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Guixé-Muntet S, Quesada-Vázquez S, Gracia-Sancho J. Pathophysiology and therapeutic options for cirrhotic portal hypertension. Lancet Gastroenterol Hepatol 2024; 9:646-663. [PMID: 38642564 DOI: 10.1016/s2468-1253(23)00438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 04/22/2024]
Abstract
Portal hypertension represents the primary non-neoplastic complication of liver cirrhosis and has life-threatening consequences, such as oesophageal variceal bleeding, ascites, and hepatic encephalopathy. Portal hypertension occurs due to increased resistance of the cirrhotic liver vasculature to portal blood flow and is further aggravated by the hyperdynamic circulatory syndrome. Existing knowledge indicates that the profibrogenic phenotype acquired by sinusoidal cells is the initial factor leading to increased hepatic vascular tone and fibrosis, which cause increased vascular resistance and portal hypertension. Data also suggest that the phenotype of hepatic cells could be further impaired due to the altered mechanical properties of the cirrhotic liver itself, creating a deleterious cycle that worsens portal hypertension in the advanced stages of liver disease. In this Review, we discuss recent discoveries in the pathophysiology and treatment of cirrhotic portal hypertension, a condition with few pharmacological treatment options.
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Affiliation(s)
- Sergi Guixé-Muntet
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sergio Quesada-Vázquez
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jordi Gracia-Sancho
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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2
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El Hajji S, Lacotte S, Moeckli B, Cauchy F, Compagnon P, Toso C. Transjugular Intrahepatic Portosystemic Shunt Is Associated With Better Waitlist Management of Liver Transplant Candidates With Hepatocellular Carcinoma. Transpl Int 2024; 37:12781. [PMID: 39044902 PMCID: PMC11265282 DOI: 10.3389/ti.2024.12781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 06/12/2024] [Indexed: 07/25/2024]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) reduces portal hypertension complications. Its impact on hepatocellular carcinoma (HCC) remains unclear. We evaluated 42,843 liver transplant candidates with HCC from the Scientific Registry of Transplant Recipients (2002-2022). 4,484 patients with and without TIPS were propensity score-matched 1:3. Analysing wait-list changes in total tumor volume, HCC count, and alpha-fetoprotein levels, and assessing survival from listing and transplantation; TIPS correlated with a decreased nodule count (-0.24 vs. 0.04, p = 0.028) over a median wait period of 284 days (IQR 195-493) and better overall survival from listing (95.6% vs. 91.5% at 1 year, p < 0.0001). It was not associated with changes in tumor volume (0.28 vs. 0.11 cm³/month, p = 0.58) and AFP (14.37 vs. 20.67 ng/mL, p = 0.42). Post-transplant survival rates (91.8% vs. 91.7% at 1 year, p = 0.25) and HCC recurrence (5.1% vs. 5.9% at 5 years, p = 0.14) were similar, with a median follow-up of 4.98 years (IQR 2.5-8.08). While TIPS was associated with a reduced nodule count and improved waitlist survival, it did not significantly impact HCC growth or aggressiveness. These findings suggest potential benefits of TIPS in HCC management, but further studies need to confirm TIPS safety.
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Affiliation(s)
- Sofia El Hajji
- Division of Abdominal Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Laboratory of Transplantation and Hepatology, University of Geneva, Geneva, Switzerland
| | - Stéphanie Lacotte
- Division of Abdominal Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Laboratory of Transplantation and Hepatology, University of Geneva, Geneva, Switzerland
| | - Beat Moeckli
- Division of Abdominal Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Laboratory of Transplantation and Hepatology, University of Geneva, Geneva, Switzerland
| | - François Cauchy
- Division of Abdominal Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Compagnon
- Division of Abdominal Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Christian Toso
- Division of Abdominal Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
- Laboratory of Transplantation and Hepatology, University of Geneva, Geneva, Switzerland
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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3
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Wei G, Zhao Y, Feng S, Yuan J, Xu G, Lv T, Yang J, Kong L, Yang J. Does depressurization of the portal vein before liver transplantation affect the recurrence of HCC? A nested case-control study. BMC Cancer 2024; 24:558. [PMID: 38702621 PMCID: PMC11069182 DOI: 10.1186/s12885-024-12322-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/30/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Portal hypertension (PHT) has been proven to be closely related to the development of hepatocellular carcinoma (HCC). Whether PHT before liver transplantation (LT) will affect the recurrence of HCC is not clear. METHODS 110 patients with depressurization of the portal vein (DPV) operations (Transjugular Intrahepatic Portosystemic Shunt-TIPS, surgical portosystemic shunt or/and splenectomy) before LT from a HCC LT cohort, matched with 330 preoperative non-DPV patients; this constituted a nested case-control study. Subgroup analysis was based on the order of DPV before or after the occurrence of HCC. RESULTS The incidence of acute kidney injury and intra-abdominal bleeding after LT in the DPV group was significantly higher than that in non-DPV group. The 5-year survival rates in the DPV and non-DPV group were 83.4% and 82.7% respectively (P = 0.930). In subgroup analysis, patients in the DPV prior to HCC subgroup may have a lower recurrence rate (4.7% vs.16.8%, P = 0.045) and a higher tumor free survival rate (88.9% vs.74.4%, P = 0.044) after LT under the up-to-date TNMI-II stage, while in TNM III stage, there was no difference for DPV prior to HCC subgroup compared with the DPV after HCC subgroup or the non-DPV group. CONCLUSION Compared with DPV after HCC, DPV treatment before HCC can reduce the recurrence rate of HCC after early transplantation (TNM I-II). DPV before LT can reduce the recurrence of early HCC.
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Affiliation(s)
- Guo Wei
- Department of General Surgery, Public health clinical center of chengdu, Chengdu, Sichuan Province, China
| | - Yong Zhao
- Department of General Surgery, Public health clinical center of chengdu, Chengdu, Sichuan Province, China
| | - Shifeng Feng
- Department of General Surgery, Public health clinical center of chengdu, Chengdu, Sichuan Province, China
| | - Jingsheng Yuan
- Department of Liver transplantation Laboratory, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Gang Xu
- Department of Liver transplantation Laboratory, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Tao Lv
- Department of Liver transplantation center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Jian Yang
- Department of Liver transplantation center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Lingxiang Kong
- Department of Liver transplantation center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
- Department of Liver transplantation Laboratory, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| | - Jiayin Yang
- Department of Liver transplantation center, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
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4
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Melandro F, Parisse S, Ginanni Corradini S, Cardinale V, Ferri F, Merli M, Alvaro D, Pugliese F, Rossi M, Mennini G, Lai Q. Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhosis. J Clin Med 2024; 13:2213. [PMID: 38673486 PMCID: PMC11050968 DOI: 10.3390/jcm13082213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
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.
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Affiliation(s)
- Fabio Melandro
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
| | - Simona Parisse
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Stefano Ginanni Corradini
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Vincenzo Cardinale
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Flaminia Ferri
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Domenico Alvaro
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.P.); (S.G.C.); (V.C.); (F.F.); (M.M.); (D.A.)
| | - Francesco Pugliese
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
| | - Massimo Rossi
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
| | - Gianluca Mennini
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
| | - Quirino Lai
- Department of General and Specialist Surgery, Sapienza University of Rome, 00185 Rome, Italy; (F.P.); (M.R.); (G.M.); (Q.L.)
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Kim DS, Yoon YI, Kim BK, Choudhury A, Kulkarni A, Park JY, Kim J, Sinn DH, Joo DJ, Choi Y, Lee JH, Choi HJ, Yoon KT, Yim SY, Park CS, Kim DG, Lee HW, Choi WM, Chon YE, Kang WH, Rhu J, Lee JG, Cho Y, Sung PS, Lee HA, Kim JH, Bae SH, Yang JM, Suh KS, Al Mahtab M, Tan SS, Abbas Z, Shresta A, Alam S, Arora A, Kumar A, Rathi P, Bhavani R, Panackel C, Lee KC, Li J, Yu ML, George J, Tanwandee T, Hsieh SY, Yong CC, Rela M, Lin HC, Omata M, Sarin SK. Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation. Hepatol Int 2024; 18:299-383. [PMID: 38416312 DOI: 10.1007/s12072-023-10629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 12/18/2023] [Indexed: 02/29/2024]
Abstract
Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.
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Affiliation(s)
- Dong-Sik Kim
- Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - YoungRok Choi
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Joong Choi
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki Tae Yoon
- Department of Internal Medicine, Pusan National University College of Medicine, Yangsan, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Cheon-Soo Park
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deok-Gie Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hae Won Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Won-Mook Choi
- Department of Gastroenterology, Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young Eun Chon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae Geun Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yuri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Ilsan, Republic of Korea
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Ah Lee
- Department of Internal Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Si Hyun Bae
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Zaigham Abbas
- Sindh Institute of Urology and Transplantation, Karachi, Pakistan
| | - Ananta Shresta
- Department of Hepatology, Alka Hospital, Lalitpur, Nepal
| | - Shahinul Alam
- Crescent Gastroliver and General Hospital, Dhaka, Bangladesh
| | - Anil Arora
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Ashish Kumar
- Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital New Delhi, New Delhi, India
| | - Pravin Rathi
- TN Medical College and BYL Nair Hospital, Mumbai, India
| | - Ruveena Bhavani
- University of Malaya Medical Centre, Petaling Jaya, Selangor, Malaysia
| | | | - Kuei Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jun Li
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Ming-Lung Yu
- Department of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | | | | | | | | | - H C Lin
- Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Masao Omata
- Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
- University of Tokyo, Bunkyo City, Japan
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Di Cola S, Lapenna L, Gazda J, Fonte S, Cusi G, Esposito S, Mattana M, Merli M. Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting. J Clin Med 2024; 13:600. [PMID: 38276106 PMCID: PMC10816519 DOI: 10.3390/jcm13020600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS "towards transplant" can offer advantages in terms of ameliorating a patient's clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting.
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Affiliation(s)
- Simone Di Cola
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Jakub Gazda
- 2nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital in Kosice, 040 11 Kosice, Slovakia;
| | - Stefano Fonte
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Giulia Cusi
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Samuele Esposito
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Marco Mattana
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
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Fichtl A, Seufferlein T, Zizer E. Risks and benefits of TIPS in HCC and other liver malignancies: a literature review. BMC Gastroenterol 2023; 23:403. [PMID: 37986043 PMCID: PMC10662760 DOI: 10.1186/s12876-023-03047-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 11/08/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated treatment option for clinically significant portal hypertension (CSPH) in the context of liver cirrhosis. Its high efficacy and safety in the management of treatment-refractory ascites and variceal bleeding have been extensively proven. Contraindications for TIPS include severe right heart failure, hepatic encephalopathy, and sepsis. However, the role of liver malignancy in TIPS is debatable. Mostly, primary liver malignancies such as hepatocellular carcinoma (HCC) emerge from advanced liver diseases. Coexisting portal hypertension in HCC often results in limited treatment options and a poor prognosis. Previous studies have shown that TIPS implantation in patients with HCC is technically feasible and is usually not associated with major adverse events. Furthermore, TIPS may help in bridging the time to liver transplantation in early HCC and allow for locoregional treatment in advanced HCC. However, several studies suggest that seeding tumour cells to the lungs by TIPS placement might worsen the prognosis. CONCLUSIONS TIPS placement in patients with coexisting liver malignancy remains a case-by-case decision, and there is no profound evidence allowing general recommendations. This review aims to provide a state-of-the-art overview of the potential risks and benefits of TIPS placement in patients with liver malignancies.
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Affiliation(s)
- Anna Fichtl
- Department of Gastroenterology and Hepatology Internal Medicine I, University Ulm, University Hospital Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany.
| | - Thomas Seufferlein
- Department of Gastroenterology and Hepatology Internal Medicine I, University Ulm, University Hospital Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany
| | - Eugen Zizer
- Department of Gastroenterology and Hepatology Internal Medicine I, University Ulm, University Hospital Ulm, Albert-Einstein-Allee 23, Ulm, 89081, Germany
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8
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Laurent C, Rayar M, Maulat C, Muscari F, Marichez A, Gregoire E, Chopinet S, Mabrut JY, Boudjema K, Lesurtel M, Adam JP, Mohkam K, Chiche L. Liver transplantation and hepatocellular carcinoma: is TIPS deleterious? A multicentric retrospective study of the ARCHET research group with propensity score matching. Langenbecks Arch Surg 2023; 408:149. [PMID: 37052722 DOI: 10.1007/s00423-023-02875-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/30/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE A transjugular intrahepatic portosystemic shunt (TIPS) before the liver transplantation (LT) has been considered a contraindication in cases of hepatocellular carcinoma (HCC) because of the risk of tumour growth. We aimed to assess the impact of TIPS on incidental HCC and oncological outcomes in transplanted patients with pre-existing HCC. METHODS All consecutive transplanted patients for cirrhosis who had a previous TIPS with or without HCC were included. Between 2007 and 2014, 1912 patients were transplanted. We included 122 (6.3%) patients having TIPS before LT. A 1:3 matched cohort of 366 patients (18.9%) having LT without previous TIPS was selected using a propensity score. Incidental HCC rate and risk factor of HCC recurrence were evaluated using multivariate analysis with a competing risk model. RESULTS Before LT, in the TIPS group, 27 (22.1%) had an HCC vs. 81 (22.1%) in the control group (p = 1). The incidental HCC rate was similar: 10.5% (10/95) in the TIPS group vs. 6.3% (18/285) in the control group (p = 0.17). Recurrence occurred in 1/27 (3.7%) patient in the TIPS group and in 7/81 (8.6%) patients in the control group, without significant difference (p = 0.51). After multivariate regression, patient's gender (p < 0.01) was significantly associated with HCC recurrence while a tumour within Milan criteria (p = 0.01, sHR: 0.17 [0.04; 0.7]) and an incidental HCC (p<0.01) were found to be protector factors against HCC recurrence. CONCLUSION TIPS did not worsen the prognosis of transplanted patients for HCC. TIPS should no longer be contraindicated for oncological reasons in patients with HCC waiting for an LT.
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Affiliation(s)
- Christophe Laurent
- Department of Digestive Surgery and Liver Transplantation, Bordeaux University Hospital, Pessac, France.
| | - Michel Rayar
- Department of Visceral Surgery, University Hospital of Rennes, Rennes, France
| | - Charlotte Maulat
- Department of Visceral Surgery, Toulouse-Rangueil University Hospital, Toulouse, France
| | - Fabrice Muscari
- Department of Visceral Surgery, Toulouse-Rangueil University Hospital, Toulouse, France
| | - Arthur Marichez
- Department of Digestive Surgery and Liver Transplantation, Bordeaux University Hospital, Pessac, France
| | - Emilie Gregoire
- Department of General Surgery and Liver Transplantation, Hôpital de la Timone, Aix-Marseille University, Marseille, France
| | - Sophie Chopinet
- Department of General Surgery and Liver Transplantation, Hôpital de la Timone, Aix-Marseille University, Marseille, France
| | - Jean Yves Mabrut
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Karim Boudjema
- Department of Visceral Surgery, University Hospital of Rennes, Rennes, France
| | - Mickael Lesurtel
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Jean-Philippe Adam
- Department of Digestive Surgery and Liver Transplantation, Bordeaux University Hospital, Pessac, France
| | - Kayvan Mohkam
- Department of General Surgery & Liver Transplantation, Hospices Civils de Lyon, Croix-Rousse University Hospital, Claude-Bernard Lyon 1 University, Lyon, France
| | - Laurence Chiche
- Department of Digestive Surgery and Liver Transplantation, Bordeaux University Hospital, Pessac, France
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Martínez-Rodrigo JJ, Boukhoubza A, Enguix DP, García-Marcos R, Vila-Carbó JJ, Domenech A, Nebot CS, Solana J, Marti-Bonmatí L. Feasibility and outcomes of transjugular intrahepatic portosystemic shunts in infants. Pediatr Radiol 2022; 53:953-962. [PMID: 36580102 DOI: 10.1007/s00247-022-05575-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/03/2022] [Accepted: 12/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Experience with transjugular intrahepatic portosystemic shunts (TIPS) in the pediatric population, especially in infants, is limited. OBJECTIVE To evaluate the feasibility, efficacy and safety of TIPS placement in infants. MATERIALS AND METHODS This retrospective non-comparative observational cohort study analyzed all pediatric patients < 12 months of age treated with TIPS while waiting for liver transplant between October 2018 and April 2021. The sample consisted of 10 infants with chronic liver disease. All had refractory ascites and decreased portal vein size. Their mean age ± standard deviation was 5 ± 1 months and their mean weight was 5.4 ± 1.0 kg. We calculated the pediatric end-stage liver disease score and portosystemic gradients before and after TIPS placement. We used ultrasound to check for complications and to assess the presence of ascites. We used paired-sample t-test for the mean comparison of paired variables. RESULTS Ten TIPS procedures were performed that were technically and hemodynamically successful except for one, in which an extrahepatic portal puncture required surgical repair. Ascites resolved in three infants and was reduced in six. The portal vein size remained stable after TIPS placement. Four infants had early stent thrombosis and two had late stent thrombosis treated with angioplasty or covered stents. CONCLUSION TIPS placement in infants is a feasible, safe and effective procedure.
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Affiliation(s)
- José J Martínez-Rodrigo
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain.
| | - Ali Boukhoubza
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Daniel Pérez Enguix
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Raúl García-Marcos
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Juan J Vila-Carbó
- Department of Pediatric Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Anna Domenech
- Department of Pediatric Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Cinta Sangüesa Nebot
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Jimena Solana
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Luis Marti-Bonmatí
- Department of Radiology, Hospital Universitario y Politécnico La Fe, Avda. de Fernando Abril Martorell, 106, 46026, Valencia, Spain
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The Relationship and Changes of Liver Blood Supply, Portal Pressure Gradient, and Liver Volume following TIPS in Cirrhosis. Can J Gastroenterol Hepatol 2022; 2022:7476477. [PMID: 36531835 PMCID: PMC9754828 DOI: 10.1155/2022/7476477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022] Open
Abstract
AIM Transjugular intrahepatic portosystemic shunt (TIPS) alters the liver blood supply and reduces portal pressure. This study was to investigate the changes and associations of the hepatic blood flow, liver volume, and portal pressure gradient (PPG) after TIPS in liver cirrhosis. METHODS Twenty-one patients with liver cirrhosis who received TIPS were recruited. The contrast CT images were used to assess the iodine density (ID) of liver parenchymal and liver volume. The ID of the liver parenchyma was used to reflect hepatic blood flow. We used a paired t-test and regression analysis to investigate the effect of TIPS on hepatic blood flow, liver volume, and PPG in individuals with cirrhosis and the factors that affect changes in liver volume. RESULTS After TIPS, there was a significant improvement in the ID of liver parenchyma at arterial phase (AP) and PPG in individuals with cirrhosis (P < 0.05). Each 1 unit increase in the ID change of whole liver parenchyma at the venous phase (VP) was significantly associated with a 269.44 cm3 increase in the liver volume after TIPS (b = 269.44, P = 0.012). With an increasing ID change of whole liver parenchyma at VP, the change in liver volume followed an increasing trend (P for overall association = 0.005). CONCLUSIONS Our data indicate that there was a significant improvement in hepatic blood flow, especially at AP, after TIPS and the change in hepatic blood supply from the portal vein is positively associated with the change in liver volume after TIPS. Increasing the blood supply to the liver from the portal vein may improve the reduction of liver volume.
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11
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Haukeland JW, Midgard H, Konopski Z, Sarna VK, Grøtta OJ, Kløw NE. [Not Available]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2022; 142:21-0911. [PMID: 36226423 DOI: 10.4045/tidsskr.21.0911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt is a treatment for complications of portal hypertension, such as bleeding gastroesophageal varices and refractory ascites. In this article we reveal our experiences with this treatment modality. MATERIAL AND METHOD All patients who had a transjugular intrahepatic portosystemic shunt inserted in the period 2011 - 2021 at Oslo University Hospital Ullevål were studied retrospectively. The cumulative incidence of death was calculated with liver transplantation as a competing event. RESULTS The procedure was technically successful in 62 of 64 patients. The average reduction of the pressure gradient between the inferior vena cava and the portal vein was 12.7 (standard deviation 5.0) mm Hg. One of 31 patients who underwent the procedure because of gastrointestinal bleeding experienced a new episode of bleeding, and 4 of 29 patients who underwent the procedure because of ascites needed a further one to two paracenteses. Two of 62 patients had complications directly related to the procedure in the form of liver abscess and portal vein thrombosis. Five of 62 patients developed symptoms of heart failure or fluid overload. After one, three and twelve months, 49 of 62 (79 %), 45 of 62 (73 %) and 38 of 62 (61 %) patients respectively were still alive. The procedure functioned as a 'bridge to liver transplantation' for eight patients with refractory ascites. INTERPRETATION Transjugular intrahepatic portosystemic shunt is a useful treatment method for complications of portal hypertension.
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Affiliation(s)
| | - Håvard Midgard
- Gastromedisinsk avdeling, Oslo universitetssykehus, Ullevål, og, Senter for eliminasjon av hepatitter (SELIHEP)
| | | | | | | | - Nils-Einar Kløw
- Radiologisk avdeling, Oslo universitetssykehus, Ullevål, og, Institutt for klinisk medisin, Universitetet i Oslo
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12
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Hinojosa-Gonzalez DE, Tellez-Garcia E, Salgado-Garza G, Roblesgil-Medrano A, Bueno-Gutierrez LC, Villegas-De Leon SU, Espadas-Conde MA, Herrera-Carrillo FE, Flores-Villalba E. Intraoperative and postoperative impact of pretransplantation transjugular intrahepatic portosystemic shunts in orthotopic liver transplantations: A systematic review and meta-analysis. Turk J Surg 2022; 38:121-133. [PMID: 36483172 PMCID: PMC9714644 DOI: 10.47717/turkjsurg.2022.5702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/17/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Orthotopic liver transplantation (OLT) remains the definitive treatment for patients afflicted with end-stage liver disease (ESLD). Transjugular intrahepatic portosystemic shunts (TIPS) have been adapted as a bridge to transplantation, allowing partial normalization of portal pressure and associated symptom improvement. Conflicting evidence exists on TIPS' impact on operative procedures. This study aimed to analyze available evidence on patients who underwent OLT with prior TIPS compared to OLT alone with the intent to determine TIPS' impact on surgical outcomes. MATERIAL AND METHODS Following PRISMA guidelines, a systematic review was conducted, identifying studies comparing TIPS + OLT versus OLT alone in patients with ESLD. Data were analyzed using Review Manager 5.3. RESULTS Thirteen studies were included. Operative time, packed red blood cells transfusions, intensive care unit admission, length of stay, dialysis, serum creatinine levels, ascites, vascular complications, bleeding revisions, reintervention, and other complications rates were similar between both groups. Fresh frozen plasma transfusion -2.88 units (-5.42, -0.35; p= 0.03), was lower in the TIPS + OLT group. CONCLUSION Our study found TIPS can be safely employed without having detrimental impacts on OLT outcomes, furthermore, these findings also suggest TIPS does not increase bleeding or complications.
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Affiliation(s)
| | - Eduardo Tellez-Garcia
- School of Medicine and Health Sciences, Monterrey Institue of Technology, Monterrey, Mexico
| | - Gustavo Salgado-Garza
- School of Medicine and Health Sciences, Monterrey Institue of Technology, Monterrey, Mexico
| | | | | | | | | | | | - Eduardo Flores-Villalba
- School of Medicine and Health Sciences, Monterrey Institue of Technology, Monterrey, Mexico
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Department of Advanced Manufacturing, School of Engineering and Sciences, Monterrey Institue of Technology, Monterrey, Mexico
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Vulasala SSR, Onteddu NKR, Kalva SP, Smolinski-Zhao S. Expanding Indications of TIPS in the Management of Portal Hypertension Complications. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2022. [DOI: 10.1055/s-0042-1748818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
AbstractTransjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical intervention to reduce portal pressure by creating a low-resistance channel between the portal and systemic circulations. It is a well-accepted treatment for gastroesophageal varices and refractory ascites. This review aims to discuss the evidence-based applications of TIPS in other complications of portal hypertension beyond gastroesophageal varices and refractory ascites.
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Affiliation(s)
- Sai Swarupa Reddy Vulasala
- Department of Radiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Nirmal Kumar Reddy Onteddu
- Division of Hospital Medicine, Department of Internal Medicine, Flowers Hospital, Dothan, Alabama, United States
| | - Sanjeeva Prasad Kalva
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Sara Smolinski-Zhao
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States
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Büttner L, Aigner A, Pick L, Brittinger J, Steib CJ, Böning G, Streitparth F. 25 years of experience with transjugular intrahepatic portosystemic shunt (TIPS): changes in patient selection and procedural aspects. Insights Imaging 2022; 13:73. [PMID: 35416547 PMCID: PMC9008097 DOI: 10.1186/s13244-022-01216-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/21/2022] [Indexed: 12/15/2022] Open
Abstract
Background TIPS is an established treatment for portal hypertension. The aim was to analyze how patient selection for TIPS implantation and procedural aspects have changed over 25 years. Routinely collected demographic, clinical, laboratory, and procedural data of 835 patients treated with TIPS in a single center were used. Time trends over the observational period from 1993 to 2018 were retrospectively analyzed. Descriptive statistical analysis was performed. Results The most common indication for TIPS implantation has changed significantly from secondary prevention of variceal hemorrhage in the early years to treatment of recurrent ascites. During the observation period, increasingly more severely ill patients became TIPS candidates. There was little change in MELD scores over this period (in total median 13.00; IQR 10.00–18.00). The proportion of patients with Child–Pugh C cirrhosis increased. The most frequent underlying diseases in total were alcohol-related liver disease (66.5%) and viral hepatitis (11.9%). However, shares of cryptogenic liver cirrhosis, autoimmune hepatitis, and NASH increased over time. The proportion of patients post liver transplant also increased. While bare metal stents were standard in the past, use of covered stents increased. The success rate of TIPS (defined by successful implantation and a decrease in the portosystemic pressure gradient ≤ 12 mmHg) increased significantly over time. The total success rate according to this definition was 84.9%. Conclusion The results of our analysis reflect technical developments in TIPS, especially in terms of stent material and gains in clinical experience, particularly regarding indications and patient selection for TIPS implantation.
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Affiliation(s)
- Laura Büttner
- Department of Radiology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Annette Aigner
- Institute of Biometry, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Lisa Pick
- Department of Radiology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Josefine Brittinger
- Department of Radiology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Christian J Steib
- Medical Clinic II, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Georg Böning
- Department of Radiology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Florian Streitparth
- Department of Radiology, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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15
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Transjugular intrahepatic portosystemic shunt versus endoscopic therapy for prevention of variceal rebleeding in patients with hepatocellular carcinoma meeting the Milan criteria. Eur J Gastroenterol Hepatol 2021; 33:436-442. [PMID: 32398493 DOI: 10.1097/meg.0000000000001750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic therapy (ET) have been recommended to prevent variceal rebleeding due to cirrhotic portal hypertension. However, which one is better for patients with hepatocellular carcinoma (HCC) remains controversial. Hence, we aimed to compare the clinical outcomes of these two treatments for these subpopulation. METHODS This retrospective study was approved by the institutional review board. The data of 98 consecutive patients with HCC meeting the Milan criteria (mean age 54.1 years) who had received TIPS placement (34 patients) or ET (64 patients) between June 2010 and December 2017 were reviewed. The clinical outcomes were evaluated and were calculated by the Kaplan-Meier method and compared by using the log-rank test. A matched cohort composed of 34 patients from each group was selected after adjustment with propensity score matching to verify the robustness of the results. RESULTS The median follow-up time was 33.1 months. The rebleeding rate was significantly lower in TIPS group (P = 0.016). A matched cohort composed of 34 patients from each group after adjustment with propensity score matching showed that TIPS reduced the risk of rebleeding (P = 0.030) without increasing long-term overt hepatic encephalopathy (P = 0.151), while there was no significant difference in overall liver transplant-free survival (P = 0.120). Thereafter, 25 patients in TIPS group (73.5%) and 42 patients in ET group (65.6%) received locoregional therapies for HCC (P = 0.431). CONCLUSION TIPS reduced the risk of rebleeding without improving survival. Locoregional therapies can be performed safely to manage HCC after sufficient prevention of variceal rebleeding.
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