Preoperative TIPS prevents the development of postoperative acute-on-chronic liver failure in patients with high CLIF-C AD score

Johannes Chang,Pauline Höfer,Nina Böhling,Philipp Lingohr,Steffen Manekeller,Jörg C Kalff,Jonas Dohmen,Dominik J Kaczmarek,Christian Jansen,Carsten Meyer,Christian P Strassburg,Jonel Trebicka,Michael Praktiknjo

doi:10.1016/j.jhepr.2022.100442

Abstract

Background & AimsAcute-on-chronic liver failure (ACLF) is a syndrome associated with organ failure and high short-term mortality. Recently, the role of surgery as a precipitating event for ACLF has been characterised. However, the impact of preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement on ACLF development in patients with cirrhosis undergoing surgery has not been investigated yet.MethodsA total of 926 patients (363 with cirrhosis undergoing surgery and 563 patients with TIPS) were screened. Forty-five patients with preoperative TIPS (TIPS group) were 1:1 propensity matched to patients without preoperative TIPS (no-TIPS group). The primary endpoint was the development of ACLF within 28 and 90 days after surgery. The secondary endpoint was 1-year mortality. Results were confirmed by a differently 1:2 matched cohort (n = 176).ResultsPatients in the no-TIPS group had significantly higher rates of ACLF within 28 days (29 vs. 9%; p = 0.016) and 90 days (33 vs. 13%; p = 0.020) after surgery as well as significantly higher 1-year mortality (38 vs. 18%; p = 0.023) compared with those in the TIPS group. Surgery without preoperative TIPS and Chronic Liver Failure Consortium–Acute Decompensation (CLIF-C AD) score were independent predictors for 28- and 90-day ACLF development and 1-year mortality after surgery, especially in patients undergoing visceral surgery. In the no-TIPS group, a CLIF-C AD score of >45 could be identified as cut-off for patients at risk for postoperative ACLF development benefiting from TIPS.ConclusionsThis study suggests that preoperative TIPS may result in lower rates of postoperative ACLF development especially in patients undergoing visceral surgery and with a CLIF-C AD score above 45.Lay summaryAcute-on-chronic liver failure (ACLF) is a syndrome that is associated with high short-term mortality. Surgical procedures are a known precipitating event for ACLF. This study investigates the role of preoperative insertion of a transjugular intrahepatic portosystemic shunt (TIPS) on postoperative mortality and ACLF development. Patients with TIPS insertion before a surgical procedure exhibit improved postoperative survival and lower rates of postoperative ACLF, especially in patients undergoing visceral surgery and with a high CLIF-C AD prognostic score. Thus, this study suggests preoperative TIPS insertion in those high-risk patients.

Highlights

This study investigates the role of preoperative insertion of a transjugular intrahepatic portosystemic shunt (TIPS) on postoperative mortality and Acute-on-chronic liver failure (ACLF) development
The median age was similar between the TIPS and no-TIPS groups
With model for end-stage liver disease (MELD) instead of Chronic Liver Failure (CLIF)-C Acute decompensation (AD) included into the multivariate analysis, MELD and surgery without preoperative TIPS remained as predictors for 28- and 90-day ACLF development with hazard ratios (HRs) of 4.6 and 3.7, respectively (Table 3 and Table S5B)

Summary

Introduction

Cirrhosis is the common end stage of chronic liver diseases and is characterised by fibrosis of liver tissue, decrease in liver function, and the development of portal hypertension.[1,2] Acute. Recent data show that high hepatic venous pressure gradients (HVPGs) of >16 and >−20 independently predicted 90-day and 1-year mortality in patients undergoing elective extrahepatic surgery.[15] These data indicate a potential benefit of TIPS insertion before surgery by reduction of the portosystemic pressure gradient. Data concerning this hypothesis are scarce, and the question of whether preoperative TIPS placement has an effect on the postoperative development of ACLF or mortality, remains unanswered. This retrospective study aimed to investigate the impact of preoperative TIPS placement on ACLF development and mortality in patients with liver cirrhosis undergoing surgery

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Discussion