Optimal Management of Ascites: TIPS

Transcription

1 Optimal Management of Ascites: TIPS Michael A. Heller, MD University of Colorado Health Sciences Center Department of Surgery Grand Rounds January 22, 2007

2 What is Ascites? The accumulation of free fluid within the abdominal cavity. Normally < 150ml in abdomen PE findings: Shifting dullness to percussion, fluid wave, bulging flank. Respiratory compromise late

3 What is Ascites? Differential diagnosis: Portal hypertension Hypoalbuminemia Miscellaneous disorders

4 What is Ascites? Transudative Increased pressure in portal vein SAAG > 1.1 Exudative Increased secretion SAAG < 1.1 Serous Albumin Ascites Albumin = SAAG

5 What is Ascites? - Pathophysiology Sequestration of fluid in the abdomen leads to further sodium and water retention by the kidneys.

6 Ascites Treatment Options Medical management Bed rest, low sodium diet, fluid restriction 15% response Diuresis Spironolactone, furosemide 90% Response Ascites unresponsive to medical management x 2 weeks termed Refractory Ascites

7 Ascites Treatment Algorithm

8 Refractory Ascites 10% develop spontaneous bacterial peritonitis Can be lethal Hepatorenal syndrome Discomfort 50% survival rate at 2 years

9 Treatment of Refractory Ascites Serial large volume paracentesis TIPS (transjugular( intrahepatic portosystemic shunt) Surgical peritoneovenous shunts Liver transplant

10 Treatment Serial Paracentesis Pros Immediate relief Relatively low risk Can be done as an outpatient Cons Does not resolve the ascites Requires frequent follow up Depletes protein stores Increases risks of SBP Development of renal failure

11 Treatment Portocaval Shunts Pros Relatively simple procedure Can be done under local anesthesia Improve renal function Decreases the need for serial paracentesis Decreased chance of SBP Cons Shunt stenosis and obstruction Disseminated intravascular coagulation (DIC)

12 Treatment Portocaval Shunts Effective at reducing ascites, but this comes at a high risk. Postoperative encephalopathy No improvement of short-term term or long-term survival Heart failure Franco et al., Arch Surg 1988

13 TIPS Transjugular intrahepatic portovenous shunt Performed by interventional radiology Creates fistula between a hepatic vein and a portal vein. Initially created to treat recurrent variceal hemorrhage

14 TIPS A side-to to-side portocaval shunt

15 TIPS What Does it Do? Decreases the intrahepatic portal pressure, thereby decreasing splanchnic vein pressure and decreasing ascites. Initially became popular in the early 1990s, and has since been tailored for specific patient populations.

16 TIPS Contraindications Initially high complication rates led more discrimination for those undergoing TIPS. Absolute Primary prevention of variceal bleeding CHF Multiple hepatic cysts Hepatoma Relative Obstruction of all hepatic veins Portal vein thrombosis Unrelieved biliary obstruction Platelets < 20 Severe pulmonary HTN Uncontrolled systemic infection or sepsis INR > 5 Moderate pulmonary HTN Boyer & Haskal, Hepatology 2005

17 TIPS How It s s Done

18 TIPS vs. Paracentesis 5 large scale randomized control trials completed to compare TIPS to paracentesis Recent META analyses x2

19 TIPS vs. Paracentesis Albillos et al., Journal of Hepatology 2005

20 TIPS vs. Paracentesis 50% of TIPS patients were free of ascites at one year, versus 12% of patients who underwent paracentesis Deltenre et al, 2005

21 TIPS vs. Paracentesis Mortality overall is unchanged by TIPS. Salerno, 2004, included the largest population of Child C cirrhotics No increase in liver related mortality

22 TIPS vs. Paracentesis Criticisms of current literature No double blinded study Heterogeneous study population May be mortality difference based upon Child s classification Quality of life and cost has not yet been fully evaluated.

23 TIPS vs. Paracentesis Overall cost of TIPS may be higher Gine et al, 2002

24 TIPS vs Surgical Shunt Surgical (LaVeen( or Denver Shunt) considered 3 rd line treatment Direct comparison of TIPS vs Surgical shunt shows superiority of TIPS Better control of ascites Better long-term patency Fewer shunt-associated infections No difference in mortality Rosemurgery et al, Annals of Surgery, 2004

25 TIPS vs Surgical Shunt Surgical shunting provides more immediate relief from ascites, while TIPS provides better long-term control. Percent of Patients with Controlled Ascites TIPS Denver Shunt 1 mo 3 mo 6 mo 12 mo 36 mo 60 mo Rosemurgery et al, Annals of Surgery, 2004 p = 60 months

26 TIPS Future Directions New PTFE-coated stent. Current stents have a 50% dysfunction rate at 1 year. New PTFE-coated stent thought to greatly reduce the rate of dysfunction Bureau et al, 2004

27 TIPS Future Directions Probability of Remaining Free of Shunt Dysfunction

28 TIPS Future Directions Probability of Shunt Dysfunction Probability of Developing Encephalopathy Bureau et al, 2004

29 Historical Perspective Goretex use as a vascular graft done first here at the University of Colorado in animals Arch Surg Oct;117(10):

30 Conclusions TIPS is a relatively safe treatment for refractory ascites, though it does not affect overall survival and increases the risk of encephalopathy. The next generation of PTFE stents may broaden the appeal of TIPS since it decreases the risk of stent dysfunction.