Preoperative Transjugular Intrahepatic Portosystemic Shunt Research Articles

Successful Preoperative Transjugular Intrahepatic Portosystemic Shunt for Portal Decompression in Patients With Inflammatory Bowel Disease and Cirrhosis Requiring Surgical Intervention.

Colorectal surgery in patients with inflammatory bowel disease (IBD) and cirrhosis has increased morbidity, which may preclude surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) is postulated to reduce surgical risk. In this retrospective single-center study, we characterized perioperative outcomes in patients with IBD and cirrhosis who underwent preoperative TIPS. We identified patients with IBD and cirrhosis who had undergone preoperative TIPS for portal decompression between 2010 and 2023. All other indications for TIPS led to patient exclusion. Demographic and medical data were collected, including portal pressure measurements. Primary outcome of interest was perioperative outcomes. Ten patients met the inclusion criteria. The most common surgical indications were dysplasia (50%) and refractory IBD (50%). TIPS was performed at a median of 47 days (IQR 34-80) before surgery, with reduction in portal pressures (22.5 vs. 18.5 mmHg, P < .01) and portosystemic gradient (12.5 vs. 5.5 mmHg, P < .01). Perioperative complications occurred in 80% of patients, including surgical site bleeding (30%), wound dehiscence (10%), systemic infection (30%), liver function elevation (50%), and coagulopathy (50%). No patients required re-operation, with median length of stay being 7 days (IQR 5.5-9.3). The 30-day readmission rate was 40%, most commonly for infection (75%), with 2 patients having intra-abdominal abscesses and 1 patient with concern for bowel ischemia. Ninety-day and one-year survival was 100% and 90%, respectively. Patients with primary sclerosing cholangitis (PSC)-cirrhosis were noted to have higher perioperative morbidity and a 30-day readmission rate. In patients with IBD and cirrhosis, preoperative TIPS facilitated successful surgical intervention despite heightened risk. Nevertheless, significant complications were noted, in particular for patients with PSC-cirrhosis.

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.

Pancreaticoduodenectomy in a patient with severe portal hypertension: the role of preoperative TIPS.

The complication rate for Pancreaticoduodenectomy (PD) is 40-50% in most published series and mortality can raise up to 4-5% even in high-volume centers. Severe portal hypertension secondary to liver disease is associated to high perioperative mortality and therefore is considered a contraindication for PD. No standardized management exists for surgically resectable patients with periampullary cancer and severe portal hypertension. The aim of this case study is to analyse the treatment alternatives in patients with periampullary cancer and severe portal hypertension and focus into the surgical treatment of these patients. We present the case of a 67 year-old patient case with a resectable ampullary cancer and portal hypertension managed with Preoperative Transjugular Intrahepatic Portosystemic Shunt (TIPS) to allow a PD. We present a literature review on the use of preoperative TIPS in patients who are candidates to PD. Neoadjuvant TIPS can be safely used in selected patients with severe portal hypertension who need a PD.

How to manage a patient with chronic liver disease undergoing colorectal surgery?

The indications for colorectal surgery in cirrhotic patients have recently been broadened, mostly due to a better understanding and multidisciplinary management of cirrhosis. However, anesthesia and colorectal surgery may both exacerbate deteriorations in liver function in a patient with chronic liver disease such that careful preoperative patient selection remains mandatory. Four scores (i.e., Child-Turcotte-Pugh, the Model for End-Stage Liver Disease, Mayo Risk Score, and (VOCAL)-Penn cirrhosis surgical risk score) are currently available to assess the severity of cirrhosis, determine the risk of decompensation, and to estimate postoperative mortality. For colorectal resection to be safely performed electively in patients with compensated liver disease, optimization of the patient is mandatory in the preoperative setting. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) is a promising strategy in patients with portal hypertension, but it requires further evaluation. Similarly, further studies are needed to validate both the feasibility and safety of the laparoscopic approach to colorectal surgery in cirrhotic patients. In summary, preoperative identification and optimization combined with meticulous postoperative care are essential for optimum outcomes in patients with chronic liver disease undergoing colorectal surgery.

SAT-331 - Preoperative transjugular intrahepatic portosystemic shunt and in-house mortality in patients with liver cirrhosis undergoing surgery

SAT-331 - Preoperative transjugular intrahepatic portosystemic shunt and in-house mortality in patients with liver cirrhosis undergoing surgery

Impact of pre-operative transjugular intrahepatic portosystemic shunt on post-operative outcomes following non-transplant surgeries in patients with decompensated cirrhosis.

Patients with cirrhosis have a high risk for morbidity and mortality in relation to abdominal surgery. Despite improvements in surgical techniques and intensive care, major abdominal surgery still remains a challenge. Major factors determining short- and long-term survival and perioperative complications in this patient population include severity of liver dysfunction, degree of portal hypertension (PHTN), and the presence of related complications such as ascites. Elective transjugular intrahepatic portosystemic shunt (TIPS) placement prior to surgery has been reported to improve perioperative outcomes, but available data is limited to case reports and small case series. We aimed to determine the impact of elective TIPS placement on perioperative outcomes after abdominal-pelvic surgeries in patients with cirrhosis. We performed a retrospective chart review of patients who underwent elective TIPS and compared these patients with a cohort of cirrhotic patients who underwent any abdominal surgeries without TIPS placement. The primary outcomes were mortality at 30 days and 1 year following surgery. Other post-operative outcomes compared between the two groups, included: blood loss, worsening ascites, wound leak, infections, encephalopathy, liver decompensation, and length of hospitalization. Among 38 patients with cirrhosis who underwent abdominal surgery, 20 patients underwent pre-operative elective TIPS placement. Demographic characteristics of the two groups were comparable including age, gender, and body mass index (BMI). The median age was 62 years with a male predominance (62.5%). Both groups had similar etiologies of cirrhosis with hepatitis C virus (HCV) (34.2%) being most common. The most frequent indications for surgery were strangulated hernia (50%) in the TIPS group and acute cholecystitis (55.6%) in the non-TIPS group. Mean pre-TIPS hepato-venous portal gradient (HVPG) was 16.5 mmHg and mean post-TIPS HVPG was 7.0 mmHg. Mortality at 1 month was not statistically different between the groups (20% vs. 5.6%, respectively, P=0.19). The 1-year mortality was also not statistically different between the two groups (20% vs. 11.1%, P=0.36). We found no statistically significant difference in mortality or rate of post-operative complications between patients who received pre-operative TIPS and those who did not in our age-matched cohort.

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

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.

Where does TIPS fit in the management of patients with cirrhosis?

SummaryIn this review, we summarise the current knowledge on the indications and contraindications of transjugular intrahepatic portosystemic shunt (TIPS) placement for the treatment of the complications of portal hypertension in cirrhosis, specifically variceal haemorrhage and ascites. Moreover, we discuss the role of TIPS for the treatment of portal vein thrombosis (PVT) and the prevention of complications after extrahepatic surgery (‘preoperative TIPS’) in patients with cirrhosis. The position of TIPS in the treatment hierarchy depends on the clinical setting and on patient characteristics. In acute variceal haemorrhage, preemptive TIPS is indicated in patients at a high risk of failing standard therapy, that is those with a Child-Pugh score of 10–13 points or Child-Pugh B with active bleeding at endoscopy, although the survival benefit in the latter group still remains to be established. Non-preemptive TIPS is a second-line therapy for the prevention of recurrent variceal haemorrhage and for the treatment of ascites. Of note, TIPS may also improve sarcopenia. Contraindications to TIPS placement, independent of clinical setting, include very advanced disease (Child-Pugh >13 points), episodes of recurrent overt hepatic encephalopathy without an identifiable precipitating factor, heart failure, and pulmonary hypertension. In patients with PVT, TIPS placement not only controls complications of portal hypertension, but also promotes portal vein recanalisation. Although the severity of portal hypertension correlates with poor outcomes after extrahepatic surgery, there is no evidence to recommend preoperative TIPS placement.

3:54 PM Abstract No. 323 Preoperative transjugular intrahepatic portosystemic shunt to improve subsequent surgical complications

Abdominal and pelvic surgeries in cirrhotic patients with portal hypertension are associated with high rates of complications due to venous congestion. Preoperative portal decompression to treat complications of elevated portal pressure may be beneficial in reducing these complications. The aim of this study is to assess outcomes of cirrhotic patients undergoing abdominal and pelvic surgery after placement of TIPS for portal decompression. A single-institution retrospective review of patients undergoing TIPS for portal decompression prior to abdominal or pelvic surgery was performed, from 2009 to 2019. Pre and postprocedural analysis included model for end stage liver disease (MELD) score, Child-Pugh Score, and rate of perioperative complications including new or worsening ascites and encephalopathy, infection, gastrointestinal bleeding, renal failure, and mortality. Between 2009 and 2019, 11 patients at our institution underwent TIPS placement specifically for portal decompression prior to abdominal surgery. 4 patients underwent partial colonic resection for colonic malignancy, 4 underwent umbilical hernia repair (3 for Flood syndrome), 1 patient each had a hemorrhagic colorectal anastomosis resection, partial nephrectomy for renal cell carcinoma, and Whipple procedure for pancreatic cancer. The average portosystemic gradient reduction was from 17 ± 4 to 6 ± 2 and mean TIPS to surgery interval was 31 days (range, 2-72 days). Average preoperative MELD score was 13 ± 4 and distribution of Child Pugh Scores was A (27%), B (36%), C (36%). Postoperatively, 2 patients developed antibiotic requiring infections. 2 patients developed bleeding complications (defined as requiring >2 units packed red blood cells). 1 patient developed new encephalopathy requiring medical treatment. No patients developed new or worsening ascites or renal failure requiring dialysis. Thirty, 90, and 1 year mortality rates were 0%, 0%, and 23% respectively. Preoperative portal decompression with TIPS can allow patients who otherwise may not be surgical candidates to undergo abdominal and pelvic surgery with a low rate of serious perioperative morbidity and mortality.

1116 The Role of Perioperative Transjugular Intrahepatic Portosystemic Shunt in Cirrhotic Patients Undergoing Extrahepatic Surgery

INTRODUCTION: The use of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the perioperative period in cirrhotic patients with portal hypertension has been limited to small case series. The aim of this study is to describe a multi-center experience with the use of TIPS prior to abdominal surgery in patients with cirrhosis and portal hypertension. METHODS: In a retrospective multi-center case-matched study, we compared outcomes between patients with cirrhosis who received TIPS prior to abdominal surgery and patients who did not. Patients with liver transplantation were excluded. All patients had ascites and were matched 1/1 for same surgical procedure and for similar Model for End Stage Liver Disease (MELD) score. Outcomes evaluated included MELD scores at 30- and 180-day post-surgery, bleeding varices, development of hepatic encephalopathy, medical and surgical complications, 30- and 180-day mortality, length of hospital stay, and 30-day readmission rate. Statistical significance was determined using a paired t test and Fischer’s exact test. RESULTS: There were 14 patients in each group. In each group, 5 patients (35.7%) underwent colorectal surgery and the remainder underwent umbilical hernia repair. The majority of patients in both cohorts had advanced cirrhosis as characterized by their pre-operative Child Pugh score B and C. TIPS was performed an average of 18.4 days prior to surgery. In the post-operative period, 4 patients with TIPS had ascites compared to 12 patients without TIPS (P = 0.006). Post-operative hepatic encephalopathy and esophageal variceal bleeding were more common in the non-TIPS cohort. Length of stay was 11.4 days in TIPS patients and 6.6 days in non-TIPS patients (P = 0.19). Five TIPS patients (35.7%) were re-admitted within 30-days compared to 7 non-TIPS patients (50%) (P = 0.7). CONCLUSION: Our study indicates that preoperative TIPS significantly improved ascites post TIPS in cirrhotic patients with portal hypertension in comparison with patients who did not receive TIPS. Our study also shows improvement although not statistically significant in 30- and 180-day MELD scores, incidence of esophageal variceal bleeding, incidence of hepatic encephalopathy, post-operative medical and surgical complications, and 180-day mortality. TIPS did not improve length of stay or readmission rates. TIPS appears to have a role in patients with cirrhosis however further studies are required to better characterize the potential benefit of TIPS in the perioperative period.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Creation Prior to Abdominal Operation: a Retrospective Analysis

PurposeTransjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly performed for patients with refractory ascites or variceal hemorrhage. While TIPS have also been created prior to planned abdominal operation to decrease morbidity related to portal hypertension, there are limited data supporting its effectiveness in that indication. The goal of this study was to determine if preoperative TIPS creation allows for successful abdominal operation with limited morbidity. MethodsA retrospective review of records of 22 consecutive patients who underwent TIPS creation for the specific indication of improving surgical candidacy, between 2011 and 2016, was performed. Clinical and serologic data were obtained for 21 patients (one patient was excluded since she was completely lost to follow-up after TIPS creation). The primary endpoint was whether patients underwent planned abdominal operation following TIPS. Operative outcomes and reasons that patients failed to undergo planned operation were examined as secondary endpoints. The mean age was 56.4±8.8 years and the mean Child-Pugh and Model for End-Stage Liver Disease (MELD) scores were 7.2±1.5 and 11.9 ± 4.3, respectively. ResultsTIPS creation was performed in all 21 patients with a 30-day mortality rate of 9.5%. Eleven patients (52.4%) subsequently underwent abdominal operation after which the 30-day postoperative mortality rate was 0%. One patient (9.1%) had major perioperative morbidity related to portal hypertension and presented with surgical wound dehiscence and infection requiring drain placement and antibiotic therapy. ConclusionsIn this population, TIPS allowed successful abdominal operation in the majority of patients, with 30-day TIPS mortality of 9.5%, no perioperative mortality, and 9.1% major postoperative morbidity attributable to portal hypertension.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Creation to Improve Surgical Candidacy Prior to Abdominal Operation: A Retrospective Analysis

Background and Hypothesis: TIPS creation is typically reserved for patients with refractory ascites or variceal hemorrhage. While TIPS have also been created prior to planned abdominal operation to decrease morbidity related to portal hypertension, there is little in the literature supporting its efficacy in that indication. The goal of this study was to determine if preoperative TIPS creation allows successful abdominal operation and improves outcomes. &#x0D; Experimental Design or Project Methods: A retrospective review of records of 22 patients who underwent preoperative TIPS creation between 2011 and 2016 was performed. Clinical and serologic data were obtained for 21 patients since one patient was completely lost to follow up after TIPS creation. The primary endpoint was whether patients underwent planned abdominal operation following TIPS. Operative outcomes and reasons that patients failed to undergo planned operation were examined as secondary endpoints. &#x0D; Results: The mean age was 56.4 ± 8.8 years, and the mean Child-Pugh and Model for End-Stage Liver Disease (MELD) scores were 7.2 ± 1.5 and 11.9 ± 4.3, respectively. Thirty-day mortality after TIPS creation was 9.5%. Eleven patients (52.4%) underwent planned abdominal operation and the thirty-day mortality rate was 0%. One of these 11 patients (9.1%) had surgical wound dehiscence and infection 53 days after operation. Reasons for failure to proceed to abdominal operation after TIPS were multifactorial. &#x0D; Conclusion and Potential Impact: In our population, TIPS allowed successful abdominal operation in the majority of patients, with thirty-day TIPS mortality of 9.5%, no perioperative mortality, and 9.1% major postoperative morbidity.

Perioperative Transjugular Intrahepatic Portosystemic Shunt (TIPS) Placement in Cirrhotics Undergoing Abdominal Surgery: A Case Series

Introduction: Operative risk in cirrhotics is related to severity of liver disease and nature of the procedure. Elective and emergent abdominal surgery in cirrhotics is associated with increased perioperative mortality. Surgery can precipitate hepatic decompensation, as well as intraoperative bleeding and ascites, which can cause wound dehiscence and peritonitis. Preoperative portal decompression via TIPS may reduce the risk of complications and impact survival. However, in emergent surgeries pre-op TIPS is not feasible, and can be considered post-op. We report on the utility of pre- and post-operative TIPS in decompensated cirrhotics, and its effect on perioperative mortality. Methods: Between 2010-2017 at the UAB, 19 cirrhotics underwent TIPS prior to abdominal surgery, and four after. Mayo Clinic post-operative mortality risk calculator was used to determine the expected 30 and 90-day mortality, which was compared to the observed mortality in our cohort. Results: TIPS was successfully performed in 23 decompensated cirrhotics, 19 preoperatively and 4 postoperatively. The hepatic venous pressure gradient decreased from 13.7±3.1 to 5.8±2.1 mm Hg after postop TIPS, and from 16±4.7 to 5.3±2.5 mm Hg after pre-op TIPS. Mean time between pre-op TIPS and surgery was 39 days, and from surgery to post-op TIPS 9 days. The mean MELD score increased from 12.7±4.2 to 15.2±4.3 after preoperative-TIPS. Mean MELD at surgery was 13.2±3.9, and increased to 17.2±6.2 at post-operative TIPS. After preoperative TIPS, hepatic encephalopathy was reported in all 19 patients and ascites in six patients with two requiring revision of TIPS within 30 days after the surgery. One preoperative TIPS patient, with a Mayo 30-day mortality risk of 41%, died 78 days from surgery. One patient, with a Mayo 30-day mortality risk of 23%, died 48 hours post-op due to surgical complications, with TIPS placed 24 hours post-op. No wound dehiscence or peritonitis was reported. Conclusion: Decompression of the portal system has been noted to reduce mortality in high-risk surgical candidates prior to elective surgery. We show that both pre- and post-operative TIPS placement in decompensated cirrhotics may reduce mortality. Further studies are needed to validate our findings and identify a patient cohort that would most benefit. A key variable to be determined is the ideal time interval between TIPS and surgery to prevent multiple hits to the liver and limit the risk of hepatic decompensation.

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

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.

Preoperative Transjugular Intrahepatic Portosystemic Shunt Placement for Extrahepatic Abdominal Surgery.

Extrahepatic abdominal surgery in patients with portal hypertension is associated with a high rate of perioperative complications and death due to the increased risk of liver failure, perioperative bleeding, and ascites. One proposed method to facilitate surgery in these patients is with preoperative placement of a transjugular intrahepatic portosystemic shunt (TIPS). By decompressing the portal circulation, this presurgical measure would theoretically decrease the potential for bleeding and improve the ability to control ascites in the perioperative and postoperative period. This article reviews the use of TIPS prior to abdominal surgery in patients with portal hypertension.

Preoperative elective transjugular intrahepatic portosystemic shunt for cirrhotic patients undergoing abdominal surgery.

Despite improvements in the surgical techniques, anesthesia and intensive care, abdominal surgery in patients with cirrhosis remains a challenge. Transjugular intrahepatic portosystemic shunt (TIPS) has been used to manage complications of portal hypertension. Preoperative TIPS (prophylactic) can theoretically improve outcomes in this population. Seven original studies were identified with 24 patients who underwent prophylactic TIPS before abdominal surgery. No perioperative mortality or major abdominal bleeding attributable to portal hypertension was reported for this cohort. One patient had poor wound healing post surgery (4.2%), one had right heart failure (4.2%), and five developed hepatic encephalopathy (20.8%) post surgery. More evidence is needed to optimize the timing of surgery post TIPS and the selection of an appropriate stent size to further decrease the associated morbidity. Overall, the decision for prophylactic TIPS placement for cirrhotic patients undergoing abdominal surgery needs individualization to allow its safe use with concomitant improvement in perioperative morbidity.

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

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.

Abstract No. 391 - Preoperative transjugular intrahepatic portosystemic shunt (TIPS) does not impact liver transplant wait time, resource utilization or the ability to perform a liver transplantation (OLTx)

Abstract No. 391 - Preoperative transjugular intrahepatic portosystemic shunt (TIPS) does not impact liver transplant wait time, resource utilization or the ability to perform a liver transplantation (OLTx)

Complicated hernia presentation in patients with advanced cirrhosis and refractory ascites: Management and outcome

Our purpose was to determine optimal management of and outcome after umbilical herniorrhaphy in patients with advanced cirrhosis and refractory ascites. A retrospective chart review was performed of 21 patients with advanced cirrhosis who underwent umbilical herniorrhaphy at The Mount Sinai Medical Center from 2002 to 2008. Univariate, multivariate, and Kaplan-Meier analysis was performed. Twenty-one patients had refractory ascites: 15 presented with incarceration and 6 with spontaneous umbilical rupture. The mortality rate was 5% and morbidity rate 71%. Two patients required perioperative liver transplantation, and 5 developed ascites-related wound complications. Follow-up at a mean of 36 months demonstrated a 20% mortality rate due to liver disease; 5% required liver transplantation and 6% had a recurrent hernia. In addition to diuretics and albumin, perioperative management of ascites consisted of preoperative transjugular intrahepatic portosystemic shunt (TIPS; n = 6), postoperative TIPS (n = 2), and closed-suction drains (n = 7). The wound complication rate was 17% in patients who underwent preoperative TIPS versus 27% in patients who did not undergo preoperative TIPS (P = NS). TIPS placement postoperatively controlled ascites adequately without additional complication in 2 patients. In this series, use of closed-suction drains did not appear to decrease ascites-related complications. Spontaneous umbilical rupture was an independent risk factor for adverse outcome. For patients presenting with umbilical rupture, preoperative TIPS and semi-elective repair appeared to improve perioperative and 36-month outcome as compared with emergent repair. Preoperative TIPS in conjunction with semi-elective repair when feasible appears preferable, particularly for patients with spontaneous umbilical rupture. The lower than anticipated mortality rate was attributed to institutional experience and to the multidisciplinary approach to patient care.

Preoperative Transjugular Intrahepatic Portosystemic Shunt for Extrahepatic Surgery in Cirrhosis

Preoperative Transjugular Intrahepatic Portosystemic Shunt for Extrahepatic Surgery in Cirrhosis