Intrahepatic vascular shunting for portal hypertension: early experience with the transjugular intrahepatic porto-systemic shunt.

The treatment of patients with portal hypertension and hemorrhaging varices remains an enigma within the surgeon's world. Many procedures have been described, which suggests that no general consensus exists regarding the proper care for these individuals. Also, these procedures usually lead to massive blood use and exposure to patients who have had multiple blood transfusions, thus posing an extreme infectious risk to the surgical team. Eight patients refractory to repeated esophageal sclerotherapy with advanced portal hypertension underwent the transjugular intrahepatic portosystemic shunt (TIPS) procedure. One other patient with altered anatomy underwent transjugular porto-caval shunt (TPCS) procedure via the caudate lobe of the liver. All procedures were successful in stopping esophageal hemorrhage within 6 hours of shunting. The portal-hepatic vein pressure gradient pre-shunt averaged 20 mm Hg, and post-shunt averaged 11 mm Hg. Two patients developed encephalopathy, which was controlled with medication and/or diet modifications. Three patients classified as Child's C-plus died within 1 week of their shunting procedure, and one patient, who had received greater than 60 units of blood, within 10 days pre-shunt, died 45 days post-shunt of multi-system organ failure. Four of the original nine patients are now classified as Child's A with active lives, eligible for transplantation without altered abdominal anatomy. The follow-up period is from 5 to 11 months. TIPS and TPCS are methods that should be considered the front-line invasive management techniques for patients with portal hypertension who have failed esophageal sclerotherapy.