Preoperative TIPS and in-hospital mortality in patients with cirrhosis undergoing surgery

Felix Piecha; Joscha Vonderlin; Friederike Frühhaber; Julia-Kristin Graß; Ann-Kathrin Ozga; Aenne Harberts; Daniel Benten; Peter Hübener; Matthias Reeh; Christoph Riedel; Peter Bannas; Jakob R Izbicki; Gerhard Adam; Samuel Huber; Ansgar W Lohse; Johannes Kluwe

doi:10.1016/j.jhepr.2023.100914

Preoperative TIPS and in-hospital mortality in patients with cirrhosis undergoing surgery

JHEP Rep. 2023 Sep 23;6(1):100914. doi: 10.1016/j.jhepr.2023.100914. eCollection 2024 Jan.

Authors

Felix Piecha¹, Joscha Vonderlin², Friederike Frühhaber¹, Julia-Kristin Graß³, Ann-Kathrin Ozga⁴, Aenne Harberts¹, Daniel Benten^{1

5}, Peter Hübener¹, Matthias Reeh³, Christoph Riedel⁶, Peter Bannas⁶, Jakob R Izbicki³, Gerhard Adam⁶, Samuel Huber¹, Ansgar W Lohse¹, Johannes Kluwe^{1

7}

Affiliations

¹ I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
² Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK) and Campus Charité Mitte (CCM), Berlin, Germany.
³ Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
⁴ Center for Experimental Medicine, Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
⁵ Department of Gastroenterology, Asklepios Hospital Harburg, Hamburg, Germany.
⁶ Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
⁷ Department of Internal Medicine and Gastroenterology, Amalie Sieveking Hospital, Hamburg, Germany.

Abstract

Background & aims: Cirrhosis is associated with an increased surgical morbidity and mortality. Portal hypertension and the surgery type have been established as critical determinants of postoperative outcome. We aim to evaluate the hypothesis that preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement in patients with cirrhosis is associated with a lower incidence of in-house mortality/liver transplantation (LT) after surgery.

Methods: A retrospective database search for the years 2010-2020 was carried out. We identified 64 patients with cirrhosis who underwent surgery within 3 months after TIPS placement and 131 patients with cirrhosis who underwent surgery without it (controls). Operations were categorised into low-risk and high-risk procedures. The primary endpoint was in-house mortality/LT. We analysed the influence of high-risk surgery, preoperative TIPS placement, age, sex, baseline creatinine, presence of ascites, Chronic Liver Failure Consortium Acute Decompensation (CLIF-C AD), American Society of Anesthesiologists (ASA), and model for end-stage liver disease (MELD) scores on in-house mortality/LT by multivariable Cox proportional hazards regression.

Results: In both the TIPS and the control cohort, most patients presented with a Child-Pugh B stage (37/64, 58% vs. 70/131, 53%) at the time of surgery, but the median MELD score was higher in the TIPS cohort (14 vs. 11 points). Low-risk and high-risk procedures amounted to 47% and 53% in both cohorts. The incidence of in-house mortality/LT was lower in the TIPS cohort (12/64, 19% vs. 52/131, 40%), also when further subdivided into low-risk (0/30, 0% vs. 10/61, 16%) and high-risk surgery (12/34, 35% vs. 42/70, 60%). Preoperative TIPS placement was associated with a lower rate for postoperative in-house mortality/LT (hazard ratio 0.44, 95% CI 0.19-1.00) on multivariable analysis.

Conclusions: A preoperative TIPS might be associated with reduced postoperative in-house mortality in selected patients with cirrhosis.

Impact and implications: Patients with cirrhosis are at risk for more complications and a higher mortality after surgical procedures. A transjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of cirrhosis, but it is unclear if it also helps to lower the risk of surgery. This study takes a look at complications and mortality of patients undergoing surgery with or without a TIPS, and we found that patients with a TIPS develop less complications and have an improved survival. Therefore, a preoperative TIPS should be considered in selected patients, especially if indicated by ascites.

Keywords: CLIF score; Child-Pugh score; Cirrhosis; MELD score; Portal hypertension; Transjugular intrahepatic portosystemic shunt; VOCAL Penn score.