Patients with congenital liver fibrosis and recurrent variceal bleeding with good liver function (normal LFT) can be ideal patients to submit to porto-systemic shunt if liver hardness make unavailable the TIPS procedure. However, sometime some patients with acute Budd-Chiari syndrome waiting for exclusion diagnosis of malignancy can be still considered for shunting procedure if they are actively bleeding despite endoscopic variceal sclerosis and present refractory ascites. Congenital portal thrombosis in children with preserved liver function but with active bleeding varices is still a good indication to Meso-Rex shunting procedure? What do you think about?
It may be recommended in few selected cases, as a temporary measure and a bridge before transplantation
Thank you so much Luis, I am trying to define some clear indications in that way, as a bridge to Liver Tx or as therapeutic option when no active Liver tx program is available.
In Eastern Asian countries there still exists -Non cirrhotic portal fibrosis,where the LFT are normal ,liver is not cirrhotic.These pts do well with poto venous shunts .Ofcourse after the wide practice of EVL, pharmaco therapy and TIPS,the indications surgery have become less and less.
i believe that patients with portal hypertension without liver cirrhosis are the ideal patients, patients with cirrhosis and recurrent variceal bleeding with good liver function (normal LFT) can be ideal patients to submit to porto-systemic shunt i
I fully agree with the comments. Patients with pre-hepatic portal hypertension or with cirrhosis and normal LFT and recurrent variceal bleeding despite adequate medical and endoscopic therapies are good indications for surgical shunting.
I agree fully. Most cases of prehepatic portal hypertension like congenital hepatic fibrosis, Non cirrhotic portal fibrosis, portal vein thrombosis are candidates for surgical shunt if medical, endoscopic or interventional radiologic [TIPSS] fails and liver function is well preserved. As regards acute or chronic Budd Chiari syndrome, Shunt should only be considered if inferior vena cava is patent (as happens in South east Asia). It may be appropriate for hepatic venous outflow tract obstruction (HVOTO) as happens more in the West only if medical thrombolysis fails.
Dear Aseni,
Yes of course there is still a role for porto-systemic shunting procedures in countries with an active program of liver transplantation. Some cases have recurrent variceal bleeding while they have good liver status, like those with PVT and those with CHF. Also, in those with cirrhotic liver who are indicated for liver transplant, porto-systemic shunting could be a palliative measure if no availability of a donor or when parents are refusing proceeding to liver transplantation.
Porto-systemic shunting is still a valid options for, as previously commentrd here, congenital portal fibrosis, idiopathic liver fibrosis among others when a tips is contraindicated or technically imposible. Nevertheless, a lot of these patients will requiere a liver trasplant the sooner or later.
I also agree with Dr Cristiano since not all sunting procedures are presumed to be patent for ever. We have some few patients with liver fibrosis and normal LFT with patent shunt (presumibly patent) after a decade from the surgical procedure; however how long they wil never bleed from gastroesophageal varices nobody knows. Somebody knows or have some information about the mean time of patency shunt after meso-Rex shunting procedure in children with portal thrombosis? Thank you!
Thank you Dr. Samad, this is an interesting issue. Can you recommend us some interersting clinical reports about Porto-systemic shunting procedure after liver transplantation?
I agree that indications are diminishing with the use of TIPS but we can’t mix up things. TIPS has its role in diseased/cirrhotic livers with liver dysfunction frequently as a bridge to transplantation; however, it has no indications in healthy livers or diseased livers with well preserved function. In cases of normal liver and prehepatic portal hypertension or deceased livers with well preserved function and repeated bleeding due to portal hipertensión, shunting surgery has a role.
I fully agree with Dr. Mikel Gastaca, TIPS has quite undiscussed indications above all as a brigde to liver Tx. However, TIPS has no indications in pts with portal hypertension secondary to liver fibrosis with good LFT or in children with portal thrombosis. TIPS can be challenging or even impossible in Budd Chiari Syndrome.
There are few indications today but in well selected patients still has a role
Portosystemic Shunt may also be required as an emergency procedure in some cases of variceal bleeding uncontrollable by other methods.
I still think portosystemic shunt have a very specific indications in very selected patients.
While liver trasplant became a standard of care of many disease, the indication for shunting procedures decreased but not dissapeared. However certain types of procedures like the spleno-renal vascular shunt did not decraeses as much as for example porto-cava. Possibly as a result of a deeper understanding of the portal haemodinamycs and the development of endovascular techniques
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