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Ng ZQ, Tan P, Theophilus M. Colorectal Surgery in Patients with Liver Cirrhosis: A Systematic Review. World J Surg 2023; 47:2519-2531. [PMID: 37212905 DOI: 10.1007/s00268-023-07069-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Colorectal surgery in patients with liver cirrhosis poses a significant challenge due to the associated peri-operative morbidity and mortality risks. The aim of this systematic review was to evaluate the outcomes in this cohort of patients following colorectal surgery. METHODS The PubMed, Embase and Cochrane databases and references were searched up to October 2022 using the PRISMA guidelines. The data collated included: patient demographics, pathology or type of colorectal operation performed, severity of liver cirrhosis, post-operative complication rates, mortality rates and prognostic factors. A quality assessment of included studies was performed with the Newcastle-Ottawa scale. RESULTS Sixteen studies reporting the outcomes of colorectal surgery in patients with liver cirrhosis were identified, including the results of 8646 patients. The indications, pathologies and/or type of operations varied. The overall complication rate ranged from 29 to 75%, minor complication ranged 14.5-37% and major complication ranged 6.7-59.3%. The mortality rates ranged from 0 to 37%. CONCLUSION Colorectal surgery in patients with liver cirrhosis still carries considerable morbidity and mortality rates. This group of patients needs to be managed in a multidisciplinary setting to achieve excellent outcomes. Future research should focus on uniform definitions to enable interpretable outcomes.
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Affiliation(s)
- Zi Qin Ng
- Department of General Surgery, Royal Perth Hospital, Wellington Street, Perth, WA, 6000, Australia.
- Department of General Surgery, St John of God Midland Hospital, Midland, WA, Australia.
| | - Patrick Tan
- Department of General Surgery, Royal Perth Hospital, Wellington Street, Perth, WA, 6000, Australia
| | - Mary Theophilus
- Department of General Surgery, Royal Perth Hospital, Wellington Street, Perth, WA, 6000, Australia
- Department of General Surgery, St John of God Midland Hospital, Midland, WA, Australia
- Curtin Medical School, Curtin University, Bentley, WA, Australia
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Lapenna L, Di Cola S, Gazda J, De Felice I, Gioia S, Merli M. New Indications for TIPSs: What Do We Know So Far? J Clin Exp Hepatol 2023; 13:794-803. [PMID: 37693277 PMCID: PMC10483008 DOI: 10.1016/j.jceh.2023.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/29/2023] [Indexed: 09/12/2023] Open
Abstract
Since 1988, transjugular intrahepatic portosystemic shunt (TIPS) has been an effective therapy for portal hypertension in many settings. Thanks to continuous technical improvements and a wiser selection of patients, excellent results have been achieved with this therapeutic strategy. The historical indications for TIPS placement, in the context of liver cirrhosis, such as refractory ascites and variceal bleeding are now well established and known. However, in recent years, new indications are emerging. These have been investigated and approved in some studies but are not yet included in guidelines and clinical practice. This review aims to highlight what is new for the role of TIPS in portal vein thrombosis (especially in patients awaiting liver transplantation), in recurrent ascites and not only refractory ascites, as a neoadjuvant therapy before abdominal surgery and, finally, in the setting of noncirrhotic portal hypertension. All these new aspects are addressed in this review with a critical approach based on the literature revision and clinical practice. Future research is needed to explore and validate the new role of TIPS in these scenarios.
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Affiliation(s)
- Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Simone Di Cola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Jakub Gazda
- 2nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital in Kosice, Slovakia
| | - Ilaria De Felice
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
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Balducci D, Montori M, De Blasio F, Di Bucchianico A, Argenziano ME, Baroni GS, Scarpellini E. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Treating Portal Hypertension in Patients with Hepatocellular Carcinoma. Medicina (Kaunas) 2023; 59:1150. [PMID: 37374354 PMCID: PMC10304577 DOI: 10.3390/medicina59061150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023]
Abstract
Liver cancer is very frequent, and hepatocellular carcinoma (HCC) accounts for the majority of liver cancer cases. Its growing incidence has been greatly affected by the increasing prevalence of metabolic-associated fatty liver disease (MAFLD). The latter is a new epidemic in our era. In fact, HCC is often generated from noncirrhotic liver and its treatment benefits from surgical and nonsurgical approaches, potentially bridged by transjugular intrahepatic portosystemic shunt (TIPS) use. TIPS use is an effective treatment for portal hypertension complications, but its application in patients with HCC and clinically significant portal hypertension (CSPH) remains controversial due to concerns about tumor rupture, dissemination, and increased toxicity. The technical feasibility and safety of TIPS use in HCC patients have been evaluated in several studies. Despite concerns about intraprocedural complications, retrospective studies have shown high success rates and low complication rates in TIPS placement for HCC patients. TIPS use in combination with locoregional treatments, such as transarterial chemoembolization (TACE) or transarterial radioembolization (TARE), has been explored as a treatment option for HCC patients with portal hypertension. These studies have shown improved survival rates in patients undergoing TIPS in combination with locoregional treatments. However, the efficacy and toxicity of TACE in combination with TIPS use require careful evaluation, as changes in venous and arterial flow can affect treatment outcomes and complications. The results from studies evaluating the impact of TIPS on systemic therapy and surgical options are also promising. In conclusion, the TIPS is a sufficiently safe, useful item available for physicians treating complications of portal hypertension. Moreover, a TIPS can be used in combination with locoregional therapy in HCC patients. Systemic chemotherapy can also benefit of the use of TIPS placement. A complex interplay affects TIPS use with surgery. The latter needs further data. The TIPS is a useful and safe add-on treatment, changing the natural course of HCC progression. Its use is regulated by a sophisticated physiologic and pathophysiologic flow of evidence.
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Affiliation(s)
- Daniele Balducci
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Michele Montori
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Federico De Blasio
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Alessandro Di Bucchianico
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Maria Eva Argenziano
- Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, 60126 Ancona, Italy
| | | | - Emidio Scarpellini
- Clinical Nutrition Unit and Internal Medicine Unit, “Madonna del Soccorso” General Hospital, Via Luciano Manara 7, 63074 San Benedetto del Tronto, Italy
- Translational Research Center for Gastrointestinal Disease (T.A.R.G.I.D.), Gasthuisberg University Hospital, KULeuven, Herestraat 49, 3000 Lueven, Belgium
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Manzano-Nunez R, Jimenez-Masip A, Chica-Yanten J, Ibn-Abdelouahab A, Sartelli M, de'Angelis N, Moore EE, García AF. Unlocking the potential of TIPS placement as a bridge to elective and emergency surgery in cirrhotic patients: a meta-analysis and future directions for endovascular resuscitation in acute care surgery. World J Emerg Surg 2023; 18:30. [PMID: 37069601 PMCID: PMC10111768 DOI: 10.1186/s13017-023-00498-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/08/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND In this systematic review and meta-analysis, we examined the evidence on transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to elective and emergency surgery in cirrhotic patients. We aimed to assess the perioperative characteristics, management approaches, and outcomes of this intervention, which is used to achieve portal decompression and enable the safe performance of elective and emergent surgery. METHODS MEDLINE and Scopus were searched for studies reporting the outcomes of cirrhotic patients undergoing elective and emergency surgery with preoperative TIPS. The risk of bias was evaluated using the methodological index for non-randomized studies of interventions, and the JBI critical appraisal tool for case reports. The outcomes of interest were: 1. Surgery after TIPS; 2. Mortality; 3. Perioperative transfusions; and 4. Postoperative liver-related events. A DerSimonian and Laird (random-effects) model was used to perform the meta-analyses in which the overall (combined) effect estimate was presented in the form of an odds ratio (summary statistic). RESULTS Of 426 patients (from 27 articles), 256 (60.1%) underwent preoperative TIPS. Random effects MA showed significantly lower odds of postoperative ascites with preoperative TIPS (OR = 0.40, 95% CI 0.22-0.72; I2 = 0%). There were no significant differences in 90-day mortality (3 studies: OR = 0.76, 95% CI 0.33-1.77; I2 = 18.2%), perioperative transfusion requirement (3 studies: OR = 0.89, 95% CI 0.28-2,84; I2 = 70.1%), postoperative hepatic encephalopathy (2 studies: OR = 0.97, 95% CI 0.35-2.69; I2 = 0%), and postoperative ACLF (3 studies: OR = 1.02, 95% CI 0.15-6.8, I2 = 78.9%). CONCLUSIONS Preoperative TIPS appears safe in cirrhotic patients who undergo elective and emergency surgery and may have a potential role in postoperative ascites control. Future randomized clinical trials should test these preliminary results.
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Affiliation(s)
| | | | | | | | | | - Nicola de'Angelis
- Colorectal and Digestive Surgery Unit, Beaujon Hospital, Paris, Île-de-France, France
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center and University of Colorado, Denver, CO, USA
| | - Alberto F García
- Department of Surgery, Fundacion Valle del Lili, Cali, Colombia
- Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia
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Abbas N, Fallowfield J, Patch D, Stanley AJ, Mookerjee R, Tsochatzis E, Leithead JA, Hayes P, Chauhan A, Sharma V, Rajoriya N, Bach S, Faulkner T, Tripathi D. Guidance document: risk assessment of patients with cirrhosis prior to elective non-hepatic surgery. Frontline Gastroenterol 2023; 14:359-370. [PMID: 37581186 PMCID: PMC10423609 DOI: 10.1136/flgastro-2023-102381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
As a result of the increasing incidence of cirrhosis in the UK, more patients with chronic liver disease are being considered for elective non-hepatic surgery. A historical reluctance to offer surgery to such patients stems from general perceptions of poor postoperative outcomes. While this is true for those with decompensated cirrhosis, selected patients with compensated early-stage cirrhosis can have good outcomes after careful risk assessment. Well-recognised risks include those of general anaesthesia, bleeding, infections, impaired wound healing, acute kidney injury and cardiovascular compromise. Intra-abdominal or cardiothoracic surgery are particularly high-risk interventions. Clinical assessment supplemented by blood tests, imaging, liver stiffness measurement, endoscopy and assessment of portal pressure (derived from the hepatic venous pressure gradient) can facilitate risk stratification. Traditional prognostic scoring systems including the Child-Turcotte-Pugh and Model for End-stage Liver Disease are helpful but may overestimate surgical risk. Specific prognostic scores like Mayo Risk Score, VOCAL-Penn and ADOPT-LC can add precision to risk assessment. Measures to mitigate risk include careful management of varices, nutritional optimisation and where possible addressing any ongoing aetiological drivers such as alcohol consumption. The role of portal decompression such as transjugular intrahepatic portosystemic shunting can be considered in selected high-risk patients, but further prospective study of this approach is required. It is of paramount importance that patients are discussed in a multidisciplinary forum, and that patients are carefully counselled about potential risks and benefits.
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Affiliation(s)
- Nadir Abbas
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan Fallowfield
- Centre for Inflammation Research, The University of Edinburgh The Queen's Medical Research Institute, Edinburgh, UK
| | - David Patch
- Hepatology and Liver Transplantation, Royal Free Hampstead NHS Trust, London, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Raj Mookerjee
- Institute for Liver and Digestive Health, University College London, London, UK
| | | | - Joanna A Leithead
- Department of Gastroenterology, Forth Valley Royal Hospital, Larbert, UK
- Hepatology, Forth Valley Royal Hospital, Larbert, UK
| | - Peter Hayes
- The Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Abhishek Chauhan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vikram Sharma
- GI and Liver Unit, Royal London Hospital, London, UK
| | - Neil Rajoriya
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Bach
- Academic Department of Surgery, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Thomas Faulkner
- Department of Anaesthetics, University Hospitals NHS Foundation Trust, Birmingham, UK
| | - Dhiraj Tripathi
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- The Liver Unit, University Hospitals NHS Foundation Trust, Birmingham, UK
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Morris SM, Abbas N, Osei-Bordom DC, Bach SP, Tripathi D, Rajoriya N. Cirrhosis and non-hepatic surgery in 2023 - a precision medicine approach. Expert Rev Gastroenterol Hepatol 2023; 17:155-173. [PMID: 36594658 DOI: 10.1080/17474124.2023.2163627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Patients with liver disease and portal hypertension frequently require surgery carrying high morbidity and mortality. Accurately estimating surgical risk remains challenging despite improved medical and surgical management. AREAS COVERED This review aims to outline a comprehensive approach to preoperative assessment, appraise methods used to predict surgical risk, and provide an up-to-date overview of outcomes for patients with cirrhosis undergoing non-hepatic surgery. EXPERT OPINION Robust preoperative, individually tailored, and precise risk assessment can reduce peri- and postoperative complications in patients with cirrhosis. Established prognostic scores aid stratification, providing an estimation of postoperative mortality, albeit with limitations. VOCAL-Penn Risk Score may provide greater precision than established liver severity scores. Amelioration of portal hypertension in advance of surgery may be considered, with prospective data demonstrating hepatic venous pressure gradient as a promising surrogate marker of postoperative outcomes. Morbidity and mortality vary between types of surgery with further studies required in patients with more advanced liver disease. Patient-specific considerations and practicing precision medicine may allow for improved postoperative outcomes.
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Affiliation(s)
- Sean M Morris
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK
| | - Nadir Abbas
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Daniel-Clement Osei-Bordom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Simon P Bach
- Department of Surgery, University Hospitals Birmingham, Birmingham, UK
| | - Dhiraj Tripathi
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Neil Rajoriya
- The Liver Unit, University Hospitals Birmingham, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Kabolowsky M, Nguyen L, Fortune BE, Santos E, Kishore S, Camacho JC. Interventional Management of Portal Hypertension in Cancer Patients. Curr Oncol Rep 2022; 24:1461-75. [PMID: 35953600 DOI: 10.1007/s11912-022-01319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches. RECENT FINDINGS In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.
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Malik AK, Varghese C, Pandanaboyana S, Sen G, Robinson S, McPherson S, Dyson J, Manas DM, Masson S, Hammond JS; Newcastle Liver Unit. Risk factors for decompensation and death following umbilical hernia repair in patients with end-stage liver disease. Eur J Gastroenterol Hepatol 2022; 34:1060-6. [PMID: 36062496 DOI: 10.1097/MEG.0000000000002417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Symptomatic umbilical hernias are a common cause of morbidity and mortality in patients with cirrhosis and end-stage liver disease (ESLD). This study set out to characterise the factors predicting outcome following repair of symptomatic umbilical hernias in ESLD at a single institution. METHODS A retrospective review was performed of all patients with ESLD who underwent repair of a symptomatic umbilical hernia between 1998 and 2020. Overall survival was predicted using the Kaplan-Meier method. Logistic regression was used to determine predictors of decompensation and 30-day, 90-day and 1-year mortality. RESULTS One-hundred-and-eight patients with ESLD underwent umbilical hernia repair (emergency n = 78, 72.2%). Transjugular shunting was performed in 29 patients (26.9%). Decompensation occurred in 44 patients (40.7%) and was predicted by emergency surgery (OR, 13.29; P = 0.001). Length of stay was shorter in elective patients compared to emergency patients (3-days vs. 7-days; P = 0.003). Thirty-day, 90-day and 1-year survival was 95.2, 93.2 and 85.4%, respectively. Model for ESLD score >15 predicted 90-day mortality (OR, 18.48; P = 0.030) and hyponatraemia predicted 1-year mortality (OR, 5.31; P = 0.047). Transjugular shunting predicted survival at 1 year (OR, 0.15; P = 0.038). CONCLUSIONS Repair of symptomatic umbilical hernias in patients with ESLD can be undertaken with acceptable outcomes in a specialist centre, however, this remains a high-risk intervention. Patients undergoing emergency repair are more likely to decompensate postoperatively, develop wound-related problems and have a longer length of stay. Transjugular shunting may confer a benefit to survival, but further prospective trials are warranted.
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Boike JR, Thornburg BG, Asrani SK, Fallon MB, Fortune BE, Izzy MJ, Verna EC, Abraldes JG, Allegretti AS, Bajaj JS, Biggins SW, Darcy MD, Farr MA, Farsad K, Garcia-Tsao G, Hall SA, Jadlowiec CC, Krowka MJ, Laberge J, Lee EW, Mulligan DC, Nadim MK, Northup PG, Salem R, Shatzel JJ, Shaw CJ, Simonetto DA, Susman J, Kolli KP, VanWagner LB. North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol 2022; 20:1636-1662.e36. [PMID: 34274511 PMCID: PMC8760361 DOI: 10.1016/j.cgh.2021.07.018] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/01/2021] [Accepted: 07/13/2021] [Indexed: 02/07/2023]
Abstract
Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.
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Affiliation(s)
- Justin R. Boike
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bartley G. Thornburg
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Michael B. Fallon
- Department of Medicine, Division of Gastroenterology and Hepatology, Banner - University Medical Center Phoenix, Phoenix, AZ, USA
| | - Brett E. Fortune
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA
| | - Manhal J. Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth C. Verna
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Juan G. Abraldes
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
| | - Andrew S. Allegretti
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Jasmohan S. Bajaj
- Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA, USA
| | - Scott W. Biggins
- Department of Medicine, Division of Gastroenterology & Hepatology, University of Washington Medical Center, Seattle, WA, USA
| | - Michael D. Darcy
- Department of Radiology, Division of Interventional Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Maryjane A. Farr
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Khashayar Farsad
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, OR, USA
| | - Guadalupe Garcia-Tsao
- Department of Digestive Diseases, Yale University, Yale University School of Medicine, and VA-CT Healthcare System, CT, USA
| | - Shelley A. Hall
- Department of Internal Medicine, Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Caroline C. Jadlowiec
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Michael J. Krowka
- Department of Pulmonary and Critical Care Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jeanne Laberge
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Edward W. Lee
- Department of Radiology, Division of Interventional Radiology, University of California-Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - David C. Mulligan
- Department of Surgery, Division of Transplantation, Yale University School of Medicine, New Haven, CT, USA
| | - Mitra K. Nadim
- Department of Medicine, Division of Nephrology and Hypertension, University of Southern California, Los Angeles, California, USA
| | - Patrick G. Northup
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Riad Salem
- Department of Radiology, Division of Vascular and Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR, USA
| | - Cathryn J. Shaw
- Department of Radiology, Division of Interventional Radiology, Baylor University Medical Center, Dallas, TX, USA
| | - Douglas A. Simonetto
- Department of Physiology, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Jonathan Susman
- Department of Radiology, Division of Interventional Radiology, Columbia University Irving Medical Center, New York, NY, USA
| | - K. Pallav Kolli
- Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Lisa B. VanWagner
- Department of Medicine, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA,Address for correspondence: Lisa B. VanWagner MD MSc FAST FAHA, Assistant Professor of Medicine and Preventive Medicine, Divisions of Gastroenterology & Hepatology and Epidemiology, Northwestern University Feinberg School of Medicine, 676 N. St Clair St - Suite 1400, Chicago, Illinois 60611 USA, Phone: 312 695 1632, Fax: 312 695 0036,
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10
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Vulasala SSR, Onteddu NKR, Kalva SP, Smolinski-Zhao S. Expanding Indications of TIPS in the Management of Portal Hypertension Complications. Journal of Clinical Interventional Radiology ISVIR 2022. [DOI: 10.1055/s-0042-1748818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
AbstractTransjugular intrahepatic portosystemic shunt (TIPS) is a nonsurgical intervention to reduce portal pressure by creating a low-resistance channel between the portal and systemic circulations. It is a well-accepted treatment for gastroesophageal varices and refractory ascites. This review aims to discuss the evidence-based applications of TIPS in other complications of portal hypertension beyond gastroesophageal varices and refractory ascites.
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Affiliation(s)
- Sai Swarupa Reddy Vulasala
- Department of Radiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Nirmal Kumar Reddy Onteddu
- Division of Hospital Medicine, Department of Internal Medicine, Flowers Hospital, Dothan, Alabama, United States
| | - Sanjeeva Prasad Kalva
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Sara Smolinski-Zhao
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, United States
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Bettinger D, Thimme R, Schultheiß M. Implantation of transjugular intrahepatic portosystemic shunt (TIPS): indication and patient selection. Curr Opin Gastroenterol 2022; 38:221-229. [PMID: 35471813 DOI: 10.1097/mog.0000000000000831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW This review summarizes indications and contraindications for implantation of transjugular intrahepatic portosystemic shunt (TIPS). Further, patient selection strategies are discussed. RECENT FINDINGS TIPS implantation is a highly effective treatment for portal hypertension. Main indications are ascites and variceal bleeding in patients with liver cirrhosis. There is growing evidence that early TIPS implantation after variceal bleeding is associated with an improved survival (preemptive TIPS).Preliminary data also suggest that an analogous concept of early TIPS implantation may be beneficial for patients with ascites. Further, well-selected patients with acute or chronic nonmalignant portal vein thrombosis can be effectively treated with TIPS implantation. In contrast, there is generally no recommendation for TIPS implantation in patients with hepatic veno-occlusive disease, noncirrhotic portal hypertension or prior before surgery to avoid complications of portal hypertension. Apart from evidence-based patient selection, the newly developed FIPS score can be an objective component in decision-making. SUMMARY Consideration of well-established indications and contraindications for TIPS implantation as well as concise patient selection criteria are essential for an optimal outcome after TIPS implantation.
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Affiliation(s)
- Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Cannella R, Tselikas L, Douane F, Cauchy F, Rautou PE, Duran R, Ronot M. Imaging-guided interventions modulating portal venous flow: evidence and controversies. JHEP Reports 2022; 4:100484. [PMID: 35677591 PMCID: PMC9168703 DOI: 10.1016/j.jhepr.2022.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 12/07/2022]
Abstract
Portal hypertension is defined by an increase in the portosystemic venous gradient. In most cases, increased resistance to portal blood flow is the initial cause of elevated portal pressure. More than 90% of cases of portal hypertension are estimated to be due to advanced chronic liver disease or cirrhosis. Transjugular intrahepatic portosystemic shunts, a non-pharmacological treatment for portal hypertension, involve the placement of a stent between the portal vein and the hepatic vein or inferior vena cava which helps bypass hepatic resistance. Portal hypertension may also be a result of extrahepatic portal vein thrombosis or compression. In these cases, percutaneous portal vein recanalisation restores portal trunk patency, thus preventing portal hypertension-related complications. Any portal blood flow impairment leads to progressive parenchymal atrophy and triggers hepatic regeneration in preserved areas. This provides the rationale for using portal vein embolisation to modulate hepatic volume in preparation for extended hepatic resection. The aim of this paper is to provide a comprehensive evidence-based review of the rationale for, and outcomes associated with, the main imaging-guided interventions targeting the portal vein, as well as to discuss the main controversies around such approaches.
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Aryan M, McPhail J, Ravi S, Harris P, Allamneni C, Shoreibah M. Perioperative Transjugular Intrahepatic Portosystemic Shunt Is Associated With Decreased Postoperative Complications in Decompensated Cirrhotics Undergoing Abdominal Surgery. Am Surg 2022; 88:1613-1620. [PMID: 35113676 DOI: 10.1177/00031348211069784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Operative risk in patients with cirrhosis is related to the severity of liver disease and nature of procedure. Pre and postoperative portal decompression via transjugular intrahepatic portosystemic shunt (TIPS) are logical approaches to facilitate surgery and improve postoperative outcomes. We compared postoperative outcomes of decompensated cirrhotics undergoing abdominal surgery either with or without perioperative TIPS placement. METHODS We performed a retrospective review of 41 decompensated cirrhotic patients who had abdominal surgery from 2010-2019 at the University of Alabama at Birmingham. Patients were stratified based on having received either perioperative TIPS or no TIPS. Demographics, laboratory data, perioperative TIPS status and postoperative complications were compared between the 2 groups using Fisher exact test and Student 2 sample t-test. RESULTS Group 1 consisted of 28 patients who had TIPS procedure, with 21 being preoperative and 7 being postoperative. Group 2 had 13 patients who had abdominal surgery without TIPS. When compared to those with perioperative TIPS, patients without TIPS had a significantly increased incidence of postoperative ascites (33% vs 77%, P = .0026), infection (18% vs 54%, P = .028), and acute kidney injury (AKI) (14% vs 46%, P = .0485). Additionally, postoperative Model of End Stage Liver Disease Sodium score was significantly higher in patients without TIPS (22 ± 4.74) when compared to those who had TIPS (17.14 ± 5.48) (P = .009). DISCUSSION Perioperative TIPS placement in decompensated cirrhotics was associated with decreased postoperative ascites, infection, and AKI when compared to those without TIPS. Further studies are needed to validate our findings.
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Affiliation(s)
- Mahmoud Aryan
- Tinsley Harrison Internal Medicine Residency, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - James McPhail
- Division of Gastroenterology and Hepatology, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sujan Ravi
- Division of Gastroenterology and Hepatology, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Patrick Harris
- Division of Gastroenterology and Hepatology, Department of Medicine, 3989Baylor University, Houston, TX, USA
| | - Chaitanya Allamneni
- Division of Digestive Diseases, Department of Medicine, 1371Emory University, Atlanta, GA, USA
| | - Mohamed Shoreibah
- Division of Gastroenterology and Hepatology, Department of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
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Li W, Duan Y, Liu Z, Lu X, She J, Qing J, Zhang C. Clinical value of hemodynamic changes in diagnosis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt. Scand J Gastroenterol 2022:1-6. [PMID: 35098853 DOI: 10.1080/00365521.2022.2029938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/02/2022] [Accepted: 01/11/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This paper aims to investigate clinical value of intrahepatic and intra-stent hemodynamic changes after transjugular intrahepatic portosystemic shunt (TIPS), by using color Doppler ultrasound during the diagnosis of hepatic encephalopathy (HE) in the patients with hepatitis B cirrhosis. METHODS A retrospective analysis of the patients with hepatitis B cirrhotic portal hypertension, who underwent TIPS in The First Affiliated Hospital of Anhui Medical University from January 2018 to January 2021, was conducted. 22 patients who developed HE within 3 months after TIPS comprised the observation group (HE group), and 51 patients who did not develop HE were randomly selected as the control group (non-HE group). The porto systemic gradient (PSG), as well as intrahepatic and intra-stent hemodynamic changes of patients in both the HE group and the non-HE group after TIPS were investigated. RESULTS The intra-stent blood flow, PSG difference, and PSG decrease percentage in the HE group were higher than those in the non-HE group, and the intra-stent flow had a weak positive correlation with PSG difference and with the PSG decrease percentage (r = 0.420, 0.258, respectively). The areas under the ROC curves of HE based on the PSG difference, the PSG decrease percentage, and the intra-stent flow were 0.762, 0.753, and 0.693, respectively. CONCLUSION The more obvious decrease in PSG, the larger the intra-stent blood flow, and the larger the possibility of HE occurrence were observed. Routine ultrasound measurement of hemodynamic changes has certain clinical significance for predicting HE occurrence.
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Affiliation(s)
- Wanyan Li
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yayang Duan
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhike Liu
- Department of Radiology, The Linquan County People's Hospital, FuYang, China
| | - Xiaofeng Lu
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingwen She
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jing Qing
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chaoxue Zhang
- Department of Ultrasound, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Chang J, Höfer P, Böhling N, Lingohr P, Manekeller S, Kalff JC, Dohmen J, Kaczmarek DJ, Jansen C, Meyer C, Strassburg CP, Trebicka J, Praktiknjo M. Pre-operative TIPS may reduce post-operative ACLF occurrence. JHEP Reports 2022; 4:100442. [PMID: 35198929 PMCID: PMC8844300 DOI: 10.1016/j.jhepr.2022.100442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/10/2021] [Accepted: 12/28/2021] [Indexed: 11/25/2022]
Abstract
Background & Aims Acute-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. Methods A 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). Results Patients 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. Conclusions This 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 summary Acute-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. This study investigates the impact of preoperative TIPS on postsurgical ACLF. Patients with preoperative TIPS, especially before visceral surgery, develop significantly lower rates of ACLF. Preoperative TIPS is associated with improved postsurgical survival. CLIF-C AD score >45 can be used as cut-off for patients at risk for postsurgical ACLF. Selected patients might benefit from preoperative TIPS insertion.
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Goel A, Khanna A, Mehrzad H, Bach S, Karkhanis S, Kamran U, Morgan J, Rajoriya N, Tripathi D. Portal decompression with transjugular intrahepatic portosystemic shunt prior to nonhepatic surgery: a single-center case series. Eur J Gastroenterol Hepatol 2021; 33:e254-9. [PMID: 33323758 DOI: 10.1097/MEG.0000000000002026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Cirrhosis increases perioperative and postoperative mortality in nonhepatic surgery. Transjugular intrahepatic portosystemic shunt (TIPSS), by reducing portal pressure, may reduce intraoperative bleeding and postoperative decompensation. We report our experience of prophylactic TIPSS in nonhepatic surgery. METHODS Patients who underwent prophylactic TIPSS before nonhepatic surgery were identified from database with retrospective data collection via an e-patient record system. Primary outcome was discharged without hepatic decompensation after a planned surgery. RESULTS Twenty-one patients [age (median, range): 55, 33-76 years, Child's score: 6, 5-9] who underwent prophylactic TIPSS before nonhepatic surgery over a period of 9 years were included. All patients underwent successful TIPSS with a reduction in portal pressure gradient from 21.5 (11-35) to 16 (7-25) mmHg (P < 0.001). Immediate post-TIPSS complications were seen in 7 (33%) patients including hepatic encephalopathy in four. Eighteen patients (86%) underwent planned surgical intervention. Significant postoperative complications included hepatic encephalopathy (3), sepsis (2) and bleed (1). Two patients died postoperatively with multi-organ failure. The primary outcome was achieved in 12 (57%) patients. Post-TIPSS portal pressure gradient was significantly higher in patients with the adverse primary outcome. Over a follow-up period of 11 (1-78) months; 1-, 6- and 12-months' survival was 90, 80 and 76%, respectively. CONCLUSION Prophylactic TIPSS is associated with complications in up to one-third of patients, with 57% achieving the primary outcome. Careful patient selection in a multidisciplinary team setting is essential. Multicentre studies are necessary before the universal recommendation of prophylactic TIPSS.
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Yeoh SW, Kok HK. Transjugular intrahepatic portosystemic shunts in portal vein thrombosis: A review. J Dig Dis 2021; 22:506-519. [PMID: 34323378 DOI: 10.1111/1751-2980.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 12/11/2022]
Abstract
The presence of portal vein thrombosis (PVT) has previously been considered a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS). However, patients with PVT may have portal hypertension complications and may thus benefit from TIPSS to reduce portal venous pressure. There is an increasing body of literature that discusses the techniques and outcomes of TIPSS in PVT. This review summarizes the techniques, indications and outcomes of TIPSS in PVT in published case reports, case series and comparative trials, especially regarding the reduction in portal hypertensive complications such as variceal bleeding. A comprehensive literature search was conducted using MEDLINE and PubMed databases. Manuscripts published in English between 1 January 1990 and 1 March 2021 were used. Abstracts were screened and data from potentially relevant articles analyzed. TIPSS in PVT has been reported with high levels of technical success, short-term portal vein recanalization and long-term PV patency and TIPSS patency outcomes. Several comparative studies, including randomized controlled trials, have shown favorable outcomes of TIPSS compared with non-TIPSS treatment of PVT complications. Outcomes of TIPSS with PVT appear similar to those in TIPSS without PVT. However, TIPSS may be more technically difficult in the presence of PVT, and such procedures should be performed in expert high-volume centers to mitigate the risk of procedural complications. The presence of PVT should no longer be considered a contraindication to TIPSS. TIPSS for PVT has been acknowledged as a therapeutic strategy in recent international guidelines, although further studies are needed before recommendations can be strengthened. KEY POINTS: Portal vein thrombosis (PVT) is no longer a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS) TIPSS often leads to the spontaneous dissolution of PVT, but can be combined with mechanical or pharmacological thrombectomy TIPSS reduces portal hypertensive complications of PVT, such as variceal bleeding, and can also facilitate liver transplantation where PVT may otherwise interfere with vascular anastomoses Studies have shown favorable long-term outcomes of TIPSS compared with TIPSS without PVT; as well as compared with non-TIPSS treatment of PVT complications TIPSS in PVT should be performed in high-volume specialist centers due to technical difficulties.
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Affiliation(s)
- Sern Wei Yeoh
- Department of Gastroenterology, Northern Health, Melbourne, Victoria, Australia.,School of Medical Education, University of Melbourne, Melbourne, Victoria, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Melbourne, Victoria, Australia.,School of Medicine, Deakin University, Melbourne, Victoria, Australia
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Schultheiß M, Bettinger D, Thimme R, Rössle M. 30 Jahre transjugulärer intrahepatischer portosystemischer Shunt (TIPS) – Rückblick und Perspektive. Z Gastroenterol 2020; 58:877-889. [DOI: 10.1055/a-1217-7866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ZusammenfassungDer transjuguläre intrahepatische portosystemische Shunt (TIPS) wird seit 30 Jahren in der Therapie der portalen Hypertonie erfolgreich eingesetzt. In nationalen und internationalen Leitlinien ist die Indikation zur TIPS-Anlage bei Varizenblutung und refraktärem Aszites wissenschaftlich gut belegt und klar definiert. Bei seltenen Indikationen wie dem hepatorenalen Syndrom, der Pfortaderthrombose oder dem neoadjuvanten Einsatz fehlt derzeit noch eine eindeutige Studienlage. Eine wichtige Kontraindikation und klinisch bedeutendste Komplikation nach TIPS ist die hepatische Enzephalopathie (HE). Es wird versucht, die Post-TIPS HE mit technischen Weiterentwicklungen der Stents zu reduzieren.
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Affiliation(s)
- Michael Schultheiß
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Dominik Bettinger
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Robert Thimme
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
| | - Martin Rössle
- Department Innere Medizin, Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg
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Abstract
Transjugular intrahepatic portosystemic shunts is an established treatment for portal hypertensive complications. Advancements in technology and technique have led to novel indications, including treatment of chronic portal vein thrombosis and use before abdominal surgery to alleviate portal hypertensive complications. Use of TIPS can facilitate the embolization of large portal-systemic shunts to alleviate refractory hepatic encephalopathy owing to excessive portal shunting. Despite these advances, transjugular intrahepatic portosystemic shunts is an invasive procedure with risk for complications and should be performed at a center with expertise to ensure a successful patient outcome.
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Affiliation(s)
- Justin R Boike
- Department of Medicine, Northwestern Feinberg School of Medicine, 676 North St. Clair Street, Suite 1400, Chicago, IL 60611, USA.
| | - Steven L Flamm
- Hepatology Program, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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García-Pagán JC, Saffo S, Mandorfer M, Garcia-Tsao G. Where does TIPS fit in the management of patients with cirrhosis? JHEP Rep 2020; 2:100122. [PMID: 32671331 PMCID: PMC7347999 DOI: 10.1016/j.jhepr.2020.100122] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/20/2020] [Accepted: 05/11/2020] [Indexed: 02/06/2023] Open
Abstract
In 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.
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Key Words
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- ARR, absolute risk reduction
- AVB, acute variceal bleeding
- Ascites
- BNP, brain natriuretic peptide
- BRTO, balloon-occluded retrograde transvenous obliteration
- Bleeding
- CHF, chronic heart failure
- CLD, chronic liver disease
- CSPH, clinically significant portal hypertension
- Cirrhosis
- EVL, endoscopic variceal ligation
- GOV, gastro-oesophageal varices
- HCC, hepatocellular carcinoma
- HE, hepatic encephalopathy
- HVPG, hepatic venous pressure gradient
- Haemorrhage
- ICA, International Club of Ascites
- IGV, isolated gastric varices
- INR, international normalised ratio
- ISMN, isosorbide mononitrate
- LVP+A, LVP with albumin
- LVP, large-volume paracenteses
- MELD, model for end-stage liver disease
- NNT, number needed to treat
- NSBB, non-selective beta blocker
- OS, overall survival
- PCI, percutaneous coronary intervention
- PFTE, polytetrafluoroethylene
- PLT, platelet count
- PSE, portosystemic encephalopathy
- PV, portal vein
- PVT, portal vein thrombosis
- Portal hypertension
- Portal vein thrombosis
- RA, refractory ascites
- RCTs, randomised controlled trials
- SBP, spontaneous bacterial peritonitis
- SEMS, self-expandable metallic stent
- TFS, transplant-free survival
- TIPS, transjugular intrahepatic portosystemic shunt
- Transjugular intrahepatic portosystemic shunt
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Affiliation(s)
- Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Saad Saffo
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Mattias Mandorfer
- Barcelona Hepatic Hemodynamic Lab, Liver Unit, Hospital Clínic, Barcelona, Spain
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, VA-Connecticut Healthcare System, West Haven, CT, USA
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
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Tripathi D, Stanley AJ, Hayes PC, Travis S, Armstrong MJ, Tsochatzis EA, Rowe IA, Roslund N, Ireland H, Lomax M, Leithead JA, Mehrzad H, Aspinall RJ, McDonagh J, Patch D. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut 2020; 69:1173-1192. [PMID: 32114503 PMCID: PMC7306985 DOI: 10.1136/gutjnl-2019-320221] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 12/15/2022]
Abstract
These guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the Liver Section of the BSG. The guidelines are new and have been produced in collaboration with the British Society of Interventional Radiology (BSIR) and British Association of the Study of the Liver (BASL). The guidelines development group comprises elected members of the BSG Liver Section, representation from BASL, a nursing representative and two patient representatives. The quality of evidence and grading of recommendations was appraised using the GRADE system. These guidelines are aimed at healthcare professionals considering referring a patient for a TIPSS. They comprise the following subheadings: indications; patient selection; procedural details; complications; and research agenda. They are not designed to address: the management of the underlying liver disease; the role of TIPSS in children; or complex technical and procedural aspects of TIPSS.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK .,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Adrian J Stanley
- Gastroenterology Department, Glasgow Royal Infirmary, Glasgow, UK
| | - Peter C Hayes
- Hepatology Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Travis
- Department if Radiology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Matthew J Armstrong
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Emmanuel A Tsochatzis
- The Royal Free Sheila Sherlock Liver Centre, UCL Institute for Liver and Digestive Health, London, UK
| | | | | | - Hamish Ireland
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Joanne A Leithead
- Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Homoyon Mehrzad
- Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Aspinall
- Department of Hepatology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Joanne McDonagh
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, UCL Institute for Liver and Digestive Health, London, UK
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23
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Allaire M, Walter A, Sutter O, Nahon P, Ganne-Carrié N, Amathieu R, Nault JC. TIPS for management of portal-hypertension-related complications in patients with cirrhosis. Clin Res Hepatol Gastroenterol 2020; 44:249-263. [PMID: 31662286 DOI: 10.1016/j.clinre.2019.09.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 08/25/2019] [Accepted: 09/13/2019] [Indexed: 02/04/2023]
Abstract
Portal hypertension is primarily due to liver cirrhosis, and is responsible for complications that include variceal bleeding, ascites and hepatorenal syndrome. The transjugular intrahepatic portosystemic shunt (TIPS) is a low-resistance channel between the portal vein and the hepatic vein, created by interventional radiology, that aims to reduce portal pressure. TIPS is a potential treatment for severe portal-hypertension-related complications, including esophageal and gastric variceal bleeding. TIPS is currently indicated as salvage therapy in this setting when patients fail to respond to standard endoscopic and medical treatment. More recently, early TIPS has been shown to be effective in decreasing risk of rebleeding after variceal hemorrhage and mortality in Child-Pugh B patients with active hemorrhage at endoscopy, and in Child-Pugh C patients. TIPS is also an efficient treatment for refractory ascites and hepatic hydrothorax. In contrast, the role of TIPS in the hepatorenal syndrome has not been precisely defined. The aim of this review was to specifically describe the current role of TIPS in management of portal hypertension in patients with cirrhosis.
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Affiliation(s)
- Manon Allaire
- Service d'hépato-gastroentérologie, CHU Côte-de-Nacre, Caen, France
| | - Aurélie Walter
- Service d'hépato-gastroentérologie, CHU Côte-de-Nacre, Caen, France
| | - Olivier Sutter
- Service de radiologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique Hôpitaux de Paris, Bondy, France
| | - Pierre Nahon
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France
| | - Nathalie Ganne-Carrié
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France
| | - Roland Amathieu
- Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France; Réanimation polyvalente, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, Bondy, France
| | - Jean-Charles Nault
- Service d'hépatologie, hôpital Jean-Verdier, hôpitaux universitaires Paris-Seine-Saint-Denis, Assistance publique des Hôpitaux de Paris, 93143 Bondy, France; Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris 13, Laboratoire génomique fonctionnelle des tumeurs solides, 75006 Paris, France; Unité de formation et de recherche santé médecine et biologie humaine, université Paris 13, communauté d'universités et établissements Sorbonne Paris Cité, Paris, France.
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24
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Vizzutti F, Schepis F, Arena U, Fanelli F, Gitto S, Aspite S, Turco L, Dragoni G, Laffi G, Marra F. Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes. Intern Emerg Med 2020; 15:37-48. [PMID: 31919780 DOI: 10.1007/s11739-019-02252-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/03/2019] [Indexed: 12/16/2022]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) represents a very effective treatment of complications of portal hypertension. Established indications to TIPS in cirrhotic patients include portal hypertensive bleeding and refractory ascites. Over the years additional indications have been proposed, such as the treatment of vascular disease of the liver, hepatic hydrothorax, hepatorenal syndrome and bleeding from ectopic varices. Indications under evaluation include treatment of portal hypertension prior to major abdominal surgery and treatment of portal vein thrombosis. In spite of these advances, there are still uncertainties regarding the appropriate workup for patients to be scheduled for TIPS. Moreover, prevention and management of post-TIPS complications including hepatic encephalopathy and heart failure are still suboptimal. These issues are particularly relevant considering aging in TIPS candidates in Western countries. Correct selection of patients is mandatory to prevent complications which may eventually frustrate the good hemodynamic results and worsen the patient's quality of life or even life expectancy. The possible role of small diameter TIPS to prevent post-procedural complications is discussed.
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Affiliation(s)
- Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Filippo Schepis
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Umberto Arena
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabrizio Fanelli
- Department of Radiology, Interventional Radiology, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Laura Turco
- Department of Internal Medicine, University of Modena and Reggio, Modena, Italy
| | - Gabriele Dragoni
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Giacomo Laffi
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Viale Morgagni 85, 50134, Florence, Italy.
- Center for Research, High Education and Transfer DENOThe, University of Florence, Florence, Italy.
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25
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Elkrief L, Ferrusquia-Acosta J, Payancé A, Moga L, Tellez L, Praktiknjo M, Procopet B, Farcau O, De Lédinghen V, Yuldashev R, Tabchouri N, Barbier L, Dumortier J, Menahem B, Magaz M, Hernández-Gea V, Albillos A, Trebicka J, Spahr L, De Gottardi A, Plessier A, Valla D, Rubbia-Brandt L, Toso C, Bureau C, Garcia-Pagan JC, Rautou PE. Abdominal Surgery in Patients With Idiopathic Noncirrhotic Portal Hypertension: A Multicenter Retrospective Study. Hepatology 2019; 70:911-924. [PMID: 30924941 DOI: 10.1002/hep.30628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/13/2019] [Indexed: 12/13/2022]
Abstract
In patients with idiopathic noncirrhotic portal hypertension (INCPH), data on morbidity and mortality of abdominal surgery are scarce. We retrospectively analyzed the charts of patients with INCPH undergoing abdominal surgery within the Vascular Liver Disease Interest Group network. Forty-four patients with biopsy-proven INCPH were included. Twenty-five (57%) patients had one or more extrahepatic conditions related to INCPH, and 16 (36%) had a history of ascites. Forty-five procedures were performed, including 30 that were minor and 15 major. Nine (20%) patients had one or more Dindo-Clavien grade ≥ 3 complication within 1 month after surgery. Sixteen (33%) patients had one or more portal hypertension-related complication within 3 months after surgery. Extrahepatic conditions related to INCPH (P = 0.03) and history of ascites (P = 0.02) were associated with portal hypertension-related complications within 3 months after surgery. Splenectomy was associated with development of portal vein thrombosis after surgery (P = 0.01). Four (9%) patients died within 6 months after surgery. Six-month cumulative risk of death was higher in patients with serum creatinine ≥ 100 μmol/L at surgery (33% versus 0%, P < 0.001). An unfavorable outcome (i.e., either liver or surgical complication or death) occurred in 22 (50%) patients and was associated with the presence of extrahepatic conditions related to INCPH, history of ascites, and serum creatinine ≥ 100 μmol/L: 5% of the patients with none of these features had an unfavorable outcome versus 32% and 64% when one or two or more features were present, respectively. Portal decompression procedures prior to surgery (n = 10) were not associated with postoperative outcome. Conclusion: Patients with INCPH are at high risk of major surgical and portal hypertension-related complications when they harbor extrahepatic conditions related to INCPH, history of ascites, or increased serum creatinine.
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Affiliation(s)
- Laure Elkrief
- Service de Transplantation, Hôpitaux Universitaires de Genève, Geneva, Switzerland.,Service d'Hépato-Gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - José Ferrusquia-Acosta
- Hepatic Hemodynamic Laboratory, European Reference Network for Rare Liver Disorders, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Audrey Payancé
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - Lucile Moga
- Service d'Hépato-Gastro-Entérologie, CHU Toulouse, Toulouse, France
| | - Luis Tellez
- Departamento de Gastroenterología y Hepatología, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Michael Praktiknjo
- Laboratory for Liver Fibrosis and Portal Hypertension, Universitatsklinikum, Bonn, Germany
| | - Bogdan Procopet
- Department of Gastroenterology, 3rd Medical Clinic, University of Medicine and Pharmacy "luliu Hatieganu," Regional Institute of Gastroenterology and Hepatology "O Fodor,", Cluj-Napoca, Romania
| | - Oana Farcau
- Department of Gastroenterology, 3rd Medical Clinic, University of Medicine and Pharmacy "luliu Hatieganu," Regional Institute of Gastroenterology and Hepatology "O Fodor,", Cluj-Napoca, Romania.,Department of Visceral Surgery and Medicine Intelspital, Bern, Switzerland
| | | | - Rustam Yuldashev
- Republican Specialized Scientific Practical Medical Center of Pediatrics, Tashkent, Uzbekistan
| | - Nicolas Tabchouri
- Service de Chirurgie Digestive, Oncologique, Endocrinienne et Transplantation Hépatique et FHU SUPORT, Hôpital Trousseau, Tours, France
| | - Louise Barbier
- Service de Chirurgie Digestive, Oncologique, Endocrinienne et Transplantation Hépatique et FHU SUPORT, Hôpital Trousseau, Tours, France
| | - Jérôme Dumortier
- Department of Digestive Diseases, Hospices Civils de Lyon, Hôpital Edouard Herriot, Université Claude Bernard Lyon 1, Lyon, France
| | - Benjamin Menahem
- Department of Digestive Surgery, University Hospital of Caen, Caen, France
| | - Marta Magaz
- Hepatic Hemodynamic Laboratory, European Reference Network for Rare Liver Disorders, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Virginia Hernández-Gea
- Hepatic Hemodynamic Laboratory, European Reference Network for Rare Liver Disorders, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Agustin Albillos
- Departamento de Gastroenterología y Hepatología, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Jonel Trebicka
- Laboratory for Liver Fibrosis and Portal Hypertension, Universitatsklinikum, Bonn, Germany
| | - Laurent Spahr
- Service d'Hépato-Gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Andrea De Gottardi
- Department of Visceral Surgery and Medicine Intelspital, Bern, Switzerland
| | - Aurélie Plessier
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - Dominique Valla
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
| | - Laura Rubbia-Brandt
- Service de pathologie Clinique, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Christian Toso
- Service de Transplantation, Hôpitaux Universitaires de Genève, Geneva, Switzerland.,Service de Chirurgie viscérale, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Juan-Carlos Garcia-Pagan
- Hepatic Hemodynamic Laboratory, European Reference Network for Rare Liver Disorders, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Pierre-Emmanuel Rautou
- Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, DHU Unity, Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France.,Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France.,Inserm, UMR 970, Paris Cardiovascular Research Center-PARCC, Paris, France
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26
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Abstract
PURPOSE OF REVIEW Cirrhotic patients have an increased risk of surgical complications and higher perioperative morbidity and mortality based on the severity of their liver disease. Liver disease predisposes patients to perioperative coagulopathies, volume overload, and encephalopathy. The goal of this paper is to discuss the surgical risk of cirrhotic patients undergoing elective surgeries and to discuss perioperative optimization strategies. RECENT FINDINGS Literature thus far varies by surgery type and the magnitude of surgical risk. CTP and MELD classification scores allow for the assessment of surgical risk in cirrhotic patients. Once the decision has been made to undergo elective surgery, cirrhotic patients can be optimized pre-procedure with the help of a checklist and by the involvement of a multidisciplinary team. Elective surgeries should be performed at hospital centers staffed by healthcare providers experienced in caring for cirrhotic patients. Further research is needed to develop ways to prepare this complicated patient population before elective surgery.
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Affiliation(s)
- Kelly E Diaz
- Department of Medicine, Mount Sinai Medical Center, New York, NY, USA
| | - Thomas D Schiano
- Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY, USA.
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