Journal of Gastrointestinal Surgery

, Volume 23, Issue 12, pp 2383–2390 | Cite as

Original Study: Transjugular Intrahepatic Portosystemic Shunt as a Bridge to Abdominal Surgery in Cirrhotic Patients

  • N. Tabchouri
  • L. Barbier
  • B. Menahem
  • J.-M. Perarnau
  • F. Muscari
  • N. Fares
  • L. D’Alteroche
  • P.-J. Valette
  • J. Dumortier
  • A. Alves
  • J. Lubrano
  • C. Bureau
  • Ephrem SalaméEmail author
Original Article



Transjugular intrahepatic portosystemic shunt (TIPS) has been suggested to reduce portal hypertension-associated complications in cirrhotic patients undergoing abdominal surgery. The aim of this study was to compare postoperative outcome in cirrhotic patients with and without specific preoperative TIPS placement, following elective extrahepatic abdominal surgery.


Patients were retrospectively included from 2005 to 2016 in four centers. Patients who underwent preoperative TIPS (n = 66) were compared to cirrhotic control patients without TIPS (n = 68). Postoperative outcome was analyzed using propensity score with inverse probability of treatment weighting analysis.


Overall, colorectal surgery accounted for 54% of all surgical procedure. TIPS patients had a higher initial Child-Pugh score (6[5–12] vs. 6[5–9], p = 0.043) and received more beta-blockers (65% vs. 22%, p < 0.001). In TIPS group, 56 (85%) patients managed to undergo planned surgery. Preoperative TIPS was associated with less postoperative ascites (hazard ratio = 0.330 [0.140–0.780]). Severe postoperative complications (Clavien-Dindo > 2) and 90-day mortality were similar between TIPS and no-TIPS groups (18% vs. 23%, p = 0.392, and 7.5% vs. 7.8%, p = 0.644, respectively).


Preoperative TIPS placement yielded an 85% operability rate with satisfying postoperative outcomes. No significant differences were found between TIPS and no-TIPS groups in terms of severe postoperative complications and mortality, although TIPS patients probably had worse initial portal hypertension.


Cirrhosis Abdominal surgery Colorectal surgery Preoperative TIPS Postoperative outcome 



NT collected the data, did the statistical analysis, and wrote the manuscript.

LB supervised statistical analysis and wrote the manuscript.

BM, FM, NF, LdA, PJV, JD, AA, and JL collected the data and corrected the manuscript.

CB and ES designed the study and corrected the manuscript.

Compliance with Ethical Standards

This retrospective study was approved by the regional ethics comity and was declared to the French Data Protection Authority.

Supplementary material

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  1. 1.
    Tsochatzis EA, Bosch J, Burroughs AK. Liver cirrhosis. The Lancet. 2014;383(9930):1749–61.CrossRefGoogle Scholar
  2. 2.
    Friedman LS. Surgery in the patient with liver disease. Trans Am Clin Climatol Assoc. 2010;121:192–205.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Nicoll A. Surgical risk in patients with cirrhosis: Surgical risk in patients with cirrhosis. J Gastroenterol Hepatol. 2012;27(10):1569–75.CrossRefGoogle Scholar
  4. 4.
    Csikesz NG, Nguyen LN, Tseng JF, Shah SA. Nationwide Volume and Mortality after Elective Surgery in Cirrhotic Patients. J Am Coll Surg. 2009;208(1):96–103.CrossRefGoogle Scholar
  5. 5.
    Meunier K, Mucci S, Quentin V, Azoulay R, Arnaud JP, Hamy A. Colorectal Surgery in Cirrhotic Patients: Assessment of Operative Morbidity and Mortality: Dis Colon Rectum. 2008;51(8):1225–31.CrossRefGoogle Scholar
  6. 6.
    Nguyen GC, Correia AJ, Thuluvath PJ. The Impact of Cirrhosis and Portal Hypertension on Mortality Following Colorectal Surgery: A Nationwide, Population-Based Study: Dis Colon Rectum. 2009;52(8):1367–74.CrossRefGoogle Scholar
  7. 7.
    Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: Update 2009. Hepatology. 2010;51(1):306.CrossRefGoogle Scholar
  8. 8.
    Lahat E, Lim C, Bhangui P, Fuentes L, Osseis M, Moussallem T, et al. Transjugular intrahepatic portosystemic shunt as a bridge to non-hepatic surgery in cirrhotic patients with severe portal hypertension: a systematic review. HPB [Internet]. 2017 Oct [cited 2017 Dec 25]; Available from:
  9. 9.
    Loffroy R, Favelier S, Pottecher P, Estivalet L, Genson PY, Gehin S, et al. Transjugular intrahepatic portosystemic shunt for acute variceal gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging. 2015;96(7–8):745–55.CrossRefGoogle Scholar
  10. 10.
    Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases: Garcia-Tsao et al. Hepatology. 2017;65(1):310–35.CrossRefGoogle Scholar
  11. 11.
    Menahem B, Lubrano J, Desjouis A, Lepennec V, Lebreton G, Alves A. Transjugular intrahepatic portosystemic shunt placement increases feasibility of colorectal surgery in cirrhotic patients with severe portal hypertension. Dig Liver Dis. 2015;47(1):81–4.CrossRefGoogle Scholar
  12. 12.
    Fagiuoli S, Bruno R, Debernardi Venon W, Schepis F, Vizzutti F, Toniutto P, et al. Consensus conference on TIPS management: Techniques, indications, contraindications. Dig Liver Dis. 2017;49(2):121–37.CrossRefGoogle Scholar
  13. 13.
    Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PCJ. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;31(4):864–71.CrossRefGoogle Scholar
  14. 14.
    Biggins SW, Kim WR, Terrault NA, Saab S, Balan V, Schiano T, et al. Evidence-Based Incorporation of Serum Sodium Concentration Into MELD. Gastroenterology. 2006;130(6):1652–60.CrossRefGoogle Scholar
  15. 15.
    Causey MW, Steele SR, Farris Z, Lyle DS, Beitler AL. An assessment of different scoring systems in cirrhotic patients undergoing nontransplant surgery. Am J Surg. 2012;203(5):589–93.CrossRefGoogle Scholar
  16. 16.
    Cho HC, Jung HY, Sinn DH, Choi MS, Koh KC, Paik SW, et al. Mortality after surgery in patients with liver cirrhosis: comparison of Child–Turcotte–Pugh, MELD and MELDNa score. Eur J Gastroenterol Hepatol. 2011;23(1):51–9.CrossRefGoogle Scholar
  17. 17.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD, the Practice Guidelines Committee of the American Association for the Study of Liver Diseases and the Practice Parameters Committee of the American College of Gastroenterology. Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis. Am J Gastroenterol. 2007;102(9):2086–102.CrossRefGoogle Scholar
  18. 18.
    Dindo D, Demartines N, Clavien P-A. Classification of Surgical Complications: A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey. Ann Surg. 2004;240(2):205–13.CrossRefGoogle Scholar
  19. 19.
    Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, et al. The “50-50 criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg. 2005;242(6):824–9.CrossRefGoogle Scholar
  20. 20.
    Kaukonen K-M, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. N Engl J Med. 2015;372(17):1629–38.CrossRefGoogle Scholar
  21. 21.
    rosenbaum_1983.pdf.Google Scholar
  22. 22.
    Austin PC. An Introduction to Propensity Score Methods for Reducing the Effects of Confounding in Observational Studies. Multivar Behav Res. 2011;46(3):399–424.CrossRefGoogle Scholar
  23. 23.
    Austin PC. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat Med. 2009;28(25):3083–107.CrossRefGoogle Scholar
  24. 24.
    Fidelman N, Kwan SW, LaBerge JM, Gordon RL, Ring EJ, Kerlan RK. The Transjugular Intrahepatic Portosystemic Shunt: An Update. Am J Roentgenol. 2012;199(4):746–55.CrossRefGoogle Scholar
  25. 25.
    Sarwar A, Zhou L, Novack V, Tapper EB, Curry M, Malik R, et al. Hospital volume and mortality after trans-jugular intrahepatic portosystemic shunt creation in the United States: Effect of hospital TIPS volume on mortality. Hepatology [Internet]. 2017 Jul 6 [cited 2017 Dec 17]; Available from:
  26. 26.
    Lebrec D, Sogni P, Vilgrain V. 2 Evaluation of patients with portal hypertension. Baillieres Clin Gastroenterol. 1997;11(2):221–41.CrossRefGoogle Scholar
  27. 27.
    Azoulay D, Buabse F, Damiano I, Smail A, Ichai P, Dannaoui M, et al. Neoadjuvant transjugular intrahepatic portosystemic shunt: a solution for extrahepatic abdominal operation in cirrhotic patients with severe portal hypertension. J Am Coll Surg. 2001;193(1):46–51.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • N. Tabchouri
    • 1
    • 2
  • L. Barbier
    • 1
    • 2
  • B. Menahem
    • 3
  • J.-M. Perarnau
    • 4
  • F. Muscari
    • 5
  • N. Fares
    • 6
  • L. D’Alteroche
    • 4
  • P.-J. Valette
    • 7
  • J. Dumortier
    • 7
  • A. Alves
    • 3
  • J. Lubrano
    • 3
  • C. Bureau
    • 6
  • Ephrem Salamé
    • 1
    • 2
    Email author
  1. 1.Department of Digestive Surgery, Hepatobiliary Surgery and Liver TransplantationUniversity Hospital of Tours, CHU ToursToursFrance
  2. 2.FHU SupportToursFrance
  3. 3.Department of Digestive SurgeryUniversity Hospital of CaenCaen CedexFrance
  4. 4.Department of HepatologyUniversity Hospital of Tours, CHU ToursToursFrance
  5. 5.Department of SurgeryHôpital RangueilToulouseFrance
  6. 6.Department of Hepatology and Gastroenterology, Purpan HospitalUniversity Hospital of ToulouseToulouse Cedex 9France
  7. 7.Department of Digestive Diseases, Hospices Civils de Lyon, Hôpital Edouard HerriotUniversité Claude Bernard Lyon 1LyonFrance

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