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Review
TIPSS 10 years on
  1. R JALAN,
  2. H F LUI,
  3. D N REDHEAD,
  4. P C HAYES
  1. Liver Unit
  2. Department of Medicine and Department of Radiology
  3. Royal Infirmary of Edinburgh
  4. 1 Lauriston Place
  5. Edinburgh EH3 9YW, UK
  1. Professor Hayes

https://doi.org/10.1136/gut.46.4.578

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    The transjugular intrahepatic portosystemic stent-shunt (TIPSS) has been a clinical reality for the past 10 years. The procedure is essentially a side-to-side H graft portosystemic shunt, with the expandable metallic stent being the H graft. Over this time, TIPSS has been put through the paces of assessment of technical feasibility, pilot studies through to randomised clinical trials looking at treatment of complications of portal hypertension. Following its introduction, there was an enthusiastic welcome for this procedure which was seen as an attractive alternative to shunt surgery—it did not require general anaesthesia (most of the time) or a laparotomy, and was applicable to many patients with severe liver disease unsuitable for surgery. Treatment of variceal haemorrhage, ascites, hepatic hydrothorax, hepatorenal syndrome, and Budd-Chiari syndrome using TIPSS has been studied. The initial enthusiasm was subsequently tempered by reports from these studies of shortcomings of TIPSS, namely the inevitable development of shunt stenosis and increased incidence of hepatic encephalopathy. In the light of the available evidence, what is the place of TIPSS in current clinical practice?

    Indications

    The first application of TIPSS was in the treatment of variceal haemorrhage, and this remains the main indication for TIPSS. The prevention of rebleeding from oesophageal varices has been the area studied most intensely. There are so far eight prospective randomised clinical trials1-8 comparing TIPSS with endoscopic treatment published as papers and three9-11 published as abstracts (table 1). A meta-analysis12 of these studies has also been published recently. The ensuing discussion will be based on the eight papers as many aspects of the discussion require information not available from the abstracts. In all but one study, bleeding rates were reduced from 35–50% to 10–25%. In the first seven studies, differences in mortality between the treatment groups were not shown. These studies were designed to …

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    Footnotes

    • Abbreviation used in this review:
      TIPSS
      transjugular intrahepatic portosystemic stent-shunt