Professor El-Omar has chosen Dr Dhiraj Tripathi, Consultant Hepatologist from the Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, and Dr David Patch, Consultant Hepatologist from the Royal Free Sheila Sherlock Liver Centre, UCL Institute for Liver and Digestive Health, London, to do the next #GUTBlog. The blog focusses on the guidelines on transjugular intrahepatic portosystemic stent-shunt (TIPSS) in the management of portal hypertension published in Gut in February 2020.
“Since the introduction of TIPSS in normal clinical practice in the late 1980s, there has been increased awareness of the procedure. Although the basic principles remain, there have been important technical developments and expansion beyond the traditional indications of variceal bleeding and refractory ascites. Our aim with this BSG guideline is to provide referring health care professionals with sufficient knowledge to facilitate appropriate referrals, not just whether to refer but also when notto refer. This multidisciplinary guideline has been kindly endorsed by British Society for the Study of the Liver (BASL) and British Society of Interventional Radiology (BSIR).
We set out to produce a clear guideline, which should be up to date and comprehensive, but also concise and provide “at a glance” advice. This is a guideline for multidisciplinary teams involved in the patient pathway from initial assessment and referral to implantation of TIPSS and follow up. We considered 4 questions that such a multidisciplinary team may ask.
- When is a TIPSS needed and how effective is it?
The guideline starts with indications for TIPSS. Variceal bleeding you would think is done and dusted. However, the concept of “early TIPSS” or pre-emptive TIPSS in selected high risk patients remains controversial, and also has significant resource implications. This was a challenging area to cover owing to emergent data which has raised several questions regarding patient selection and efficacy. This led to much debate in the group, but we reached a consensus and also accepted further study was required. With ascites there was discussion on patient selection and the importance of considering liver transplantation for all eligible patients. Emergent indications include TIPSS in portal vein thrombosis, prophylactic TIPSS prior to non-hepatic surgery, INCPH and Budd Chiari Syndrome. These are more niche but we wanted to provide some advice, albeit based on low level evidence.
- I have decided that a TIPSS may be indicated, but is my patient really a suitable candidate?
Careful patient selection can reduce the risk of complications, such as hepatic encephalopathy. We recommend at least two tests to screen for covert and overt hepatic encephalopathy. Cardiac function also comes under scrutiny. Recent evidence supports the use of biomarkers such as NT-proBNP in addition to traditional clinical assessment to assess for presence of severe left ventricular dysfunction and pulmonary hypertension. We advise against TIPSS in established chronic kidney disease. Nutritional assessment is important, but for patients with refractory ascites, the potential of TIPSS to improve nutritional parameters should be balanced against the increased risk of hepatic encephalopathy in sarcopenia prior to TIPSS.
- What are the nuts and bolts of performing a TIPSS?”
We did not set out to describe in detail the TIPSS procedure, as the procedure is well established. We make recommendations in preparation for TIPSS and key aspects of the TIPSS procedure. PTFE covered stents have superseded bare stents due to superior patency and clinical efficacy. We advise caution in significant reduction in portal pressure following elective TIPSS due to the risk of hepatic encephalopathy.
- What do I need to know to set up a TIPSS service?
Service development is particularly topical at present since commissioning for TIPSS is an important area for the NHS. Most units perform 11-20 procedures per year, and we advise that units should perform at least 10 procedures per year or 20 or more procedures per year to undertake complex cases such as portal or hepatic vein thrombosis and transplant recipients. Harmonisation of key disciplines (interventional radiology, hepatology, intensive care, and anaesthesia) is essential for units to offer emergency TIPSS.
As with any aspect of clinical medicine there are areas that require further study. We highlight these in the research recommendations. Areas covered include early TIPSS, secondary prevention against variceal rebleeding, hepatorenal syndrome, prophylactic TIPSS, ectopic varices and hydrothorax. We also believe further study is required on the role of nutritional and cardiac evaluation. Although large RCTs remain the gold standard, high quality registries can also provide valuable long-term data to answer some of these questions and for the purposes of service evaluation and development.”
Dr Dhiraj Tripathi (@dtrip2015)
Dr David Patch (@DavidPatch1)