis in the second and in the third after a fall. This represents an overall mortality of 21%. Three patients have rebled at mean follow-up of 11.3 months. One of these had repeat TIPSS while the other two had balloon dilatation of the stent with control of bleeding. Four patients developed mild chronic encephalopathy which was readily controlled with medical therapy. CONCLUSIONS: TIPSS is an effective means for control of bleeding from oesophageal and/or gastric varices not responding to other methods. Further follow-up is required with regard to rates of rebleeding, encephalopathy and survival.