Preoperative transjugular intrahepatic portosystemic shunt (TIPS) for cirrhotic patients undergoing abdominal and pelvic surgeries

Background  Surgery for patients with cirrhosis is associated with increased morbidity and mortality. Perioperative complications including hemorrhage, wound dehiscence, and peritonitis result from underlying portal hypertension. Perioperative control of portal hypertension could decrease the risk of such complications. This study aimed to describe the authors’ experience with the placement of transjugular intrahepatic portosystemic shunts (TIPS) in patients with cirrhosis to improve surgical outcomes. Methods  A retrospective chart review was performed for seven patients who underwent TIPS placement before elective abdominal or pelvic surgery at the University of Colorado Health Sciences Center from 1998 to 2006. The TIPS indication for each patient was to minimize perioperative complications. Results  The seven patients in this study underwent their planned surgical procedure within a mean of 13 days from the time of TIPS placement. Two patients required a blood transfusion of two units or less. Three patients experienced a total of four postoperative complications including wound infection, peritonitis, pneumonia, and new ascites. One patient died of liver failure 14 months after surgery. Conclusions  The preparation of patients with cirrhosis and portal hypertension for elective surgery using preoperative portal decompression may decrease the risk of perioperative morbidity and mortality.     

Albumin-bilirubin grade versus MELD score for predicting survival after transjugular intrahepatic portosystemic shunt (TIPS) creation

Objectives

The purpose of this study was to compare the albumin-bilirubin (ALBI) grade and model for end-stage liver disease (MELD) scores for predicting survival after transjugular intrahepatic portosystemic shunt (TIPS) creation.

Hemodynamic and metabolic effects of transjugular intrahepatic portosystemic shunt (TIPS) during anesthesia for orthotopic liver transplantation

Recently, the tranjugular intrahepatic portosystemic shunt (TIPS) has been advocated as a safe bridge to orthotopic liver transplantation (OLT). We retrospectively studied 53 consecutive cirrhotic patients who underwent OLT: 27 patients with TIPS were compared to 26 controls. Hemodynamic and oxyphoretic data (Fick method) were collected during six phases of OLT. There were no significant differences in demographic data and Child-Pugh class, nor in surgical time and blood product requirements before the anhepatic phase between TIPS patients and controls. In the TIPS group, we observed a marked hyperdynamic profile with a lower systemic vascular resistance index, higher cardiac index, and depressed oxygen consumption before native liver removal. During the same period, the TIPS group developed a greater acidosis and was treated with a larger amount of Na-HCO₃. Following the anhepatic phase, no differences between the two groups were detected. All transplantations were successful, and no complications related to TIPS were observed. These results seem to be the consequence of a reduced liver function reserve with a direct hemodynamic effect due to the TIPS.     

Neoadjuvant transjugular intrahepatic portosystemic shunt: a solution for extrahepatic abdominal operation in cirrhotic patients with severe portal hypertension.

BACKGROUND: Major abdominal surgery, although technically feasible per se, can be contraindicated in some cirrhotic patients because of severe portal hypertension. The present study reports our experience of seven such patients who were prepared for major abdominal surgery by transjugular intrahepatic portosystemic shunt (TIPS). STUDY DESIGN: There were seven cirrhotic patients (six men and one woman aged 47 to 69 years) with portal hypertension. Portal hypertension was considered severe because of the presence of at least one of the following: history of variceal bleeding (five of seven patients), varices at risk of bleeding (red signs or cardial location of varices; four of seven patients), or intractable ascites (three of seven patients). The planned operations included colon, gastroesophageal, kidney, and aortic procedures in three, two, one, and one patient, respectively. Because portal hypertension was the leading cause of surgical contraindication, the following "two-step strategy" was applied to the seven patients: first, TIPS to control portal hypertension, followed, after a delay of at least 1 month, by abdominal surgery. RESULTS: The TIPS procedure was successfully performed in all patients without complications. The hepatic venous pressure gradient decreased from 18+/-5 to 9+/-5 mm Hg (p<0.01). All patients were operated on with a delay ranging from 1 month to 5 months after TIPS (2.9+/-1.3 months; median 3 months). The planned operation was performed in six of the seven patients. One patient with cancer of the cardia did not have resection because of extensive abdominal spreading of the tumor. Intraoperative transfusion was necessary in only two patients. Operative mortality occurred in one patient, 36 days after resection of a left colon cancer. CONCLUSIONS: The minimally invasive nature of TIPS allows us to propose the following two-step management of cirrhotic patients with severe portal hypertension needing abdominal surgery: decompression of the portal system by TIPS followed by elective surgery.     

经颈静脉肝内门-体分流术后5年肝功能变化

目的评估经颈静脉肝内门-体分流(TIPS)术后患者5年肝功能变化。方法收集因门静脉高压伴食管胃底静脉曲张破裂出血或顽固性腹腔积液、临床随访时间5年以上的76例患者资料,均行TIPS进行治疗,随访患者术后1、6、12、24、36、48、60个月的肝功能指标变化,并按照Child-Pugh分数、支架门静脉位置、支架直径进行分层分析。结果手术成功率为100%。随访时间为62~132个月,平均(72.3±16.4)个月。术后患者门静脉压力由术前平均(37.12±7.61)cmH2O降至术后(22.23±6.95)cmH2O(t=12.72,P0.05)。与术前相比,术后1、6、12个月Child-Pugh A级患者Child-Pugh评分增高(P均0.05),而Child-Pugh B级患者评分下降(P均0.05)。Child-Pugh C级患者术后第6个月评分下降(P0.05)。与支架位于门静脉右支者相比,位于左支者术后1、6、12、24个月Child-Pugh评分较低(P均0.05);与支架直径≥8mm者相比,直径8mm者术后1、6个月Child-Pugh评分较低(P均0.05)。结论 TIPS对远期肝功能无明显影响。TIPS对Child-Pugh B级和C级患者前期肝功能有益处,但无法改善Child-Pugh A级患者肝功能。支架直径及支架位置是影响术后前期肝功能的重要因素。     

经颈静脉肝内门体分流术与肝细胞癌的相关性

经颈静脉肝内门体分流术（TIPS）可有效治疗肝硬化患者门静脉高压,但可能影响患者血流动力学和肝功能。TIPS与肝硬化及肝癌具有潜在相关性,可能与肝脏血流动力学改变和肠道群菌失调等有关,目前对于其间关系仍不明确。本文就TIPS与肝细胞癌相关性研究进展进行综述。     

经颈静脉肝内门体分流术后抗凝治疗现状

经颈静脉肝内门体分流术(TIPS)可治疗门静脉高压,但术后常发生分流道狭窄或闭塞。TIPS术后抗凝治疗可预防支架内血栓形成,但同时增加出血风险,且目前尚缺乏统一标准。本文就TIPS术后抗凝治疗现状进行综述。     

Impact of transjugular intrahepatic portosystemic shunt on orthotopic liver transplantation

Transjugular intrahepatic portosystemic shunt (TIPS) is being increasingly utilized prior to liver transplantation for portal hypertensive bleeding refractory to sclerotherapy or as initial management of variceal bleeding. The impact of TIPS on subsequent orthotopic liver transplantation (OLT) is uncertain. The purpose of this study was to analyze the effect of TIPS on OLT in terms of operative transfusion requirements, operative time, length of hospital stay, and graft and patient survival. The results in 17 patients undergoing TIPS for control of initial or recurrent variceal bleeding prior to OLT between June 1991 and December 1992 were compared to two other groups undergoing transplantation: 32 control patients with a history of variceal bleeding not treated by TIPS and 11 patients with a previous surgical portosystemic shunt. Compared with control and surgical shunt patients, patients who underwent TIPS had less transfusion requirement for packed red blood cells and fresh frozen plasma during OLT. The operative time and hospital stay of the TIPS patients were slightly, but not significantly, less. In contrast to patients having TIPS, the patients with a history of a previous surgical shunt had an increased requirement for packed red blood cells, longer operative time, and longer stay in the intensive care unit and hospital. Two patients had recurrent variceal bleeding after TIPS; one patient was found to have an occluded stent, and the other patient (with a patent stent) responded to sclerotherapy. Of the 14 patients with ascites, 8 patients improved and 6 patients had complete resolution after TIPS. There were no major complications related to TIPS, although 3 patients had new or recurrent hepatic encephalopathy that was easily manageable. Thus the preoperative performance of TIPS is associated with less operative transfusion requirement during OLT, presumably secondary to a reduction in portal hypertension. TIPS is preferred to surgical shunt for pretransplant refractory variceal bleeding, as the latter is associated not only with significant morbidity and mortality but also increased transfusion requirements and prolonged operative time and hospital stay.

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Resumen El shunt portosistémico intrahepático transyugular (TIPS) es de utilización creciente con anterioridad al trasplante hepático en pacientes con sangrado por hipertensión portal refractario a la escleroterapia, o como modalidad inicial de manejo en la hemorragia varicosa. El impacto del TIPS sobre un subsiguiente trasplante ortotópico de hígado (TOH) es todavía incierto. El propósito del presente estudio fue analizar el efecto del TIPS sobre el TOH en términos de los requerimientos operatorios de transfusión, el tiempo operatorio, la duración de la hospitalización y la sobrevida tanto del trasplante como del paciente. Los resultados en 17 pacientes sometidos a TIPS para el control de sangrado varicoso inicial o recurrente antes de TOH en el período junio 1991 a diciembre 1992 fueron comparados con otros dos Grupos sometidos a trasplante: 32 pacientes control con historia de hemorragia varicosa no tratada por medio de TIPS y 11 pacientes que habían recibido previamente un shunt portosistémico. En comparación con los pacientes del Grupo control y del Grupo quirúrgico, los pacientes sometidos a TIPS exhibieron menores requerimientos operatorios de transfusión de glóbulos rojos y plasma fresco congelado en el curso del TOH. El tiempo operatorio y la duración de la hospitalización en los pacientes con TIPS fueron ligeramente más cortos, aunque no en forma significativa. En contraste con los pacientes sometidos a TIPS, aquellos con historia de shunt quirúrgico previo, exhibieron un requerimiento mayor de glóbulos rojos y un timepo operatorio más prolongado, así como una más prolongada estancia tanto en la unidad de cuidado intensivo como en el hospital. Dos pacientes presentaron hemorragia varicosa recurrente luego de TIPS: un paciente desarrolló trombosis de la prótesis y el otro, con la prótesis permeable, respondió a la escleroterapia. De los 14 pacientes con ascitis, 8 mejoraron y 6 presentaron resolución completa luego del TIPS. No se registraron complicaciones mayores relacionadas con el TIPS, aunque 3 pacientes exhibieron encefalopatía hepática nueva o recurrente que fue facilmente manejable. En RESUMEN, la realización preoperatoria de TIPS se asocia con menos requerimientos transfusionales en el curso del TOH, presumiblemente como resultado de la reducción de la hipertensión portal. El TIPS es preferible al shunt quirúrgico en el tratamiento de la hemorragia varicosa refractaria pretrasplante, puesto que el shunt se asocia con significativas morbilidad y mortalidad y también con mayores requerimientos transfusionales y más prolongados tiempo operatorio y estancia hospitalaria.

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Résumé Le shunt portocave (PC) intrahépatique par voie transjugulaire (TIPS) est utilisé de plus en plus souvent, avant la transplantation hépatique, en cas d'hémorragie par rupture de varices oesophagiennes n'étant pas contrôlée par la sclérothérapie ou parfois comme traitement initial. L'influence du TIPS sur la transplantation hépatique orthotopique (THO) ultérieure n'est pas connue. Nous avons analysé l'effet du TIPS sur la THO en termes de nécessité et de quantité de transfusion sanguine, la durée d'intervention, la durée de séjour hospitalier, la survie du patient et du greffon. Entre Juin 1991 et Décembre 1992, 17 patients ayant eu un TIPS ont été comparés à deux autres groupes de patients ayant eu une transplantation: 32 patient sans avoir un TIPS au préalable, et 11 patients ayant eu un shunt PC chirurgical. Comparés aux patients contrôles et aux patients ayant eu un shunt PC chirurgical, les patients ayant eu un TIPS ont eu moins besoin de culots globulaires et de plasma frais pendant la THO. Les durées d'opération et d'hospitalisation des patients ayant eu un TIPS étaient moindres mais pas de façon significative. Comparés aux patients ayant eu un TIPS, les patients ayant eu un shunt PC chirurgical ont eu besoin de plus de transfusions (culots globulaires), et leur durée d'intervention et de séjour en soins intensifs et à l'hôpital étaient plus longues. Deux patients ont eu une récidive hémorragique après TIPS: l'un avait une occlusion du shunt, l'autre a répondu de façon satisfaisante par sclérothérapie. Des 14 patients ayant une ascite, huit se sont améliorés et six ont eu une résolution complète après TIPS. Il n'y avait eu aucune complication majeure en rapport avec la pose du TIPS. Trois patients ont eu une encéphalopathie nouvelle ou récidivante facilement contrôlable. En résumé, la pose du TIPS préopératoire est associé avec moins de transfusion pendant la THO, peut-être par réduction de l'hypertension portale. Le TIPS doit être préféré aux shunts chirurgicaux pour les candidats à la THO ayant saigné de varices oesophagiennes non contrôlés par sclérothérapie car cette dernièrc modalité est associée avec une plus grand mortalité, morbidité et des besoins de transfusions, une durée d'opération et d'hospitalisation plus élevées.

     

经颈静脉肝内门体分流术后肝性脑病研究进展

肝性脑病(HE)可引起不同程度的神经精神异常。经颈静脉肝内门体分流术(TIPS)术后高发HE,严重制约其在门静脉高压症治疗中的应用。本文主要对TIPS术后HE的发病机制、危险因素和治疗方面的研究进展进行综述。     

Predictors of mortality and stenosis after transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunts (TIPSs) are used to treat variceal hemorrhage and refractory ascites. We sought to determine factors associated with stenosis and mortality after TIPS placement in patients with end-stage liver disease. This is a retrospective review of 90 TIPSs placed over a 3-year period. Demographic, clinical, and biochemical parameters were analyzed in univariate analyses to determine their association with stenosis and death. Multivariate analyses were conducted using logistic regression and Cox proportional hazard modeling. Thirty-five TIPSs were placed for recurrent variceal bleeding; 14 TIPSs, for uncontrolled variceal bleeding; 34 TIPSs, for refractory ascites; and 7 TIPSs, for other causes. The overall mortality rate was 33%, and 18 patients died within 30 days of TIPS placement. The 1-year stenosis rate was 49%. Fourteen patients underwent liver transplantation a mean of 116 [plusmn] 143 days after TIPS placement. Prothrombin time greater than 17 seconds, serum creatinine level greater than 1.7 mg/dL, total bilirubin level greater than 3 mg/dL, and uncontrolled variceal bleeding as an indication for TIPS placement were significant predictors of 30-day mortality. Serum creatinine level was a predictor of 30-day mortality in individuals with recurrent variceal hemorrhage or ascites. Multivariate analyses showed that creatinine level greater than 1.7 mg/dL and uncontrolled variceal bleeding as an indication for TIPS placement were independently associated with 30-day mortality. Individuals with both coagulopathy and renal insufficiency had a 30-day mortality rate of 78%. Urgent placement of TIPS was associated with an increased risk for stenosis (hazard ratio = 4.5; 95% confidence interval, 1.9 to 10.1; P [lt ] .001), but no other clinical variables were associated with stenosis. Uncontrolled variceal bleeding as an indication for TIPS placement, coagulopathy, hyperbilirubinemia, and renal insufficiency were associated with increased mortality in patients with TIPSs. Individuals with both coagulopathy and renal insufficiency had high mortality. Urgent TIPS placement for uncontrolled variceal bleeding was associated with stenosis. (Liver Transpl 2002;8:271-277.)     

Liver transplantation in patients with transjugular intrahepatic portosystemic shunts

BACKGROUND: In patients with intractable oesophageal variceal bleeding, transjugular intrahepatic portosystemic shunts (TIPSS) are being used increasingly as a bridge to orthotopic liver transplantation (OLTx). There is little information in the literature concerning variations in the operative techniques of OLTx required because of the presence of TIPSS. METHODS: A retrospective review of patients treated by TIPSS prior to OLTx was undertaken. The aims were to assess the effectiveness of TIPSS in bridging patients to OLTx and to examine whether TIPSS influence the operative management of OLTx. RESULTS: Over a 4-year period eight adult patients underwent TIPSS insertion prior to OLTx in the Australian National Liver Transplant Unit (ANLTU). Transplantation was performed at a mean of 14.6 (0.3-53.8) months after TIPSS insertion. Prevention of major recurrent variceal haemorrhage prior to transplantation was achieved in six cases. In two patients the stents were predominantly intrahepatic and they did not interfere with OLTx. In five patients the stents extended into the portal vein, requiring removal during OLTx either by division of the stent with the recipient portal vein, followed by removal of the fractured stent wires from the portal veins (n = 3), or by 'endarterectomy' of the recipient portal vein, allowing removal of the intact stent (n = 2). In one case where the stent extended into the suprahepatic inferior vena cava, removal was achieved by traction without difficulty. All patients are alive at a mean of 24 (7-53) months post-transplant and none has portal vein abnormalities. When compared to 178 adult patients who had no TIPSS and underwent primary OLTx during the same study period, there was no difference in the length of operating time or the usage of blood products during OLTx. CONCLUSION: Transjugular intrahepatic portosystemic shunts offer a bridge to OLTx by providing effective control of variceal haemorrhage. In the present series TIPSS did not increase surgical morbidity or mortality, but emphasis is placed upon the need for optimal TIPSS placement within the liver to facilitate subsequent OLTx.     

Severe venoocclusive disease after liver transplantation treated with transjugular intrahepatic portosystemic shunt

Venoocclusive disease (VOD) is due to hepatic sinusoidal lining injury leading to portal hypertension; its incidence after liver transplantation is about 2%. When severe, it does not respond to medical therapy and has a high mortality; retransplantation is the only therapeutic option. However, there are no detailed data regarding the use of transjugular intrahepatic portosystemic shunt for VOD after liver transplantation. We describe two patients who developed severe VOD after liver transplantation, failed defibrotide therapy, and were treated by transjugular intrahepatic portosystemic shunt (TIPS). The portal hypertension resolved completely and one had full histological recovery. We believe that TIPS should be attempted as it may resolve progressive portal hypertension and the hepatic congestion, while allowing the clinician time for listing for further liver transplantation if the patient fails to respond.     

Transjugular intrahepatic portosystemic shunt (TIPS): an experience with treatment of portal hypertension in patients with cirrhosis of the liver

TIPS procedures have been successfully performed in 18 of 21 patients aged 34-64 (mean age 40 years) with cirrhosis of the liver with acute gastroesophageal bleedings (5) or history of bleeding episodes from gastroesophageal varices (13). The patients were classified according to Child (1964): A--4; B--8 and C--6. The portal pressure before creation of the shunt measured 17-39 (mean 28.1 +/- 7.6) mm Hg. Dilation of the hepatic tissue was performed by a balloon 10 mm in diameter and 4-6 cm long with placement of metallic endoprostheses 10-12 mm in diameter and 80 mm long. The portal pressure after anastomoses were made dropped to 6-28 (mean 20.3 +/- 5.7) mm Hg. The angiogram showed a rapid flow of the contrast medium through the portocaval anastomosis towards the right heart and no filling of the esophageal veins was seen. TIPS procedure is an effective measure to stop variceal gastroesophageal bleeding in patients with portal hypertension. The necessity of regular surveillance and reinterventions makes this approach a temporary measure to reduce hazardous consequences of gastroesophageal hemorrhages.     

Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created using covered stents of different diameters: A systematic review and meta-analysis

PurposeThe purpose of this study was to make a systematic review and meta-analysis to determine the stent diameter (8 mm vs. 10 mm) that conveys better safety and clinical efficacy for transjugular intrahepatic portosystemic shunt (TIPS).Materials and methodsFour databases were used to identify clinical trials published from inception until March 2020. Data were extracted to estimate and compare one-year and three-year overall survivals, hepatic encephalopathy, variceal rebleeding, and shunt dysfunction rates between patients with 8 mm covered stents and those with 10 mm covered stents.ResultsFive eligible studies were selected, which included 489 patients (316 men, 173 women). The 8 mm covered stent group had higher efficacy regarding one-year or three-year overall survival (odds ratio [OR], 2.88; P = 0.003) and (OR, 1.81; P = 0.04) and lower hepatic encephalopathy (OR, 0.69; P = 0.04) compared with 10 mm covered stent group. There were no significant differences in variceal rebleeding rate (OR 0.80; P = 0.67). However, shunt dysfunction was lower in 10 mm covered stent group (OR, 2.26; P = 0.003).ConclusionsOur results suggest that the use of 8 mm covered stents should be preferred to that of 10 mm covered stents for TIPS placement when portal pressure is frequently monitored.     

Transjugular intrahepatic portosystemic shunt (TIPS) placement: A comparison of outcomes between patients with hepatic hydrothorax and patients with refractory ascites

Purpose

To compare the outcomes in patients who had transjugular intrahepatic portosystemic shunts (TIPS) placed for hepatic hydrothorax with those who had it placed for refractory ascites.

双源CT肝静脉和门静脉成像在经颈静脉肝内门体分流术术前的应用

目的探讨双源CT肝静脉和门静脉成像在经颈静脉肝内门体分流术（TIPS）前的临床应用价值。方法门静脉高压合并上消化道出血或大量腹水的28例肝硬化患者接受双源CT门静脉成像,采用最大密度投影（MIP）、多平面重建（MPR）、容积再现（VR）和表面遮盖显示（SSD）等后处理技术判断肝静脉及门静脉的显示情况、分支走行及二者的关系。结果 28例患者均成功完成双源CT肝静脉和门静脉成像,能够清晰显示肝静脉1～3级以上分支及门静脉的解剖变异,MIP、MPR及VR重建图像可以直观地评价门静脉和肝静脉的位置、管径,并了解门静脉高压侧支循环的分布范围和程度。双源CT门静脉成像有助于TIPS术前定位。结论双源CT门静脉成像是无创性检查门静脉和肝静脉的可靠方法 ,为TIPS术前制定个体化手术方案提供了依据,具有较高的临床应用价值。     

The Budd-Chiari syndrome: outcome after treatment with the transjugular intrahepatic portosystemic shunt

Background

The role of portosystemic shunting in the treatment of the Budd-Chiari syndrome is still under debate. Medical therapy and liver transplantation are alternative treatments. The aim of this study was to determine the outcome of a transjugular intrahepatic portosystemic shunt implantation.

Methods

Thirty-five patients with severe Budd-Chiari syndrome and a Child-Pugh score of 9.2±1.9, who were not responsive to medical therapy, were elected for the transjugular shunt treatment, which was successfully accomplished in 33. Eleven patients had a fulminant/acute (history <2 months); 13, a subacute (<6 months); and 11, a chronic course of the disease. The shunt was established by using conventional self-expandable stents in 25 patients and polytetrafluoroethylene-covered stents in 8 patients. The mean follow-up was 37±29 months.

Results

The shunt reduced the portosystemic pressure gradient from 29±7 to 10±4 mm Hg and improved the portal flow velocity from 9.2±11 to 51±17 cm/s. Clinical symptoms as well as the biochemical test results improved significantly during 4 weeks after shunt treatment. Three patients died and 2 received liver transplants. The cumulative 1- and 5-year survival rate without transplantation in all patients was 93% and 74%, respectively, and in patients with fulminant/acute disease 91% and 91% respectively (no deaths in this time period). On the average, 1.4±2.2 revisions per patient were needed during the mean follow-up of 3 years with a 1-year probability of 47%.

Conclusions

The transjugular shunt provides an excellent outcome in patients with severe fulminant/acute, subacute, and chronic Budd-Chiari syndrome. It may be regarded as a treatment for the acute and long-term management of these patients.