Elsevier

Transplantation Proceedings

Volume 51, Issue 1, January–February 2019, Pages 41-43
Transplantation Proceedings

26th Congress of the Spanish Liver Transplantation Society
Candidates for liver transplantation
Use of Peritoneovenous Shunt for the Management of Refractory Ascites

https://doi.org/10.1016/j.transproceed.2018.04.089Get rights and content

Abstract

Background

Guidelines for the management of refractory ascites (RA) recommend transjugular intrahepatic portosystemic shunting (TIPS), diuretics, and paracentesis as the main strategies, discouraging use of surgical peritoneovenous shunts (PVSs). However, PVSs, including both Denver (DS) or saphenoperitoneal (SPS) modalities, may still have indications. Herein we report our experience with PVSs in the context of modern surgical and anesthetic management.

Methods

In our unit, PVSs are offered to patients with ascites refractory to diuretics in which TIPS are contraindicated. Heart function and spontaneous bacterial peritonitis must be assessed before surgical indication.

Results

Seven procedures were performed on 5 patients (6-DS, 1-SPS) in 2013. Their mean age was 61 (range, 54–68) years. In 3 patients, the indication was RA without options for liver transplant; 2 patients were on the waiting list for liver transplantation, which were performed to improve renal function and quality of life (QOL). The median hospital stay was 6.5 (range, 3–12) days. All patients were alive after 12 months. One patient died 2 years after the first DS and another later died due to liver insufficiency with patency of the DS. The ascites was well-controlled in 4 of 5 patients at up to 48 months of follow-up. Decreases in diuretics doses, proper weight maintenance, and a dramatic improvement in QOL (measured by a modified Ascites Symptom Inventory-7 [ASI-7] test) were observed after the procedures.

Conclusion

PVSs are useful for the treatment of patients with RA who develop resistance to common therapies, leading to a major improvement in QOL. These surgical procedures should be included in the armamentarium of experienced liver surgeons.

Section snippets

Indications for PVS

At our center, PVSs (DS or SPS) are offered to patients with RA due to chronic liver failure, who have become refractory to diuretics treatment and with contraindications to transjugular intrahepatic portosystemic shunting (TIPS) due to encephalopathy. Patient candidates may or may not be on a transplant waiting list. Renal function, anesthetic risk, and cardiac output are fully screened in all patients. The diagnosis of heart insufficiency is a contraindication for PVS as this procedure may

Results

From 2013, 7 PVS procedures were performed at our center on 5 patients. Six were DS procedures and 1 was an SPS procedure. The main cause of end-stage liver disease was alcohol abuse. In 2 cases, PVS was indicated to improve renal function and QOL before the liver transplant and in 3 cases to control the RA in patients with no indication for transplantation. The mean age was 61 (range, 54–68) years. In 1 case, surgery was accompanied by inguinal hernia repair due to a giant hernia that led to

Discussion

Current guidelines [7] consider intensive diuretics treatment with additional dietary sodium restriction and large-volume paracentesis as the primary treatment options for patients with refractory ascites. However, the negative impact on systemic hemodynamics and renal function are the main adverse events associated with these strategies. TIPS is a viable treatment option in chronic disease patients, but may be associated with higher rates of hepatic encephalopathy. Both LVP and TIPS may lead

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Cited by (6)

M.D.A., R.C., and I.G.-L. have contributed equally to this study.

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