Neoadjuvant transjugular intrahepatic portosystemic shunt: A solution for extrahepatic abdominal operation in cirrhotic patients with severe portal hypertension

BACKGROUND: Major abdominal surgery, although technically feasible per se, can be contraindicated in some cirrhotic patients because of severe portal hypertension. The present study reports our experience of seven such patien ts who were prepared for major abdominal surgery by transjugular intrahepat ic portosystemic shunt (TIPS). STUDY DESIGN: There were seven cirrhotic patients (six men and one woman ag ed 47 to 69 years) with portal hypertension. Portal hypertension was consid ered severe because of the presence of at least: one of the following: hist ory of variceal bleeding (five of seven patients), varices at risk of bleed ing (red signs or cardial location of varices; four of seven patients), or intractable ascites (three of seven patients). The planned operations inclu ded colon, gastroesophageal, kidney and aortic procedures in three, two, on e, and one patient, respectively. Because portal hypertension was the leadi ng cause of surgical contraindication, the following "two-step strategy" wa s applied to the seven patients: first, TIPS to control portal hypertension , followed, after a delay of at least 1 month, by abdominal surgery. RESULTS: The TIPS procedure was successfully performed in all patients with out complications. The hepatic venous pressure gradient decreased from 18 /- 5 to 9 +/- 5 mmHg (p < 0.01). All patients were operated on with a delay ranging from 1 month to 5 months after TIPS (2.9 +/- 1.3 months; median 3 months). The planned operation was performed in six of the seven patients. One patient with cancer of the cardia did nor have resection because of ext ensive abdominal spreading of the tumor. Intraoperative transfusion was nec esssry in only two patients. Operative mortality occurred in one patient, 3 6 days after resection of a left colon cancer. CONCLUSIONS: The minimally invasive nature of TIPS allows us to propose the following two-step management of cirrhotic patients with severe portal hyp ertension needing abdominal surgery: decompression of the portal system by TIPS followed by elective surgery. (J Am Coll Surg 200 1;193: 46-51. (C) 20 01 by the American College of Surgeons).