Riassunto analitico
BACKGROUND Surgery in patients with cirrhosis and clinically significant portal hypertension (CSPH) is burdened by severe comorbidities and increased post-surgical mortality, both of which are directly correlated with the grade of PH. As a result, these patients, especially oncological, experience reduced access to surgical treatment. To address this, the use of Transjugular Intrahepatic Portosystemic Shunt (TIPS) has been employed to reduce PH, with increasing evidence that the under-dilation strategy is able to reduce shunt-related complications, extending TIPS applicability. AIM The objective of the study is to evaluate if decreasing PH by placing TIPS increases the eligibility of patients with cirrhosis to planned surgical interventions. PATIENTS AND METHODS All patients treated with pre-operative TIPS to achieve eligibility for a programmed intervention between January 2016 and September 2022 were retrospectively included. Demographics, anamnestic information, hemodynamic and laboratory exams were collected at baseline and before surgery. The endpoints of the study were the rate of failure to access at surgery, the 3-months and 1-year overall survival and the impact of type of surgery, stage of liver disease and TIPS caliber on main outcomes. RESULTS Twenty-four patients had pre-operative TIPS as the main indication. Most patients (79%) received TIPS for oncological surgery. Alcohol-related cirrhosis was the main etiology. The mean age was 62 years. Sixty-six percent of patients were decompensated at TIPS placement. The mean Child-Pugh, MELD and CLIF-AD score were 7.1 ± 1.6, 11.8 ± 3.4 and 46.2 ± 7.5, respectively. Before TIPS, ECOG performance status and ASA classification were restricted in most patients. After TIPS insertion, porto-systemic pressure gradient significantly decreased in all patients (p < 0.001). Mean follow-up for the whole cohort was 755 days with no patient lost to follow-up. Three-months and 1 year survival rates in the group of patients who underwent planned interventions were 86 and 82%, respectively. The rate of failure was 12.5%. No survival differences between compensated and decompensated patients were shown. The median interval from TIPS placement and surgical or endoscopic intervention was 40 days. Incidence of post-TIPS overt hepatic encephalopathy (OHE) was 25%, with no case of persistent HE. Patients who required blood products transfusions were characterized by higher Child-Pugh, MELD and CLIF-AD score and C-RP levels at baseline. 52% of patients developed post-operative complications, most of which were mild (class II according to Clavien–Dindo classification). Development of post-surgery complications was found to be associated with the invasiveness of surgery interventions. CONCLUSIONS Pre-operative TIPS results feasible, safe and efficacious in our experience. The use of small caliber TIPS in this setting represents a step forward to expand the indications and safety of pre-operative TIPS. Further investigations are needed to assess correct patients’ selection and to define more detailed indications for this procedure.
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