간회복) TIPS

Transjugular intrahepatic portosystemic shunt(TIPS)

Transjugular intrahepatic portosystemic shunt (TIPS or TIPSS) is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein. It is used to treat portal hypertension (which is often due to liver cirrhosis) which frequently leads to intestinal bleeding, life-threatening esophageal bleeding (esophageal varices) and the buildup of fluid within the abdomen (ascites).

An interventional radiologist creates the shunt using an image-guided endovascular (via the blood vessels) approach, with the jugular vein as the usual entry site.

The procedure was first described by Josef Rösch in 1969 at Oregon Health and Science University. It was first used in a human patient by Dr. Ronald Colapinto, of the University of Toronto, in 1982, but did not become reproducibly successful until the development of endovascular stents in 1985. In 1988 the first successful TIPS was realized by M. Rössle, G.M. Richter, G. Nöldge and J. Palmaz at the University of Freiburg.^[1] The procedure has since become widely accepted as the preferred method for treating portal hypertension that is refractory to medical therapy, replacing the surgical portocaval shunt in that role.

Surgery[edit]

Ascites that is refractory to medical therapy is considered an indication for liver transplantation. In the United States, the MELD score (online calculator)^[22] is used to prioritize patients for transplantation.

In a minority of people with advanced cirrhosis that have recurrent ascites, shunts may be used. Typical shunts used are portacaval shunt, peritoneovenous shunt, and the transjugular intrahepatic portosystemic shunt (TIPS). However, none of these shunts has been shown to extend life expectancy, and are considered to be bridges to liver transplantation. A meta-analysis of randomized controlled trials by the international Cochrane Collaboration concluded that "TIPS was more effective at removing ascites as compared with paracentesis...however, TIPS patients develop hepatic encephalopathy significantly more often".^[23]

Ascites

Ascites is the abnormal buildup of fluid in the abdomen.^[1] Technically, it is more than 25 mL of fluid in the peritoneal cavity.^[3] Symptoms may include increased abdominal size, increased weight, abdominal discomfort, and shortness of breath.^[2] Complications can include spontaneous bacterial peritonitis.^[2]

In the developed world, the most common cause is liver cirrhosis.^[3] Other causes include cancer, heart failure, tuberculosis, pancreatitis, and blockage of the hepatic vein.^[3] In cirrhosis, the underlying mechanism involves high blood pressure in the portal system and dysfunction of blood vessels.^[3] Diagnosis is typically based on a examination together with ultrasound or a CT scan.^[2] Testing the fluid can help in determining the underlying cause.^[2]

Treatment often involves a low salt diet, medication such as diuretics, and draining the fluid.^[2] A transjugular intrahepatic portosystemic shunt (TIPS) may be placed but is associated with complications.^[2] Effects to treat the underlying cause, such as by a liver transplant may be considered.^[3] Of those with cirrhosis, more than half develop ascites in the ten years following diagnosis.^[3] Once ascites has developed in this group, average life expectancy is less than three years.^[3] The term is from the Greek askítes meaning "baglike".^[4]

Hepatorenal syndrome

Hepatorenal syndrome (often abbreviated HRS) is a life-threatening medical condition that consists of rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure. HRS is usually fatal unless a liver transplant is performed, although various treatments, such as dialysis, can prevent advancement of the condition.

HRS can affect individuals with cirrhosis, severe alcoholic hepatitis, or liver failure, and usually occurs when liver function deteriorates rapidly because of a sudden insult such as an infection, bleeding in the gastrointestinal tract, or overuse of diuretic medications. HRS is a relatively common complication of cirrhosis, occurring in 18% of people within one year of their diagnosis, and in 39% within five years of their diagnosis. Deteriorating liver function is believed to cause changes in the circulation that supplies the intestines, altering blood flow and blood vessel tone in the kidneys. The kidney failure of HRS is a consequence of these changes in blood flow, rather than direct damage to the kidney. The diagnosis of hepatorenal syndrome is based on laboratory tests of individuals susceptible to the condition. Two forms of hepatorenal syndrome have been defined: Type 1 HRS entails a rapidly progressive decline in kidney function, while type 2 HRS is associated with ascites (fluid accumulation in the abdomen) that does not improve with standard diuretic medications.

The risk of death in hepatorenal syndrome is very high; the mortality of individuals with type 1 HRS is over 50% over the short term, as determined by historical case series. The only long-term treatment option for the condition is liver transplantation. While awaiting transplantation, people with HRS often receive other treatments that improve the abnormalities in blood vessel tone, including supportive care with medications, or the insertion of a transjugular intrahepatic portosystemic shunt(TIPS), which is a small shunt placed to reduce blood pressure in the portal vein. Some patients may require hemodialysis to support kidney function, or a newer technique called liver dialysis which uses a dialysis circuit with albumin-bound membranes to bind and remove toxins normally cleared by the liver, providing a means of extracorporeal liver support until transplantation can be performed.

예문)

• Effect of Transjugular Intrahepatic Portosystemic Shunt for Variceal bleeding in Hepatocellular Carcinoma Patients with Portal Vein Thrombosis (RISS) 문맥혈전이 동반된 간세포암종 환자에서 정맥류 출혈에 대한 경 경정맥 간내 문맥정맥 단락술의 효과
  소리듣기
• A Case of Massive Bleeding Duodenal Varices Successfully Controlled with Transjugular Intrahepatic Portosystemic Shung (RISS) 경정맥 간내문맥 - 간정맥 단락술로 십이지장정맥류 대량 출혈을 성공적으로 치료한 1 예
  소리듣기
• Transjugular Embolization of the Internal Spermatic Vein for the Treatment of Varicocele (RISS) 경정맥을 통한 정계정맥류의 경피적 색전술
  소리듣기
• The Results of Long - term Follow - up after Transjugular Intrahepatic Portosystemic Shunt for Gastric and Esophageal Bleeding (RISS) 위 및 식도 정맥류 출혈시 경내경정맥 간내문맥간정맥 단락술의 치료효과
  소리듣기
• Long - term Outcome Following Transjugular Intrahepatic Portosystemic Shunt for Gastric & Esophageal Variceal Bleeding (RISS) 위 및 식도 정맥류출혈환자에서 TIPS 의 치료효과에 대한 장기 추적 관찰