Elsevier

Journal of Hepatology

Volume 25, Issue 2, August 1996, Pages 135-144
Journal of Hepatology

Transjugular intrahepatic portosystemic shunts: comparison with paracentesis in patients with cirrhosis and refractory ascites: a randomized trial

https://doi.org/10.1016/S0168-8278(96)80065-1Get rights and content

Abstract

Background/Aims: Transjugular intrahepatic portosystemic shunts reduce portal pressure and can control ascites in patients with cirrhosis. We carried out a controlled study to evaluate this procedure for the management of refractory ascites in patients with cirrhosis and to clarify its mechanism of action.

Methods: Twenty-five patients with refractory ascites were included in the trial; 13 were randomly assigned to shunts and 12 to paracentesis. Four patients in each group were Child-Pugh class C and the others were class B. Follow-up ranged from 9 to 34 months. Hemodynamic values, liver and renal tests and neurohumoral factors were measured before and at 4 months after inclusion.

Results: Shunts were successfully placed in 10 out of 13 patients. At 4 months, ascites had improved in all class B patients in the shunt group and in none of the patients in the paracentesis group (p<0.05); ascites did not improve in any of the class C patients in either of the groups. At 2 years, the overall survival rate was 29±13% (mean±SE) in the shunt group and 56±17% in the paracentesis group (p<0.05). In class B patients, there was no significant difference in mortality. At 4 months, portal pressure was significantly lower than before the shunt, while plasma levels of atrial natriuretic peptide were significantly higher and plasma levels of renin and norepinephrine significantly lower.

Conclusions: In this trial, intrahepatic shunts were effective on refractory ascites in patients with cirrhosis. However, the overall survival rate was lower in shunted patients than in those treated with paracentesis. The efficacy of intrahepatic shunts on ascites was only observed in class B patients. Survival did not improve in class B patients, and decreased in class C patients compared to paracentesis. The efficacy of shunts on ascites might be due to neurohumoral factors which control natriuresis and depend on hepatic sinusoidal pressure.

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    The following persons participated in the French Group of Clinicians: Didier Lebrec, Nathalie Giuily, Antoine Hadengue, Valérie Vilgrain, Richard Moreau, Adrián Gadano, Claudine Lassen, Jean-Pierre Benhamou, Serge Erlinger, Jacques Bernuau, Alain Chemtob, Françoise Degos, François Durand, Annie Elman, Sophie Hillaire, Patrick Marcellin, Thierry Soupison, Florence Vachiery, Dominique Valla, Marie-Pierre Vullierme, and Song Yang, (INSERM U-24, Service d'Hépatologie and Service de Radiologie, Hôpital Beaujon, Clichy), Thierry Poynard, (Groupe Hospitalier de la Pitié-Salpétrière, Paris), Philippe Sogni, (Hôpital Cochin, Paris), Dominique Roulot, (Hôpital Avicenne, Bobigny), Jean-Luc Saraux, (Hôpital Emile Roux, Eaubonne), Jean-Pierre Capron, Dominique Capron, (Centre Hospitalier Universitaire, Amiens), Emmanuel Carteret (Groupe Médical Saint Rémi, Reims), Abdeslam Bental, (Centre Hospitalier, Abbeville) and Yves Ajavon, (Hôpital Jean Verdier, Bondy). The following persons participated in the Group of Biolgoists: Daniel Bichet, (Hôpital du Sacré-Coeur, Montréal, Canada), Stéphane Cailmail (INSERM U-24, Clichy), Kathleen Laborde, (Hôpital Necker, Paris) and Eric Pussard (Centre Hospitalier de Bicêtre, Le Kremlin-Bicêtre).

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