TIPS - anastomose portossistêmica intra-hepática transjugular. Revisão

Abstract

At the present time several therapeutic options are used for the treatment of bleeding esophageal varices in patients with portal hypertension. We will review the main medical publications on transjugular intrahepatic portosystemic shunt (TIPS), a procedure seldom used among us. TIPS works as a portocaval side-to-side shunt and decreases the risk of esophageal bleeding through lowering of the portal system pressure and a decrease of the portal hepatic pressure gradient. TIPS consists in the percutaneous insertion, through the internal jugular vein, of a metallic stent under fluoroscopic control in the hepatic parenchyma creating a true porta caval communication. There are several studies demonstrating the efficacy of TIPS, although only a few of them are randomized and control-matched to allow us to conclude that this procedure is safe, efficient and with a good cost benefit ratio. In this review, we search for the analysis of the TIPS utilization, its techniques, its major indications and complications. TIPS has been used in cases of gastroesophageal bleeding that has failed with pharmacologic or endoscopic treatment in patients Child-Pugh B and C. It can be used also as a bridge for liver transplantation. Others indications for TIPS are uncontrolled ascites, hepatic renal syndrome, and hepatic hydrothorax. The main early complications of TIPS using are related to the insertion site and hepatic encephalopathy and the stent occlusion is the chief late complication.

Mortality and complications in patients with portal hypertension who underwent transjugular intrahepatic portosystemic shunt (TIPS) - 12 years experience

“…TIPS dysfunction/stenosis was observed in 19 (26.4%) of cases, lower indices than those found in most of the studies as Jabbour et al (14) (52%), Zhuang et al (30) (43.16%), Russo et al (24) (49%), Yoon et al (28) (45%) and Sanyal et al (25) (75%). Acute infections were found in 15 (20.8%), acute kidney insufficiency in 11 (15.2%) and cardiologic complications with arrhythmia in 2 (2.9%) of cases, however these complications are not reported in indices in literature (4) . Technical complications were observed in 7 (9.7%) patients, being these similar to those observed in other studies, such as hematomas on the puncture site and stent migration, but with higher indices than those reported by Jabbour et al (14) (7%) and Zhuang et al (30) (4.8%).…”

“…More severe complications occur from 1% to 2% and include hemoperitoneum, sepsis, hemobilia, worsening of hepatic and cardiopulmonary insufficiency (23) . After the procedure, there may occur complications as lung acute edema, pneumonias, adult respiratory distress syndrome and kidney acute insufficiency (4) . Bacteremia or bacterial sepsis may also occur from 1% to 2% of cases, being necessary, before the procedure, perform antibiotic prophylaxis (22) .…”

Early Hepatic Encephalopathy after a Transjugular Intrahepatic Portosystemic Shunt Procedure: Case Report

“…However, this procedure can cause ammonia to pass into the system, being able to reach the brain, and developing Post-TIPS HE [7], which is a complication that occurs in 25% -33% of patients undergoing TIPS and is usually resolved with protein restriction and the use of lactulose or neomycin sulfate. However, in about 5% -10% of patients, HE needs to be solved with a new intervention to occlude the TIPS or reduce its diameter [8].…”

Análise do custo dos pacientes em lista de espera para o transplante hepático

“…Em nosso país, um importante estudo do HCFMUSP encontrou dados que indicam a probabilidade de 58% dos pacientes cirróticos desenvolverem ascite em 10 anos. [35][36][37] Uma complicação relativamente frequente em pacientes com ascite é a peritonite bacteriana espontânea. [38][39][40] A peritonite bacteriana espontânea é uma infecção grave e algumas vezes fatal do líquido ascítico ocasionada por bactérias translocadas do intestino para a cavidade peritoneal.…”

“…Outra complicação comum que acomete os pacientes cirróticos são as varizes esofágicas, que ocorrem em cerca de 90% dos pacientes, com risco de sangramento de 30% a 60%, e frequência de morte associadas à hemorragia digestiva alta (HDA) de aproximadamente 12% a 20%. 34,35 O tratamento envolve condutas medicamentosas ou endoscópicas como a ligadura elástica de varizes esofágicas (LEVE) ou utilização de balão esofágico na urgência. 44 Além disso, muito frequentemente está presente a encefalopatia hepática, considerada como uma das maiores complicações da fibrose hepática, atingindo mais de um terço destes pacientes.…”