Transjugular intrahepatic portosystemic shunt as a bridge to elective abdominal surgery in cirrhotic patients: friend or foe?

Abstract

Background: While abdominal surgery is associated with higher morbidity and mortality in cirrhotic patients, preoperative TIPS has been suggested as a means to reduce portal hypertension and postoperative complications. This study aims to compare cirrhotic patients with preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement and cirrhotic patients without TIPS, in terms of morbidity and mortality after elective extra hepatic abdominal surgery. Study design: Patients were retrospectively included from 2005 to 2016 in four tertiary referral hospitals. Patients who underwent preoperative TIPS (n=66) were compared to control patients without TIPS (n=68). Postoperative outcome was analyzed using inverse probability of treatment weighting. Results: Ten patients (15%) did not undergo planned surgery after receiving TIPS procedure. Preoperative TIPS placement was associated with less postoperative ascites (HR=0.33, 95 per cent i.c. 0.14 to 0.78) but this did not translate into better postoperative outcomes. Patients with hepatic venous pressure gradient (HVPG) ≤13 mmHg and MELDNa ≤15 seemed to benefit from preoperative TIPS placement in terms of severe postoperative complications (HR=0.21, 0.05 to 1.02 and HR=0.16, 0.03 to 1.05, respectively). TIPS patients in colorectal surgery and HVPG >13 mmHg subgroups required more intraoperative red blood cells transfusions (HR=15.03, 1.71 to 132.17 and HR=4.10 1.16 to 14.47, respectively). Conclusions: Although TIPS placement before elective surgery decreased postoperative ascites, this study failed to demonstrate a benefit in terms of intra and postoperative outcome. Results suggest nevertheless a decrease in severe postoperative complications in patients with mild hepatopathy (HVPG ≤13 mmHg and MELDNa ≤15) but further evaluation is necessary.