Published online Feb 7, 2021. doi: 10.3748/wjg.v27.i5.416
Peer-review started: November 23, 2020
First decision: December 17, 2020
Revised: December 20, 2020
Accepted: January 15, 2021
Article in press: January 15, 2021
Published online: February 7, 2021
Processing time: 66 Days and 20.3 Hours
Transjugular intrahepatic portosystemic shunt (TIPS) is a technique for the treatment of portal hypertension-related complications such as esophageal variceal bleeding and refractory ascites by establishing shunt channels in the hepatic parenchyma between the hepatic vein and the portal vein. It can also be used as a bridging therapy for decompensated patients with cirrhosis and other patients waiting for liver transplantation. However, the high incidence of postoperative hepatic encephalopathy (HE) seriously affects the prognosis and survival of patients, and it is particularly important to find accurate methods to predict post-TIPS HE. Some studies have shown that the clearance rate of indocyanine green before operation has good predictive value for the prognosis of patients undergoing hepatectomy. We hypothesized that indocyanine green retention rate at 15 min (ICG-R15) may can predict postoperative HE after TIPS (post-TIPS HE); therefore, prevention and treatment can be implemented in high-risk HE patients to avoid adverse outcomes.
TIPS is currently used in the management of complications of portal hypertension. However, the incidence of HE remains an issue in TIPS placement and affects patient quality of life and long-term outcomes. The preoperative ICG-R15 has been developed as a prognostic indicator in patients undergoing surgery, but there are limited data on its role in TIPS. The purpose of this study was to explore whether ICG-R15 can be used as a predictor of post-TIPS HE and compared the clinical value of the ICG-R15, Child-Pugh score (CPS), and model for end-stage liver disease (MELD) score for the prediction of post-TIPS HE in decompensated cirrhosis patients with portal hypertension (PHT).
The aim of this study was to explore whether ICG-R15 can be used as a predictor of post-TIPS HE and compared the clinical value of the ICG-R15, CPS, and MELD score for the prediction of post-TIPS HE in decompensated cirrhosis patients with PHT. According to the ICG-R15 value, appropriate and timely intervention can be implemented in patients with high-risk HE patients.
We conducted a prospective study of 195 patients with PHT who underwent elective TIPS. All patients underwent the ICG-R15 test, CPS evaluation, and MELD scoring. According to whether they developed HE or not, the patients were divided into two groups: HE group and non-HE group. Descriptive data are presented as the mean ± SD, and qualitative variables are presented as frequencies or percentages. Student's t test or the Mann-Whitney U test was utilized to compare quantitative variables between groups, and the chi-square test or Fisher's exact test was used for qualitative variables. Univariate and multivariable logistic regression analyses were used to determine HE-related risk factors after TIPS. The prediction of one-year post-TIPS HE by ICG-R15, CPS, and MELD score was evaluated by the areas under the receiver operating characteristic curves (AUCs). Pairwise comparison of AUCs in three different function tools was analysed.
A total of 195 patients with PHT were included and 23% (45/195) of the patients developed post-TIPS HE. The ICG-R15 was identified as an independent predictor of post-TIPS HE. The AUCs for the ICG-R15, CPS, and MELD score for predicting post-TIPS HE were 0.664 (95% confidence interval [CI]: 0.557-0.743, P = 0.0046), 0.596 (95%CI: 0.508-0.679, P = 0.087), and 0.641 (95%CI: 0.554-0.721, P = 0.021), respectively. Molodianovitch et al[17] showed that there was statistical significance in pairwise comparison between AUCs of ICG-R15 and MELD score (P = 0.0229).
TIPS for PHT in patients with cirrhosis should be considered after careful selection based on patient characteristics and liver function. The ICG-R15 has appreciated clinical value for predicting the occurrence of post-TIPS HE and is a choice for evaluating the prognosis of patients undergoing TIPS.
We can learn from this study that monitoring patients who underwent TIPS with an ICG-R15 value above 30% can better prevent adverse outcomes. Future studies will focus on the incidence of complications and survival in terms of the value of ICG-R15 and randomized controlled trials are needed in order to verify our results.