Ascites surgery On the Web
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Surgery is the mainstay of treatment for refractory ascites. Refractory ascites is defined as ascites that can not be mobilized or the early recurrence of which can not be satisfactorily prevented by medical therapy. Large volume paracentesis is the choice treatment for patients with tense ascites. Transjugular intrahepatic portosystemic shunt (TIPS) would be indicated when there is frequent (> 3 times per month) need for large volume paracentesis to manage ascites. Liver transplantation is indicated for refractory ascites treatment in patients that can not be underwent TIPS.
- Surgery is the mainstay of treatment for refractory ascites. Refractory ascites is defined as ‘ascites that can not be mobilized or the early recurrence of which can not be satisfactorily prevented by medical therapy'.
- Refractory ascites is contributed with very poor prognosis, 50% of them would die within 6 months. Using beta-blocker agents (for preventing esophageal varices in cirrhosis) can cause poorer prognosis in ascitis.
- The process of administering various surgical treatments is as following:
|Large volume paracentesis|
|Salt restriction and diuretics|
|Salt restriction and diuretics||TIPS possible||TIPS not possible|
|TIPS||Repeated Large volume paracentesis|
Large volume paracentesis
- Large volume paracentesis is the choice treatment for patients with tense ascites.
- The rate of complications is very low in this procedure.
- The most common complication following paracentesis is paracentesis-induced circulatory dysfunction (PICD). The condition is due to systemic vasoconstriction in response to massive central fluid loss, which can lead to hepatorenal syndrome in 20% of patients.
- Paracentesis of less than 5 L fluid can be done without need to colloid infusion for preventing PICD.
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- Transjugular intrahepatic portosystemic shunt (TIPS) would be indicated when there is frequent (> 3 times per month) need for large volume paracentesis to manage ascites.
- TIPS is side-to-side anastomosis between high pressure portal vein and low pressure hepatic vein, in order to decline the portal congestion.
- TIPS is more effective than paracentesis in mobilizing ascites fluid. However, it is more prevalent in TIPS patients to develop hepatic encephalopathy.
- Liver transplantation is indicated for refractory ascites treatment in patients that can not be underwent TIPS.
- Moore KP, Wong F, Gines P, Bernardi M, Ochs A, Salerno F, Angeli P, Porayko M, Moreau R, Garcia-Tsao G, Jimenez W, Planas R, Arroyo V (2003). "The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club". Hepatology. 38 (1): 258–66. doi:10.1053/jhep.2003.50315.
- Krag A, Madsen BS (2015). "To block, or not to block in advanced cirrhosis and ascites: that is the question". Gut. 64 (7): 1015–7. doi:10.1136/gutjnl-2014-308424. PMID 25398769.
- Biecker E (2011). "Diagnosis and therapy of ascites in liver cirrhosis". World J Gastroenterol. 17 (10): 1237–48. doi:10.3748/wjg.v17.i10.1237. PMC 3068258. PMID 21455322.
- Pache I, Bilodeau M (2005). "Severe haemorrhage following abdominal paracentesis for ascites in patients with liver disease". Aliment. Pharmacol. Ther. 21 (5): 525–9. doi:10.1111/j.1365-2036.2005.02387.x. PMID 15740535.
- Ginès P, Titó L, Arroyo V, Planas R, Panés J, Viver J, Torres M, Humbert P, Rimola A, Llach J (1988). "Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis". Gastroenterology. 94 (6): 1493–502. PMID 3360270.
- Peltekian KM, Wong F, Liu PP, Logan AG, Sherman M, Blendis LM (1997). "Cardiovascular, renal, and neurohumoral responses to single large-volume paracentesis in patients with cirrhosis and diuretic-resistant ascites". Am. J. Gastroenterol. 92 (3): 394–9. PMID 9068457.
- Rössle M, Siegerstetter V, Huber M, Ochs A (1998). "The first decade of the transjugular intrahepatic portosystemic shunt (TIPS): state of the art". Liver. 18 (2): 73–89. PMID 9588766.
- Saab S, Nieto JM, Lewis SK, Runyon BA (2006). "TIPS versus paracentesis for cirrhotic patients with refractory ascites". Cochrane database of systematic reviews (Online) (4): CD004889. doi:10.1002/14651858.CD004889.pub2. PMID 17054221.