Treatment of refractory ascites using transjugular intrahepatic portosystemic shunt (TIPS) : A caution

• Published in: Digestive diseases and sciences 1997, Vol.42 (1), p.161-166
• Main Authors: MARTINET, J.-P, FENYVES, D, LEGAULT, L, ROY, L, DUFRESNE, M. P, SPAHR, L, LAFORTUNE, M, POMIER-LAYRARGUES, G
• Format: Article
• Language: English
• Subjects: Aged; Aldosterone - blood; Ascites - etiology; Ascites - metabolism; Ascites - mortality; Ascites - surgery; Biological and medical sciences; Creatinine - blood; Diuretics - adverse effects; Diuretics - therapeutic use; Female; Hepatic Encephalopathy - etiology; Humans; Hypertension, Portal - complications; Liver Cirrhosis - complications; Liver, biliary tract, pancreas, portal circulation, spleen; Male; Medical sciences; Middle Aged; Pilot Projects; Portasystemic Shunt, Transjugular Intrahepatic; Prospective Studies; Recurrence; Renin - blood; Sodium - urine; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Survival Rate
• ISSN: 0163-2116; 1573-2568
• DOI: 10.1023/A:1018861827399

Ascites becomes refractory to medical treatment in nearly 10% of cirrhotic patients, who then require repeated large-volume paracentesis. In this prospective study we evaluated the use of transjugular intrahepatic portosystemic shunt (TIPS) in 30 patients with refractory ascites. TIPS was successful in all and resulted in a 54% reduction in portacaval gradient (from 22.8 +/- 0.8 to 10.4 +/- 0.6 mm Hg). Ascites became easily controlled with diuretics in 26 patients following TIPS. Ascites recurrence associated with shunt stenosis was observed during follow-up in eight patients; revision could be undertaken in five of them and resulted in good control of ascites. In responders, a marked decrease in plasma aldosterone and renin activity, a reduction in serum creatinine, and a rise in urinary sodium excretion were observed. Creatinine and inulin clearances improved significantly; PAH clearance remained unchanged. However, new-onset or worsening hepatic encephalopathy was seen in 14 patients. Severe disabling chronic encephalopathy occurred in five patients; it could be reversed successfully by balloon occlusion of the shunt in three. The cumulative survival rate was 41 and 34% at 1 and 2 years, respectively. In summary, TIPS can control refractory ascites in a majority of patients but is associated with a high rate of chronic disabling HE. In addition, the survival rate is poor. Randomized trials are needed to evaluate the exact role of TIPS in the management of refractory ascites. It is unlikely to improve survival but can ameliorate quality of life in nontransplant candidates and be useful as a bridge to transplantation, in particular, to improve denutrition associated with longstanding tense ascites.