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 22 November 2017

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Transjugular intrahepatic portosystemic stent-shunt does not reduce early graft survival in orthotopic liver transplantation

Transjugular intrahepatic portosystemic stent-shunt does not improve early graft function, or reduce peri-operative blood transfusion requirements, claims a report in this month's European Journal of Gastroenterology and Hepatology.

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The transjugular intrahepatic portosystemic stent-shunt (TIPSS) is an expandable metal stent-shunt inserted between the hepatic and portal veins.

It was initially introduced to prevent variceal hemorrhage by producing a reduction in portal pressure.

In such cases insertion of a TIPSS has been shown to produce hemostasis in up to 80% of cases and a 75% 1-year survival rate.

Since then, its use has been extended to include management of diuretic resistant ascites and Type 1 hepatorenal syndrome, cirrhotic hydrothorax, Budd-Chiari syndrome and portal vein thrombosis.

In diuretic resistant or refractory ascites 75-90% of cases may lose ascites or become more diuretic sensitive following insertion of a TIPSS and renal function may improve significantly in patients with hepatorenal syndrome.

Patients with Budd-Chiari syndrome and cirrhosis with portal vein thrombosis may also demonstrate improvements in their clinical profile.

Many of these current indications for TIPSS use are also indications for consideration of orthotopic liver transplantation.

Reports in the literature have suggested that TIPSS insertion can reduce peri-operative transfusion times during orthotopic liver transplant.

This may result in fewer cases of poor, early graft function by reducing portosystemic shunting, leading to improved portal blood supply to the graft.

Researchers from the departments of Medicine and Radiology and the Scottish Liver Transplant Unit at the Royal Infirmary hospital in Edinburgh, UK, have therefore tested the hypotheses that TIPSS improves early graft function and reduces transfusion requirements.

They carried out a retrospective review of 82 liver transplant recipients between 1993 and 1999, with subgroups containing 29 patients who had TIPSS prior to first orthotopic liver transplant and 53 matched controls with TIPSS.

A longer hospital stay was required in the TIPSS patients
Eur J Gastroenterol Hepatol

No significant difference in the early graft function in the 2 groups was identified.

The prothrombin time before an orthotopic liver transplant was independently predictive of initial poor function.

Transfusion times and total operating times were similar for both groups, although transfusion requirements were greater in those patients where TIPSS led to technical difficulties during the operation (n = 6).

The TIPSS patients required a longer hospital stay than the non-TIPSS subjects (41 ± 8 versus 26 ± 4 days).

Pulmonary infection was found to be less common in the TIPSS group, who also experienced reduced wound infections.

The 12-month patient and graft survival rates in both groups were similar.

Serum albumin levels assessed before orthotopic liver transplant independently predicted 12-month graft survival.

Dr Dhiraj Tripathi, one of the researchers who carried out the study, said their findings showed that "TIPSS does not improve early graft function, nor reduce blood transfusion requirements peri-operatively."

"TIPSS prior to transplantation, despite having the potential for technical operative complications, has no detrimental effects on patient and graft survival, and if required should be undertaken."

He added, "The longer post-operative hospital stay in the TIPSS group is worthy of further study."

Eur J Gastroenterol Hepatol 2002; 14(8): 827-832
07 August 2002

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