演題

RS3-140-13-2

門脈圧亢進症に対するシャント手術とTIPSの治療成績

[演者] 細川 勇:1,2
[著者] René Adam:1, Marc-antoine Allard:1, Henri Bismuth:1, 宮崎 勝:2,3, Denis Castaing:1
1:Centre Hépato-Biliaire,AP-HP Hôpital Paul Brousse, 2:千葉大学大学院 臓器制御外科学, 3:国際医療福祉大学三田病院 外科・消化器センター

Background: Implantation of transjugular intrahepatic portosystemic shunts (TIPS), rather than surgical shunts, has emerged as the standard treatment for patients with complicated portal hypertension. This study compared outcomes in patients who underwent TIPS and surgical shunt implantation for complicated portal hypertension.
Methods: The cohort consisted of 471 consecutive patients who underwent portosystemic shunts from 1994 to 2014 at a single institution. Patients who underwent surgical shunts and TIPS were compared following one-to-one propensity score matching. The primary study endpoints were overall survival (OS) and shunt failure, defined as major variceal rebleeding, relapse refractory ascites, irreversible shunt occlusion, liver failure requiring liver transplantation, or death.
Results: This study evaluated 334 consecutive patients with cirrhosis who underwent elective surgical shunts (n=34) or TIPS (n=300) for repeated variceal bleeding or refractory ascites. Following propensity-score matching, there were no between-group differences in morbidity and 30-day mortality rates. However, shunt failure was significantly less frequent after surgical shunt than TIPS (19% vs. 52%; p=0.02). The 5-year shunt failure-free survival (77% vs. 15%; p=0.008) and OS (93% vs. 42%; p=0.04) rates were significantly higher for surgical shunts. Multivariate analysis revealed that a Model for End-Stage Liver Disease (MELD) score >14 and TIPS were independently associated with shunt failure. In patients with MELD scores ≤14, the 5-year OS rate remained significantly higher after surgical shunts than TIPS (100% vs. 40%; p<0.001).
Conclusions: Surgical shunts achieve better results than TIPS in patients with complicated portal hypertension and low MELD scores. The widespread indications for TIPS should be reevaluated.
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