Introduction of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) service for refractory ascites in a non-transplant liver unit
Introduction TIPSS has been shown to be an effective treatment for patients with refractory ascites (RA).The majority of TIPSS procedures in the UK are performed in a transplant centre. In 2009, Derby Teaching Hospitals introduced TIPSS service. The aim of our study was to evaluate our experience and assess its impact on the care of this patient group. Methods 56 successful TIPSS procedures were performed between May 2009 and August 2015, 32 for RA were included in this analysis.Data on patient demographics, aetiology of liver disease, inpatient bed days (6 months before and after the procedure), Model for End-Stage Liver Disease (MELD) scores, Child-Pugh score, procedure details, clinical outcomes, mortality and complications were collected retrospectively from our centres clinical results database.Complete response was defined as no further need for paracentesis and partial if frequency reduced to >50%. Results 25/32 (78%) patients were male with a median age of 58 years (range, 39-77 years). 30 patients were Child-Pugh class B, 2 Child-Pugh C, with a median MELD and MELD Na of 11 (range, 6-16) and 14 (range, 6-22) respectively. Alcoholic Liver Disease was most common aetiology of cirrhosis (86.5%) followed by non-alcoholic fatty liver disease (6.45%). Pre-TIPSS and post-TIPSS hepatic venous pressure gradients (HVPG) were 20 mmHg (range, 10-30) and 8 mmHg (range, 1-21) respectively. Cumulative mortality at 1, 3, and 12 months was 3%, 9%,and 18% (n = 28) respectively. One early death (within 30 days) was secondary to pneumonia. Ascites resolved completely after the first procedure in 66% and partially in 6% of patients.Cummulative response rate was 24, 62 and 90 percent at 30,60 and 90 days respectively. Five patients (16%) showed no improvement in RA, of whom 2 underwent liver transplantation. 9 patients (28%) developed hepatic encephalopathy (HE), 5 of whom (16%) developed refractory HE, with 3 patients requiring TIPSS reduction. The number of inpatient days reduced from 23 (range, 4-52) days in the 6 months pre-TIPSS to 8 (range 0-48) in the 6 months post TIPSS. The main reason for hospital admission was elective admission for ascites drainage. Conclusion A safe and effective TIPSS service for patients with refractory ascites can be successfully introduced into a comprehensive secondary care liver service by careful patient selection and technical proficiency. Excellent outcomes with acceptable complication rates can be achieved for patients with a significant reduction in resource utilisation (inpatient bed days and paracentesis). An established elective service is an important precursor for the provision of early and rescue TIPSS for variceal bleeding.