Liver: Shunting & Variceal Surgery

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Procedure

  • Endovascular Stent Placed Through Liver Creating a Portosystemic Shunt
    • From Intrahepatic Portal Vein to Hepatic Vein
    • Decreases Portal Pressure

Indications

  • Generally Considered a Short-Term Solution Until Liver TXP
  • Portal Hypertension Complications:
    • Esophageal Varices – Second Rebleed After Endoscopy
    • Bleeding Ectopic Varices
    • Ascites – If Diuresis Fails & Unable to Tolerate Serial Paracentesis
  • Other Possible Indications (If Primary Tx Fails):
    • Budd-Chiari Syndrome
    • Hepatorenal Syndrome

Absolute Contraindications

  • Heart Failure
  • Severe Tricuspid Regurgitation
  • Severe Pulmonary Hypertension
  • Polycystic Liver Disease
  • Sepsis
  • Unrelieved Biliary Obstruction

Complications

  • TIPS Dysfunction (50% in First Year) – From Stenosis or Thrombosis
    • Tx: Repeat TIPS
  • Hepatic Encephalopathy (30-45%) – From Portal Blood Bypassing Liver
  • Heart Failure (20%) – From Large Volume Shift
  • Liver Failure (20%)

TIPS 1

TIPS 2

Surgical Portosystemic Shunt (PSS)

Basics

  • Largely Replaced by TIPS & Have Become More of a Historical Interest
  • Very Effective at Stopping Hemorrhage but High Complication Rates
  • 50% Mortality Rate

Types

  • Portocaval Shunt
    • Shunt: Portal Vein to IVC
  • Mesocaval Shunt
    • Shunt: SMV to IVC
  • Splenorenal Shunt
    • Shunt: Splenic Vein to Left Renal Vein
    • Must Ligate Adrenal Vein, Gonadal Vein & IMV

Indications

  • Bleeding Varices That Fail Emergent Endoscopic Tx with Preserved Liver Function
  • Not Good Surgical Candidates but Have Contraindication to TIPS (Heart Failure)

Portocaval Shunt 3

Mesocaval Shunt 4

Splenorenal Shunt (Using Adrenal Vein Graft) 5

Mesoportal (Rex) Shunt

Procedure

  • Shunt: SMV to Left Portal Vein

Indication

  • Recurrent Variceal Bleeding Caused by PVT & Endoscopy Fails
  • SMV Must Be Patent

Rex Shunt – Splenic Vein Graft (Thin Arrow) from SMV (Thick Arrow) to Left Portal Vein 6

Sugiura Procedure

Procedure

  • Surgical Devascularization of Gastroesophageal Junction
    • Non-Shunt Variceal Surgery

Indication

  • Recurrent Variceal Bleeding Caused by PVT & Endoscopy Fails
    • If Thrombosis Diffuse

References

  1. Patanwala I, King MJ, Barrett DA, Rose J, Jackson R, Hudson M, Philo M, Dainty JR, Wright AJ, Finglas PM, Jones DE. Folic acid handling by the human gut: implications for food fortification and supplementation. Am J Clin Nutr. 2014 Aug;100(2):593-9.(License: CC BY-3.0)
  2. NeSmith M, Jou J, Fennerty MB, Kolbeck KJ, Lee B, Ahn J. Transjugular Intrahepatic Portosystemic Shunt Prior to Endoscopic Mucosal Resection for Barrett’s Esophagus in the Setting of Varices. ACG Case Rep J. 2014 Jul 8;1(4):189-92. (License: CC BY-NC-ND-4.0)
  3. Witjes CD, Ijzermans JN, Vonk Noordegraaf A, Tran TK. Management strategy after diagnosis of Abernethy malformation: a case report. J Med Case Rep. 2012 Jun 28;6:167. (License: CC BY-2.0)
  4. Kirmizi S, Kayaalp C, Yilmaz S. Hydatid liver cyst causing portal vein thrombosis and cavernous transformation: a case report and literature review. Gastroenterol Hepatol Bed Bench. 2016 Fall;9(4):331-335. (License: CC BY-3.0)
  5. Aydin U, Yazici P, Kilic M. Porto-systemic shunt using adrenal vein as a conduit; an alternative procedure for spleno–renal shunt. BMC Surg. 2007 Jun 7;7:7. (License: CC BY-2.0)
  6. Wei Z, Rui SG, Yuan Z, Guo LD, Qian L, Wei LS. Partial splenectomy and use of splenic vein as an autograft for meso-Rex bypass: a clinical observational study. Med Sci Monit. 2014 Nov 11;20:2235-42. (License: CC BY-NC-ND-4.0)