Table 3

Studies on pre-operative tips in cirrhosis patients

StudyPatients and surgery typesProcedure and study detailsFindings
Lahat et al83 2018 Systematic review19 studies—all retrospective
64 patients (largest series 18 patients)		Planned surgery for

  • Gastrointestinal cancer in 38 (59%) patients

  • Benign digestive/pelvic surgery in 21 (33%) patients

  • TIPS successful in all patients

  • Encephalopathy −4.7% (controlled in all cases with treatment)

  • All patients could be operated within a median delay of 30 days from TIPS (mortality rate: 8%)

    1-year survival—80%

Fares et al102 2018
Retrospective study (2005–2013)		28 patients included
Digestive (43%)
Liver resections (25%)
Abdominal wall surgery (21%) and
Interventional Gastrointestinal endoscopy (11%)		Primary endpoint:

  • Rate of failure (defined by inability to proceed to the planned intervention after TIPS placement or persistent decompensation 3 months after intervention)


Secondary endpoints:

  • Rate of complications

  • Parameters associated with failure

  • 1-year survival

  • Median time between TIPS and surgery—24 days

  • 1-year survival—70%

  • Procedure failure—6 (21%) patients

(4/6 patients with HCC: two because of tumour progression before surgery)

  • Persistent decompensation—2 patients

  • Hepatic surgery, history of encephalopathy and viral-related cirrhosis were associated with failure.

Tabchouri et al84 2019
Retrospective study (2005–2016)		66 patients (compared with no TIPS group n=68)Colorectal surgery performed in 54% patients
TIPS patients had higher CTP score, received more beta-blockers.
85% of patients in TIPS group underwent planned surgery

  • In TIPS group, 56 (85%) patients underwent planned surgery

  • Encephalopathy—15%

  • In TIPS and no-TIPS group, severe postoperative complications (18% vs 23%, p=0.392) and 90-day mortality (7.5% v 7.8%, p=0.64) were similar.

Goel et al82 2021
Retrospective study		Twenty-one patients undergoing prophylactic TIPS before non-hepatic surgery were identified.Primary outcome
Discharged patients without hepatic decompensation after the planned surgery.

  • TIPS successful in all patients.

  • 57% patients achieved primary outcome.

  • Reduction in portal pressure gradient from 21.5 (11–35) to 16 (7–25) mm Hg (p<0.001).

  • Post-TIPS complications in 7 (33%) patients with 4 patients experiencing encephalopathy

  • Post-TIPS portal pressure gradient was significantly higher in patients with adverse primary outcome.

  • 1, 6 and 12 months survival was 90%, 80% and 76%, respectively.

Chang et al103 2022
Retrospective study		In total, 926 patients (363 with cirrhosis undergoing surgery and 563 patients with TIPS) were included.Propensity score matching (1:1) of preoperative TIPS (TIPS group) with patients without preoperative TIPS (no-TIPS group).
Primary endpoint

  • Development of ACLF within 28 and 90 day after surgery


Secondary endpoint:

  • 1-year mortality

  • Patient in no-TIPS group had higher rates of ACLF within 28 days (29% v 9%; p=0.016) and 90 days (33% vs 13%; p=0.02) after surgery

  • 1-year mortality was also higher in the no TIPS group (38% vs 18%; p=0.023) in comparison to TIPS group.

  • Surgery without preoperative TIPS and CLIF-C AD score were independent predictors of mortality and ACLF development at 28 and 90 days.

  • CLIF-C AD score >45 was identified as a threshold for patients at risk of ACLF development in the postoperative period and will benefit from TIPS.

  • ACLF, acute-on-chronic liver failure; ASA, American Society of Anesthesiologist; CLIF-C AD, Chronic Liver Failure Consortium-Acute Decompensation score; CTP, Child-Turcotte-Pugh score; HCC, hepatocellular carcinoma; TIPS, Transjugular intrahepatic portosystemic shunt.