Cirrhosis surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2] Sudarshana Datta, MD [3]

Overview[edit | edit source]

Patients with decompensated liver cirrhosis are usually candidates for liver transplantation. Liver transplantation may be carried out based on MELD score and assessment of the patient’s quality of life, absence of contraindications and disease severity. In cases where transplantation is contraindicated, a patient may undergo the TIPS procedure. A transjugular intrahepatic portosystemic shunt, also TIPS, is an artificial channel in the liver from the portal vein to a hepatic vein, created via the jugular vein. The main purpose of the TIPS procedure is to decompress the portal vein which would in turn help to prevent rebleeding from varices, and also prevent ascites formation. TIPS is used to treat portal hypertension which is often due to cirrhosis.

Surgery[edit | edit source]

Transplantation[edit | edit source]

• Patients with decompensated cirrhosis (having complications such as encephalopathy, ascites, variceal hemorrhage, hepatorenal syndrome or compromised hepatic function) are treated with liver transplantation.^[1][2]
• Liver transplantation may be carried out after assessment of the patient’s quality of life, absence of contraindications and disease severity.^{[3][4][5][6][7][8]}
• The evaluation of a patient with cirrhosis for transplantation begins once the MELD score is >10. This provides an adequate window for pre-transplanation evaluation.^{[2][5][6][9][10][11][12][13][14][15]}
• Patients typically become candidates for liver transplantation once the MELD score is  ≥15, but this may not leave enough time for patient education and counseling, especially in cases where hepatic encephalopathy sets in. ^{[16][17][18][19][20]}
•  Patients qualify as candidates for liver transplantation irrespective of their MELD score in the following conditions: ^[21][22][23]
  • Hepatic artery thrombosis
  • Hilar cholangiocarcinoma
  • HCC
  • Hepatopulmonary syndrome
  • Refractory ascites, hepatic encephalopathy or variceal hemorrhage
  • Portal hypertensive gastropathy
  • Intractable pruritus in a patient with primary biliary cirrhosis
  • Cystic fibrosis
  • Primary hyperoxaluria
  • Familial amyloid polyneuropathy
• Survival from liver transplantation has been improving over the 1990s, and the five-year survival rate is now around 80%, depending largely on the severity of disease and medical comorbidities in the recipient.^[24]
• In the United States, the MELD score is used to prioritize patients for liver transplantation.^[25]
• Transplantation necessitates the use of immunosuppressants (cyclosporine or tacrolimus).^{[26][27][28][29][30]}

Prevalence

• Patients with primary biliary cirrhosis treated with ursodeoxycholic acid (UDCA) have decreased need for liver transplantation.^[31]

Symptoms After Surgery

• Complications of end stage liver disease present before transplantation are typically resolved after the surgery.
• Complications such as variceal bleeding, encephalopathy, and hepatorenal syndrome are usually resolved after a successful transplantation.
• Pruritis, which may be associated with cirrhosis, is typically cleared up post-surgery.

Survival

• Liver transplantation may have a significant effect on the long term survival of the patient.^{[32][33][34][35][36]}
• The overall survival rates of patients have demonstrated a significant increase in patients post transplantation. The overall post-surgical survival rate at 1,5 and 10 years is 87%,80%, and 67% respectively.^[37]

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TIPS (Transjugular Intrahepatic Portosystemic Shunt)[edit | edit source]

• A transjugular intrahepatic portosystemic shunt, also TIPS, is an artificial channel in the liver from the portal vein to a hepatic vein, created via the jugular vein.^[38][39]
• The main purpose of the TIPS procedure is to decompress the portal vein which would in turn help to prevent rebleeding from varices, and also prevent ascites formation.^[40]

Indications

• TIPS is used to treat portal hypertension which is often due to cirrhosis.
• The scar tissue in the liver due to cirrhosis causes blockages in the portal vein, leading to portal vein hypertension.
• Due to the increased pressure in the portal vein, veins that are bypassing the liver may rupture. The possibility of rupture makes a transjugular intrahepatic portosystemic shunt a beneficial procedure.

Contraindications

• Absolute contraindications:^[40]
  • congestive heart failure
  • Uncontrolled sepsis
  • Uncontrolled systemic infection
  • Unresolved biliary obstruction
  • Multiple hepatic cysts
  • Severe pulmonary hypertension
• Relative contraindications:^[40]
  • Hepatoma
  • Severe coagulopathy
  • Portal vein thrombosis
  • Hepatic vein thrombosis
  • Moderate pulmonary hypertension
  • Thrombocytopenia

Survival

• TIPS procedure has a 30-day mortality rate of 45% for people that need an emergency portacaval shunt.^[41][42]
• The mortality rate due to the TIPS procedure itself is less than 2%.
• Some of the causes of death associated with TIPS include myocardial infarction during the procedure and intraperitoneal hemorrhage due to a rupture or puncture of the portal vein.^[41]

Complications

• Complications of TIPS include puncture and dilation of the portal vein, hematoma at the puncture site and thrombosis of the stent that is placed in the hepatic vein during the procedure.^[41]
• It is more difficult to perform liver transplantation after a patient has already undergone the TIPS procedure. Inserting a shunt into the liver needs to be exceedingly precise in patients that have the possibility of obtaining a new liver. In transplant cases, patient and graft survival is worse in individuals that previously had a shunt placed in the hepatic vein.^[40]

Drawbacks

• Two of the major drawbacks that may be present with the TIPS procedure are stent dysfunction and portosystemic encephalopathy.^[43]
• There also may be a frequent need for endovascluar reintervention to make sure that the stent remains patent.^[43]

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References[edit | edit source]

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