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TRANSCRIPT
SURGICAL TREATMENT OF REFRACTORY ASCITES
BYPROF/ GOUDA ELLABBAN
S.C.U. HOSPITAL
• Poor prognostic sign in cirrhotic patients.
• 50% Of cirrhotics develop ascites within 10 years.
• 15% are refractory to standard medical therapy.
• 50% of ascitic patients succumb in 2 years.
Ascites
Ascites
• Most commonly a result of decompensated liver disease.
• Etiology of ascites can be classified on the basis of SAAG (Serum ascites albumin gradient calculated by serum albumin-ascitic albumin.
• Gradient≥ 1.1 indicate portal hypertension related cause
• High gradient≥ 1.1– cirrhosis– congestive heart failure– venoocclusive disease– Budd chiari syndrome– Portal vein thrombosis– Myxedema– Metastatic liver disease
• Low Gradient (<1.1)– Peritoneal
carcinomatosis– pancreatic ascites– Biliary ascites– Nephrotic syndrome– Chylous ascites– Serositis (connective
tissue diseases)– Infection (TB, fungal,
HIV, Whipples ds)
Systemic effects• Preascites stage
– Renal sodium handling is abnormal although no overt retention is noted
– Retention of sodium occurs as a homeostatic mechanism to compensate for increased capacity of splanchnic area
– An impaired ability to excrete free water is noted– Increased total body water relative to sodium
results in dilutional hyponatremia.
Renal function abnormalities• Sodium retention• water retention• renal hypoperfusion• factors responsible for renal dysfunction include
• Extrarenal factors– Renin angiotensin-
aldosterone system– Sympathetic nervous system– Endothelin– Atrial natriuretic peptide
• Intrarenal factors– Arachidonic acid– Nitrous oxide– Kallikrein-kinin system– Adenosine– Renin-angiotensin system
Theories of ascites formation
• Underfill theory• Overfill theory• Peripheral arterial vasodilation theory
Underfill theory
• Loss of intravascular volume secondary to sequestration of ascitic fluid was believed to be a primary event,
• Secondary activation of compensatory pathways such as renin angiotensin resulted in perpetuation of ascites.
• Not accepted as there is evidence indicating expanded plasma volume in cirrhosis
Overflow theory
• Explained ascites as a consequence of sodium and water retention which were considered primary events
Peripheral arterial vasodilation hypothesis
Portal hypertension
Splanchnic arterial vasodilation
Stimulation of Sympathetic nervous system, renin angiotensin and non-osmotic ADH
Sodium and water retention
Normalized effectivearterial blood volume
No ascites
Disease progression
Lack of normalization of EABV
Ascites
Hormonal mechanism
Splanchnic and peripheral vasodilation
Effective plasma volume ↓
Volume receptors ↑
Renin↑
Angiotensin II
Aldosterone
Sympathetic↑ Renal E2↓prostaglandin
Kallikreinkinin
system↓
Natriureticfactor
Increased tubular Na reabsorption
Treatment• Sodium restriction in diet• Diuretics: Potassium sparing, Loop diuretics• Water restriction if hyponatremia (<130meq/l)
occurs• Large volume paracentesis• Peritoneovenous shunts• Saphenoperitonal shunting• Transjugular intrahepatic portosystemic shunt
(TIPS)• Transplantation
Refractory ascites
• Prolonged history of ascites unresponsive to
400 mg of Spironolactone or 30 mg amiloride
plus up-to 120 mg of Furosemide daily for 2
wks
• Patients who can not tolerate diuretics.
Refractory ascitesComplications of medical therapy
•Peritonitis •Malnutrition•Hypovolaemia•Hyponatraemia•Electrolytes imbalance•Reduced renal blood flow•Renal failure
Refractory ascites
Treatment objectives:
• Improve nutritional & electrolyte balance.•Eliminate risk of SBP.•Relieve dyspnea.• Improve mobility.• Increase circulatory blood flow.• Increase renal blood flow & diuresis.•Reduce hospitalization.
Peritoneo-Venous Shunting
Begun in 1970’sTransfer ascitic fluid into
venous circulation
•Hyde Shunt•Holter Valve•LeVeen Shunt•Denver Shunt
Peritoneo-Venous Shunting
Transfer Ascitic Fluid into Venous Circulation
Benefits of Shunting
• Increases blood volume• Retains nutrients & electrolytes• Increase renal blood flow• Increases diuresis • Weight loss & girth reduction
Peritoneo-Venous Shunting
Additional benefits: Cirrhotic ascites*
Increases natriuretic response to diuretics.
Reduces activity of the renin & angiotensin.
Reduces sodium retention.
Peritoneo-Venous Shunting
Wash The shunt with Heparinized Saline
Peritoneo-Venous Shunting
Exposure of Internal Jugular VeinAbdominal IncisionCreation of Subcutaneous TunnelComplete Paracentesis
Partially replacement with SalineTight Peritoneal ClosurePlacement of Venous Catheter in SVCPurse string of IJVSpontaneous Shunt Function
Peritoneo-Venous Shunting
Confirm Placement at Cavo-atrial JunctionMarking Valve Position
Peritoneo-Venous ShuntingPossible complications
Shunt occlusion
Infection
Disseminated intravascular coagulation
Fluid overload
SVC thrombosis
Conclusion
PV Shunting is a minor surgical procedure.Careful selection of patients is mandatory. Despite high rate of blockage (20%) :
EasySafeEffective
A therapeutic option for RA in decompensated cirrhotic patients.
Peritoneo-Venous Shunting
TRANSJAGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNT (TIPS)
TIPS IN REFRACTORY ASCITESTransjugular portacaval shunt: TIPS
Effective on refractory ascites
More effective than paracentesis in control of ascites
More encephalopathy than paracentesis
Required the control of permeability of shunts
Same survival
Risk of liver failure in Child C patients
Well supported in patients with preserved liver
function.
Venous access through I.J.vein
Insertention of the sheath into the hepatic vein
Puncture of the portal vein
Advancement of the guide wire into the portal vein
Balloon dilatation of shunt tract
Placement of the stent
TIPS : COMPLICATIONS
• Complications related specifically to TIPS procedure.
• Complications related to puncture site.
• Complications related to portosystemic shunting.
• Complications related to transhepatic portal venous canulation and dilatation.
Gouda Ellabban 19/01/07
• Complications related to stenting and the stent.
• Complications related to infection.
Gouda Ellabban 19/01/07
Venography shows right hepatic vein
Portography of the portal vein
Balloon dilatation with constriction at the hepatic vein
Complete dilatation of the hepatic parenchyma
Deployment of the stent
TIPS
• Technically feasible
• Complications 9 - 50%
Infection Intraperitoneal Bleeding
Congestive Failure Subcapsular Hematoma
Acute Renal Failure Hemobilia
• Mortality (30 day) 3 - 13%
Saphenoperitoneal shunt (SPS) in the treatment of
refractory ascites
Gouda Ellabban 19/01/07
Saphenoperitoneal shunt (SPS)
• SPS plays a major role in the surgery of refractory ascites.
• It allows ascitic fluid to flow back into the circulation when the intra-abdominal pressure rises above venous pressure
• It avoids the insertion of foreign expensive shunt
Gouda Ellabban 19/01/07
• It is performed under local anethesiaexposure of long saphenous vein
• It is divided 15 cm distally.
• The proximal cut end of the long saphenous vein was tunneled under the skin towards the abdominal incision.
• Then it is anastomosied to the cut edges of the incision in the peritoneum with continuous suture
Gouda Ellabban 19/01/07
Saphenoperitoneal shunt is anindisputably elegant and easy type ofintractable ascites permanentdrainage.
SPS offers all the advantages of PVSshunting without using protheticmaterial. It is safe, effective andsuitable for the mangement ofintractable ascites.
LIVER
TRANSPLANTATION
History of Liver Transplantation
• 1st human liver transplant was performed in 1967
• Between 1967 and 1979 the survival rate was 33%
• By 1979, the use of Cyclosporin- steroid combination doubled the 1 year survival rate
Who needs a liver transplant?
• End-stage cirrhosis• Metabolic disorders• Fulminant hepatic
failure (viral or drug induced)
Organ Procurement
• Uniform Anatomical Gift Act (UAGA) requirements:
Brain Death
Familial consent
Recipient Contraindications
• Has evolved over the past several years• Now generally includes:
– Widespread malignancy– Uncontrolled infection– Severe cardiac/ neurologic disease– Inability to tolerate appropriate
immunosuppression
The Recipients are…..
VERY SICK PATIENTS
The CASE….• 3 surgical phases:
1. Recipient hepatectomy (orthotopic technique)
2. Anhepatic phase
3. Revascularization or Neohepatic Phase
Recipient HepatectomyMobilization of:
suprahepatic vena cava
infrahepatic vena cava
portal triad: portal vein, hepatic artery, bile duct
Extracorporeal Circulation
Veno- veno bypass is established: blood from the femoral and portal vein bypasses the liver via extracorporeal circulation and returns to the heart via RIJ (via CVL)
Anhepatic Phase and Revascularization
• New liver is sutured in place: suprahepatic vena cava, infrahepatic vena cava, portal vein
• Hepatic artery anastomosed just prior to revascularization
• After the hepatic artery anastomosis and reperfusion, the bile duct is connected
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