Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1444_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 33 / HPB Trauma 411
two silk occlusion ties) is exceptional at stopping ongoing bleeding at the
bottom of deep central hepatic injury tracts (including retrohepatic IVC
injuries). ese should be deated approximately 72 hours after the ini-
tial placement. If hemorrhage continues, they should be left in situ for 2
to 3 additional days. Although unusual, penetrating injuries to the hepatic
artery may require ligation (assuming the portal vein is intact). Portal vein
injuries should ideally be repaired with 5-0 or 6-0 Prolene once control is
obtained. Clamps above and below the injury are essential for visualiza-
tion. Alternate damage control options for portal vein injury include TIVS
(temporary intravascular shunt) with a small chest tube conduit and liga-
tion (assuming the hepatic artery is intact). Return to the operating suite
in patients with packed abdomens should occur in 48 to 72 hours (assum-
ing hypothermia, coagulopathy, and acidosis are corrected). If an atrial–
caval shunt is contemplated, two experienced surgical teams (one for the
chest and one for the abdomen) are essential. e decision to pursue this
shunt must be made early in the exploration process as they rarely result in
patient salvage.
Postoperative Management and Complications
Complications following hepatic trauma include both early (bleeding and
abdominal compartment syndrome) and late (infected hematoma, bile
leak, liver failure, and associated ileus) diagnoses. Delayed laparoscopic
washout with copious irrigation and insertion of a closed suction drain-
age catheter is particularly helpful in patients who have large collections
of infected hematoma and/or bilomas. is is decidedly more common
in high-grade hepatic injuries (8% to 10% risk of biloma in grade III to V
injuries). If a bile leak persists, then placement of an intrabiliary stent via
endoscopic retrograde cholangiopancreatography (ERCP) is helpful in
lowering biliary pressure and encouraging closure of the leak. As a result,
successful “nonoperative” therapy requires access to percutaneous drain-
age, laparoscopy, ERCP, and/or angiography in selected cases. It should
also be noted that gunshot wounds with right upper quadrant trajectories
(i.e., thoracoabdominal) can be treated nonoperatively in the context of
normal hemodynamics and the absence of peritonitis. Concurrent injuries
to the duodenum and transverse colon must be ruled out however (i.e., triple-
contrast CT). Furthermore, one must also monitor for the development of
a bronchobiliary stula. Most bronchobiliary stula can be successfully
treated with a biliary stent and appropriate drainage. Hepatic failure typi-
cally occurs in response to shock liver and/or inow occlusion (Pringle)
required at the time of the operative procedure. Standard supportive care
for hepatic failure is indicated.
Outcomes and Follow-up
Planned surveillance cross-sectional imaging (e.g., CT) is not required for
major liver injuries (as opposed to splenic injuries). Repeat imaging should
be based on any deterioration in laboratory tests or patient symptoms. e
appropriate delay in time to return to physical/combat sports is debatable
following major hepatic injury. Despite a known 4- to 8-week hypertrophy
response following elective hepatic resection, the time to regeneration and
complete organ healing is unclear in the context of hepatic injuries.
Conclusion
If diagnosis and therapy are rapid, patients who present in physiologic
extremis as a result of major hepatic hemorrhage have a good chance of
survival in the context of a prolonged hospital stay. Complications must be
managed appropriately and without delay.
Section IV / Multidisciplinary HPB Care412
EXTRAHEPATIC BILIARY TRACT INJURIES
Extrahepatic biliary tree (common bile duct and gallbladder) injuries are
incredibly uncommon. ey are also relatively simple to treat relative to
the context of nonelective (i.e., laparoscopic cholecystectomy) injuries.
Diagnosis typically occurs within the operating theater at the time of
urgent exploration for concurrent injuries. Trauma to the biliary tree is
suspected upon identication of bile within the peritoneal cavity. If the
diagnosis is delayed, a biloma will form in the setting of a typically sterile
eld. As a result, patient symptoms will consist of nausea, mild right upper
quadrant discomfort, and often an ileus. e WBC and bilirubin levels may
also be elevated. ese patients require identication of the biloma with
either ultrasound or CT, in addition to subsequent percutaneous drainage
and cholangiography. In scenarios of very small partial-thickness common
bile duct injuries, placement of an intrabiliary stent via ERCP may be suf-
cient. With any signicant injury, however, immediate control of sepsis
and subsequent, appropriately timed exploration by an HPB surgeon is
warranted.
Management
Preoperative Considerations
In the setting of a hemodynamically stable patient with a delayed diagnosis
of an extrahepatic biliary tract injury, complete cholangiography is essen-
tial prior to exploration. An experienced colleague and/or team approach
is also crucial.
Operative Care and Technical Tips
Any injury to the gallbladder is an absolute indication for cholecystec-
tomy. Although primary repair is occasionally described in very large
series, it is almost never indicated. A full-thickness common bile duct
injury is generally an indication for a standard Roux-en-Y hepaticojeju-
nostomy to minimize the long-term risk of anastomotic strictures. In the
setting of small, partial-thickness sharp (i.e., noncautery and nongun-
shot) injuries, primary repair with T-tube drainage/control may also be
a viable option.
Postoperative Management, Complications, and Follow-up
Although most high-volume hepatobiliary surgeons do not utilize closed
suction drainage for their hepaticojejunostomies, injury in the context of
patients with additional trauma and physiologic stressors may provide an
indication for drainage in some scenarios. e dominant long-term poten-
tial complication remains stricture of the biliary anastomosis. Stricture
is particularly plausible in the context of hepaticojejunostomies required
for very youthful patients with a long life expectancy. It also mandates a
detailed discussion with the patient prior to discharge (i.e., risks and symp-
toms associated with stricture—cholangitis, jaundice). ese patients are
often amenable to dilations of their anastomoses with either an endoscopic
or a percutaneous approach.
Conclusion
Injury to the extrahepatic biliary tree is unusual. Cholecystectomy is indi-
cated for any trauma to the gallbladder. Full-thickness common bile duct
injuries require a Roux-en-Y hepaticojejunostomy, whereas minor partial-
thickness injuries can occasionally be treated with primary repair and
decompression.
Chapter 33 / HPB Trauma 413
PANCREAS INJURIES
As with hepatic trauma, injuries to the pancreas can be challenging to
even the most experienced trauma/general surgeon. Pancreatic injuries are
divided into injuries of the left (body/tail) and right (head) organ. Clearly,
injuries to the right pancreas place adjunctive structures (i.e., portal vein,
IVC, aorta, duodenum, bile duct) at risk as well.
Management
Preoperative Considerations
Absolute indications for operative exploration of a suspected injury to the
pancreas include (1) hypotension, (2) diuse peritonitis, and (3) obvious
full-thickness organ disruption in the pancreatic neck/body/tail on cross-
sectional imaging.
Operative Care and Technical Tips
All pancreatic hematomas should be opened and explored to dene the
integrity of the pancreatic capsule. All segments and surfaces of the pan-
creas can be directly inspected by utilizing standard exposure maneuvers
(Kocher maneuver, division of ligament of Treitz, entry into the lesser sac,
medial mobilization of the tail of pancreas and spleen). If a disruption in
the pancreatic capsule is noted (grade I or II), a closed suction drain must
be placed adjacent to the injury. If a pancreatic laceration/hole is noted
in the setting of an intact main pancreatic duct, a viable omental plug or
patch should be combined with closed suction drainage. In general, inju-
ries with disruption of the main pancreatic duct at any location to the left
of the superior mesenteric vein/portal vein (SMV/PV) should undergo a
distal pancreatectomy (grade III). Endoscopic (ERCP)-based pancreatic
duct stenting across a truly disrupted main pancreatic duct fails almost
uniformly. Similarly, a Roux-en-Y pancreaticojejunostomy to the pancreatic
segment distal to the transaction is typically fraught with complications
and stula due to the soft texture of an otherwise normal gland.
Dening the integrity of the main pancreatic duct can be challeng-
ing. Ultrasonography has become incredibly valuable for surgeons who are
trained to evaluate pancreatic gland anatomy. In the absence of this skill,
however, intraoperative cholecystocholangiography remains the best alter-
native option. Utilize a combination cocktail of both methylene blue and
radioopaque contrast material (± fentanyl) when obtaining images.
Injuries to the right pancreas (head) with main duct disruption
typically require a pancreatoduodenectomy. In the context of damage
control resuscitation due to massive hemorrhage, the initial surgery does
not typically allow for either a completed resection or reconstruction. As
a result, the “trauma Whipple” is usually performed in two stages. e
second procedure (completion of resection and reconstruction) should
be performed within 24 hours. More specically, if reexploration is
delayed beyond 24 hours, the viscera become so edematous that recon-
struction is extremely challenging due to limited mobility of the pan-
creatobiliary limb and dicult, sloppy anastomoses. It should also be
noted that most combined pancreaticoduodenal injuries do not require a
Whipple procedure. In these patients (i.e., with ampullary, common bile,
and pancreatic duct integrity), procedures such as pyloric exclusion with
gastrojejunostomy or the Cali triple tube decompression are superior
options. It must be reemphasized that the “bailout” maneuver for pan-
creatic head trauma remains drainage (closed suction or negative suc-
tion dressing) with early reexploration in conjunction with experienced
pancreatic surgeons.
Section IV / Multidisciplinary HPB Care414
Postoperative Management and Complications
Regardless of the technique, up to 25% of distal pancreatectomies will
generate a pancreatic leak and subsequent stula. is stula rate may be
higher in the setting of trauma due to the impact of concurrent injuries
and physiologic stress/exhaustion. Soft texture, contaminated elds, and
bruised pancreas glands make surgery of the pancreas in the injured popu-
lation challenging and fraught with complications. Wrapping the pancreas
stump with viable omentum may be helpful. Octreotide has not been reli-
ably shown to reduce the time to closure of pancreatic stulas in injured
patients. In addition to these early consequences, delayed endocrine insuf-
ciency (i.e., diabetes) is also a concern. It is clear that upon removal of
60
+
% of pancreatic tissue in young trauma patients, approximately half will
go on to achieve glucose intolerance, and up to 25% will develop diabetes.
Conclusion
Injuries to the pancreatic head typically involve catastrophic concurrent
injuries to the surrounding organs and vasculature. Damage control scenar-
ios demand drainage once ongoing hemorrhage is stopped. Injury to the left
pancreas most commonly requires a distal pancreatectomy. Maintaining
control of a postoperative pancreatic stula is essential at all times.
Suggested Readings
Ball CG, Dixon E, Kirkpatrick AW, et al. A decade of experience with injuries to the
gallbladder. J Trauma Manag Outcomes 2010;4:3.
Ball CG, Wyrzykowski AD, Nicholas JM, et al. A decade’s experience with balloon tam-
ponade for the emergency control of hemorrhage. J Trau ma 2011;70:330–333.
Chinnery GE, Krige JE, Kotze UK, et al. Surgical management and outcome of civilian
gunshot injuries to the pancreas. Br J Surg 2012;99.
Feliciano DV. Biliary injuries as a result of blunt and penetrating trauma. Surg Clin
North Am 1994;74:897–907.
Kozar RA, Feliciano DV, Moore EE, et al. Western Trauma Association/critical deci-
sions in trauma: operative management of adult blunt hepatic trauma. J Trauma
2011;71:1–5.
Pachter HL. Prometheus bound: evolution in the management of hepatic trauma—
from myth to reality. J Trauma 2012;72:321–329.
Pachter HL, Feliciano DV. Complex hepatic injuries. Surg Clin North Am 1996;76:
763–782.
Subramanian A, Dente CJ, Feliciano DV. Management of pancreatic trauma in the
modern era. Surg Clin North Am 2007;87:1515–1532.
415
Tremendous advances in interventional radiology (IR) technique have
benetted the inter ventional radiologist and surgeon alike. A close relation-
ship with IR physicians is crucially important to ideal HPB surgery practice
and management of complex HPB patients. Multiple IR techniques play
important roles in preoperative diagnosis, patient optimization (i.e., biliary
drainage, portal vein embolization), denitive treatment (e.g., percutane-
ous ablation, transarterial treatment of liver tumors), and rescue of HPB
patients from postoperative complications (e.g., treatment of pseudoaneu-
rysms, drainage of intra-abdominal abscess).
e goal of this chapter is to familiarize HPB practitioners with spe-
cic IR techniques: percutaneous biliar y stenting, transjugular intrahepatic
portosystemic shunting (TIPS), portal vein embolization (PVE), percutane-
ous radiofrequency ablation (RFA), transarterial treatment of liver tumors,
percutaneous drainage of intra-abdominal abscess, and transarterial treat-
ment of pseudoaneurysms (PSAs).
PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY AND BILIARY
INTERVENTION IN THE MANAGEMENT OF BILIARY OBSTRUCTION
As endoscopic techniques have become more common in cases of bili-
ary obstruction, percutaneous biliary interventions have decreased in
frequency. Percutaneous biliary intervention continues to be useful when
endoscopic techniques have failed or in instances where they are unlikely to
succeed. Given the complexity and risks associated with the procedure, the
decision to move forward with the percutaneous procedure is usually made
with multidisciplinary expertise, including HPB surgeons, interventional
radiologists, and endoscopists.
Biliary obstruction may be caused by benign or malignant pathol-
ogy, and obstructive jaundice can be conrmed with ultrasound, com-
puted tomography (CT), or magnetic resonance cholangiopancreatography
(MRCP). Ultrasound may demonstrate the presence of intrahepatic or
extrahepatic biliary ductal dilation and may demonstrate the level of
obstruction. Contrast-enhanced CT of the abdomen is more likely to
identify the level and nature of obstruction. While MRCP provides excel-
lent three-dimensional imaging, this study should be used as an adjunct
to contrast-enhanced CT given its limited ability to demonstrate surgical
clips, hardware, and other anatomic landmarks. In cases where bile leak
is suspected, radionuclide hepatobiliary scintigraphy may be performed.
Indications and contraindications are shown in Table 34.1.
Biliary intervention can be performed with conscious sedation, deep
sedation, or general anesthesia. Patients should be made NPO with clear
liquids only 6 hours prior to the procedure. Patients should have intrave-
nous access and be hydrated, as manipulation of the biliary tree can cause
a patient to become septic and hypotensive, requiring rapid resuscitation.
Interventional Radiology
Support of HPB Surgery
Robert L. King and Matthew S. Johnson
34
Section IV / Multidisciplinary HPB Care416
Indications
1. Precisely dene biliary anatomy
2. Drain obstructed bile ducts
3. Obtain tissue or bile for diagnosis
4. Manage benign strictures
5. Manage intrahepatic or extrahepatic stone disease
6. Manage biliary malignancies
Contraindications
Absolute
1. Uncorrectable coagulopathy
2. No available percutaneous access to the biliary system (e.g., colonic inter-
position or very high left liver remnant)
Relative
1. Ascites (consider paracentesis before or during procedure)
2. Intrahepatic processes that cause multilevel obstruction not amenable to
percutaneous treatment (e.g., polycystic liver disease or widespread intra-
hepatic metastases)
Indications and Contraindications to Percutaneous Biliary
Intervention
TABLE
34.1
Per Society of Interventional Radiology (SIR) guidelines, prophylactic anti-
biotics should be administered immediately prior to instrumenting the
obstructed biliary tree. If culture data are available, antibiotic choice should
be tailored to specic organisms. More recently, and in patients with previ-
ous biliary instrumentation, the incidence of resistant organism coloniza-
tion in the bile is very high.
For a left biliary duct puncture, a subxiphoid approach is used. For
a right puncture, a lateral approach is used with the cranial/caudal posi-
tion as low as possible. Ideally, this will be below the 10th rib to avoid a
transpleural puncture. e access needle is then passed through the
hepatic parenchyma under uoroscopic guidance. Contrast is injected
through the needle as the needle is slowly retracted until a bile duct is
opacied. Once a bile duct is identied, a cholangiogram is then performed
using gentle short injections of contrast until adequate lling of the ducts
is obtained. (It is not always possible to opacify central ducts from the ini-
tial access. Instead, a “regional” cholangiogram is performed to assess the
local ducts and the access site.) If the initial access is acceptable—that is,
the duct is entered as peripherally as possible and the central angles are
favorable for placement of a catheter—it may be used for placement of a
6- to 8-Fr sheath. Alternatively, a second access may be obtained by choos-
ing an acceptable peripheral duct, which has been opacied from the origi-
nal injection. It may be necessary to intermittently inject contrast though
the initial access to keep the ducts adequately opacied. A exible guide-
wire is then advanced through the access needle into a central duct. e
needle is removed and replaced with a 6- to 8-Fr sheath over the guidewire.
A complete cholangiogram can then be performed through this sheath or
through a 4- to 5-Fr catheter, if the sheath tip is not central enough to obtain
adequate visualization of the central ducts. e obstruction is then crossed
with a combination of a hydrophilic wire and 4- to 5-Fr catheter. e same
wire/catheter combination is then advanced into the proximal jejunum.
e hydrophilic wire is then exchanged for a nonhydrophilic sti wire, the
tract is then dilated to the appropriate size, and an internal/external biliary
stent is then placed with the tip positioned as distal in the bowel as possible
Chapter 34 / Interventional Radiology Support of HPB Surgery 417
while maintaining the peripheral catheter side hole at the ductal site entry
point. is position ensures that the ducts peripheral to the puncture site
are not excluded from drainage. If the obstruction cannot be crossed, an
external biliary drain is placed with its tip as central as possible. e cath-
eter is then sutured to the skin and placed to an external gravity drainage
bag. e internal/external stent can usually be capped the following day
and may remain capped as long the patient is afebrile and without other
signs of cholangitis.
Malignant strictures can be treated as above, or an indwelling stent
may be placed in cases of palliation. e lesion is crossed using conventional
techniques. Occasionally, cholangioplasty may be performed to facilitate
crossing of the lesion with the stent. Self-expanding bare metal or covered
stents may be utilized. Once the stent is in place, a repeat cholangiogram
is performed to ensure free ow of contrast across the stent. When this has
been conrmed, the parenchymal access tract is coil embolized.
Technical Tips
1. Puncture the biliary system as peripheral as possible to avoid ductal
exclusion and injury of larger central vessels. (Fig. 34.1 shows large intra-
hepatic hematoma from laceration of hepatic artery.)
2. During pullback injection, small “pu ” of contrast should be introduced.
Contrast in the portal vein and hepatic artery will head to the
periphery
FIGURE 34.1 Coronal CT showing large intrahepatic hematoma (long arrow)
from inadvertent hepatic artery laceration during percutaneous transhepatic
cholangiography (PTC) (short arrows) placement.
Section IV / Multidisciplinary HPB Care418
of the liver and clear completely. e hepatic vein will clear centrally
toward the heart.
3. Overinjecting a dilated infected biliary system can lead to sepsis, shock,
and death.
4. If the wire does not initially advance smoothly, the entry angle of the duct
may be too acute or the needle may be just outside the duct. Pulling back
and repeating a more peripheral puncture will likely be helpful.
5. A short nitinol wire, increased uoro magnication, and twirling move-
ments of the wire may be benecial.
6. Advancing a 6-Fr 25-cm-long sheath immediately proximal to the
obstruction will allow more forward force to be placed on the coaxial
catheters and guidewires.
7. e duct distal to the obstruction can be punctured, and a snare can be
placed allowing through and through access.
Postprocedural Management
e patient should have his or her vital signs checked frequently immedi-
ately after the procedure. While procedure-related complications follow-
ing biliary catheter placement are infrequent, bleeding from injury to the
hepatic artery or portal vein is possible. is usually manifests as bleeding
through or around the catheter, but would also be suggested by tachycardia
with or without hypotension. Cholangiography might demonstrate com-
munication between the catheter tract and blood vessel. Portal bleeding
is usually easily treated by replacement of the indwelling catheter with a
bigger catheter and/or one advanced more centrally such that its side holes
no longer communicate with the portal vein. Hepatic arterial bleeding is
usually treated with embolization of the injured artery. Pneumothorax and
the equally uncommon bilious pleural eusion are rare complications; both
are treated by catheter drainage of the pleural space.
e external or internal/external biliary catheter should undergo rou-
tine catheter care including daily site cleaning and dressing changes. Biliary
catheters, whether external drains or internal/external catheters, should be
ushed: Our standard procedure is to ush catheters with 10mL of sterile
saline twice a day. Bile leak around the catheter, persistent pericatheter or
right upper quadrant pain, and/or diculty ushing the catheter are all
indications for cholangiography and possible catheter replacement.
Patients are observed overnight for symptomatic management and
to allow for early detection of delayed procedural complications. At our
institution, patients with benign bile duct strictures are normally man-
aged with 12 months of stenting. Once the initial stent has been placed
( usually 10 to 12Fr), it is serially upsized every few months to 20 Fr as tol-
erated by the patient. e 12-month timeframe starts once the 20-Fr stent
has been placed. e stent is exchanged every 3 months during this time. At
12months, serum liver chemistry tests and cholangiogram are performed.
If contrast ows freely through the treated stricture, a “clinical trial” is initi-
ated. is involves placing a new catheter such that the tip is proximal to the
previous stricture. e catheter is then capped for 2 weeks, at which time
the patient returns for a repeat cholangiogram and serum liver chemistry
evaluation. If the liver chemistry tests are stable, the cholangiogram shows
resolved stricture, and the patient is doing well clinically (e.g., no fevers or
signs of cholangitis), the catheter is removed. An alternative to the clinical
trial to test the integrity of a treated bile duct stricture is the Whittaker test,
which involves manometry measurement of bile duct pressure proximal
and distal to the stricture. Patients with “denitively” treated benign bile
duct strictures must have long-term annual follow-up of liver chemistry
tests with their primary physician, gastroenterologist, or HPB surgeon.
Chapter 34 / Interventional Radiology Support of HPB Surgery 419
Immediate Complications
1. Bleeding (subcapsular/intraparenchymal/peritoneal/pleural/
biliary—hemobilia)
2. Infection (cholangitis/sepsis)
3. Bile duct perforation
4. Stent migration/malposition
Delayed Complications
1. Infection (pancreatitis/cholecystitis/cholangitis)
2. Pancreatitis
3. Bile leak in the peritoneum or pleural space
4. Stent occlusion, migration, kinking, or dislodgement
5. Biloma
e average rate of major complications is about 2%, although complica-
tion rates can vary from 4% to 25% depending on the institution and opera-
tor experience. e majority of these complications can be treated by the
interventionalist. Pleural transgression is usually treated with a chest tube.
A patient who is bleeding should be treated with standard resuscitative
measures. In addition, coagulopathy secondary to jaundice must be cor-
rected (administration of vitamin K and replacing plasma clotting factors).
Bleeding in and around a catheter is usually due to a side hole within a
blood vessel that was crossed. Advancing the catheter will stop the major-
ity of the bleeding that is venous. If the patient continues to bleed, an arte-
riogram should be performed with the biliary catheter removed over a wire,
maintaining access. Coil embolization distal and proximal to the bleeding
arterial site is therapeutic. Infectious cholangitis should be treated with
7to 10 days of antibiotic coverage for biliary/gastrointestinal (GI) bacte-
ria. Additionally, a cholangiogram should be performed to ensure the cath-
eter is functioning properly. Sepsis or septic shock requires ICU admission.
Insertion-site cellulitis may suggest misplaced side holes and should be
managed with cholangiography with catheter replacement, if indicated. If
cellulitis is present with a well-positioned patent catheter, then antibiot-
ics should be administered. Biliary catheter obstruction usually requires
reevaluation with repeat cholangiogram and replacement. Biliary catheter
dislodgement should prompt urgent evaluation as new ly created tracts may
close within hours. Stent occlusion can be treated with recanalization and
cholangioplasty, or new stent placement.
Outcomes/Follow-up
Eective biliary drainage is established in close to 100% of bile ducts
accessed in appropriately selected patients. Percutaneous drainage can
successfully treat between 70% and 100% of iatrogenic bile duct injuries.
Reported technical success rate for nontransplant bile duct strictures
approaches 100% with transplant stenosis having a more modest success
rate of 45% to 80%. e covered stent patency for biliary obstruction is 90%
to 95%, 76% to 92%, and 76% to 85% at 3, 6, and 12 months, respectively.
TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT
A TIPS is a percutaneous technique used to treat portal hypertension and
its complications. A TIPS is placed to facilitate reduction of the portal
venous pressure by placing a decompressive stent between a hepatic vein
and an intrahepatic portal vein (Fig. 34.2 shows TIPS). Since its inception
over 20 years ago, more than 1,000 patients have been enrolled in multiple
controlled trials studying ecacy and safety of the procedure. Furthermore,
FIGURE 34.2 (A-C). Schematic of TIPS. (From Mulholland MW, Lillemoe
KD, Doherty GM, et al. Greeneld’s surgery: scientic principles & practice,
5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)