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Successful Preoperative Transjugular Intrahepatic Portosystemic Shunt for Portal Decompression in Patients With
Christian Karime1, Asrita Vattikonda1, Jana G Hashash2
1Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA.
Insights
Preoperative transjugular intrahepatic portosystemic shunt (TIPS) in patients with inflammatory bowel disease (IBD) and cirrhosis can facilitate colorectal surgery. However, significant complications, especially in primary sclerosing cholangitis (PSC)-cirrhosis patients, warrant careful consideration.
Area of Science:
- Gastroenterology
- Hepatology
- Colorectal Surgery
Background:
- Colorectal surgery in patients with inflammatory bowel disease (IBD) and cirrhosis is associated with high morbidity.
- Preoperative transjugular intrahepatic portosystemic shunt (TIPS) may mitigate surgical risks in this population.
Purpose of the Study:
- To evaluate perioperative outcomes in patients with IBD and cirrhosis who underwent preoperative TIPS.
- To assess the safety and efficacy of TIPS as a bridge to surgery in high-risk patients.
Main Methods:
- Retrospective single-center study of patients with IBD and cirrhosis undergoing preoperative TIPS for portal decompression.
- Data collected included demographics, portal pressure measurements, and perioperative outcomes.
- Exclusion criteria applied to all other indications for TIPS.
Main Results:
- Ten patients met inclusion criteria; common indications were dysplasia and refractory IBD.
- TIPS reduced portal pressures (22.5 to 18.5 mmHg) and portosystemic gradient (12.5 to 5.5 mmHg).
- 80% experienced complications (bleeding, infection, liver dysfunction), 40% were readmitted within 30 days (mostly for infection).
- 90-day and 1-year survival rates were 100% and 90%, respectively.
- Patients with PSC-cirrhosis had higher morbidity and readmission rates.
Conclusions:
- Preoperative TIPS can facilitate colorectal surgery in patients with IBD and cirrhosis, despite increased risks.
- Significant perioperative complications and readmissions were observed, particularly in patients with PSC-cirrhosis.
- Careful patient selection and management are crucial for this high-risk group.
Background:
Colorectal surgery in patients with inflammatory bowel disease (IBD) and cirrhosis has increased morbidity, which may preclude surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) is postulated to reduce surgical risk. In this retrospective single-center study, we characterized perioperative outcomes in patients with IBD and cirrhosis who underwent preoperative TIPS.
Methods:
We identified patients with IBD and cirrhosis who had undergone preoperative TIPS for portal decompression between 2010 and 2023. All other indications for TIPS led to patient exclusion. Demographic and medical data were collected, including portal pressure measurements. Primary outcome of interest was perioperative outcomes.
Results:
Ten patients met the inclusion criteria. The most common surgical indications were dysplasia (50%) and refractory IBD (50%). TIPS was performed at a median of 47 days (IQR 34-80) before surgery, with reduction in portal pressures (22.5 vs. 18.5 mmHg, P < .01) and portosystemic gradient (12.5 vs. 5.5 mmHg, P < .01). Perioperative complications occurred in 80% of patients, including surgical site bleeding (30%), wound dehiscence (10%), systemic infection (30%), liver function elevation (50%), and coagulopathy (50%). No patients required re-operation, with median length of stay being 7 days (IQR 5.5-9.3). The 30-day readmission rate was 40%, most commonly for infection (75%), with 2 patients having intra-abdominal abscesses and 1 patient with concern for bowel ischemia. Ninety-day and one-year survival was 100% and 90%, respectively. Patients with primary sclerosing cholangitis (PSC)-cirrhosis were noted to have higher perioperative morbidity and a 30-day readmission rate.
Conclusions:
In patients with IBD and cirrhosis, preoperative TIPS facilitated successful surgical intervention despite heightened risk. Nevertheless, significant complications were noted, in particular for patients with PSC-cirrhosis.
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