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Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients: a case-control
1Providence Seattle Medical Center, 500 16th Ave, Seattle, WA 98124, USA.
Insights
Surgical shunt is a more effective, durable, and cost-efficient treatment for variceal bleeding in cirrhotic patients compared to transjugular intrahepatic portasystemic shunt (TIPS). Good-risk patients should be considered for surgical intervention.
Area of Science:
- Hepatology
- Gastroenterology
- Surgical Innovation
Background:
- Portal hypertension and variceal bleeding are serious complications of cirrhosis.
- Transjugular intrahepatic portasystemic shunt (TIPS) and surgical shunts are options for portal decompression.
- Evaluating the comparative effectiveness and cost of these procedures is crucial for patient management.
Purpose of the Study:
- To compare the efficacy, durability, and cost-effectiveness of surgical shunt versus TIPS for managing variceal bleeding in patients with Child-Pugh class A or B cirrhosis.
- To determine the optimal treatment strategy for good-risk patients with portal hypertensive bleeding.
Main Methods:
- Retrospective case-control study at an academic liver disease referral center.
- Included patients with Child-Pugh class A or B cirrhosis and prior variceal bleeding.
- Compared outcomes between patients undergoing TIPS (n=20) and surgical shunt (n=20), including mortality, rebleeding, hospitalizations, diagnostic procedures, shunt revisions, and costs.
Main Results:
- Thirty-day mortality was higher in the TIPS group (20%) compared to surgical shunt (0%), though long-term mortality did not differ.
- TIPS was associated with significantly more rebleeding episodes, hospital readmissions, diagnostic studies, and shunt revisions.
- Hospital, professional, and total charges were significantly higher for TIPS compared to surgical shunt.
Conclusions:
- Surgical portal decompression is more effective, durable, and less costly than TIPS in Child-Pugh class A and B cirrhotic patients with variceal bleeding.
- Good-risk patients with portal hypertensive bleeding should be referred for surgical shunt procedures.
- Surgical shunt offers superior long-term outcomes and cost-effectiveness in this patient population.
Hypothesis:
In good-risk patients with variceal bleeding undergoing portal decompression, surgical shunt is more effective, more durable, and less costly than angiographic shunt (transjugular intrahepatic portasystemic shunt [TIPS]).
Design:
Retrospective case-control study.
Setting:
Academic referral center for liver disease.
Patients:
Patients with Child-Pugh class A or B cirrhosis with at least 1 prior episode of bleeding from portal hypertension (gastroesophageal varices, portal hypertensive gastropathy).
Intervention:
Portal decompression by angiographic (TIPS) or surgical (portacaval, distal splenorenal) shunt.
Main Outcome Measures:
Thirty-day and long-term mortality, postintervention diagnostic procedures (endoscopic, ultrasonographic, and angiographic studies), hospital readmissions, variceal rebleeding episodes, blood transfusions, shunt revisions, and hospital and professional charges.
Results:
Patients with Child-Pugh class A or B cirrhosis undergoing TIPS (n = 20) or surgical shunt (n = 20) were followed up for 385 and 456 patient-months, respectively. Thirty-day mortality was greater following TIPS compared with surgical shunt (20% vs 0%; P =.20); long-term mortality did not differ. Significantly more rebleeding episodes (P<.001); rehospitalizations (P<.05); diagnostic studies of all types (P<.001); shunt revisions (P<.001); and hospital (P<.005), professional (P<.05), and total (P<. 005) charges occurred following TIPS compared with surgical shunt.
Conclusions:
Operative portal decompression is more effective, more durable, and less costly than TIPS in Child-Pugh class A and B cirrhotic patients with variceal bleeding. Good-risk patients with portal hypertensive bleeding should be referred for surgical shunt.
