Elective Surgery but not Transjugular Intrahepatic Portosystemic Shunt Precipitates Acute‐On‐Chronic Liver Failure

Abstract

Acute-on-chronic liver failure (ACLF) is a syndrome associated with organ failure and high short-term mortality. Presence of ACLF at interventions, such as surgery or transjugular intrahepatic portosystemic shunt (TIPS), has been shown to determine outcome, but those interventions have also been attributed to precipitate ACLF in different studies. However, dedicated investigation for the risk of ACLF development in these interventions, especially in elective settings, has not been conducted. Patients with cirrhosis undergoing elective surgery were propensity score matched and compared to patients receiving TIPS. The primary endpoint was ACLF development within 28 days after the respective procedure. The secondary endpoint was 3-month and 1-year mortality. In total, 190 patients were included. Within 28 days, ACLF developed in 24% of the surgery and 3% of the TIPS cohorts, with the highest ACLF incidence between 3 and 8 days. By day 28 after the procedure, ACLF improved in the TIPS cohort. In both cohorts, patients developing ACLF within 28 days after surgery or TIPS placement showed significantly worse survival than patients without ACLF development at follow-up. After 12 months, mortality was significantly higher in the surgery cohort compared to the TIPS cohort (40% vs. 23%, respectively; P = 0.031). Regression analysis showed a European Foundation Chronic Liver Failure Consortium acute decompensation (CLIF-C AD) score ≥50 and surgical procedure as independent predictors of ACLF development. CLIF-C AD score ≥50, C-reactive protein, and ACLF development within 28 days independently predicted 1-year mortality. Conclusion: Elective surgical interventions in patients with cirrhosis precipitate ACLF development and ultimately death, but TIPS plays a negligible role in the development of ACLF. Elective surgery in patients with CLIF-C AD ≥50 should be avoided, while the window of opportunity would be CLIF-C AD <50. (Hepatology Communications 2021;0:1-13).C irrhosis is the common end stage of chronic liver disease. Unstable clinical courses of disease may occur after the development of acute decompensation (AD). However, AD can progress to acute-on-chronic liver failure (ACLF), a specific syndrome characterized by the development of organ

Preoperative TIPS prevents the development of postoperative acute-on-chronic liver failure in patients with high CLIF-C AD score

“…An observational multicenter study suggested that placement of TIPS in patients with ACLF and acute variceal bleeding improves survival and rebleeding rates [13]. In the context of surgery, our group could show a negligible precipitating effect of TIPS placement for the development of ACLF compared to surgical interventions [14].…”

“… 13 In the context of surgery, our group could show a negligible precipitating effect of TIPS placement for the development of ACLF compared with surgical interventions. 14 …”

Extrahepatic Surgery in Cirrhosis Significantly Increases Portal Pressure in Preclinical Animal Models

“…Even though there has been substantial progress in the fields of hepatology and surgery in managing patients with cirrhosis, surgery-associated AD and mortality remains high and correlates with severity of liver disease (Friedman, 2010 ; de Goede et al, 2012 ). Recently, the role of surgery as a precipitating event for ACLF development has been characterized, resulting in high rates of ACLF development even after electively performed surgical procedures (Klein et al, 2020 ; Chang et al, 2021 ). Therefore, in many hospitals, with the presence of cirrhosis especially in advanced stages is considered a contraindication for all kinds of surgery.…”

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“…In previous studies, our group showed that about 25% of patients with cirrhosis develop postoperative ACLF, including emergency surgery (Klein et al, 2020). Similar rates of post-operative ACLF are demonstrated even in elective surgical procedures, thus establishing surgical procedures as a precipitant of ACLF (Chang et al, 2021). In clinical practice, Child-Turcotte-Pugh-Score is commonly used for pre-operative risk stratification.…”

“…Even though there has been substantial progress in the fields of hepatology and surgery in managing patients with cirrhosis, surgery-associated AD and mortality remains high and correlates with severity of liver disease (Friedman, 2010;de Goede et al, 2012). Recently, the role of surgery as a precipitating event for ACLF development has been characterized, resulting in high rates of ACLF development even after electively performed surgical procedures (Klein et al, 2020;Chang et al, 2021). Therefore, in many hospitals, with the presence of cirrhosis especially in advanced stages is considered a contraindication for all kinds of surgery.…”