Cirrhosis surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]
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Overview
Typically for a patient with progressed cirrhosis of the liver, transplantation may be the only viable treatment. If transplantation is not possible or desired, a patient may undergo the TIPS procedure which has demonstrated a great deal of success.
Surgery
Transplantation
If complications cannot be controlled or when the liver ceases functioning, liver transplantation is necessary. Survival from liver transplantation has been improving over the 1990s, and the five-year survival rate is now around 80%, depending largely on the severity of disease and other medical problems in the recipient.[1] In the United States, the MELD score [2] is used to prioritize patients for transplantation. Transplantation necessitates the use of immune suppressants (ciclosporin or tacrolimus).
- Prevalence
A recent study was completed between 1995 and 2006 that sought out to determine if there was a correlation between ursodeoxycholic acid (UDCA) and a decreases in liver transplantations for treating primary biliary cirrhosis.[3] In 2006 the results showed that over a ten year period the amount of liver transplantations needed for people with cirrhosis decreased by an average of 5.4 cases per year.[3] Although no causal relationship has been confirmed, this study has shown strong support to the notion that UDCA use has decreased the need for liver transplantation in patients presenting with primary biliary cirrhosis.[3]
- Symptoms After Surgery
Complications of end stage liver disease that were present before transplantation are typically resolved after the surgery. Complications such as variceal bleeding, encephalopathy, and hepatorenal syndrome are usually resolved after a successful transplantation. Pruritis, which can be associated with cirrhosis, is typically cleared up post-surgery.
- Survival
In cases in which transplantation is indicated for a patient with cirrhosis, transplantation can have a significant effect on the long term survival of the patient. A study conducted between 1982 and 1999 researched 400 patients who underwent liver transplants due to end stage cirrhosis.[4] The patients in the study are indicated for surgery because either their quality of life is significantly poor or they are not projected to survive longer than a year. The overall survival rates from this particular study demonstrate a significant increase in the amount of years a patient with cirrhosis can survive. For the entire study, the overall survival rate at 1 year post surgery was 87%, at 5 years post surgery was 78%, and at 10 years post surgery was 67%.[4] Since this study occurred in the 1980s as well as the 1990s, the data was further broken down to show the significant improvements that have been made in transplantation more recently. In the 1980s the survival rate at 1 year post surgery was 72%, at 3 years post surgery was 70%, and at 5 years post surgery was 66%.[4] On the contrary, in the 1990s the survival rate at 1 year post surgery was 87%, at 3 years post surgery was 83%, and at 5 years post surgery was 80%.[4]
TIPS (Transjugular Intrahepatic Portosystemic Shunt)
A transjugular intrahepatic portosystemic shunt, also TIPS, is an artificial channel in the liver from the portal vein to a hepatic vein (for blood). It is created endovascularly (via the blood vessels) via the jugular vein. It's main purpose is to decompress the portal vein which would in turn help to prevent rebleeding from varices, and it could also prevent ascites formation.[5] In most cases, the success rate for the decompression of the portal vein is quite high at more than 90%.[5]
- Indications
It is used to treat portal hypertension which is often due to cirrhosis. The scar tissue that is present on the liver due to cirrhosis causes blockages, which in turn causes hypertension within the portal vein. Because of the increased pressure in the portal vein, blood flows preferentially towards organs in the stomach that would typically drain into the portal vein. These veins that are bypassing the liver and filling with blood in the abdomen may rupture. The possibility of rupture makes a transjugular intrahepatic portosystemic shunt a benificial procedure.
- Contraindications
Not all patients with cirrhosis are eligible for the TIPS procedure. There are some conditions in which the patient would be absolutely contraindicated from undergoing the TIPS procedure, and there are some in which the patient would be relatively contraindicated. Some of the absolute contraindications include congestive heart failure, uncontrolled sepsis, uncontrolled systemic infection, unrelieved biliary obstruction, multiple hepatic cysts, and severe pulmonary hypertension.[5] Some of the relative contraindications include hepatoma, severe coagulopathy, portal vein thrombosis, blockage of all the hepatic veins, moderate pulmonary hypertension, and thrombocytopenia.[5]
- Survival
Compared to other procedures, the TIPS procedure appears to be a safe option for people with portal hypertension due to cirrhosis. The TIPS procedure has a 30-day mortality rate of 45% for people that need an emergency portacaval shunt.[6] Typically, the survival rate is substantially less. The mortality rate directly due to the TIPS procedure itself is less than 2%. Some of these causes of death include myocardial infarctions during the procedure as well as an intraperitoneal hemorrhage due to a rupture or puncture of the portal vein.[6] These complications are rare and many of the people that die from this procedure have some sort of bleeding occurring before the procedure even begins.[6]
- Complications
Although the TIPS procedure is a less invasive alternate to transplantation, there are some complications that may be present. Complications involving the puncture of the portal vein have been previously noted. It is possible for there to be hemorrhage or hematoma from the puncture site.[6] There are also complications associated with the dilation of the portal vein. There is a high likelihood of death if this portion of the procedure does not go correctly.[6] There is also a possibility of there being thrombosis of the stent that is placed in the hepatic vein during the procedure.[6]
If the patient going through the TIPS procedure is in line for a liver transplantation, this can further complicate the procedure. Inserting a shunt into the liver needs to be exceedingly precise in patients that have the possibility of obtaining a new liver. In transplant cases, it has been shown in some studies that the patient and graft survival was somewhat worse in those individuals that previously had a shunt placed in the hepatic vein.[5] It is typically more difficult to perform the transplantation after a patient has already undergone the TIPS procedure.
- Drawbacks
Two of the major weaknesses that can be present with the TIPS procedure are stent dysfunction and portosystemic encephalopathy.[7] A problem also arises due to the fact that there is a frequent need for endovascluar reintervention to make sure that the stent remains patent.[7]
References
- ↑ liver transplant outlook and survival rates
- ↑ Cosby RL, Yee B, Schrier RW (1989). "New classification with prognostic value in cirrhotic patients". Mineral and electrolyte metabolism. 15 (5): 261–6. PMID 2682175.
- ↑ 3.0 3.1 3.2 Lee J, Belanger A, Doucette JT, Stanca C, Friedman S, Bach N (2007). "Transplantation trends in primary biliary cirrhosis". Clinical Gastroenterology and Hepatology : the Official Clinical Practice Journal of the American Gastroenterological Association. 5 (11): 1313–5. doi:10.1016/j.cgh.2007.07.015. PMID 17900996. Retrieved 2012-09-06. Unknown parameter
|month=ignored (help) - ↑ 4.0 4.1 4.2 4.3 Liermann Garcia RF, Evangelista Garcia C, McMaster P, Neuberger J (2001). "Transplantation for primary biliary cirrhosis: retrospective analysis of 400 patients in a single center". Hepatology (Baltimore, Md.). 33 (1): 22–7. doi:10.1053/jhep.2001.20894. PMID 11124816. Retrieved 2012-09-06. Unknown parameter
|month=ignored (help) - ↑ 5.0 5.1 5.2 5.3 5.4 Boyer TD, Haskal ZJ (2005). "The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension". Hepatology (Baltimore, Md.). 41 (2): 386–400. doi:10.1002/hep.20559. PMID 15660434. Retrieved 2012-09-06. Unknown parameter
|month=ignored (help) - ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Freedman AM, Sanyal AJ, Tisnado J, Cole PE, Shiffman ML, Luketic VA, Purdum PP, Darcy MD, Posner MP (1993). "Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review". Radiographics : a Review Publication of the Radiological Society of North America, Inc. 13 (6): 1185–210. PMID 8290720. Retrieved 2012-09-06. Unknown parameter
|month=ignored (help) - ↑ 7.0 7.1 Colombato L (2007). "The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension". Journal of Clinical Gastroenterology. 41 Suppl 3: S344–51. doi:10.1097/MCG.0b013e318157e500. PMID 17975487. Retrieved 2012-09-06.