Preoperative TIPS and in-hospital mortality in patients with cirrhosis undergoing surgery

Use of Transjugular Intrahepatic Portosystemic Shunt (TIPS) to Provide for Safe Pancreaticoduodenectomy in Patients with Portal Hypertension

BACKGROUND

Pancreaticoduodenectomy (PD) is a complex operation associated with high morbidity, especially in the setting of hepatic fibrosis/cirrhosis and portal hypertension. Portal hypertension can be a near-certain contraindication for PD, potentially precluding patients with resectable malignancy from a curative operation. Transjugular intrahepatic portosystemic shunt (TIPS) is an artificial path between the portal vein and suprahepatic veins for decreasing the portal pressure, defined as a hepatic venous pressure gradient > 5 mmHg. TIPS can be used as a bridge to facilitate the safe performance of PD.

METHODS

This is a single-institution retrospective analysis of patients treated with TIPS prior to PD from July 2011 to July 2022. The patient's preoperative management, perioperative course, and postoperative complications were analyzed and reported.

RESULTS

Out of 1140 patients in a pancreatic resection database, four underwent preoperative TIPS before PD. The cohort included two males and two females, with a mean age of 66 years and body mass index of 30.2. All patients had portal hypertension, with a reduction in the mean gradient following TIPS, 13 mmHg to 2.5 mmHg. Three patients had cirrhosis, and one had portal thrombosis. The median estimated blood loss and operative time were 275 mL and 267 min, respectively. Postoperatively, one patient experienced a grade IIIa complication and three developed hepatic encephalopathy at a median of 98 days. All patients received chemo-radiation (two neoadjuvant, three adjuvant) and developed recurrent metastatic disease at a median of 13.5 months. Median overall survival was 21.8 months.

CONCLUSION

TIPS in patients with portal hypertension should be considered as a bridge to a safe PD for patients with peri-ampullary adenocarcinoma.

Transjugular Intrahepatic Portosystemic Shunt (TIPS): A Bridge to Bariatric Surgery in Morbidly Obese Patients with Cirrhosis and Clinically Significant Portal Hypertension

BACKGROUND

In cirrhotic patients, portal hypertension increases mortality after surgery. We evaluated the impact of pre-operative transjugular intrahepatic portosystemic shunt (TIPS) on the outcomes of bariatric surgery in cirrhosis.

METHODS

Multicentric retrospective cohort. The decision for TIPS placement has been made according to hepatic venous pressure gradient (HVPG) values and centers' policy. The primary outcome: 1-year decompensation-free survival; secondary outcomes: 1-year acute-on-chronic liver failure (ACLF) and survival.

RESULTS

Fifty-three patients were included (2010-2022): 92% Child-Pugh A, MELD score 8, age 55 years, BMI 38.3 ± 13 kg/m2, 9 (18%) had TIPS. At baseline, patients with TIPS had more esophageal varices (89% vs 10%, p < 0.001), more previous decompensations (22% vs 0%, p = 0.002), and a higher HVPG (14 vs 7 mmHg, p < 0.001). All patients in the TIPS group had clinically significant portal hypertension vs 11% of patients without TIPS, p < 0.001. One-year decompensation-free survival was 77.8% and 93.2% in patients with and without TIPS, p = 0.064. ALCF occurred in 3 patients (6.8%) without TIPS and none with TIPS. All patients were alive 1 year after surgery.

CONCLUSIONS

In patients with cirrhosis and clinically significant portal hypertension (CSPH) undergoing bariatric surgery, TIPS placement was safe and had similar outcomes after surgery as patients without TIPS.

Preoperative risk evaluation and optimization for patients with liver disease

The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient's liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.

Surgical risk stratification in patients with cirrhosis

Individuals with cirrhosis experience higher morbidity and mortality rates than the general population, irrespective of the type or scope of surgery. This increased risk is attributed to adverse effects of liver disease, encompassing coagulation dysfunction, altered metabolism of anesthesia and sedatives, immunologic dysfunction, hemorrhage related to varices, malnutrition and frailty, impaired wound healing, as well as diminished portal blood flow, overall hepatic circulation, and hepatic oxygen supply during surgical procedures. Therefore, a frequent clinical dilemma is whether surgical interventions should be pursued in patients with cirrhosis. Several risk scores are widely used to aid in the decision-making process, each with specific advantages and limitations. This review aims to discuss the preoperative risk factors in patients with cirrhosis, describe and compare surgical risk assessment models used in everyday practice, provide insights into the surgical risk according to the type of surgery and present recommendations for optimizing those with cirrhosis for surgical procedures. As the primary focus is on currently available risk models, the review describes the predictive value of each model, highlighting its specific advantages and limitations. Furthermore, for models that do not account for the type of surgical procedure to be performed, the review suggests incorporating both patient-related and surgery-related risks into the decision-making process. Finally, we provide an algorithm for the preoperative assessment of patients with cirrhosis before elective surgery as well as guidance perioperative management.

Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhosis

Abdominal surgery is associated with high postoperative mortality and morbidity in cirrhotic patients. Despite improvements in surgical techniques, clinical management, and intensive care, the outcome could be influenced by the degree of portal hypertension, the severity of hepatopathy, or the type of surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement, in addition to medical therapy, plays an important role in managing the complications of portal hypertension such as ascites, hepatic encephalopathy, variceal bleeding or portal vein thrombosis. To date, the improvement of post-surgery outcomes in cirrhotic patients after TIPS placement remains unclear. Only observational data existing in the literature and prospective studies are urgently needed to evaluate the efficacy and safety of TIPS in this setting. This review aims to outline the role of TIPS as a tool in postoperative complications reduction in cirrhotic patients, both in the setting of emergency and elective surgery.