Abstract No. 375 Hepatobiliary Infection After Transjugular Intrahepatic Portosystemic Shunt Creation in Patients with Prior Biliary Intervention: A Multi-Institution Retrospective Study

Prior biliary intervention is a known risk factor for hepatobiliary infection after liver tumor ablation and embolization, presumably because of colonization of the biliary system by enteric organisms. The purpose of this study was to determine whether prior biliary intervention also increases the risk of infection after transjugular intrahepatic portosystemic shunt (TIPS) creation. This multi-institution retrospective study analyzed patients undergoing TIPS creation who had prior biliary interventions (bilioenteric anastomoses, sphincterotomies, internal plastic or metal stents, or percutaneous biliary drains). Medical records were reviewed to identify post-TIPS hepatobiliary infections (endoTIPSitis, liver abscesses, or cholangitis). Among 1083 TIPS performed at 3 tertiary care medical centers, 38 patients (mean age, 55, n=26 males) had prior biliary interventions, including bilioenteric anastomoses (n=9), sphincterotomies (n=21), internal plastic stents (n=13), internal metal stents (n=2), and percutaneous biliary drains (n=2). Biliary intervention occurred a median of 427 days prior to TIPS creation (n=23 for ascites; n=13 for varices; n=4 for portal vein thrombosis). Six patients developed hepatobiliary infections, including endoTIPSitis (n=4), liver abscesses (n=2), and cholangitis (n=1), a median of 17.5 days after TIPS. All patients required hospitalization (median 16.5 total and 3.5 ICU days). Two patients died from hepatobiliary infection, two had resolution only after liver transplant, and one required life-long suppressive intravenous antibiotics. The incidence of hepatobiliary infection at 30 days, treating death and liver transplant as competing risks, was 13.4% (95% CI=5.8-26.5%). Neither intraprocedural (p=0.48) nor post-TIPS prophylactic antibiotics (p=0.99) reduced infection risk. Bilioenteric anastomoses were associated with higher infection risk compared to other types of biliary intervention (HR=6.1, p=0.01). Prior hepatobiliary intervention may increase the risk of serious hepatobiliary infection after TIPS creation. This risk may impact the decision to offer elective TIPS to patients with primary sclerosing cholangitis, secondary biliary cirrhosis, liver transplant with bilioenteric anastomosis, or other conditions in which there may be coexisting biliary system colonization and portal hypertension.