Outcomes of Transjugular Intrahepatic Portosystemic Shunt Placement Prior to Abdominal Surgery in Patients with Hepatic Decompensation

Abstract

Introduction: Abdominal surgery in patients with liver disease has been associated with an increased risk of perioperative mortality. Transjugular intrahepatic portosystemic shunt (TIPS) is typically performed to reduce porto-systemic pressure gradient (PSG). We aimed to evaluate the utility of pre-operative TIPS placement in patients with cirrhosis, and its effect on perioperative mortality. Methods: This is a retrospective study of 16 patietns with cirrhosis who had TIPS placement prior to abdominal surgery between 2010 and 2015. Patients with and without hepatic decompensation were included. Hepatic decompensation was defined as the presence of one or more of the following: ascites, hepatic encephalopathy (HE) or history of variceal bleeding (VB). We used the Mayo Clinic postoperative mortality risk calculator to determine the expected 30-day mortality and compared it to the observed mortality in our cohort. Results: Sixteen patients with cirrhosis (75% males, 87.5% Caucasians, with mean age of 50.3+10 years) were included. Fifteen patients had decompensated cirrhosis (ascites [14/15, 93%], VB [4/15, 26.7%] and HE [9/15, 60.0%]), while one patient had ascites due allograft dysfunction after orthotopic liver transplant (OLT). The mean PSG was reduced from 14.8+5.0 mm Hg pre-TIPS to 5.3+2.7 mm Hg post-TIPS. The mean Model for End Stage Liver Disease (MELD) score increased from 13.6+4.4 before TIPS to 15.7+4.5 after TIPS. All sixteen patients had abdominal surgeries, one was emergent and 11 were hernia repair. Median time to surgery was 39 days. Median hospital stay was four days. The mean expected post-operative 30-day mortality risk was 27.3+21.6%. Observed 30-day postoperative mortality rate was found to be 0%. Data was available on 12/16 patients at one year and the observed mortality was 8%. After TIPS, HE was reported in all 16 patients and ascites in six patients with two requiring revision of TIPS within 30 days after the surgery. One patient, with a post-operative 30-day mortality risk of 43.6%, died (78 days from surgery, 46 days of hospitalization) and five patients received liver transplant. Conclusion: Our retrospective review indicates that pre-operative TIPS placement in patients with decompensated cirrhosis, especially ascites, can help reduce the post-operative mortality. Further studies are needed to identify patient population that would most benefit from such an intervention.