Intrahepatic portosystemic shunting: is minilaparotomy-assisted transmesenteric-transjugular approach still relevant?

Purpose To determine whether the minilaparotomy-assisted transmesenteric transjugular shunt placement has an acceptable clinical profile compared to the transjugular method, for systemic diversion of portal blood. Materials and Methods In a retrospective review, from January 2005 to December 2010, forty-nine patients with minilaparotomy-assisted transmesenteric transjugular portosystemic shunt were compared to sixty-three patients with conventional TIPS. The main end point was primary shunt dysfunction. The secondary end points included early technical success, peri-procedural mortality, and early procedural-related complications. Death, loss to follow up, and liver transplantation were considered as competing events. Results No significant difference was found in primary or secondary end points, the number of the patients who eventually underwent liver transplantation, or number of deaths during the follow-up period. The shunt primary patency rates at 6 months and 12 months were 91.86% and 88.03%, in the conventional TIPS group, and 85.32% and 81.82% in the minilaparotomy assisted transmesenteric- transjugular group, respectively (P= 0.870). Minilaparotomy wound-related complications included wound dehiscence, incisional hernia, wound infections, and persistent leakage of ascites. Difficult targeting of the portal vein occurred mainly in the conventional TIPS group. The site of focal stenosis was identified more commonly in the hepatic end of the shunt in patients with conventional TIPS and more commonly in portal end in patients with minilaparotomy-assisted transmesenteric- transjugular shunt (P= 0.045). In a multivariable-adjusted Cox regression analysis, the cumulative time to primary shunt dysfunction was not affected when it was simultaneously adjusted for sex, age, serum total bilirubin before the IPS insertion, MELD score ( Conclusion Minilaparotomy-assisted transmesenteric transjugular IPS is a safe and viable option to consider when a transjugular IPS is not technically feasible. Operators should be aware of some differences in the risks associated with each approach.