Published online Feb 27, 2024. doi: 10.4240/wjgs.v16.i2.471
Peer-review started: November 22, 2023
First decision: December 8, 2023
Revised: December 15, 2023
Accepted: January 9, 2024
Article in press: January 9, 2024
Published online: February 27, 2024
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Esophageal-gastric variceal bleeding (EGVB) represents a severe complication among patients with cirrhosis and often culminates in fatal outcomes. Interventional therapy, a rapidly developing treatment modality over the past few years, has found widespread application in clinical practice due to its minimally inva
To probing the efficacy of TIPS for treating cirrhotic EGVB and its influence on the prognosis of patients afflicted by this disease.
A retrospective study was conducted on ninety-two patients presenting with cirrhotic EGVB who were admitted to our hospital between September 2020 and September 2022. Based on the different modes of treatment, the patients were assigned to the study group (TIPS received, n = 50) or the control group (per
Following surgical intervention, there was an improvement in the incidence of varicosity compared to the preoperative status in both cohorts. Notably, the study group exhibited more pronounced enhancements than did the control group (P < 0.05). PVV increased, and PVD decreased compared to the preoperative values, with the study cohort achieving better outcomes (P < 0.05). PLT and WBC counts were elevated postoperatively in the two groups, with the study cohort displaying higher PLT and WBC counts (P < 0.05). No differences were detected between the two groups in terms of serum ALB, TBIL, or AST levels either preoperatively or postoperatively (P < 0.05). Postoperative scores across all dimensions of life quality surpassed preoperative scores, with the study cohort achieving higher scores (P < 0.05). At 22.00%, the one-year postoperative rebleeding rate in the study cohort was significantly lower than that in the control group (42.86%; P < 0.05); conversely, no marked difference was obser
TIPS, which has demonstrated robust efficacy in managing cirrhotic EGVB, remarkably alleviates varicosity and improves hemodynamics in patients. This intervention not only results in a safer profile but also contributes significantly to a more favorable prognosis.
Core Tip: Esophageal-gastric variceal bleeding (EGVB) is a severe and life-threatening complication associated with cirrhosis. The implementation of transjugular intrahepatic portosystemic shunt (TIPS) has emerged as an effective strategy for both the treatment and prophylaxis of EGVB. The objective of this study was to evaluate the effectiveness of TIPS in terms of cirrhosis-triggered EGVB treatment and to probe its impact on patient prognosis. The research outcomes contribute valuable insights into the management of acute variceal bleeding and the enhancement of long-term prognostic outcomes for individuals with advanced hepatopathy. A comprehensive understanding of the benefits and potential risks associated with TIPS is pivotal for the development of personalized strategies for the treatment of variceal bleeding attributed to cirrhosis.
- Citation: Hu XG, Dai JJ, Lu J, Li G, Wang JM, Deng Y, Feng R, Lu KP. Efficacy of transjugular intrahepatic portosystemic shunts in treating cirrhotic esophageal-gastric variceal bleeding. World J Gastrointest Surg 2024; 16(2): 471-480
- URL: https://www.wjgnet.com/1948-9366/full/v16/i2/471.htm
- DOI: https://dx.doi.org/10.4240/wjgs.v16.i2.471
Portal hypertension constitutes a cluster of clinical syndromes stemming from elevated pressure within the portal venous system and is primarily attributed to cirrhosis triggered by diverse factors[1]. The fundamental pathophysiological features of portal hypertension include obstruction of blood flow and/or increased blood flow in the portal venous system, augmented intravascular static pressure in the portal vein and its branches, and the formation of collateral cir
Presently, therapeutic strategies for EGVB include pharmacotherapy, triple-lumen dual-balloon catheters for pressure hemostasis, endoscopic therapy, and interventional and surgical procedures. Among these modalities, interventional treatment is highly regarded by clinical practitioners due to its straightforward procedural execution, minimal trauma, and prompt hemostatic outcomes[4]. Interventional treatments primarily include partial splenic embolization (PSE), per
A retrospective examination of the clinical data of 92 patients diagnosed with cirrhotic EGVB who were admitted to our institution between September 2020 and September 2022 was also conducted. The inclusion criteria were as follows: (1) Diagnosed with GEVB through gastroscopy; (2) Aged at least 18 years; (3) Had an unsatisfactory response to conservative treatments, including medications and endoscopy; (4) Underwent first-time TIPS or PTVE procedures; and (5) Provided complete data and the ability to read, comprehend, and provide informed consent. Exclusion criteria encompassed: (1) Clear indications of mental illness; (2) Pregnant or lactating women; (3) Contraindications for surgery; (4) Systemic infection, fever, or organic heart disease; (5) Severe hepatic encephalopathy, hepatic space-occupying lesions, or hepatic diabetes; (6) Total bilirubin (TBIL) levels exceeding three times the upper limit of normal; (7) Portal vein obstruction or stenosis; and (8) Gastrointestinal bleeding attributed to other cirrhosis-linked factors. The patients were further allocated into the study group (n = 50) or the control group (n = 42) based on distinct treatment modalities.
Within the study cohort, the TIPS procedure was performed as follows: Patients were placed in the supine position and subjected to standard aseptic draping, after which local anesthesia was administered. Under X-ray guidance, the right internal jugular vein was punctured, and a Rups-100 guidewire was inserted into the right hepatic vein approximately 1 cm distal to its confluence with the inferior vena cava. Following the measurement of right atrial pressure, a puncture needle was used to access the right branch of the portal vein from the right hepatic vein. A guidewire was then advanced into the main portal vein, and portal vein pressure was gauged. After the portal systemic collateral circulation pressure gradient was obtained, a guidewire was introduced into the splenic vein to access the angiography portal. A balloon was inflated and placed through the shunt channel. Variceal vein embolization was performed using a spring coil. A Gore stent was introduced over a guidewire, and the status of the stent and the patency of the shunt tract were reassessed through repeat angiography. Upon confirmation of favorable conditions, the postoperative portal systemic collateral circulation pressure gradient was reassessed, and the guide catheter was subsequently removed, thereby confirming the conclusion of the procedure.
Within the control cohort, PTVE was performed as follows: Patients were placed in the supine position, standard aseptic draping was applied, and local anesthesia was administered. Under the guidance of ultrasound, percutaneous liver puncture was performed to access the portal vein branch. A supersmooth guidewire was placed, followed by the use of a 4F introducer sheath. Portal vein angiography was conducted to validate portal venous pressure and evaluate the magnitude of varices. A suitable quantity of absolute ethyl alcohol was infused to induce solidification of the blood vessels. Variceal vein embolization was carried out using a spring coil. After embolization, repeat angiography was performed to verify the absence of abnormalities. Pressure was once again measured, and the catheter was removed. The puncture route was sealed using a spring coil and gelatin sponge, completing the procedure.
Varicosity status: Following relevant guidelines, the evaluation of variceal status in the patient cohorts was conducted both preoperatively and one month postoperatively. Variceal conditions were categorized into four classes: Absence of varices, mild varices (presenting as linear formations), moderate varices (exhibiting sinuous tortuosity and elevation), and severe varices (manifesting as bead-like, nodular, or tumorous formations).
Hemodynamics: With the assistance of Doppler ultrasonography, the hemodynamic conditions of the portal vein were examined in the two groups preoperatively and one month postoperatively. The parameters under consideration in
Peripheral blood cell count: Before the surgical procedure and one month after surgery, 1 mL of fasting venous blood was drawn from both cohorts. After centrifugation at 3500 r/min, the supernatant was harvested for further analysis. The platelet count (PLT), red blood cell (RBC) count, and white blood cell count (WBC) count were ascertained with the use of a fully automatic hematology analyzer.
Liver function: Preoperatively and one month postoperatively, 3 mL of fasting venous blood was drawn from both patient cohorts. Following centrifugation at 3500 r/min, the supernatant was collected for subsequent analysis. Serum albumin (ALB), TBIL, and aspartate transaminase (AST) levels were measured via enzyme-linked immunosorbent assay.
Quality of life: The Generic Quality of Life Inventory-74 questionnaire was used to evaluate the overall quality of life in the two groups preoperatively and one month postoperatively. This instrument comprises four dimensions, wherein so
Rebleeding and survival rates: All patients underwent biweekly follow-up appointments at the designated portal hy
The data analysis was performed with the assistance of SPSS 25.0 software. The measurement data are presented as the mean ± SD, while the enumeration data are presented as n (%). For normally distributed data, one-way analysis of variance and t tests were used, whereas for enumeration data analysis, the χ2 test was used. The rank sum test was per
The study cohort consisted of a total of 50 patients-29 males and 21 females-with an average age of 54.62 ± 7.17 years. Within the control cohort, there were 42 individuals-26 males and 16 females-with an average age of 55.18 ± 6.95 years. Statistical analysis revealed no significant differences between the two cohorts with respect to sex, age, or etiology of liver cirrhosis (P > 0.05) (Table 1).
Item | Study group (n = 50) | Control group (n = 42) | Z/t/χ2 | P value | |
Gender | Male | 29 (58.00) | 26 (61.90) | 0.145 | 0.704 |
Female | 21 (42.00) | 16 (38.10) | |||
Age (years) | 54.62 ± 7.17 | 55.18 ± 6.95 | 0.378 | 0.706 | |
Etiology of liver cirrhosis | Viral hepatitis | 28 (56.00) | 23 (54.76) | 0.000 | 0.989 |
Alcoholic hepatitis | 15 (30.00) | 14 (33.33) | |||
Other | 7 (14.00) | 5 (11.90) |
Preceding surgical intervention, the rates of absence, mild, moderate, and severe varices within the study group were 0.00% (0/50), 18.00% (9/50), 40.00% (20/50), and 42.00% (21/50), respectively. Compared to those of the control cohort, for which the incidence rates were 0.00% (0/42), 11.90% (5/42), 40.48% (17/42), and 47.62% (20/42), the differences were not significantly different (P > 0.05). Postsurgery, the study group exhibited rates of 38.00% (19/50), 32.00% (16/50), 18.00% (9/50), and 12.00% (6/50) for absence, mild, moderate, and severe varices, respectively. These rates were greater than those of the control group [9.52% (4/42), 50.00% (21/42), 23.81% (10/42), and 16.67% (7/42) (P < 0.05)] (Table 2).
Item | Study group (n = 50) | Control group (n = 42) | Z | P value | |
Prior to surgery | Absence | 0 (0.00) | 0 (0.00) | 0.533 | 0.465 |
Mild | 9 (18.00) | 5 (11.90) | |||
Moderate | 20 (40.00) | 17 (40.48) | |||
Severe | 21 (42.00) | 20 (47.62) | |||
One month postoperatively | Absence | 19 (38.00) | 4 (9.52) | 5.269 | 0.022 |
Mild | 16 (32.00) | 21 (50.00) | |||
Moderate | 9 (18.00) | 10 (23.81) | |||
Severe | 6 (12.00)a | 7 (16.67)a |
Before the surgical intervention, there were no substantial differences in the PVV or PVD between the two cohorts (P > 0.05). Postoperatively, the PVV increased, while the PVD decreased in the two groups, with the study cohort demon
Preoperatively, no statistically significant differences were observed in the PLT, RBC, or WBC between the two patient cohorts (P > 0.05). Postoperatively, the PLT and WBC counts were 134.17 ± 22.35 × 109/L and 5.54 ± 0.92 × 109/L, respectively, which were greater than the PLT (134.17 ± 22.35 × 109/L) and WBC (5.08 ± 0.86) counts, respectively, in the control group. This difference was statistically significant (P < 0.05). Nevertheless, with regard to RBC, the study cohort had an RBC count of 3.31 ± 0.65 × 1012/L, whereas the control cohort had an RBC count of 3.29 ± 0.67 × 1012/L; moreover, no marked difference was detected between the two groups (P = 0.885) (Table 4).
Item | Study group (n = 50) | Control group (n = 42) | t | P value | |
PLT (× 109/L) | Preoperatively | 84.37 ± 16.38 | 85.19 ± 15.92 | 0.242 | 0.809 |
Postoperatively | 134.17 ± 22.35a | 115.64 ± 19.15a | 4.225 | 0.001 | |
RBC (× 1012/L) | Preoperatively | 3.21 ± 0.72 | 3.18 ± 0.73 | 0.198 | 0.844 |
Postoperatively | 3.31 ± 0.65 | 3.29 ± 0.67 | 0.145 | 0.885 | |
WBC (× 109/L) | Preoperatively | 4.41 ± 0.75 | 4.39 ± 0.76 | 0.127 | 0.900 |
Postoperatively | 5.54 ± 0.92a | 5.08 ± 0.86a | 2.461 | 0.016 |
Preoperatively, there were no discernible differences in the serum ALB, TBIL, or AST levels between the two cohorts of patients (P > 0.05). Postoperatively, the patients in the study group had an ALB level of 32.41 ± 4.96 g/L, a TBIL level of 34.81 ± 7.79 μmol/L, and an AST level of 75.39 ± 9.81 U/L. The control group exhibited an ALB concentration of 33.74 ± 6.62 g/L, a TBIL concentration of 33.01 ± 8.11 μmol/L, and an AST concentration of 74.47 ± 8.25 U/L. No difference was detected between the two patient cohorts (P > 0.05) (Table 5).
Item | Study group (n = 50) | Control group (n = 42) | t | P value | |
ALB (g/L) | Preoperatively | 30.75 ± 6.24 | 31.29 ± 5.37 | 0.440 | 0.661 |
Postoperatively | 32.41 ± 4.96 ns | 33.74 ± 6.62 ns | 1.100 | 0.274 | |
TBIL (μmol/L) | Preoperatively | 33.16 ± 8.05 | 31.86 ± 6.92 | 0.822 | 0.413 |
Postoperatively | 34.81 ± 7.79 ns | 33.01 ± 8.11 ns | 1.083 | 0.282 | |
AST (U/L) | Preoperatively | 76.49 ± 7.17 | 77.28 ± 7.02 | 0.531 | 0.596 |
Postoperatively | 75.39 ± 9.81 ns | 74.47 ± 8.25 ns | 0.481 | 0.632 |
Preceding surgery, there were no differences in the scores on various dimensions of quality of life between the two cohorts (P > 0.05). Subsequent to surgery, the scores for each dimension of quality of life surpassed the preoperative values in both groups. Specifically, within the study cohort, the social function, psychological function, physical function, and material life condition scores were 78.36 ± 3.81, 70.16 ± 5.83, 65.25 ± 7.39, and 63.81 ± 6.78, respectively. These scores were all higher than those within the control cohort, which were 75.50 ± 3.66, 65.28 ± 5.19, 60.67 ± 6.98, and 60.62 ± 5.75, respectively. The differences were statistically significant (P < 0.05) (Table 6).
Item | Study group (n = 50) | Control group (n = 42) | t | P value | |
Social function | Preoperatively | 49.89 ± 4.17 | 49.92 ± 4.35 | 0.034 | 0.973 |
Postoperatively | 78.36 ± 3.81a | 75.50 ± 3.66a | 3.651 | < 0.001 | |
Psychological function | Preoperatively | 48.30 ± 5.07 | 48.85 ± 4.96 | 0.523 | 0.602 |
Postoperatively | 70.16 ± 5.83a | 65.28 ± 5.19a | 4.203 | < 0.001 | |
Physical function | Preoperatively | 45.69 ± 6.58 | 46.41 ± 6.75 | 0.517 | 0.607 |
Postoperatively | 65.25 ± 7.39a | 60.67 ± 6.98a | 3.037 | 0.003 | |
Material life condition | Preoperatively | 46.29 ± 5.11 | 46.57 ± 5.13 | 0.261 | 0.794 |
Postoperatively | 63.81 ± 6.78a | 60.62 ± 5.75a | 2.407 | 0.018 |
One year after surgery, the rebleeding rate within the study group was 22.00% (11/50), which was significantly lower than the rebleeding rate observed in the control group (42.86%; 18/42) (P < 0.05). The one-year survival rate within the study cohort was 62.00% (31/50), and in contrast to the survival rate of 52.38% (22/42) in the control group, the difference was not statistically significant (P > 0.05) (Table 7).
Item | Study group (n = 50) | Control group (n = 42) | χ2 | P value |
Re-bleeding rate | 11 (22.00) | 18 (42.86) | 4.600 | 0.032 |
Survival rate | 31 (62.00) | 22 (52.38) | 0.865 | 0.352 |
In the context of liver cirrhosis, hepatic tissues undergo diffuse fibrosis, culminating in the impedance of portal venous drainage, augmented pressure, and the initiation of EGVB[8]. While pharmacological interventions can proficiently ma
TIPS placement is classified as an interventional therapy and involves the establishment of a shunt channel between the portal and hepatic veins to embolize varicose veins. This process reduces portal vein pressure and alleviates variceal severity, effectively controlling bleeding[14-16]. PTVE is also categorized as an interventional therapy that utilizes liquid embolism agents to occlude varicose veins and employs a spring coil to embolize the main trunk of the gastric coronary vein, achieving hemostasis[17-19]. In this research, the postoperative variceal conditions within the study cohort were superior to both the preoperative conditions and the control group, suggesting that TIPS may be more efficacious at ameliorating variceal conditions in patients with cirrhotic EGVB. Concerning these rationales, PTVE accomplishes hemo
In summary, in the management of EGVB in cirrhotic patients, TIPS placement is an effective and safe therapeutic option. It dramatically mitigates the severity of varices and hemodynamics, aiding cirrhotic patients in alleviating their condition, averting the onset of complications, elevating the quality of life, and attaining superior treatment outcomes. Our study established a theoretical foundation for advocating TIPS as a primary intervention for patients afflicted with cirrhosis complicated by EGVB. However, it is essential to acknowledge the limitations inherent in our investigation. First, this study adopted a retrospective design rather than a randomized controlled trial, thereby introducing the potential for se
The transjugular intrahepatic portosystemic shunt (TIPS) is an important method for treating upper gastrointestinal bleeding caused by portal hypertension in patients with liver cirrhosis. Nevertheless, additional research endeavors are needed to elucidate the precise therapeutic efficacy of TIPS for managing variceal bleeding and to discern its implications for patient prognosis.
The primary objective of this study was to scrutinize the efficacy of TIPS for the management of esophageal-gastric variceal bleeding (EGVB) in individuals with cirrhosis and to evaluate its consequential influence on patient prognosis. This study endeavors to meticulously assess the advantageous outcomes associated with TIPS, aiming to furnish evi
Through in-depth research on the therapeutic effect and prognosis of TIPS placement, this paper aimed to provide additional comprehensive information for clinical doctors to better guide treatment decision-making and improve disease management.
A retrospective study was undertaken involving 92 patients afflicted with cirrhotic EGVB who were admitted to our hospital between September 2020 and September 2022. The patient cohort was dichotomized into two groups based on distinct treatment modalities: The TIPS treatment group (n = 50) and the percutaneous transhepatic variceal embolization treatment group (n = 42). Comparative analyses were also conducted on the varicosity status, hemodynamic parameters, and quality of life of the patients in both groups, both preoperatively and postoperatively. Additionally, a comparative examination was undertaken to evaluate the 1-year rebleeding and survival rates between the two treatment groups.
Postoperative varicosity improved in both groups, with the study group showing better outcomes. Portal vein flow velocity increased and portal vein diameter decreased postoperatively, again with the study group demonstrating su
TIPS treatment has demonstrated robust efficacy in the management of cirrhotic EGVB by significantly diminishing varicosity and enhancing hemodynamics in affected patients. This intervention not only represents a safer alternative but also contributes to a more favorable prognosis in this clinical context.
Cirrhosis, as a grave and chronic ailment, profoundly influences both the quality of life and the life expectancy of afflicted individuals. Consequently, a thorough exploration of treatment modalities and prognosis pertaining to EGVB induced by cirrhosis is of paramount importance, as this review offers invaluable insights and reference points for clinicians engaged in clinical practice.
Provenance and peer review: Unsolicited article; Externally peer reviewed.
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Specialty type: Gastroenterology and hepatology
Country/Territory of origin: China
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P-Reviewer: Wagner-Skacel J, Austria S-Editor: Fan JR L-Editor: A P-Editor: Xu ZH
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