A Glasgow Tipple-transjugular intrahepatic portosystemic shunt insertion prior to Whipple resection

Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhosis

Abdominal surgery is associated with high postoperative mortality and morbidity in cirrhotic patients. Despite improvements in surgical techniques, clinical management, and intensive care, the outcome could be influenced by the degree of portal hypertension, the severity of hepatopathy, or the type of surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement, in addition to medical therapy, plays an important role in managing the complications of portal hypertension such as ascites, hepatic encephalopathy, variceal bleeding or portal vein thrombosis. To date, the improvement of post-surgery outcomes in cirrhotic patients after TIPS placement remains unclear. Only observational data existing in the literature and prospective studies are urgently needed to evaluate the efficacy and safety of TIPS in this setting. This review aims to outline the role of TIPS as a tool in postoperative complications reduction in cirrhotic patients, both in the setting of emergency and elective surgery.

Comparison of complications for cirrhotic versus non-cirrhotic patients undergoing pancreaticoduodenectomy

PURPOSE

To compare the outcomes between patients with cirrhosis and those without who have undergone pancreatoduodenectomy (PD) in our institution.

METHODS

A review of patients undergoing PD from the time period of January 2010 to December 2020 was performed. Patients that have undergone open or laparoscopic PD and had liver cirrhosis diagnosed prior to surgery were included and matched on a 1:2 basis with non-cirrhotic patients based on age, gender, Eastern Cooperative Oncology Group (ECOG), and date of surgery. Data was obtained from our medical records and ten major postoperative complications variables were compared to the matched group.

RESULTS

Overall, 16 patients with cirrhosis were compared to 32 matched controls. No significant differences were found in pancreatic fistula (18.8% vs. 21.8%; P= 1.000), hemorrhage (6.3% vs. 6.2%; P= 1.000), delayed gastric emptying (6.3% vs. 15.6%; P= 0.648), wound infection (0% vs. 9.3%; P= 0.541), and intraabdominal abscess (31.2% vs 6.2%; 0.4998) for cirrhotic vs. non-cirrhotic respectively. There were no postop ileus, gastric fistula, mesenteric portal thrombosis, biliary fistula, and abdominal ischemic event in either group. The average length of stay for both groups was similar (6.9 vs. 9.3 days; P= 0.4019). There were no mortalities and major morbidity was similar (37.5% vs 34.3%; P=0.3549). One patient required readmission for liver-related decompensation with full recovery.

CONCLUSION

PD in patients with cirrhosis can be safe and feasible in well-selected patients. In a high-volume institution, postoperative complications are similar to those patients without cirrhosis of the liver.

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

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.

Liver resection after Transjugular Portosystemic Stent Shunt (TIPSS)

Hepatocellular carcinoma (HCC) often arises in cirrhotic livers. Generally, decompensated liver cirrhosis is a contraindication to surgery. Even in compensated liver cirrhosis, liver resection for HCC carries a high risk of post-hepatectomy liver failure and decompensation of cirrhosis. Thus, in current staging systems such as the Barcelona Classification of Liver Cancer (BCLC) or the Hong Kong Classification of Liver Cancer (HKLC), liver resection is limited to smaller tumors in compensated cirrhosis. While transjugular portosystemic stent shunts (TIPSS) are widely used for the treatment of complications of portal hypertension such as recurrent esophageal bleeding or refractory ascites, the presence of a TIPSS is generally considered a contraindication for liver resection. Herein, we describe – to our knowledge for the first time – liver resection of an intermediate HCC with a diameter of 11 cm in a patient who had previously received a TIPSS for decompensated cirrhosis. With open surgery, radical resection (R0) was able to be achieved, and the patient left the hospital after 6 days following an uncomplicated postoperative course. Thus, in highly selected cases, liver resection following TIPSS may be considered.