Suntul portosistemic transjugular intrahepatic (TIPS) in ascita refractara si hidrotoraxul refractar (partea II)

01.07.2007, 01:00

INDICATII SPECIFICE ALE TIPS

ASCITA REFRACTARA

Ascita refractara se defineste ca ascita ce nu poate fi mobilizata prin dieta hiposodata si tratament diuretic adecvat sau intoleranta la terapia diuretica optimala, cu complicatii conexe importante: encefalopatie hepatica, dezechilibre ale electrolitilor sau insuficienta renala [19, 20].

Ascita refractara este o complicatie majora a cirozei hepatice si se asociaza cu o supravietuire extrem de redusa [20, 21]. Pentru tratamentul sau au fost propuse mai multe optiuni. Terapia standard consta in paracenteze repetate asociate cu infuzia concomitenta de albumina; suntul peritoneovenos, TIPS si transplantul hepatic sunt alternativele propuse. Pe baza studiilor disponibile pana in prezent TIPS si-a dovedit eficacitatea in tratamentul ascitei refractare, dar in ceea ce priveste ameliorarea supravietuirii acestor bolnavi, rezultatele sunt contradictorii [22].

Eficacitatea TIPS in controlul ascitei se coreleaza cu reducerea semnificativa a hipertensiunii portale si a fost verificata in studii efectuate pe un numar important de pacienti [14, 23, 24].

La pacientii cu hemoragii variceale repetate, scopul TIPS este reprezentat de reducerea gradientului portosistemic sub 12 mmHg [23, 25], insa nu exista date despre reducerea optima a acestui gradient pentru controlul ascitei refractare; in general se considera acceptabila reducerea cu 40-50% a gradientului initial [1]. Un gradient portosistemic mare inainte de TIPS se pare ca este factor de raspuns favorabil la pacientii cu ascita refractara [26].

Pe de alta parte, reducerea fluxului portal poate duce la agravarea functiei hepatice si inducerea insuficientei hepatice [1].

Nu exista criterii clare care sa indice cand un pacient non responsiv la terapia diuretica /complicatii ale acesteia trebuie tratat prin paracenteze repetate si albumina sau cand acesta ar trebui sa beneficieze de un TIPS. Atitudinea recomandata de majoritatea specialistilor este de a incerca intai terapia standard: 3-4 paracenteze mari asociate cu infuzia de albumina pot recupera pacientul aducandu-l in stadiul responsiv la tratament diuretic, daca nu, pentru un interval de 2-3 luni se pot repeta paracentezele largi la intervale mai mari sau mai mici, dupa care, daca in continuare este nevoie de mai mult de 2 paracenteze largi/luna se considera ca tratamentul altereaza foarte mult calitatea vietii pacientului si atunci devine prioritara indicatia de TIPS.

TIPS este de asemenea de ales in cazul in care survin complicatii aditionale ascitei refractare cum sunt : peritonite bacteriene spontane recurente, hernii ombilicale mari, hidrotorax recurent sau sindrom hepatorenal [14, 16, 27].

Pacientii cu encefalopatie hepatica si cei cu bilirubina>3mg/dl vor fi exclusi pentru TIPS.

Transplantul hepatic ramane o indicatie ferma la pacientii cu ciroza hepatica si ascita refractara, insa se poate realiza practic la un numar redus de pacienti in primul rand datorita disponibilitatii reduse dar si altor factori cum sunt continuarea abuzului de alcool, asocierea hepatocarcinomului, diverse infectii. Totusi, la cei care pot beneficia de un transplant hepatic, montarea prealabila a unui TIPS nu are consecinte negative , ci dimpotriva permite un timp de asteptare mai lung si nu impieteaza tehnic procedura.

Criteriile de responsivitate variaza: lipsa ascitei la 3 luni/1 an documentate ultrasonografic sau criterii clinice: controlul ascitei (ceea ce inseamna ca nu mai este nevoie de paracenteze) sau absenta recurentei ascitei. Astfel, daca luam in considerare primul criteriu de responsivitate, se apreciaza ca intre 38-61% din pacienti nu mai au ascita la 3 luni dupa montarea TIPS [1, 14, 15, 16, 28]. Intr-o metaanaliza recenta se apreciaza ca aproximativ 50% din bolnavii la care s-a montat un TIPS nu au ascita la 1 an, comparativ cu doar 11% din cei la care tratamentul a continuat cu paracenteze plus albumina [22].Intr-un alt studiu, unde lipsa de raspuns a fost apreciata ca recurenta clinica a ascitei, circa 58% din pacienti au inregistrat un raspuns favorabil, comparativ cu 20% in grupul celor tratati cu paracenteze si albumina [29].

Supravietuirea in lipsa transplantului hepatic la pacientii cu TIPS pentru ascita refractara este in general intre 43-70% [14, 30].

HIDROTORAXUL HEPATIC REFRACTAR

Este o complicatie rara, afectand 5-10% din pacientii cu ciroza hepatica si ascita. Se datoreaza migrararii fluidului ascitic in cavitatea toracica prin defecte diafragmatice, conform unui gradient presional.

Managementul clinic al acestor pacienti este similar cu al celor cu ascita. Pacientii cu hidrotorax recurent/persistent in ciuda restrictiei sodice si tratamentului diuretic maximal, care necesita toracocenteze repetate, intra in categoria celor cu hidrotorax refractar. Acesti pacienti au de obicei ascita moderata, dar necesita toracocenteze repetate pentru eliminarea lichidului pleural si ameliorarea dispneei.

Similar peritonitei bacteriene spontane, lichidul pleural se poate infecta si poate constitui o cauza de refractaritate. Acest lucru se constata la aproximativ 13% din pacientii cu hidrotorax refractar [31].

Studiile realizate pana in prezent au aratat ca TIPS este eficace la 70-80% din pacienti prin disparitia hidrotoraxului la 3 luni/1an sau lipsa nevoii de toracocenteze. Supravietuirea pacientilor se pare ca este similara cu a celor fara TIPS [ 32, 33].

Pacientii cu hidrotorax refractar si indicatie de TIPS sunt considerati de asemenea candidati pentru transplantul hepatic, TIPS fiind utilizat ca o punte in asteptarea acestuia.

Bibliografie

1. Rossle M, Grandt D. TIPS an update. Best Practice & Research Clinical Gastroenterology 2004; 18(1): 99-123
2. Shiffman ML, Jeffers L, Hoofnagle JH. The role of transjugular intrahepatic portosystemic shunt for treatment of portal hypertension and its complications: a conference sponsored by the National Digestive Disease Advisory Board. Hepatology 1995; 22: 1591-7
3. Spencer EB, Cohen DT, Darey MD. Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax. Journal of Vascular and Interventional Radiology 2002; 13: 385–90
4. Perello A, Garcia-Pagan JC, Gilabert R. TIPS is a useful long-term derivative therapy for patients with Budd–Chiari syndrome uncontrolled by medical therapy. Hepatology 2002; 35: 132–9
5. Siegerstetter V, Deibert P, Ochs A. Treatment of refractory hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients. European Journal of Gastroenterology and Hepatology 2001; 13: 529–34
6. Brensing KA, Textor J, Perz J. Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study. Gut 2000; 47: 288–95
7. Brensing KA, Textor J, Strunk H. Transjugular intrahepatic portosystemic stent-shunt for hepatorenal syndrome. Lancet 1997; 349: 697
8. Rosado B, Kamath PS. Transjugular intrahepatic portosystemic shunt: an update. Live Transpl 2003; 9: 207-17
9. van Buuren HR, ter Borg PC. Transjugular intrahepatic portosystemic srhunt (TIPS): indications and long-term patency. Scand J Gastroenterol Suppl 2003; 239: 100-4
10. Charon JP, Alaeddin FH, Pimpalwar SA. Results of a retrospective multicenter trial of the Viatorr Expanded Polytetrafluoroetylene-covered Stent-Graft for transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 2004; 15/1219-30
11. Lind CD, Malisch TW, Chong WK. Incidence of shunt occlusion or stenosis following transjugular intrahepatic portosystemic shunt placement. Gastroenterology 1994; 106:1277–83
12. Rossle M, Siegerstetter V, Huber M. The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art. Liver 1998; 18: 73–89
13. Haskal ZJ, Martin L, Cardella JF. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. SCVIR Standards of Practice Committee. Journal of Vascular and Interventional Radiology 2001; 12:131–6
14. Roosle M, Ochs A, Gulberg V. A comparison of paracentesis and transjugular intrahepatic portosystemic shunting in patients with ascites. N Eng J Med 2000; 342: 1701-7
15. Lebrec D, Giuily N, Hadengue A. Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial. J Hepatol 1996; 25: 135-44
16. Gines P, Uriz J, Calaborra B. Transjugulat intrahepatic portosystemic shunting versus paracentesis plus albumin for refractory ascites in cirrhosis. Gastroenterology 2002; 123: 1839-47
17. Kochar N, Tripathi D, Ireland H. Transjugular intrahepatic portosystemic stent shunt (TIPSS) modification in the management of post-TIPSS refractory hepatic encephalopathy. Gut 2006; 55: 1617-23
18. Silva RF, Arroyo PC, Duca WJ. Complications following transjugular intrahepatic portosystemic shunt: a retrospective analysis. Transplantation Proceedings 2004; 36: 926-8
19. Arroyo V, Gines P, Gerbes AL. Definition and diagnostic criteria of refractory ascites and hepatorenal syndrome in cirrhosis. International Ascites Club. Hepatology 1996; 23: 164–76
20. Rosemurgy AS, Zervos E, Clark WC. TIPS versus Peritoneovenous Shunt in the treatment of medically intractable ascites. A Prospective Randomized Trial. Anals of Surgery 2004; 239(6): 883-91
21. Guardiola J, Xiol X, Escribia JM. Prognosis assessment of cirrhotic patients with refractory ascites treated with a peritoneovenous shunt. Am J Gastroenterol 1995; 90: 2097–102
22. Delterne P, Mathurin P, Dharancy S. Transjugular intrahepatic portosystemic shunt in refractory ascites: a meta-analysis. Liver International 2005; 25: 349-56
23. Sanyal AJ, Freedman AM, Luketic VA. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997; 112: 889-98
24. Boyer T. Transjugular intrahepatic portosystemic shunt: Current Status. Gastroenterology 2003; 124: 1700-10
25. Garcia-Tsao G, Groszmann RJ, Fisher RL. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 1985; 5: 419-24
26. Satheesh N, Singh R, Yoselewitz M. Correlation between portal/hepatic vein gradient and response to transjugular intrahepatic portosystemic shunt creation in refractory ascites. J Vasc interv Radiol 2004; 15: 1431-4
27. Valeriano V, Salerno F, Merli M. TIPS versus paracentesis in the treatment of refractory ascites: preliminary result of a randomized controlled trial. Gastroenterology 2000; 118: A1090
28. Sanyal A, Genning C, Reddy KR. The North American Study for the treatment of refractory ascites. Gastroenterology 2003; 124: 634-41
29. Albillos A, Banares R, Gonzalez M. A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. Journal of Hepatology 2005; 43: 990-6
30. Membreno F, Baez AL, Pandula R. Differences in long term survival after transjugular intrahepatic portosystemic shunt for refractory ascites and variceal bleed. Journal of Gastroenterology and Hepatology 2005; 20: 474-81
31. Bozkurt S, Stein J, Teuber G. Hepatic hydrothorax. Z Gastroenterol 2005; 43: 1319-28
32. Siegerstetter V, Deibert P, Ochs A. Treatment of refractory hydrothorax with transjugular intrahepatic portosystemic shunt: long term result in 40 patients. European Journal of Gastroenterology and Hepatology 2001: 13: 529-34
33. Spencer EB, Cohen DT, Darey MD. Safety and efficacy of transjugular intrahepatic portosystemic shunt for the treatment of hepatic hydrothorax. Journal of Vascular and Interventional Radiology 2002; 13: 385-90

EMCB
https://arhiva.emcb.ro/article.php?story=20070629174234283