Unlocking the potential of TIPS placement as a bridge to elective and emergency surgery in cirrhotic patients: a meta-analysis and future directions for endovascular resuscitation in acute care surgery

Portal hypertension (PH) is a key driver of hepatic decompensation and mortality among patients with advanced chronic liver disease or cirrhosis. PH in cirrhotic patients occurs due to increased intrahepatic resistance that induces systemic hemodynamic disturbances [1]. When the hepatic venous pressure gradient (HVPG) rises up to 10 mmHg (i.e., clinically significant portal hypertension) [2], patients may develop gastroesophageal varices or other portosystemic collaterals, but even more importantly, hepatic complications such as ascites, hepatic encephalopathy, portal hypertensive bleeding or portal vein thrombosis [3].

Surgery, particularly major surgery, is one of the precipitants of acute decompensation in patients with cirrhosis and PH, and postoperative morbidity and mortality correlate with liver disease severity [4]. Consequently, surgery may be contraindicated in some patients with cirrhosis and PH. Therefore, surgeons often encounter challenging situations when evaluating patients with advanced cirrhosis who require elective or emergency surgeries in the context of acute care and general surgery. This is because the presence of advanced liver disease, such as portal hypertension, can impact the decision to perform a surgical procedure that would otherwise be performed without concern for complications and poor outcomes.

Transjugular intrahepatic portosystemic shunt (TIPS) has been used to manage complications related to PH, including portal hypertensive bleeding, ascites, and portal vein thrombosis [5]. It has been proposed that preoperative TIPS placement, by lowering portal pressure, would improve postoperative outcomes [5, 6]. Available evidence suggests that preoperative TIPS placement may be safe and could potentially reduce postoperative liver outcomes [7]. Unfortunately, we need more research to test the effects of TIPS in the field of surgery. Such research would be of particular interest to surgeons and other healthcare professionals caring for cirrhotic patients undergoing surgical procedures [8] and could inform clinical practice and guide future research efforts in this field.

To date, the role of TIPS in the preoperative setting of patients requiring elective and emergency surgery remains unclear. Moreover, little quantitative evidence is available to know the number of patients who can undergo surgery after preoperative TIPS and their associated postoperative outcomes; for example, postoperative liver-related events (LRE).

In this systematic review and meta-analysis, we examined the evidence on using transjugular intrahepatic portosystemic shunt (TIPS) placement as a bridge to elective and emergency surgery in cirrhotic patients. We aimed to assess the perioperative characteristics, management approaches, and outcomes of this intervention, which is used to achieve portal decompression and enable the safe performance of surgery. We hypothesized that preoperative TIPS deployment reduces morbidity and mortality in cirrhotic patients undergoing surgery.

The present meta-analytic review adhered to the principles from the Cochrane Handbook of Systematic Reviews of Interventions and was reported according to the PRISMA [9] and “Meta-analysis of Observational Studies in Epidemiology” (MOOSE) reporting guidelines [10].

To achieve our main objective, this SR and MA answered the following questions:

Although not registered in PROSPERO, a protocol prepared before the review kickoff was used to guide the execution of the systematic review.

Electronic database searching found 564 records (titles and abstracts), of which 25 were eligible for inclusion in this SR. In the full-text review, three studies were excluded, leaving 22 articles for inclusion. After conducting a snowball scanning of the references cited in these 22 articles, five additional references were found. Therefore, twenty-seven articles were finally included in the SR [14‐40]. Of these, four were comparative studies, of which three were evaluated as appropriate to combine in meta-analyses [19, 37, 40]. Figure 1 shows the PRISMA diagram for the selection of the studies.

This meta-analytic review assessed the outcomes of cirrhotic patients that underwent surgery with preoperative TIPS as an adjunct to decompress the portal system. Only studies reporting observational data were found. Three key points can be extracted from our work: first, it is feasible to deploy TIPS as a bridge to surgery as it appears not to jeopardize the attainment/execution of surgical procedures. The data shows that 90% of patients who underwent preoperative TIPS attained/achieved surgery. Second, different types of operations were performed with preoperative TIPS and no differences in LREs were found. Therefore, and acknowledging that available data are limited, it appears that the type of procedure should not be considered a contraindication to offer surgery to cirrhotic patients with PH, even in cases where emergency surgery is needed. And third, the preoperative decompression of the portal circulation through TIPS may have a beneficial effect on the occurrence of postoperative ascites. However, we found no significant effect of preoperative TIPS on other outcomes such as perioperative transfusions, and postsurgical liver events other than ascites, i.e., hepatic encephalopathy, ACLF, and mortality.

The data assembled show that TIPS can be successfully deployed or performed in a variety of surgical procedures and settings across multiple surgical specialties/disciplines. As shown in Fig. 2, abdominal, thoracic, gynecologic, and vascular/endovascular procedures were all performed with preoperative TIPS. Tumor resection surgery was the most common procedure, followed by non-oncologic gastrointestinal procedures such as hernia repair. In addition, there were cases of aortic aneurysm repair, aortic valve replacement, and coronary artery bypass in which TIPS was utilized. While further research is needed to fully understand the effect of TIPS on surgical and postoperative outcomes, surgeons should consider the use of TIPS as a potential tool in the surgical management of cirrhotic patients, including emergency and surgical rescue situations [41]. As such, it should be included in the armamentarium of surgeons practicing in these settings and should also be included in the research agenda of general and emergency surgeons worldwide. It is important to note, however, that the use of TIPS should be restricted to centers with a high volume of cases and a demonstrated expertise in the preoperative deployment of TIPS. Effective communication between the surgeon, interventional radiologist, and hepatologist is also essential for the achievement of optimal outcomes.

We found that preoperative TIPS resulted in lower odds of postoperative ascites after combining data derived from propensity score matching techniques in a random-effects meta-analysis. This is not surprising as TIPS directly acts on the main driver of ascites occurrence by decompressing the hepatic sinusoids and reducing portal pressure. Although no randomized studies have been performed for TIPS in perioperative medicine, preoperative TIPS may protect an already exhausted liver vascular structure unprepared to tolerate the pathophysiological changes that occur as a stress response to surgery [5]. The effects of TIPS could be of greater significance in patients requiring longer or more invasive surgeries as these procedures elicit greater stress responses. However, further prospective (and particularly randomized) studies are required to validate our findings regarding postoperative outcomes in patients undergoing preoperative TIPS. These studies should also evaluate if preoperative TIPS could reduce the hospital cost derived from postoperative ascites care and other liver-related events.

In contrast to the role that preoperative TIPS may have in reducing the odds of postoperative ascites, our analyses found no differences in mortality, perioperative transfusions, hepatic encephalopathy, and ACLF. Since the studies included in our MA are retrospective, there would be an unavoidable selection bias, where both TIPS candidates and those cirrhotic patients that did not underwent to a TIPS creation had a preserved liver function that would impact directly in the risk of developing an LRE during and after the surgery.

In our opinion, future studies should be focused on three priorities: 1. To assess the effectiveness of preoperative TIPS in randomized clinical trials, as mentioned above, and specifically if there are reduced costs resulting from less postoperative ascites, 2. To assess the factors associated with not achieving/attaining surgery after preoperative TIPS and, 3. To identify predictors of postoperative liver decompensation in patients who underwent surgery with preoperative TIPS. Specifically, is there a role for determining hepatic venous pressure gradient in the perioperative care of cirrhotic patients undergoing major surgery, and the predictive performance of noninvasive tests for postoperative outcomes. Moreover, given the well-known advantages of PTFE-covered stent grafts in terms of hepatic encephalopathy and survival [42], future research should also assess whether the prophylactic use of these endoprostheses positively impacts the outcomes of patients undergoing elective or emergency surgery. These data may inform decision-making and clinical guidelines development. Meanwhile, preoperative TIPS should be employed cautiously in well-selected patients and performed by teams with experience in the procedure and demonstrated high-case volume.

Preoperative TIPS appears to be safe in cirrhotic patients with PH who undergo elective and emergency surgery and may have a role in postoperative ascites control. Since available evidence to date is insufficient to provide any recommendation of the TIPS role in this setting, our results underscore the unmet need for prospective randomized studies to elucidate the effect of preoperative TIPS on liver outcomes and mortality after surgery in cirrhotic patients.