Universitat Autònoma de Barcelona, Barcelona, Spain.
Vall d'Hebron University Hospital, Barcelona, Spain.
World J Emerg Surg. 2023 Apr 17;18(1):30. doi: 10.1186/s13017-023-00498-4.
In this systematic review and meta-analysis, we examined the evidence on transjugular intrahepatic portosystemic shunt (TIPS) 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 elective and emergent surgery.
MEDLINE and Scopus were searched for studies reporting the outcomes of cirrhotic patients undergoing elective and emergency surgery with preoperative TIPS. The risk of bias was evaluated using the methodological index for non-randomized studies of interventions, and the JBI critical appraisal tool for case reports. The outcomes of interest were: 1. Surgery after TIPS; 2. Mortality; 3. Perioperative transfusions; and 4. Postoperative liver-related events. A DerSimonian and Laird (random-effects) model was used to perform the meta-analyses in which the overall (combined) effect estimate was presented in the form of an odds ratio (summary statistic).
Of 426 patients (from 27 articles), 256 (60.1%) underwent preoperative TIPS. Random effects MA showed significantly lower odds of postoperative ascites with preoperative TIPS (OR = 0.40, 95% CI 0.22-0.72; I2 = 0%). There were no significant differences in 90-day mortality (3 studies: OR = 0.76, 95% CI 0.33-1.77; I2 = 18.2%), perioperative transfusion requirement (3 studies: OR = 0.89, 95% CI 0.28-2,84; I2 = 70.1%), postoperative hepatic encephalopathy (2 studies: OR = 0.97, 95% CI 0.35-2.69; I2 = 0%), and postoperative ACLF (3 studies: OR = 1.02, 95% CI 0.15-6.8, I2 = 78.9%).
Preoperative TIPS appears safe in cirrhotic patients who undergo elective and emergency surgery and may have a potential role in postoperative ascites control. Future randomized clinical trials should test these preliminary results.
在这项系统评价和荟萃分析中，我们研究了经颈静脉肝内门体分流术（TIPS）作为肝硬化患者择期和急诊手术桥接的证据。我们旨在评估该干预措施的围手术期特征、管理方法和结果，该干预措施用于实现门脉减压并能够安全进行择期和急诊手术。
我们在 MEDLINE 和 Scopus 上检索了报告术前 TIPS 治疗后行择期和急诊手术的肝硬化患者结局的研究。使用干预措施的非随机研究方法学指数和 JBI 病例报告评价工具评估偏倚风险。我们关注的结局为：1. TIPS 术后手术；2. 死亡率；3. 围手术期输血；和 4. 术后肝脏相关事件。使用 DerSimonian 和 Laird（随机效应）模型进行荟萃分析，以比值比（汇总统计量）的形式呈现总体（合并）效应估计。
在 426 名患者（来自 27 篇文章）中，256 名（60.1%）患者行术前 TIPS。随机效应 MA 显示术前 TIPS 术后腹水的可能性显著降低（OR=0.40，95%CI 0.22-0.72；I2=0%）。术前 TIPS 与 90 天死亡率（3 项研究：OR=0.76，95%CI 0.33-1.77；I2=18.2%）、围手术期输血需求（3 项研究：OR=0.89，95%CI 0.28-2.84；I2=70.1%）、术后肝性脑病（2 项研究：OR=0.97，95%CI 0.35-2.69；I2=0%）和术后 ACLF（3 项研究：OR=1.02，95%CI 0.15-6.8，I2=78.9%）之间均无显著差异。
术前 TIPS 似乎对接受择期和急诊手术的肝硬化患者是安全的，并且在术后腹水控制方面可能具有潜在作用。未来的随机临床试验应检验这些初步结果。
