title: Conversion of failed transjugular intrahepatic portosystemic shunt to distal splenorenal shunt in patients with Child A or B cirrhosis.
abstract: OBJECTIVE
  The authors demonstrate the feasibility of converting failed transjugular intrahepatic portosystemic shunt (TIPS) to distal splenorenal shunt (DSRS) in patients with good hepatic reserve for long-term control of variceal bleeding.
  
  
  BACKGROUND
  TIPS is an effective method for decompressing the portal venous system and controlling bleeding from esophageal and gastric varices. TIPS insufficiency is, however, a common problem, and treatment alternatives in patients with an occluded TIPS are limited because most have already failed endoscopic therapy.
  
  
  METHODS
  The records of five patients who underwent conversion from TIPS to DSRS because of TIPS failure or complication in the past 36 months were reviewed.
  
  
  RESULTS
  Four patients had ethanol-induced cirrhosis and one patient had hepatitis C virus cirrhosis. Three patients were Child-Pugh class A and two were class B. All patients had excellent liver function, with galactose elimination capacities ranging from 388 to 540 mg/min (normal 500 +/- 100 mg/min). The patients had TIPS placed for acute (2) or sclerotherapy-resistant (3) variceal hemorrhage. All five TIPS stenosed 3 to 23 months after placement, with recurrent variceal hemorrhage and failed TIPS revision. One patient had stent migration to the superior mesenteric vein that was removed at the time of DSRS. All five patients underwent successful DSRS, and none have had recurrent hemorrhage 18 to 36 months after surgery.
  
  
  CONCLUSIONS
  TIPS provides inadequate long-term therapy for some Child-Pugh A or B patients with recurrent variceal hemorrhage. TIPS failure in patients with good liver function can be salvaged by DSRS in many cases.
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
authors.forename: N
authors.initials: N
authors.lastname: Selim
authors.forename: M J
authors.initials: MJ
authors.lastname: Fendley
authors.forename: T D
authors.initials: TD
authors.lastname: Boyer
authors.forename: J R
authors.initials: JR
authors.lastname: Galloway
authors.forename: G D
authors.initials: GD
authors.lastname: Branum
mesh_terms: D000328:Adult; D000465:Algorithms; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D005548:Foreign-Body Migration / Q000209:etiology; D006471:Gastrointestinal Hemorrhage / Q000150:complications / Q000601:surgery*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000009:adverse effects; D011183:Postoperative Complications; D012008:Recurrence; D012189:Retrospective Studies; D013164:Splenorenal Shunt, Surgical; D015607:Stents; D017211:Treatment Failure