Patel Pragnesh, Irani Malcolm, Graviss Edward A, Nguyen Duc T, Quigley Eamonn M M, Victor David W
Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital, Houston, TX, USA.
Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA.
Transl Gastroenterol Hepatol. 2023 Jan 25;8:9. doi: 10.21037/tgh-21-133. eCollection 2023.
Patients with cirrhosis have a high risk for morbidity and mortality in relation to abdominal surgery. Despite improvements in surgical techniques and intensive care, major abdominal surgery still remains a challenge. Major factors determining short- and long-term survival and perioperative complications in this patient population include severity of liver dysfunction, degree of portal hypertension (PHTN), and the presence of related complications such as ascites. Elective transjugular intrahepatic portosystemic shunt (TIPS) placement prior to surgery has been reported to improve perioperative outcomes, but available data is limited to case reports and small case series. We aimed to determine the impact of elective TIPS placement on perioperative outcomes after abdominal-pelvic surgeries in patients with cirrhosis.
We performed a retrospective chart review of patients who underwent elective TIPS and compared these patients with a cohort of cirrhotic patients who underwent any abdominal surgeries without TIPS placement. The primary outcomes were mortality at 30 days and 1 year following surgery. Other post-operative outcomes compared between the two groups, included: blood loss, worsening ascites, wound leak, infections, encephalopathy, liver decompensation, and length of hospitalization.
Among 38 patients with cirrhosis who underwent abdominal surgery, 20 patients underwent pre-operative elective TIPS placement. Demographic characteristics of the two groups were comparable including age, gender, and body mass index (BMI). The median age was 62 years with a male predominance (62.5%). Both groups had similar etiologies of cirrhosis with hepatitis C virus (HCV) (34.2%) being most common. The most frequent indications for surgery were strangulated hernia (50%) in the TIPS group and acute cholecystitis (55.6%) in the non-TIPS group. Mean pre-TIPS hepato-venous portal gradient (HVPG) was 16.5 mmHg and mean post-TIPS HVPG was 7.0 mmHg. Mortality at 1 month was not statistically different between the groups (20% 5.6%, respectively, P=0.19). The 1-year mortality was also not statistically different between the two groups (20% 11.1%, P=0.36).
We found no statistically significant difference in mortality or rate of post-operative complications between patients who received pre-operative TIPS and those who did not in our age-matched cohort.
肝硬化患者接受腹部手术时，发病和死亡风险较高。尽管手术技术和重症监护有所改善，但大型腹部手术仍然是一项挑战。决定该患者群体短期和长期生存以及围手术期并发症的主要因素包括肝功能障碍的严重程度、门静脉高压（PHTN）程度以及腹水等相关并发症的存在。据报道，术前择期行经颈静脉肝内门体分流术（TIPS）可改善围手术期结局，但现有数据仅限于病例报告和小型病例系列。我们旨在确定择期TIPS置入对肝硬化患者腹盆腔手术后围手术期结局的影响。
我们对接受择期TIPS的患者进行了回顾性病历审查，并将这些患者与一组未行TIPS置入而接受任何腹部手术的肝硬化患者进行比较。主要结局是术后30天和1年的死亡率。两组之间比较的其他术后结局包括：失血量、腹水恶化、伤口渗漏、感染、肝性脑病、肝功能失代偿和住院时间。
在38例接受腹部手术的肝硬化患者中，20例患者术前接受了择期TIPS置入。两组的人口统计学特征具有可比性，包括年龄、性别和体重指数（BMI）。中位年龄为62岁，男性占主导（62.5%）。两组肝硬化病因相似，丙型肝炎病毒（HCV）最为常见（34.2%）。TIPS组最常见的手术指征是绞窄性疝（50%），非TIPS组是急性胆囊炎（55.6%）。TIPS术前平均肝静脉门静脉梯度（HVPG）为16.5 mmHg，TIPS术后平均HVPG为7.0 mmHg。两组间1个月时的死亡率无统计学差异（分别为20%和5.6%，P = 0.19）。两组间1年死亡率也无统计学差异（20%和11.1%，P = 0.36）。
在我们年龄匹配的队列中，我们发现术前接受TIPS的患者与未接受TIPS的患者在死亡率或术后并发症发生率方面无统计学显著差异。
