Editorial: TIPSS in patients with cirrhosis and hepatocellular carcinoma

Hepatocellular carcinoma (HCC) complicating cirrhosis occurs more frequently as cirrhosis becomes advanced and therefore HCC often co-exists with significant liver dysfunction and portal hypertension. In the widely accepted Barcelona-Clinic Liver Cancer (BCLC) staging system patients with very advanced liver disease (i.e. Child–Pugh stage C) have the worst outlook.1 Indeed, in the early natural history studies in HCC, a significant proportion of deaths were due to complications of portal hypertension.2 The presence of HCC, and in particular a central lesion, is considered a relative contra-indication to TIPSS though there is little evidence to indicate poor outcomes in this patient group.3 To explore this issue further, Bettinger et al. report their experience of TIPSS in 40 patients with HCC and symptomatic portal hypertension.4 This report, from a centre with extensive experience of TIPSS, highlights several issues with regard to indications, patient selection, and outcomes for patients with HCC. First, patient selection was strict: only 15% of patients with HCC and symptomatic portal hypertension were selected for TIPSS. The indications for TIPSS were most frequently refractory ascites and varices though only 10% were for acute, uncontrolled variceal haemorrhage. Although the broad criteria for selection were specified factors considered to be absolute contraindications were not reported and perhaps surprisingly some patients with malignant portal venous involvement were treated with TIPSS. Second, the clinical outcomes after TIPSS were acceptable, with technical success and complications similar to published data, despite most patients having bare metal TIPSS and the presence of portal vein thrombosis. However, without stratification by BCLC stage it is difficult to determine how these patients have survived in comparison to their peers. TIPSS may therefore have a role in the management of patients with HCC and symptomatic portal hypertension in selected cases and in experienced centres. The use of TIPSS here appears to have been largely palliative, successfully providing control of portal hypertension and symptoms, and on occasion allowing the use of selective chemoembolization. Any benefit in terms of survival, however, could only be inferred from further comparative studies. Declaration of personal interests: None. Declaration of funding interests: D. Tripathi received speaker fees from Gore Medical.