[Intrahepatic portasystemic shunt as a salvage treatment of uncontrolled hemorrhage caused by rupture of esophageal varices in patients with liver cirrhosis].

OBJECTIVES

Patients who continue to bleed despite standard treatment including sclerotherapy have a poor prognosis with a mortality up to 90%. TIPS has been used as salvage therapy for ruptured oesophageal varices refractory to all conventional treatments.

METHODS

During a period of 3 years, 65 cases of variceal rupture in cirrhotic patients were treated at our center and a salvage TIPS was performed in 15 patients (23%) for active uncontrolled hemorrhage despite standard medical and endoscopic treatment (Child A, 2; B, 1; C, 12). The procedure was technically successful in all cases and hemorrhage was controlled in 11/15 cases (73%).

RESULTS

Three patients died of persistent bleeding and liver failure; one case of moderate and persistant hemorrhage was controlled by transfusions until bleeding ceased. This patient was transplanted 3 months after TIPS and is alive 3.5 years later. Two patients had early recurrence of hemorrhage due to TIPS thrombosis. These 2 cases of thrombosis were deobstructed but both patients died of liver failure despite bleeding control. Overall, 7 patients died within 60 days of TIPS by hemorrhage and/or liver failure. One patient died of liver failure 7 months after TIPS following surgery for aortic aneurysm. None of the 8 survivors after 60 days had bleeding recurrence or encephalopathy. Actuarial survival was 42.7 +/- 14% at 1 and 2 years.

CONCLUSION

TIPS is currently the alternative of choice for persistant bleeding refractory to standard management. However despite control of hemorrhage, operative mortality remains high due to the underlying severe cirrhosis.