[Intrahepatic portasystemic shunt and hemorrhagic emergencies in the cirrhotic patient]

From March 1992 to March 1994, 26 patients underwent Transjugular Intrahepatic Portosystemic Shunt (TIPS) for emergency treatment of variceal bleeding. Patients were all cirrhotic, with a mean age 55 +/- 13 yrs, Child's score was A = 4, B = 10, C = 12. TIPS was performed in case of failure or impossibility to obtain hemostasis after endoscopic and/or medical treatment. Hemostasis was successful in all cases of TIPS, and the portocaval gradient was lowered from 19 to 9 mmHg. Early complications occurred in 30% of cases. They consisted of: spontaneously regressive hemobilia (15%) and shunt thrombosis (15%) (3/4 were repermeabilized). Early mortality accounted for 15% of patients in the whole group and 25% in Child C'patients. During follow-up (m = 8 +/- 6 m), only one patient rebled, de novo hepatic encephalopathy occurred in 15% of patients always regressive in response to Lactulose therapy. One year mortality rate was 57%. A comparison between TIPS and other emergency hemostasis methods: endoscopic sclerotherapy, surgical portocaval shunt and esophageal transsection was performed on the early mortality rate according to the percentage of Child C'patients in the various series. TIPS is better than other methods in series with a low percentage of Child C'patients. TIPS should be proposed: in case of failure of endoscopic methods; for patients waiting for liver transplantation; when portal vein patency is compromised by thrombosis. This last indication implies that portal patency must be confirmed with angiography or better by with duplex sonography once primary hemostasis of variceal bleeding has been completed.