Correspondence

Transjugular Intrahepatic Portosystemic Stent Shunt for Ascites

N Engl J Med 1995; 333:878-879September 28, 1995

Article

To the Editor:

Ochs et al. (May 4 issue)1 reported their experience using transjugular intrahepatic portosystemic stent shunts to control refractory ascites. The shunts were successfully placed in all 50 study patients, and 74 percent had total remission of ascites within three months. However, 9 of 18 patients in Child–Pugh class B and 20 of 32 in class C died within the follow-up period of 426±333 days (mean ±SD). Many shunts became occluded or stenosed, and many patients had hepatic encephalopathy after the procedure. On the basis of their uncontrolled prospective study, the authors suggest that the procedure is effective for many patients with liver cirrhosis and refractory ascites and that liver transplantation should be considered for patients who (after shunting) have a doubling of their serum bilirubin concentrations or incomplete responses to the shunt. We believe these recommendations are misleading, since no effort was made to stratify the patients according to their candidacy for liver transplantation before the stent–shunt procedure was performed.

In a similar study from the University of Pittsburgh,2 the transjugular intrahepatic portosystemic stent shunt was also shown to be highly successful in controlling variceal bleeding and ascites. However, the limited long-term patency of the shunt and the progressive decline in hepatic synthetic function indicated that it was a short-term solution to the complications of portal hypertension.

The poor survival, limited long-term patency, and progressive encephalopathy associated with the stent–shunt procedure is in sharp contrast to the current results of liver transplantation, in which one-year patient survival is better than 75 percent, and five-year survival is better than 70 percent, with most patients reporting their quality of life to be good or excellent.3 Patients with organic renal disease, whom Ochs et al. do not recommend as candidates for shunting, may receive a combined liver-and-kidney transplant with similar results.

Until adequately controlled studies are done, we believe that liver transplantation remains the treatment of choice for patients with Child–Pugh class B or C liver cirrhosis who meet candidacy criteria. The stent shunt should be considered a temporary measure for patients who are candidates for transplantation and require immediate control of the complications of portal hypertension and as a definitive procedure for patients who are not surgical candidates and have a short life expectancy.

Alfredo J. Fabrega, M.D.
Maureen Martin, M.D.
University of Iowa Hospitals and Clinics, Iowa City, IA 52242-1086

3 References

1. 1

   Ochs A, Rossle M, Haag K, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for refractory ascites. N Engl J Med 1995;332:1192-1197
   Full Text | Web of Science | Medline

2. 2

   Martin M, Zajko AB, Orons PD, et al. Transjugular intrahepatic portosystemic shunt in the management of variceal bleeding: indications and clinical results. Surgery 1993;114:719-727
   Web of Science | Medline

3. 3

   Wood RP, Ozaki CF, Katz SM, Monsour HP Jr, Dyer CH, Johnston TD. Liver transplantation: the last ten years. Surg Clin North Am 1994;74:1133-1154
   Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree that liver transplantation should be considered in all patients with cirrhosis of Child–Pugh classes B and C. Of the 50 patients in our study, 35 were excluded from transplantation because of age (12 patients over 65 years of age), cancers (3 patients), continued alcohol abuse (7), and severe accompanying diseases (13 with myocardial infarction, cardiomyopathy, diabetes mellitus with vascular complications, refractory spontaneous bacterial peritonitis with cutaneous fistula, or wasting syndrome). Of the remaining 15 patients, 3 received transplants 1, 11, and 12 months after the stent–shunt procedure, and 3 died 6, 12, and 17 months after the procedure, of hepatocellular carcinoma or of liver failure induced by resumed heavy alcohol abuse. Nine patients improved after stent–shunt placement to such a degree that transplantation was no longer considered.

As suggested, we reevaluated the data on these 15 patients. All the patients had complete remission of ascites, except one with only partial remission (no need for paracentesis) who refused shunt revision. Four patients had recurrent ascites, which resolved after shunt revision. The cumulative one- and two-year survival rates (Kaplan–Meier estimates) of patients eligible for transplantation were compared with those of the ineligible patients. Patients eligible for transplantation had significantly better one- and two-year survival rates (86 and 80 percent) than patients not eligible for transplantation (34 and 23 percent, respectively).

Thus, the 15 patients eligible for transplantation who received stent shunts in our study appear to have done at least as well as the patients cited by Fabrega and Martin who underwent immediate transplantation. In patients not eligible for transplantation, the stent–shunt procedure may not prolong life but may improve the clinical situation (e.g., circulatory, renal, and nutritional measures; decreased risk of bacterial peritonitis) and quality of life. It may help patients with refractory ascites and compensated hepatocellular function, irrespective of whether liver transplantation is indicated. Liver transplantation without previous stent–shunt implantation may be reserved for patients with contraindications (e.g., decompensated liver function, severe hepatic encephalopathy, or cavernomatosis of the portal vein). We agree with Wong and Blendis1 that patient selection is important. Stent shunts should not be inserted in all patients who are dying from liver failure, since this procedure cannot save every patient.

Andreas Ochs, M.D.
Klaus Haag, M.D.
Martin Rössle, M.D.
Albert Ludwig University School of Medicine, 79106 Freiburg, Germany

1 References

1. 1

   Wong F, Blendis L. Transjugular intrahepatic portosystemic shunt for refractory ascites: tipping the sodium balance. Hepatology 1995;22:358-364
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Sergio Savastano, Diego Miotto, Giuseppe Casarrubea, Selina Teso, Matteo Chiesura-Corona, Gian Pietro Feltrin. (1999) Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma in Patients With Child's Grade A or B Cirrhosis. Journal of Clinical Gastroenterology 28:4, 334-340
   CrossRef