Percutaneous Transsplenic Balloon-Assisted Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Portal Vein Obliteration for Portal Vein Recanalization: Feasibility, Safety and Effectiveness

Purpose To assess the feasibility, safety and effectiveness of portal vein recanalization (PVR)–transjugular portosystemic shunt (TIPS) placement via splenic access using a balloon puncture technique. Materials and Methods In a single-center retrospective study from March 2017 to February 2021, 14 consecutive patients with portal hypertension, chronic liver disease and portal vein occlusion or near-complete (> 95%) occlusion were referred for PVR–TIPS placement. Feasibility, safety and effectiveness including procedural characteristics such as technical success, complication profile and splenic access time (SAT), balloon positioning time (BPT), conventional portal vein entry time (CPVET), overall procedure time (OPT), fluoroscopy time (FT), dose–area product (DAP) and air kerma (AK) were evaluated. Results Transsplenic PVR–TIPS using balloon puncture technique was technically feasible in 12 of 14 patients (8 men, 49 ± 13 years). In two patients without detectable intrahepatic portal vein branches, TIPS placement was not feasible and both patients were referred for further treatment with nonselective beta blockers and endoscopic variceal ligation. No complications grade > 3 of the Cardiovascular and Interventional Radiological Society of Europe classification system occurred. The SAT was 25 ± 21 min, CPVET was 33 ± 26 min, the OPT was 158 ± 54 min, the FT was 42 ± 22 min, the DAP was 167.84 ± 129.23 Gy*cm2 and the AK was 1150.70 ± 910.73 mGy. Conclusions Transsplenic PVR–TIPS using a balloon puncture technique is feasible and appears to be safe in our series of patients with obliteration of the portal vein. It expands the interventional options in patients with chronic PVT.

After A Year of Follow Up Non-Cirrhotic Portal Hypertension Patient with Partial Spleen Embolization (PSE) Management

Non-cirrhotic portal hypertension (NCPH) is a heterogeneous group of liver disorders leading to portal hypertension. There are multiple approaches to managing portal hypertension' clinical complications to treat/prevent spontaneous hemorrhage by mitigating thrombocytopenia. Portal hypertension complications have been traditionally managed with serial endoscopic variceal ligation (EVL) or with invasive open surgical procedures such as orthotopic liver transplantation (OLT) or portosystemic shunting, splenectomy.6–9 There are several risks associated with splenectomies, such as hemorrhagic complications or intraoperative blood loss.5,6,14 Partial Spleen Embolization (PSE) ‎may overcome the limitations of splenectomy and provide patients with an alternative treatment. An eighteen-year-old male has a splenomegaly history since he was 12 years old and has recurring hematemesis and melena. After performing abdominal computed tomography, laboratory studies, and several endoscopies, the results indicated secondary hypersplenism due to non-cirrhotic portal hypertension. The patient had 13 endoscopies and 2 EVL in 5 years. Despite adequate treatment, the patients developed recurrent variceal bleeding and no improvement in blood function. The patient underwent PSE at Integrated Cardiovascular Center in Dr. Cipto Mangunkusumo, General Hospital, Jakarta, Indonesia. It was performed through the femoral access with a PVA (polyvinyl alcohol) embolus. The procedure went successful, and there was no major complication with the patient. Twenty days after the patient had an abdominal CT scan, it showed no abscess, and the spleen volume was reduced by 20%. Long-term results over a year after the procedure are presented. PSE is a safe, effective, semi-invasive alternative to splenectomy in non-cirrhotic portal hypertension because it preserves functional spleen mass and avoids postprocedure accelerated liver disease or encephalopathy.

Assessment of Non-invasive Markers for the Prediction of Esophageal Variceal Hemorrhage

Background: Esophageal variceal (EV) hemorrhage is a life-threatening consequence of portal hypertension in cirrhotic patients. Screening upper endoscopy and endoscopic variceal ligation to identify and treat EVs have contraindications, complications, and high costs. We sought to identify non-invasive tests (NITs) as alternatives to endoscopic EV screening.Methods: In this case-control study, we retrospectively analyzed 286 cirrhotic patients treated for EVs at the Second People's Hospital of Fuyang City, China from January to December 2019. We applied ROC curve analysis to assess the accuracy of various NITs in predicting EV hemorrhage.Results: There were significant differences between the hemorrhage and non-hemorrhage groups in median serum albumin (ALB) (p < 0.001), median bilirubin (TBIL) (p < 0.046), prothrombin (PT) time (p < 0.001), Golgi protein 73 (GP73; p = 0.012) and Child-Pugh (C-P) scores (p < 0.001). For ALB (cutoff <33.2g/L), PT time (cutoff > 14.2 seconds), GP73 (cutoff > 126.4 ng/ml), and C-P scores, the areas under the ROC curves (AUCs) were 73.4% (95% CI: 67.5–79.2), 68.6% (95% CI: 62.4–74.8), 62.2% (95% CI: 52.8–71.5) and 69.8% (95%CI: 63.8–75.8), respectively, with corresponding sensitives of 71.5, 59.8, 69.8, and 92.2% and specificities of 65.6%, 70.1%, 56.5%, and 38.6%. When ALB was combined with GP73, the AUC was 74.3% (95% CI: 66.1–82.5) with a sensitivity of 65.1% and specificity of 76.5%. When ALB, PT, and C-P scores were combined, the AUC was 76.5% (95% CI: 70.9–82.1) with a sensitivity of 79.5% and specificity of 64.3%. When ALB, PT, GP73, and C-P scores were combined, the AUC was 75.2% (95% CI: 67.3–83.1) with a sensitivity of 54.0% and specificity of 86.9%.Conclusion: ALB, TBIL, GP73, and C-P scores, may be used to predict EV hemorrhage in cirrhotic patients. The combination of multiple NITs is better than a single index and can increase diagnostic performance.

Practice Guidelines of the Central European Hepatologic Collaboration (CEHC) on the Use of Thrombopoietin Receptor Agonists in Patients with Chronic Liver Disease Undergoing Invasive Procedures

Background: Second-generation thrombopoietin receptor agonists (TPO-RAs) are emerging as the new standard for managing thrombocytopenia (TCP) in patients with chronic liver diseases (CLDs) undergoing scheduled procedures. However, practical guidance for their routine use in CLD patients undergoing specific invasive procedures is lacking. Methods: These practice guidelines were developed by the Initiative Group for Central European Hepatologic Collaboration (CEHC), composed of nine hepatologist/gastroenterologist experts from Central Europe. Using an adapted Delphi process, the CEHC group selected ten invasive procedures most relevant to the hepatology/gastroenterology setting in the region. Consensus recommendations for each invasive procedure are reported as a final percentage of expert panel responses. Results: A consensus was agreed that TPO-RAs should be considered for raising platelet count in CLD patients undergoing scheduled abdominal surgery, high-bleeding risk dentistry, endoscopic polypectomy, endoscopic variceal ligation, liver biopsy, liver surgery, liver transplantation and percutaneous ablation, but it was also agreed that they are less beneficial or not necessary for endoscopy without intervention and paracentesis. Conclusions: Using a modified Delphi method, experts reached an agreement for TCP management in CLD patients undergoing ten invasive procedures. These practice guidelines may help with decision making and patient management in areas where clinical evidence is absent or limited.

Positive white nipple sign on esophageal varices: Not a just bystander; our experience

Background and study aims The goal of this study was to assess whether a white nipple sign on esophageal varices is of no prognostic significance or mandates more attention. Patients and methods We retrospectively analyzed data from 2601 patients undergoing upper gastrointestinal endoscopy for variceal bleed from January 2008 to January 2020. Intraprocedural events like onset of active spurt while performing endoscopy, active spurt while attempting to band the varix with a nipple, need for rescue glue therapy required to control bleed in cases of failed endoscopic variceal ligation (EVL), slipping of band and rebleed despite successful band application, need for emergency intubation, and pulmonary aspiration-related complications were noted. Results A total of 2601 patients underwent endoscopy for variceal bleeding. Of them, 631 had a positive white nipple sign. Of that subgroup, 137 (21.7 %) patients developed active spurt during endoscopy. In patients with the white nipple sign, 12.3 % required endotracheal intubation and 6.7 % developed aspiration pneumonia, which were significantly higher than in those without the sign. Rescue glue injection in esophageal varices was needed in 5.6 % as compared to 0.6 % in those without white nipple. Conclusions The white nipple sign is not only a predictor of recent bleed, but it carries statistically significant increased risk of intraoperative bleeding, need for endotracheal intubation, esophageal glue injections, and aspiration-related complications. Therefore, it is not just a bystander, but rather, a sign of increased danger and a need to be more vigilant with patient management.

Additional Benefits Conferred by Endoscopic Sclerotherapy to Liver Cirrhosis Patients Receiving Endoscopic Variceal Ligation

Objective. Gastroesophageal varices are a direct consequence of portal hypertension in cirrhosis. The management of gastroesophageal varices has evolved over the last decade resulting in reduced mortality and morbidity rates. The study was aimed to analyze the short-term and long-term efficacy of different endoscopic methods in the treatment of gastric varices in cirrhotic patients. Methods. From January 2016 to December 2019, 135 patients with liver cirrhosis and gastric varices undergoing different endoscopic treatment protocols were retrospectively analyzed. The patients were divided into three groups according to endoscopic variceal ligation, endoscopic sclerotherapy, and a combination of both, respectively. Main outcomes including the overall response rate, hemostasis, short- and long-term rebleeding (3 months before and after treatment), complication, blood pressure, heart rate, portal venous pressure (PVP), portal vein diameter (PVD), portal vein velocity (PVV), portal vein blood flow (PVF) detected by ultrasound, recurrence rate, and mortality were analyzed after treatments. Results. The overall response rate in the combined group was higher than that in the ligation group and the sclerotherapy group ( P < 0.05 ). The incidence rate of complications in the combined group and the ligation group was lower than that in the sclerotherapy group ( P < 0.05 ). After treatment, the PVP, PVD, and PVF were reduced in the combined group compared with the ligation group and the sclerotherapy group, while the PVV was not ( P < 0.05 ). Lower rates of long-term rebleeding, recurrence, and mortality were noted in the combined group compared to the ligation group and the sclerotherapy group ( P < 0.05 ). Conclusion. Endoscopic variceal ligation combined with endoscopic sclerotherapy is more effective than both alone in treating liver cirrhosis and gastric varices. The combined therapy contributed to reduced short-term and long-term rebleeding rate, decreased long-term recurrence rate, and mortality.

Endoscopic injection sclerotherapy improves liver function compared with endoscopic variceal ligation

Liver function is a most important prognostic factor in patients with liver cirrhosis. Also, portal hypertension is a fatal complication of liver cirrhosis and variceal treatment is indispensable. However, changes of liver functions after endoscopic variceal treatments are unknown. The aim of this study was to evaluate prognosis and liver functions after endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL). A total of liver cirrhotic 103 patients who underwent prophylactic EIS and EVL were enrolled. Overall survival rate was higher in EIS group than EVL group (p = 0.03). Multivariate analysis showed that EIS was a negative factor for death (HR: 0.46, 95% confidence interval: 0.24–0.88, p = 0.02). Liver functions were assessed by blood test taken at before and 3 months after treatment. In EIS group, albumin and prothrombin time improved (p < 0.01), leading to improvement of Child–Pugh score, ALBI score and MELD score (p < 0.05). However, these did not improve in EVL group. EIS was a significant factor related to the elevated value of albumin after treatment in linear regression analysis (estimated regression coefficient: 0.17, 95% confidence interval: 0.05–0.29, p = 0.005). These results revealed that EIS could improve liver functions and prognosis.