A Comparison of Paracentesis and Transjugular Intrahepatic Portosystemic Shunting in Patients with Ascites

Rössle, Martin; Ochs, Andreas; Gülberg, Veit; Siegerstetter, V.; Holl, Joseph; Deibert, Peter; Olschewski, Manfred; Reiser, Maximilian; Gerbes, Alexander L.

doi:10.1056/nejm200006083422303

Cited by 519 publications

(361 citation statements)

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“…The 27% 90-day survival rate for the current study patients with ascites is far below the reported range of 1-year transplantation-free survival rates of 41-69% for patients with ascites who underwent TIPS. 4,41 Therefore, we caution the use of TIPS in the subgroup of patients who have concomitant malignancies and hepatogenic ascites and in the subgroup of patients who have hepatic primary malignancies, regardless of indication.…”

Section: Discussionmentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunts: Experience in the oncology setting

Wallace

Madoff

Ahrar

et al. 2004

Cancer

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BACKGROUNDTransjugular intrahepatic portosystemic shunt (TIPS) placement has emerged as an effective and minimally invasive method of treating portal hypertension and its associated complications. To the authors' knowledge there is limited documentation of its use for percutaneous shunting in patients with hepatic and extrahepatic malignancies. The current study reports the authors' experience with TIPS in the oncology setting.METHODSThirty‐eight patients with cancer underwent TIPS procedures. Nineteen patients had a history of hepatic malignancy. All medical records and imaging studies were reviewed retrospectively. The indication for TIPS, the presence of malignancy, procedural details, complications, survival, and treatment success were assessed.RESULTSPrimary technical success was accomplished in 37 of 38 patients (97%) without technical procedure‐related complications. Hepatic encephalopathy occurred in 15 of 34 patients (44%), with 3 patients requiring shunt reduction. Premature shunt occlusion (< 30 days) occurred in 3 patients (8%). Recurrent hemorrhage occurred in 1 of 19 patients (5%), and ascites and hepatic hydrothorax resolved or improved subjectively in 9 of 12 patients (75%). Shunts traversed malignancy in 9 patients, and varying degrees of portal compromise were encountered in 12 patients (32%). The overall 30‐day and 90‐day survival rates were 84% and 60%, respectively. There was a statistically significant difference in 90‐day survival rates for patients who had ascites and hepatic hydrothorax indications (27%) compared with patients who had variceal and portal gastropathy indications (84%; P = 0.0075). In addition, the 90‐day survival rate was significantly lower in patients who had primary hepatic malignancies (36%) compared with the remainder of the study population (74%; P = 0.0077), and it was significantly lower in patients who had model for end‐stage liver disease (MELD) scores ≥ 12 (P = 0.0020).CONCLUSIONSTIPS was performed safely for patients with cancer without increasing rates of procedure‐related complications. However, some patients subgroups, such at those with malignancy and ascites, primary hepatic malignancy, or MELD scores ≥ 12, had the lowest 90‐day survival rates. Cancer 2004. © 2004 American Cancer Society.

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Section: Discussionmentioning

confidence: 99%

Transjugular intrahepatic portosystemic shunts: Experience in the oncology setting

Wallace

Madoff

Ahrar

et al. 2004

Cancer

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“…There have been 4 randomized controlled trials comparing TIPS versus large-volume paracentesis as a treatment for refractory ascites. [50][51][52][53] In the first study, none of the Child-Pugh class C patients eliminated their ascites, and their overall survival was significantly worse in the TIPS group. 50 Thus, TIPS is generally considered to be contraindicated in Child-Pugh class C patients.…”

Section: Transjugular Intrahepatic Portosystemic Shunt (Tips)mentioning

confidence: 99%

The management of ascites in cirrhosis: Report on the consensus conference of the International Ascites Club

et al. 2003

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Ascites is a common complication of cirrhosis, and heralds a new phase of hepatic decompensation in the progression of the cirrhotic process. The development of ascites carries a significant worsening of the prognosis. It is important to diagnose noncirrhotic causes of ascites such as malignancy, tuberculosis, and pancreatic ascites since these occur with increased frequency in patients with liver disease. The International Ascites Club, representing the spectrum of clinical practice from North America to Europe, have developed guidelines by consensus in the management of cirrhotic ascites from the early ascitic stage to the stage of refractory ascites. Mild to moderate ascites should be managed by modest salt restriction and diuretic therapy with spironolactone or an equivalent in the first instance. Diuretics should be added in a stepwise fashion while maintaining sodium restriction. Gross ascites should be treated with therapeutic paracentesis followed by colloid volume expansion, and diuretic therapy. Refractory ascites is managed by repeated large volume paracentesis or insertion of a transjugular intrahepatic portosystemic stent shunt (TIPS). Successful placement of TIPS results in improved renal function, sodium excretion, and general well-being of the patient but without proven survival benefits. Clinicians caring for these patients should be aware of the potential complications of each treatment modality and be prepared to discontinue diuretics or not proceed with TIPS placement should complications or contraindications develop. Liver transplantation should be considered for all ascitic patients, and this should preferably be performed prior to the development of renal dysfunction to prevent further compromise of their prognosis. (HEPATOLOGY 2003;38:258-266.)

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“…What could be the source of this disparity? One explanation is a methodological differences between the current study and prior studies [2][3][4]8]. Other studies censored patients who underwent OLT, such that the date of transplantation was considered the last day of follow-up and not counted as an event.…”

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confidence: 92%

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Survival in Cirrhotic Patients with High MELD Scores: The TIPping Point

Hwang

Sze

2016

Dig Dis Sci

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Although a survival benefit following transjugular intrahepatic portosystemic shunt (TIPS) creation for variceal bleeding [1] and ascites [2,3] has been reported in randomized controlled trials (RCTs) in cirrhotic patients, clinical outcomes after TIPS placement in patients with late-stage liver disease and high Model for End-Stage Liver Disease (MELD) scores remain controversial. The MELD score was originally created to predict the survival after TIPS placement in patients with cirrhosis; by intention, a high MELD score predicts poor survival after TIPS [4]. While the RCTs supported early TIPS placement for variceal bleeding and favored TIPS over repeated large-volume paracentesis in patients with Child-Pugh scores up to 11 or 13, the investigators intentionally excluded patients with severely compromised liver function and higher scores. The RCTs also did not report on outcomes relative to the MELD scores.Consequently, data regarding TIPS outcomes in patients with high MELD scores have historically been derived from non-randomized studies. Angermayr et al. [5] reported a 60% 1-year mortality rate in patients with MELD [ 18. Ferral et al. [6] reported a 90-day mortality rate of 34.8% in patients after elective TIPS with MELD scores of 18-24 and 65.5% in patients with MELD C 18, yielding a 90-day mortality of 44% for all patients with MELD C 18. Casadaban et al. [7] stated that survival rates after emergent TIPS placement for acute variceal bleeding were predicted by MELD scores and were inferior to survival rates reported in the elective TIPS placement population, with a 90-day mortality rate of 36% for MELD 19-25 and 83% for MELD C 26.The high post-TIPS mortality rates reported in patients with high MELD scores have led some to conclude that TIPS procedures should not be performed in those patients, particularly if the MELD is [25 [6]. Although such a conclusion implies that TIPS placement is harmful, or at least, not beneficial to that subset of patients, this assumption remains conjectural. The prognosis of patients with high MELD scores is generally poor, with reported 1-year mortality of approximately 30% for MELD scores between 20 and 29 and approximately 60% for MELD scores C30 [8]. Given the variability among patient cohorts in how MELD scores are stratified, and in how survival outcomes are reported, and given the similarities in the reported survival statistics for high-MELD patients with and without TIPS, it is difficult to isolate the effect of TIPS placement from the overall dismal survival typical of high-MELD patients.In this issue of Digestive Diseases and Sciences, Ascha et al. [9] have taken a step toward answering the question of whether TIPS placement increases or decreases survival in patients with high MELD scores. They retrospectively analyzed a cohort of 144 patients with MELD score C15 who underwent TIPS procedures, matched them by MELD score and age to 144 patients who had not undergone TIPS procedures, excluding patients with hepatocellular carcinoma or those who died within 48 h of ...

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A Comparison of Paracentesis and Transjugular Intrahepatic Portosystemic Shunting in Patients with Ascites

Abstract: In comparison with large-volume paracentesis, the creation of a transjugular intrahepatic portosystemic shunt can improve the chance of survival without liver transplantation in patients with refractory or recurrent ascites.

Cited by 519 publications

References 28 publications

Transjugular intrahepatic portosystemic shunts: Experience in the oncology setting

Transjugular intrahepatic portosystemic shunts: Experience in the oncology setting

The management of ascites in cirrhosis: Report on the consensus conference of the International Ascites Club

Survival in Cirrhotic Patients with High MELD Scores: The TIPping Point

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