Initial transcatheter thrombolysis for acute superior mesenteric venous thrombosis.

AIM: To determine the optimal initial treatment modality for acute superior mesenteric vein thrombosis (ASMVT) in patients with circumscribed peritonitis. METHODS: A retrospective review was made of the Vascular Surgery Department's medical records to identify adult patients (≥ 18 years old) presenting with circumscribed peritonitis and diagnosed with ASMVT by imaging or endoscopic examination. Patients were selected from the time period between October 2009 and October 2012 to assess the overall performance of a new first-line treatment policy implemented in May 2011 for patients with circumscribed peritonitis, which recommends transcatheter thrombolysis with local anticoagulation and endovascular mechanical thrombectomy. Of the 25 patients selected for study inclusion, 12 had undergone emergency surgical exploration (group 1) and 13 had undergone the initial catheter-directed thrombolysis (group 2). Data extracted from each patient's records for statistical analyses included method of diagnosis, symptoms, etiology and risk factors, thrombus location, initial management, morbidity, mortality, duration and total cost of hospitalization (in Renminbi, RMB), secondary operation, total length of bowel resection, duration of and findings in follow-up, and death/survival. RESULTS: The two treatment groups showed similar rates of morbidity, 30-d mortality, and 1-year survival, as well as similar demographic characteristics, etiology or risk factors, computed tomography characteristics, symptoms, findings of blood testing at admission, complications, secondary operations, and follow-up outcomes. In contrast, the patients who received the initial non-operative treatment of transcatheter thrombolysis had significantly shorter durations of admission to symptom elimination (group 1: 18.25 ± 7.69 d vs group 2: 7.23 ± 2.42 d) and hospital stay (43.00 ± 13.77 d vs 20.46 ± 6.59 d), and early enteral or oral nutrition restoration (20.50 ± 5.13 d vs 8.92 ± 1.89 d), as well as significantly less total length of bowel resection (170.83 ± 61.27 cm vs 29.23 ± 50.24 cm) and lower total cost (200020.4 ± 91505.62 RMB vs 72785.6 ± 21828.16 RMB) (P < 0.05 for all). Statistical analyses suggested that initial transcatheter thrombolysis is correlated with quicker resolution of the thrombus, earlier improvement of symptoms, stimulation of collateral vessel development, reversal of intestinal ischemia, receipt of localizing bowel resection to prevent short bowel syndrome, shorter hospitalization, and lower overall cost of treatment. CONCLUSION: For ASMVT patients with circumscribed peritonitis, early diagnosis is key to survival, and non-operative transcatheter thrombolysis is feasible and effective as an initial treatment.

[Hepatic venousaplasty and transjugular intrahepatic portosystemic shunt in the treatment of Budd-Chiari syndrome with occlusion of the hepatic veins].

OBJECTIVE: To determine the outcome of hepatic venousaplasty and transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of the Budd-Chiari syndrome with occlusion of the hepatic veins. METHODS: Fifty patients of the Budd-Chiari syndrome with occlusion of the hepatic veins (23 males and 27 females, with a mean age of (39 ± 11) years) were elected for venousaplasty or TIPS. The average of Child-Pugh scores was 9.6 ± 2.6. Three patients had a acute course of the disease, while 47 patients had a subacute or a chronic course of the disease. The clinical presentation was ascites in all 50 cases, with concomitant upper gastrointestinal bleeding in 10 patients, hepatorenal syndrome in 4 patients and impaired liver function in all patients. Hepatic venousplasty was performed for 12 patients with occlusion of hepatic venous. Hepatic and inferior caval venousplasty were performed for 6 patients with occlusion of hepatic and inferior caval vein. TIPS was performed for 13 patients with occlusion of small hepatic vein. Modified TIPS was performed for 19 patients with extensive occlusion of hepatic vein. RESULTS: The procedure of treatment was successfully performed in all patients. The shunt reduced the portosystemic pressure gradient from (41 ± 10) to (27 ± 6) cmH2O (1 cmH2O = 0.098 kPa, t = 20.20, P = 0.001) and improved the portal flow velocity from (14 ± 10) to (52 ± 14) cm/s (t = 15.02, P = 0.001) after TIPS or modified TIPS. Clinical symptoms and the biochemical test results improved significantly during 3 weeks after hepatic venousplasty and shunt treatment. During the hospitalization, the death occurred in 1 case due to hepatic failure and the acute occlusion of shunt was treated with secondary intervention in another case. The mean follow-up was (82 ± 46) months. The revisions of shunt with TIPS were needed in 2 patients and the inflation of stenosised hepatic vein in another 2 patients during the follow-up. All patients were still observed. CONCLUSION: Hepatic venousaplasty and TIPS provide an excellent outcome in patients of Budd-Chiari syndrome with occlusion of the hepatic veins.

Delayed liver laceration following transjugular intrahepatic portosystemic shunt for portal hypertension.

The transjugular intrahepatic portosystemic shunt (TIPS) is an acceptable procedure that has proven benefits in the treatment of patients who have complications from portal hypertension due to liver cirrhosis. Delayed liver laceration is a rare complication of the TIPS procedure. We describe a patient with portal hypertension due to liver cirrhosis, who suddenly presented with abdominal hemorrhage and liver laceration 8 d after TIPS. Few reports have described complications after TIPS placement. To the best of our knowledge, this is the first report describing delayed liver laceration. This potential and serious complication appears to be specific and fatal for TIPS in portal hypertension. We advocate careful attention to the technique to avoid this complication, and timely treatment is extremely important.

[The retrospective study of transjugular intrahepatic portosystemic shunt with covered or uncovered stents in patients with portal hypertension].

OBJECTIVE: To retrospectively compare the clinical outcome in patients with portal hypertension treated with transjugular intrahepatic portosystemic shunt (TIPS) using Fluency stent-graft (PTFE-covered stents) or bare stents. METHODS: Approval of study and treatment protocol and waiver of informed consent for the retrospective study were obtained from institutional review board. Informed consent was obtained from each patient before procedure. Sixty consecutive patients with portal hypertension treated with TIPS from April 2007 to April 2009 were included. TIPS creation was performed with Fluency stent-graft in 30 patients (group A) and with bare stents in 30 patients (group B). Liver function, TIPS patency and clinical outcome were evaluated every 3 months. RESULTS: During hospitalization, there was no hepatic encephalopathy and recurrency of variceal bleeding.Acute shunt occlusion was observed in one patient with group A and another patient with group B.Follow-up was performed with average time of (6.2 +/- 3.9) months in group A and (8.3 +/- 4.4) months in group B. The rates of recurrent bleeding, acute shunt occlusion, hepatic encephalopathy and death were 3.3% and 20.0%, 0 and 30.0%, 16.7% and 20.0%, 0 and 13.3% in group A and B. The rates of recurrent bleeding, acute shunt occlusion and death in group A was lower than those in group B. There was no difference of hepatic encephalopathy between group A and B. The decrease of portal pressure and portosystemic pressure gradient, and the increase of portal flow and shunt flow in group A were higher than those in group B. There were no difference of liver function, ammonia and MELD between group A and B. CONCLUSIONS: Fluency stent-graft is safe and effective in TIPS creation, with high patency rate. Covered-stent can improve the clinical outcome of portal hypertension.

[Damage control surgery for acute mesenteric ischemia].

OBJECTIVE: To examine the outcome of damage control surgery (DCS) in patients with acute mesenteric ischemia (AMI). METHODS: Clinical data of 15 consecutive AMI cases treated with DCS from May 2001 to March 2009 at the Research Institute of General Surgery, Jinling Hospital were retrospectively analyzed. Eleven patients had acute superior mesenteric vein thrombosis (MVT) on admission, and 4 suffered from acute mesenteric arterial embolism/thrombosis (MAE/MAT). The staged damage control approach included immediate resection of the involved bowel (but no attempts to restore gastrointestinal continuity), open thrombectomy, transfer of the patients to ICU for resuscitation, and thrombolysis prior to the planned definitive reconstructive procedure. RESULTS: Of 15 patients, 10 (66.7%) survived. The mean remnant small bowel length was (209.0+/-53.8) cm (120 to 280 cm). None of the survived patients was parenteral nutrition-dependent. Of the 5 deaths, 2 died of recurrence of thrombosis and necrosis of the remaining bowel,1 of massive gastrointestinal bleeding. One patient abandoned treatment intra-operatively, and another with total small bowel resection abandoned treatment postoperatively. CONCLUSIONS: Damage control approach improves the survival of patients with AMI. Thrombectomy and thrombolysis are necessary for AMI management to prevent progression or further development of the thrombosis.

[Long-term results of TIPS, TIPS with CVO and combined TIPS and portal azygous disconnection for the treatment of portal hypertension].

OBJECTIVE: To analyze the long-term results of TIPS, TIPS with coronary vein occlusion (CVO) and combined TIPS and portal azygous disconnection for the treatment of portal hypertension and variceal bleedings. METHODS: Three hundreds and fifty-eight patients with portal hypertension were admitted because of variceal bleeding from July 1993 to May 2008. All patients were divided into 3 groups: 227 cases in group TIPS, 36 cases in TIPS and CVO group, 95 cases in combined TIPS and portal azygous disconnection group. The rates of successful operation, shunt patency, rebleeding, encephalopathy and survival were observed and compared by statistics methods. RESULTS: There were 349 cases (97.5%) underwent successful surgery and 9 cases with failure surgery. The rates of occluded shunts, encephalopathy, rebleeding, and death in early periods were 2.5%, 31.8%, 4.7% and 9.0% respectively. The rate of encephalopathy and death in group with TIPS were higher than in group with combined TIPS and portal azygous disconnection (P < 0.01). The rate of encephalopathy and death were 41.2% and 24.7% in 85 cases with emergency TIPS. During the follow-up 1 - 15 years, the rate of patency shunts in 12 and 24 months after operation was 74.0% and 48.1% respectively. The rate of 1-year patency shunts in group with combined TIPS and portal azygous disconnection was higher than in group with TIPS, TIPS and CVO (P < 0.01 and P < 0.05). The rebleeding in group with TIPS was higher than in group with combined TIPS and portal azygous disconnection (P < 0.01), and the survival rate in group with TIPS was lower than in group with TIPS and CVO, combined TIPS and portal azygous disconnection (P < 0.01 and P < 0.01). CONCLUSIONS: TIPS is an efficient therapy for portal hypertension with CVO, combined TIPS and portal azygous disconnection can improve the results of TIPS for portal hypertension.

[Transjugular intrahepatic portosystemic shunt in the treatment of Budd-Chiari syndrome with extensive occlusion of the hepatic veins].

OBJECTIVE: To explore the outcome of a transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of 11 patients with Budd-Chiari syndrome with extensive occlusion of the hepatic veins. METHODS: Eleven patients with Budd-Chiari syndrome with extensive occlusion of the hepatic veins were elected for TIPS. Three patients had a acute; eight, a subacute or a chronic course of the disease. All patients were associated with variceal bleeding and massive ascites. The diagnosis of Budd-Chiari syndrome was established by duplex-sonography, CT, MRI, upper digestive barium meal, angiography of hepatic veins and IVC, and liver biopsy. The shunt with diameter of 10 cm was established between the inferior caval vein and the intrahepatic portal vein with self-expandable stents in all patients. The mean follow-up was 63 +/- 43 months. RESULTS: The shunt reduced the portasystemic pressure gradient from 41.2 +/- 10.5 to 12.4 +/- 4.7 cm H2O and improved the portal flow velocity from 11.2 +/- 2.8 to 52.2 +/- 13.7 cm/s. Clinical symptoms and the biochemical test results improved significantly during 3 weeks after shunt treatment. Ten patients are alive without clinical symptoms except one death due to hepatic failure. Revision in 2 patients was needed during the follow-up. The inflation of stenosing shunt was performed in 1 patient, and the reimplantation of stent in another patient. Eight patients had no revisions. CONCLUSIONS: TIPS provided an excellent outcome in patients with Budd-Chiari syndrome with extensive occlusion of the hepatic veins. It might be regarded as a treatment for the acute and long-term management of these patients.

Effect of somatostatin versus octreotide on portal haemodynamics in patients with cirrhosis and portal hypertension.

OBJECTIVES: Elevated portal inflow is part of the pathogenesis of portal hypertension in patients with cirrhosis. Vasoactive substances appear to play a primary role in the regulation of portal flow. The aim of this study was to investigate the effects of somatostatin and octreotide on portal pressure and plasma levels of insulin-like growth factor (IGF-1), nitric oxide (NO), endothelin-1 (ET-1) and glucagon (GLU). METHODS: Portal pressures of 14 cirrhotic patients with portal hypertension who underwent transjugular intrahepatic portosystemic shunt (TIPS) were directly measured via a catheter placed in the portal vein. Portal pressure and IGF-1, NO, ET-1 and GLU plasma levels were determined at baseline, and at 8 h and 24 h after administration of somatostatin or octreotide via portal vein catheter in a randomized, double-blind, cross-over design. RESULTS: The average decrease in portal pressure after intravenous infusion of somatostatin and octreotide was 9.4 +/- 1.0 cmH2O and 5.0 +/- 1.0 cmH2O, respectively (P < 0.01). Plasma levels of GLU and IGF-1 decreased significantly 8 and 24 h after somatostatin and octreotide infusion (P < 0.05). However, there were no significant decreases in plasma NO or ET-1 levels. There was a significant difference between somatostatin and octreotide groups (P < 0.01). CONCLUSION: Both somatostatin and octreotide can significantly reduce portal pressure, although somatostatin is more potent than octreotide. The underlying mechanisms may involve inhibition of the secretion of GLU, IGF-1 and other hormones as well as a decrease in hepatic metabolism and portal inflow leading to a reduction in portal pressure.

Functional hepatic flow in patients with liver cirrhosis.

AIM: To evaluate hepatic reserve function by investigating the change of functional hepatic flow and total hepatic flow in cirrhotic patients with portal hypertension. METHODS: HPLC method was employed for the determination of concentration of D-sorbitol in human plasma and urine. The functional hepatic flow (FHF) and total hepatic flow (THF) were determined by means of modified hepatic clearance of D-sorbitol combined with duplex doppler color sonography in 20 patients with cirrhosis and 10 healthy volunteers. RESULTS: FHF, evaluated by means of the D-sorbitol clearance, was significantly reduced in patients with cirrhosis in comparison to controls (764.74+/-167.91 vs 1195.04+/-242.97 mL/min, P<0.01). While THF was significantly increased in patients with cirrhosis in comparison to controls (1605.23+/-279.99 vs 1256.12+/-198.34 mL/min, P<0.01). Portal blood flow and hepatic artery flow all were increased in cirrhosis compared to controls (P<0.05 and P<0.01). D-sorbitol total clearance was significantly reduced in cirrhosis compared to control (P<0.01), while D-sorbitol renal clearance was significantly increased in cirrhosis (P<0.05). In controls FHF was similar to THF (1195.05+/-242.97 vs 1256.12+/-198.34 mL/min, P=0.636), while FHF was significantly reduced compared with THF in cirrhosis (764.74+/-167.91 vs 1605.23+/-279.99 mL/min, P<0.01). CONCLUSION: Our method that combined modified hepatic clearance of D-sorbitol with duplex doppler color sonography is effective in the measurement of FHF and THF. FHF can be used to estimate hepatic reserve function.

Influence of portal pressure change on intestinal permeability in patients with portal hypertension.

OBJECTIVE: To investigate intestinal permeability in patients with portal hypertension and its relationship with portal pressure. METHODS: Twenty patients with portal hypertension were divided into two groups (A, B), 10 patients per group. In group A, patients were treated with combined transjugular intrahepatic portosystemic shunt (TIPS) and modified Sugiura. In group B, patients were treated with modified Sugiura only. Intestinal permeability was assessed before operation, two weeks after TIPS, and two weeks after modified Sugiura; 20 healthy control subjects were also assessed. RESULTS: Intestinal permeability was significantly higher in the patients than in the control group (P<0.01). In group A, portal pressure, intestinal permeability decreased two weeks after TIPS (P<0.05), and no obvious change was noted two weeks after modified Sugiura; but they were significantly lower than those before TIPS (P<0.05). In group B, intestinal permeability was not different before and after operation. Intestinal permeability in group A was not different from that in group B before treatment, but significantly lower after modified Sugiura (P<0.05). Portal pressure was significantly correlated with intestinal permeability (r=0.627, P<0.01). CONCLUSIONS: This study shows that combined TIPS and modified Sugiura can lower portal pressure and intestinal permeability, and enhance the therapeutic efficacy on portal hypertension.