Letter to the Editor: Abdominal Surgery in Idiopathic Noncirrhotic Portal Hypertension: Is Preemptive TIPS Reducing Postoperative Complications?
Authors: Emanuele Felli, Antonio Saviano, Simona Tripon, Thomas F. Baumert, Patrick Pessaux
Journal: Hepatology (2019)

Supported by Fondation ARC pour la Recherche sur le Cancer (TheraHCC, TheraHCC2.0 IHUARC IHU201301187, and IHUARC2019 IHU201901299). Potential conflict of interest: Dr. Pessaux consults for Integra and owns stock in VirtualiSurg. To The Editor: We read with great interest the article by Elkrief et al. reporting long‐term outcomes of abdominal surgery in patients with idiopathic noncirrhotic portal hypertension (INCPH).1 In a subgroup analysis, the authors compared the outcome of patients who had (n = 33) or did not have (n = 10) a preemptive transjugular intrahepatic portosystemic shunt (TIPS), showing that TIPS before surgery had no significant impact on postoperative outcomes. This retrospective subgroup analysis had some limitations. The comparison of the clinical characteristics between the groups was performed on the data after TIPS placement, and the small sample size reduced the statistical power of the analysis. These data are still preliminary to draw any firm conclusion (as already discussed by the authors) but could potentially dissuade clinicians in using preemptive TIPS in this clinical context. INCPH is a rare disease, and it is unlikely that survival analysis of larger cohorts will be available in the immediate future. To help readers and to highlight the magnitude of the differences between the two groups, we reanalyzed the clinical and postoperative data reported by Elkrief et al. and calculated the effect size using logit computation of standardized mean differences. As indicated in Table 1, the two groups showed large differences, not only in beta‐blocker use but also in history of variceal bleeding, portal vein thrombosis, and portosystemic collaterals (higher in the TIPS group). Importantly, large differences were found in the occurrence of grade 3 or higher postoperative complications within 1 month after surgery (lower in the TIPS group). Thus, it cannot be excluded that patients who underwent decompression had more severe portal hypertension before TIPS positioning and that preemptive TIPS reduced the occurrence of severe postoperative complications and/or allowed the achievement of long‐term outcomes comparable to patients with less severe complications. The results need to be confirmed on larger, ideally prospective, cohorts and should not discourage the use of this technique in the care of preoperative patients. Moreover, preemptive TIPS could also be an important measure to increase surgical eligibility for complex operations by diminishing intraoperative bleeding and allowing a technically less demanding dissection.2 In patients undergoing splenectomy, a preemptive calibrated TIPS could reduce the incidence of portal vein thrombosis (postoperative rate of 50% in Elkrief et al.). Hence, even though conclusive data on the postoperative benefit of preemptive TIPS in these patients are still lacking, a potential benefit in the surgical feasibility and severe postoperative complications should be considered in the preoperative workup. Table 1 - Effect Size for the Comparison of the Patients With/Without Portal Decompression Before Surgery Variable Effect Size (Patient With Portal Decompression vs. Patient Without) Clinical Features Male 0.3822 Age 0.0204 Age‐adjusted Charlson Comorbidity Index 0.0669 ASA score 0.0579 At least one extrahepatic comorbidity associated with INCPH −0.2375 History of ascites 0.085 Ascites at surgery Absent −0.085 Controlled with diuretics 0.1611 Clinically detected −0.1192 Endoscopic Data Previous variceal bleeding 0.8493 Treatments Anticoagulation therapy 0.1684 Antiplatelet agents −0.3822 Diuretic agents 0.1586 Beta blockers −1.2448 Imaging Data Portal vein thrombosis 0.8023 Portosystemic collaterals at imaging 0.7977 Laboratory Data Platelets −0.1287 Hemoglobin −0.0096 INR 0.1019 Serum bilirubin 0.2177 Serum creatinine −0.0273 Serum albumin −0.0664 MELD score 0.056 Surgical Data Major surgery 0.2357 Minor surgery −0.2357 Emergency procedures 0.1611 Postoperative Outcomes Occurrence of ≥1 grade ≥3 postoperative complication within 1 month after surgery −0.5832 Occurrence of ≥ 1 portal hypertension–related complication within 3 months after surgery −0.2296 Death within 6 months after surgery 0.0581 Unfavorable outcome −0.0367 Effect size values <0.1 indicated very small differences; between 0.1 and 0.3 indicated small differences; between 0.3 and 0.5 indicated moderate differences; and >0.5 indicated large differences (values in bold). Effect size for continuous variables was calculated after estimation to mean and SD and log transformation (Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014;14:135).Abbreviations: ASA, American Society of Anesthesiologists; INR, international normalized ratio; MELD, Model for End‐Stage Liver Disease.