TIPS: The long and short of it

doi:10.1053/gast.1997.v112.agast971040

Gastroenterology

Volume 112, Issue 3, March 1997, Pages 1040-1043

https://doi.org/10.1053/gast.1997.v112.agast971040 Get rights and content

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Cited by (13)

A Pathophysiologic, Gastroenterologic, and Radiologic Approach to the Management of Gastric Varices
2004, Gastroenterology
Gastric varices (GV) occur in 20% of patients with portal hypertension either in isolation or in combination with esophageal varices (EV). There is no consensus for optimum treatment of GV and because they comprise an inhomogenous entity, accurate classification is vital to determine the appropriate management. Gastroesophageal varices (GOV) are classified as GOV1 (EV extending down to cardia or lesser curve) or GOV2 (esophageal and fundal varices). Isolated gastric varices (IGV) may be located in the fundus (IGV1) or elsewhere in the stomach (IGV2). GV possibly bleed less frequently than EV, but GV bleeding is typically difficult to control, associated with a high risk for rebleeding, and high mortality. Fundal varices, large GV (>5 mm), presence of a red spot, and Child’s C liver status are associated with a high risk for bleeding. GOV1 have a much lower risk for bleeding. A portosystemic pressure gradient of ≥12 mm Hg is not necessary for GV bleeding, probably related to the high frequency of spontaneous gastrorenal shunts in these patients. GOV1 should be treated as for EV. First-line treatment of bleeding fundal varices is endoscopic variceal obturation. TIPS is currently second-line acute treatment and is used for prevention of rebleeding. The role of some newer interventional radiologic techniques requires further appraisal. This review describes the pathophysiology, diagnosis, natural history, endoscopic, and interventional radiologic treatment options for GV.
Cost-Effectiveness of N-Butyl-2-Cyanoacrylate (Histoacryl) Glue Injections Versus Transjugular Intrahepatic Portosystemic Shunt in the Management of Acute Gastric Variceal Bleeding
2003, American Journal of Gastroenterology
Citation Excerpt :
Nevertheless, several studies that have economically evaluated TIPS against endoscopic therapy (18, 20) or surgical methods of shunting (22, 23) have failed to demonstrate a long term cost benefit. This has been attributed mostly to the high incidence of encephalopathy and shunt insufficiency in the long run post-TIPS (24), which require additional hospitalization and intervention. Our study identified readmission for complications but did not record quality-of-life measures.
The management of bleeding gastric varices has not been standardized. Although transjugular intrahepatic portosystemic shunt (TIPS) is used in most centers, endoscopic treatment with N-butyl-2-cyanoacrylate (cyanoacrylate) glue has recently been shown to be effective. Cost-effectiveness analyses of these methods are lacking.
We performed a retrospective review of patients with bleeding gastric varices treated either by TIPS or cyanoacrylate glue injection. Economic analysis was based on direct costs for a fixed financial year. The two groups were compared for a period of 6 months follow-up, to liver transplantation, or death for each patient.
Between January, 1995 and December, 1999, 20 patients with bleeding gastric varices had TIPS; 23 patients had cyanoacrylate glue injection from January, 2000 to October, 2001. There were no significant differences between the two groups in patient characteristics, transfusion requirement, and gastric variceal anatomy. In the TIPS group, 15/20 patients had the procedure performed within 24 h of hemorrhage, and 90% of stent insertions were successful. Complications consisted of two cases of pulmonary edema, two cases of severe encephalopathy, and a 15% stenosis rate at 6 months. In the glue group, there were 3 ± 1.5 endoscopies and 2 ± 1 injections per patient, with a 96% initial hemostasis. There was one case of (glue) pulmonary embolism and one blocked front endoscope lens, which required repair. The initial rebleed rate was significantly lower in patients who had TIPS (15% vs 30%, p = 0.005). The inpatient stay was shorter in the glue group (13 ± 1 vs 18 ± 2 days, p = 0.05), but there was no difference in the overall mortality rate. The median cost within 6 months of initial gastric variceal bleeding was $4,138 ($3,009–$8,290) for glue versus $11,906 ($8,200–$16,770) for TIPS (p < 0.0001).
In this comparable group of patients, cyanoacrylate glue injection was more cost effective than TIPS in the management of acute gastric variceal bleeding. A prospective, randomized trial would be required to confirm our analysis.
Hyperdynamic circulation in portal hypertension: A comparative model of arterio-venous fistula
2000, Medical Hypotheses
Complications of portal hypertension remain perplexing physiologic phenomena in the understanding of shunt hemodynamics with multiple theories. Hyperdynamic circulation was also found in sepsis, chronic anemia and arterio-venous (A-V) fistula which relate to an increase in nitric oxide. We hypothesize that portosystemic collaterals may mimic an A-V fistula in which the high-pressure portal blood connects with the lower pressure systemic venous circulation. Although these collaterals decompress the portal circulation, a number of secondary hemodynamic phenomena occur which increase portal blood flow and tend to counteract the portal hypotensive effect of the portosystemic shunt. The consequent increases in cardiac output and portal blood flow perfuse the compromised liver. As portal blood flow increases, collateral flow increases and is nearly totally shunted in the systemic circulation. This shunt may eventually introduce a vicious cycle of hyperdynamic circulation into a compromised host. Ultimately, high-output cardiac failure occurs, leading to cirrhotic cardiomyopathy.
The timing and role of nontransplant surgery in management of variceal bleeding
1999, Gastrointestinal Endoscopy Clinics of North America
Transjugular intrahepatic portosystemic shunts [4] (multiple letters)
1998, Gastroenterology
Portal hypertension
2006, Modern Surgical Care: Physiologic Foundations and Clinical Applications, Third Edition

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