Shunt-preserving disconnection of the portal to systemic circulation in patients with hepatic encephalopathy

Abstract

Background Portosystemic shunt obliteration by surgical or interventional radiological techniques can be effective for patients with hepatic encephalopathy (HE) although this approach is often associated with accumulation of ascites and/or formation of esophageal varices. Purpose To evaluate the clinical efficacy and safety of shunt-preserving disconnection of the portosystemic circulation (SPDPS) in patients with HE. Material and Methods Nine patients with HE and a splenorenal shunt were treated by SPDPS: eight underwent selective coil embolization of the splenic vein and one underwent stent-graft closure of the shunt. The primary endpoint was change in HE severity based on the West-Haven criteria. The secondary endpoints were changes in serum ammonia levels, hepatic function, HE recurrence during the follow-up period, and post-treatment HE recurrence based on the West-Haven diagnostic criteria. Results The technical success rate was 100% with no severe complications. After the procedure, the mean portal blood pressure increased from 18 mmHg to 22 mmHg ( P = 0.02), the mean HE grades fell from 2.1 to 1.1 ( P < 0.01), and one month after the procedure, the mean serum ammonia level decreased from 177 µg/dL to 87 µg/dL ( P = 0.03) and the mean total Child-Pugh score from 8 to 7 ( P = 0.07). Conclusion SPDPS using selective coil embolization and stent-graft closure of the shunt can be an effective and safe treatment for patients with HE.

Hyperammonemia in Hepatic Encephalopathy

“…The most notable findings strongly supporting the critical role of hyperammonemia in the neurological/psychiatric symptoms and electroencephalographic abnormalities following HE were that these findings were improved by lowering blood ammonia levels in these patients, [17][18][19][20][21][22] as well as arterial or venous ammonia levels that were found to closely predict mortality rate with 75-80% sensitivity and specificity, and an 80% diagnostic accuracy. The severity of encephalopathy was also shown to correlate well with blood and brain ammonia levels in animal models of HE.…”

Safety and efficacy of interventional embolization in cirrhotic patients with refractory hepatic encephalopathy associated with spontaneous portosystemic shunts

“…The choice of embolization modality can influence the overall incidence of complications. Compared to other procedures, SVE has a relatively mild impact on portal pressure elevation, thereby contributing to a comparably lower rate of complications 22 , 33 . Nevertheless, there is a paucity of studies entailing a comprehensive assessment of its safety.…”