Transjugular intrahepatic portosystemic stent-shunt (TIPSS) insertion as a prelude to orthotopic liver transplantation in patients with severe portal hypertension

Objective: To investigate the impact of preoperative transjugular intrahepatic portosystemic stent-shunt (TIPSS) on patients undergoing liver transplantation. Design: A retrospective non-randomized comparative clinical study. Setting: Tertiary referral institution. Patients, participants: Twenty-four patients with liver cirrhosis, portal hypertension and gastro-oesophageal varices who underwent liver transplantation. Interventions: TIPSS insertion had been performed preoperatively in 12 patients. Main outcome measures: Operative dissection times and blood transfusion requirements during liver transplantation. Postoperative complication rate. Cumulative patient and graft survival. Results: There were no significant differences in outcome measures between patients with and without previous TIPSS insertion with respect to recipient hepatectomy times (mean 192 min (126-280) versus 196 min (145-254)), total operating time (mean 484 min (330-690) versus 486 min (370-580)), intraoperative blood transfusion (mean 11 units (2-29) versus 12 units (2-30)), intraoperative fresh frozen plasma transfusion (mean 9 units (1-16) versus 11 (2-23) units), patient survival (83% versus 92% cumulative 1-year survival), graft survival (80% versus 83% cumulative 1-year survival), or postoperative complication rates. Conclusion: TIPSS insertion is feasible and relatively safe as a 'bridge to transplantation' in patients who have had a variceal haemorrhage. There is little evidence that preoperative TIPSS insertion directly affects the performance of liver transplantation as TIPSS neither hinders nor facilitates surgery or post operative survival. Although it is important that the potential hazards of TIPSS extension into the inferior vena cava or superior mesenteric vein be recognized, liver transplant surgeons need not be unduly concerned about the overall impact of TIPSS as it becomes more universally available in the management of variceal haemorrhage.