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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

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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

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### Transplantation

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Main article: Liver transplantation

* 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)

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Main article: Transjugular intrahepatic portosystemic shunt

* 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

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1. ↑ Hoganson DA, Irgens RL, Doi RH, Stahly DP (1975). "Bacterial sporulation and regulation of dihydrodipicolinate synthase in ribonucleic acid polymerase mutants of Bacillus subtilis". J. Bacteriol. 124 (3): 1628–9. PMC 236086. PMID 811651.
2. ↑ 2.0 2.1 Alessandria C, Ozdogan O, Guevara M, Restuccia T, Jiménez W, Arroyo V, Rodés J, Ginès P (2005). "MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation". Hepatology. 41 (6): 1282–9. doi:10.1002/hep.20687. PMID 15834937.
3. ↑ Schaubel DE, Sima CS, Goodrich NP, Feng S, Merion RM (2008). "The survival benefit of deceased donor liver transplantation as a function of candidate disease severity and donor quality". Am. J. Transplant. 8 (2): 419–25. doi:10.1111/j.1600-6143.2007.02086.x. PMID 18190658.
4. ↑ Volk ML, Lok AS, Pelletier SJ, Ubel PA, Hayward RA (2008). "Impact of the model for end-stage liver disease allocation policy on the use of high-risk organs for liver transplantation". Gastroenterology. 135 (5): 1568–74. PMID 19009713.
5. ↑ 5.0 5.1 Kremers WK, van IJperen M, Kim WR, Freeman RB, Harper AM, Kamath PS, Wiesner RH (2004). "MELD score as a predictor of pretransplant and posttransplant survival in OPTN/UNOS status 1 patients". Hepatology. 39 (3): 764–9. doi:10.1002/hep.20083. PMID 14999695.
6. ↑ 6.0 6.1 Schmidt LE, Larsen FS (2007). "MELD score as a predictor of liver failure and death in patients with acetaminophen-induced liver injury". Hepatology. 45 (3): 789–96. doi:10.1002/hep.21503. PMID 17326205.
7. ↑ Sharma P, Schaubel DE, Gong Q, Guidinger M, Merion RM (2012). "End-stage liver disease candidates at the highest model for end-stage liver disease scores have higher wait-list mortality than status-1A candidates". Hepatology. 55 (1): 192–8. doi:10.1002/hep.24632. PMC 3235236. PMID 21898487.
8. ↑ Foley DP, Fernandez LA, Leverson G, Chin LT, Krieger N, Cooper JT, Shames BD, Becker YT, Odorico JS, Knechtle SJ, Sollinger HW, Kalayoglu M, D'Alessandro AM (2005). "Donation after cardiac death: the University of Wisconsin experience with liver transplantation". Ann. Surg. 242 (5): 724–31. PMC 1409855. PMID 16244547.
9. ↑ Said A, Williams J, Holden J, Remington P, Gangnon R, Musat A, Lucey MR (2004). "Model for end stage liver disease score predicts mortality across a broad spectrum of liver disease". J. Hepatol. 40 (6): 897–903. doi:10.1016/j.jhep.2004.02.010. PMID 15158328.
10. ↑ Bambha K, Kim WR, Pedersen R, Bida JP, Kremers WK, Kamath PS (2008). "Predictors of early re-bleeding and mortality after acute variceal haemorrhage in patients with cirrhosis". Gut. 57 (6): 814–20. doi:10.1136/gut.2007.137489. PMID 18250126.
11. ↑ Reverter E, Tandon P, Augustin S, Turon F, Casu S, Bastiampillai R, Keough A, Llop E, González A, Seijo S, Berzigotti A, Ma M, Genescà J, Bosch J, García-Pagán JC, Abraldes JG (2014). "A MELD-based model to determine risk of mortality among patients with acute variceal bleeding". Gastroenterology. 146 (2): 412–19.e3. doi:10.1053/j.gastro.2013.10.018. PMID 24148622.
12. ↑ Inaba K, Barmparas G, Resnick S, Browder T, Chan LS, Lam L, Talving P, Demetriades D (2011). "The Model for End-Stage Liver Disease score: an independent prognostic factor of mortality in injured cirrhotic patients". Arch Surg. 146 (9): 1074–8. doi:10.1001/archsurg.2011.109. PMID 21576598.
13. ↑ Chalasani N, Kahi C, Francois F, Pinto A, Marathe A, Bini EJ, Pandya P, Sitaraman S, Shen J (2002). "Model for end-stage liver disease (MELD) for predicting mortality in patients with acute variceal bleeding". Hepatology. 35 (5): 1282–4. doi:10.1053/jhep.2002.32532. PMID 11981782.
14. ↑ Amitrano L, Guardascione MA, Bennato R, Manguso F, Balzano A (2005). "MELD score and hepatocellular carcinoma identify patients at different risk of short-term mortality among cirrhotics bleeding from esophageal varices". J. Hepatol. 42 (6): 820–5. doi:10.1016/j.jhep.2005.01.021. PMID 15885352.
15. ↑ Kim MS, Kato TS, Farr M, Wu C, Givens RC, Collado E, Mancini DM, Schulze PC (2013). "Hepatic dysfunction in ambulatory patients with heart failure: application of the MELD scoring system for outcome prediction". J. Am. Coll. Cardiol. 61 (22): 2253–2261. doi:10.1016/j.jacc.2012.12.056. PMC 3939720. PMID 23563127.
16. ↑ Freeman RB, Wiesner RH, Edwards E, Harper A, Merion R, Wolfe R (2004). "Results of the first year of the new liver allocation plan". Liver Transpl. 10 (1): 7–15. doi:10.1002/lt.20024. PMID 14755772.
17. ↑ Cejas NG, Villamil FG, Lendoire JC, Tagliafichi V, Lopez A, Krogh DH, Soratti CA, Bisigniano L (2013). "Improved waiting-list outcomes in Argentina after the adoption of a model for end-stage liver disease-based liver allocation policy". Liver Transpl. 19 (7): 711–20. doi:10.1002/lt.23665. PMID 23775946.
18. ↑ Northup PG, Wanamaker RC, Lee VD, Adams RB, Berg CL (2005). "Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis". Ann. Surg. 242 (2): 244–51. PMC 1357730. PMID 16041215.
19. ↑ Teh SH, Nagorney DM, Stevens SR, Offord KP, Therneau TM, Plevak DJ, Talwalkar JA, Kim WR, Kamath PS (2007). "Risk factors for mortality after surgery in patients with cirrhosis". Gastroenterology. 132 (4): 1261–9. doi:10.1053/j.gastro.2007.01.040. PMID 17408652.
20. ↑ Veldt BJ, Lainé F, Guillygomarc'h A, Lauvin L, Boudjema K, Messner M, Brissot P, Deugnier Y, Moirand R (2002). "Indication of liver transplantation in severe alcoholic liver cirrhosis: quantitative evaluation and optimal timing". J. Hepatol. 36 (1): 93–8. PMID 11804670.
21. ↑ Moylan CA, Brady CW, Johnson JL, Smith AD, Tuttle-Newhall JE, Muir AJ (2008). "Disparities in liver transplantation before and after introduction of the MELD score". JAMA. 300 (20): 2371–8. doi:10.1001/jama.2008.720. PMC 3640479. PMID 19033587.
22. ↑ Cholongitas E, Marelli L, Kerry A, Goodier DW, Nair D, Thomas M, Patch D, Burroughs AK (2007). "Female liver transplant recipients with the same GFR as male recipients have lower MELD scores--a systematic bias". Am. J. Transplant. 7 (3): 685–92. doi:10.1111/j.1600-6143.2007.01666.x. PMID 17217437.
23. ↑ Bambha KM, Biggins SW (2008). "Inequities of the Model for End-Stage Liver Disease: an examination of current components and future additions". Curr Opin Organ Transplant. 13 (3): 227–33. doi:10.1097/MOT.0b013e3282ff84c7. PMID 18685308.
24. ↑ liver transplant outlook and survival rates
25. ↑ Cosby RL, Yee B, Schrier RW (1989). "New classification with prognostic value in cirrhotic patients". Mineral and electrolyte metabolism. 15 (5): 261–6. PMID 2682175.CS1 maint: Multiple names: authors list (link)
26. ↑ "A comparison of tacrolimus (FK 506) and cyclosporine for immunosuppression in liver transplantation". N. Engl. J. Med. 331 (17): 1110–5. 1994. doi:10.1056/NEJM199410273311702. PMID 7523946.
27. ↑ "Defining the outcome of immunosuppression withdrawal after liver transplantation - Devlin - 2003 - Hepatology - Wiley Online Library".
28. ↑ "Randomised trial comparing tacrolimus (FK506) and cyclosporin in prevention of liver allograft rejection. European FK506 Multicentre Liver Study Group". Lancet. 344 (8920): 423–8. 1994. PMID 7520105.
29. ↑ Fung J, Kelly D, Kadry Z, Patel-Tom K, Eghtesad B (2005). "Immunosuppression in liver transplantation: beyond calcineurin inhibitors". Liver Transpl. 11 (3): 267–80. doi:10.1002/lt.20373. PMID 15719409.
30. ↑ Perry I, Neuberger J (2005). "Immunosuppression: towards a logical approach in liver transplantation". Clin. Exp. Immunol. 139 (1): 2–10. doi:10.1111/j.1365-2249.2005.02662.x. PMC 1809260. PMID 15606606.
31. ↑ Lee J, Belanger A, Doucette JT, Stanca C, Friedman S, Bach N (2007). "Transplantation trends in primary biliary cirrhosis". Clinical Gastroenterology and Hepatology : the Official Clinical Practice Journal of the American Gastroenterological Association. 5 (11): 1313–5. doi:10.1016/j.cgh.2007.07.015. PMID 17900996. Retrieved 2012-09-06.CS1 maint: Multiple names: authors list (link)
32. ↑ Salpeter SR, Luo EJ, Malter DS, Stuart B (2012). "Systematic review of noncancer presentations with a median survival of 6 months or less". Am. J. Med. 125 (5): 512.e1–6. doi:10.1016/j.amjmed.2011.07.028. PMID 22030293.
33. ↑ Askgaard G, Tolstrup JS, Gerds TA, Hamberg O, Zierau L, Kjær MS (2016). "Predictors of heavy drinking after liver transplantation for alcoholic liver disease in Denmark (1990-2013): a nationwide study with competing risks analyses". Scand. J. Gastroenterol. 51 (2): 225–35. doi:10.3109/00365521.2015.1067903. PMID 26161590.
34. ↑ Merion RM (2004). "When is a patient too well and when is a patient too sick for a liver transplant?". Liver Transpl. 10 (10 Suppl 2): S69–73. doi:10.1002/lt.20265. PMID 15382215.
35. ↑ Abt PL, Desai NM, Crawford MD, Forman LM, Markmann JW, Olthoff KM, Markmann JF (2004). "Survival following liver transplantation from non-heart-beating donors". Ann. Surg. 239 (1): 87–92. doi:10.1097/01.sla.0000103063.82181.2c. PMC 1356197. PMID 14685105.
36. ↑ Roberts MS, Angus DC, Bryce CL, Valenta Z, Weissfeld L (2004). "Survival after liver transplantation in the United States: a disease-specific analysis of the UNOS database". Liver Transpl. 10 (7): 886–97. doi:10.1002/lt.20137. PMID 15237373.
37. ↑ Liermann Garcia RF, Evangelista Garcia C, McMaster P, Neuberger J (2001). "Transplantation for primary biliary cirrhosis: retrospective analysis of 400 patients in a single center". Hepatology (Baltimore, Md.). 33 (1): 22–7. doi:10.1053/jhep.2001.20894. PMID 11124816. Retrieved 2012-09-06.CS1 maint: Multiple names: authors list (link)
38. ↑ McCormick PA, Dick R, Burroughs AK (1994). "Review article: the transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of portal hypertension". Aliment. Pharmacol. Ther. 8 (3): 273–82. PMID 7918921.
39. ↑ Loffroy R, Estivalet L, Cherblanc V, Favelier S, Pottecher P, Hamza S, Minello A, Hillon P, Thouant P, Lefevre PH, Krausé D, Cercueil JP (2013). "Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage". World J. Gastroenterol. 19 (37): 6131–43. doi:10.3748/wjg.v19.i37.6131. PMC 3787342. PMID 24115809.
40. ↑ 40.0 40.1 40.2 40.3 Boyer TD, Haskal ZJ (2005). "The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension". Hepatology (Baltimore, Md.). 41 (2): 386–400. doi:10.1002/hep.20559. PMID 15660434. Retrieved 2012-09-06.
41. ↑ 41.0 41.1 41.2 Freedman AM, Sanyal AJ, Tisnado J, Cole PE, Shiffman ML, Luketic VA, Purdum PP, Darcy MD, Posner MP (1993). "Complications of transjugular intrahepatic portosystemic shunt: a comprehensive review". Radiographics : a Review Publication of the Radiological Society of North America, Inc. 13 (6): 1185–210. PMID 8290720. Retrieved 2012-09-06.CS1 maint: Multiple names: authors list (link)
42. ↑ Senanayake SM, Niriella MA, Weerasinghe SK, Kasturiratne A, de Alwis JP, de Silva AP, Dassanayake AS, de Silva HJ (2012). "Survival of patients with alcoholic and cryptogenic cirrhosis without liver transplantation: a single center retrospective study". BMC Res Notes. 5: 663. doi:10.1186/1756-0500-5-663. PMC 3543705. PMID 23198995.
43. ↑ 43.0 43.1 Colombato L (2007). "The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension". Journal of Clinical Gastroenterology. 41 Suppl 3: S344–51. doi:10.1097/MCG.0b013e318157e500. PMID 17975487. Retrieved 2012-09-06.

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