Selected transjugular intrahepatic portosystemic shunt versus laparoscopic splenectomy plus endoscopic varices ligation in the treatment of portal hypertension

Zhong Wu, PhD, Jin Zhou, PhD, Bing Peng, PhD

West China Hospital, Sichuan Unviersity

Background: Liver cirrhosis is associated with higher morbidity and reduced survival with appearance of portal hypertension and resultant decompensation. Transjugular intrahepatic portosystemic shunts (TIPS) are known to be efficacious in reducing portal venous pressure and control of complications secondary to portal hypertension such as variceal bleeding and ascites. Endoscopic variceal ligation (EVL) is very effective in controlling acute variceal hemorrhage with a favorable short-term efficacious. Splenectomy could effectively improve thrombocytopenia caused by hypersplenism and the long-term liver function. The present study was to compare elective TIPS and laparoscopic splenectomy (LS) plus EVL in their efficacy in preventing recurrent bleeding and long-term improvement in liver function in patients with liver cirrhosis and portal hypertension.

Materials and methods: Between January 2009 and March 2012, we enrolled 83 patients (55 with TIPS and 28 with LS plus EVL) with portal hypertension and a history of gastro-esophageal variceal rebleeding secondary to liver cirrhosis. The inclusion criteria were patients who were diagnosed as liver cirrhosis and had an episode of gastro-esophageal variceal bleeding (at least 72 hours after diagnostic endoscopy of bleeding). Clinical characteristics, perioperative outcomes and follow-up were recorded.

Results: No significant differences were observed between the two treatment groups with respect to patients’ characteristics and preoperative variables. Within 30 days after surgery, one patient in TIPS group died of multiple organ dysfunction syndromes, while no patient in LS group died. Complication occurred in 14 patients in the TIPS group including re-bleeding (n=5), encephalopathy (n=4), ascite (n=2), bleeding from a pseudoaneurysm of the thoracoabdominal aorta (n=2) and Pulmonary infection (n=1, 1.8%) as compared with 5 patients in the LS group including pulmonary effusion (n=1), pancreatic leakage (n=1) and portal vein thrombosis (n=3). During a median follow-up of 13.6 months in TIPS group and 12.3 months in LS group, the actuarial survival was 100% in the LS group versus 85.5% in the TIPS group. Complications of TIPS group included encephalopathy (n=8) and re-bleeding (n=6). None sever complication occurred in LS group. Five patients had mild esophageal variceal detected by endoscopic examination. No special therapy was offered to them. Encephalopathy occurred in eight patients in the TIPS group and none in the LS group. In TIPS group, no significant difference was found between the pre- and post-operative time according to the hematological parameters (hemoglobin and platelet count) while a gradually deterioration was shown in liver function variables. In contrast, patients in LS group had an improvement in both hematological parameters and liver function.

Conclusion: LS plus EVL was superior to TIPS in the prevention of gastro-esophageal variceal rebleeding and other severe complications in cirrhotic patients. It improved long-term liver function and was associated with low rate of portosystemic encephalopathy.

Table Complications of both groups during short- and long-term follow up

Session: Podium Presentation

Program Number: S007