Cirrhotic patients with a transjugular intrahepatic portosystemic shunt undergoing major extrahepatic surgery

A transjugular intrahepatic portosystemic shunt (TIPS) can potentially reduce the risk of perioperative complications in cirrhotic patients undergoing surgery but experience is limited. The aim of our study was to assess the clinical outcomes in consecutive cirrhotic patients with a patent TIPS undergoing major extrahepatic surgery.

Between July 1992 and January 2007, 25 cirrhotic patients with a patent TIPS underwent abdominal or cardiothoracic surgery at a single center. Preoperative laboratory and clinical features and postoperative outcomes were reviewed.

Mean subject age was 49+/-12 years. The TIPS was placed at a median of 20 days before surgery (range, 1 to 2338 d). In 19 patients, the TIPS had been previously placed for management of refractory ascites or bleeding varices whereas in 6 patients, the TIPS was specifically placed for portal decompression before planned surgery. The mean hepatic venous pressure gradient was significantly reduced from 19.6+/-5.5 to 8.7+/-2.9 mm Hg post-TIPS (P<0.001). The mean preoperative Model for End Stage Liver Disease (MELD) score was 15+/-7.6 and Child-Turcotte-Pugh scores were A (8%), B (64%), and C (28%). Nineteen abdominal and 6 cardiothoracic surgeries were performed under emergent (32%) or urgent (24%) circumstances. Postoperatively, severe ascites developed in 29% and encephalopathy in 17%. The median postoperative intensive care unit and hospital stay were 1 day (range, 0 to 26 d) and 7 days (0 to 32 d), respectively. During a median follow-up of 33 months, actuarial 1-year patient survival was 74%. The 3 patients (12%) who died during their hospitalization all had MELD scores > or = 25 and required emergency surgery.

Portal decompression via TIPS may allow selected cirrhotic patients to safely undergo major surgery with an acceptable rate of short-term morbidity and mortality.