Background and Aim:
Transjugular Intrahepatic Portosystemic Shunt (TIPS) is a procedure that is used to treat complications of portal hypertension such as variceal hemorrhage, refractory ascites, and hydrothorax. The safety and benefits of TIPS are controversial in patients with underlying hepatic encephalopathy (HE).
Methods:
We utilized the national readmissions database from 2010-2015 (ICD-9) to identify all patients with cirrhosis who underwent TIPS procedure for esophageal variceal bleeding. Subsequently, the study cohort was stratified into two groups based on the presence or absence of HE. We excluded patients with hepatocellular carcinoma (HCC), and those currently listed for or had undergone liver transplant. The impact of HE on TIPS outcomes was assessed through a multivariate model adjusted for age, gender, etiology of liver disease, comorbidities, and hepatic decompensatory events.
Results:
here were 6572 TIPS procedures related hospital admissions between 2010-2015. Of these, 1900 also had HE. The mean age was higher in the HE group (57.4 ± 11.4 vs. 56.0 ± 10.7, <0.001) as compared to the non-HE group. Alcohol liver disease was more prevalent in HE group, while hepatitis B and C were more commonly observed in the non-HE. Diabetes mellitus was more prevalent in the HE. Multivariable analysis showed that individuals with HE who underwent TIPS for variceal bleeding had higher mortality (OR: 1.61, 95% CI: 1.13 – 2.29, p=0.008) as compared to those without HE. Furthermore, the HE group had longer hospital stay (β: 4.03, 95% CI: 3.10 – 4.96, p<0.001), and higher hospitalization cost (β: 50,019, 95% CI: 36,780 – 63,258, p<0.001) as compared to the non-HE group (Table 1). However, the 30-day readmission rates were similar between HE and non-HE groups (Figure 1). In HE patients who underwent TIPS for variceal bleeding, mortality rates, and 30-day readmission rates remained unchanged from 2010 to 2015.
Conclusion:
Patients with HE at the time of TIPS placement had higher mortality rates and higher utilization of hospital resources compared to those without HE. Therefore, we suggest the implementation of risk stratification for patients with HE before consideration of TIPS placement.

Table 1: Primary outcomes in patients with HE who underwent TIPS procedures

Figure 1: Kaplan-Meier curve showing the 30 days readmission rate in patients with and without HE

Syed Hamaad Rahman

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