Transjugular Intrahepatic Portosystemic Shunt (TIPS) Extension for Transhepatic Mesocaval Shunt Creation: A Case Series for Treating Refractory Upper Gastrointestinal Bleeding in Patients with Chronic Portal Vein Thrombosis.

Transjugular intrahepatic portosystemic shunt (TIPS) is known to benefit patients with decompensated liver disease by alleviating portal pressure. However, TIPS creation is technically difficult and challenging to perform in patients with chronic portal vein thrombosis (PVT) (4,5). Multiple endovascular techniques for portal vein recanalization with or without creating portosystemic shunt are available to decompress and alleviate portal hypertension in patients with PVT. In this case series, we represent TIPS extension to create an endovascular mesocaval shunt for the treatment of refractory upper gastrointestinal bleeding.

Liver volumetry in cirrhotic patients with or without hepatocellular carcinoma: Its correlation with Child-Pugh, model for end-stage liver diseases and indocyanine green dye test.

BACKGROUND AND OBJECTIVES: To evaluate the correlation between non-tumoral liver volume (NTLV) by computed tomography (CT) volumetry and indocyanine green retention at 15 minutes (ICG-r15%), Child-Pugh score (CTP) and model for end-stage liver diseases (MELD) score in cirrhotic patients having hepatocellular carcinoma (HCC) (group A) and in cirrhotics without HCC (group B). METHODS: As many as 111 consecutive patients with liver cirrhosis, who underwent triple-phase CT abdomen, were retrospectively included in our study. They were classified into group A (cirrhosis with HCC, n = 69) and group B (cirrhosis only, n = 42). Segmental liver volume, tumor and NTLV were calculated using Myrian XP-Liver segmentation software. In group B, NTLV was the same as the total liver volume (TLV). The correlation of NTLV with ICG-r15%, CTP and MELD scores was analyzed using appropriate correlation tests for each group. RESULTS: NTLV had a good and significant negative correlation with ICG-r15% (ρ = - 512; p < 0.001) in group A, but not in group B. It also had a significant negative correlation with CTP (ρ = - 251; p = 0.038) and MELD (ρ = - 323; p = 0.007) scores only in group A. Furthermore, ICG-r15% had a good and significant positive correlation with CTP and MELD scores in both groups (p < 0.05). CONCLUSION: NTLV showed a significant negative correlation with ICG-r15% in cirrhotic patients with HCC, but not in cirrhotic patients without HCC. Therefore, CT volumetry can be a valuable tool to predict the functional hepatic volume in patients of cirrhosis with HCC subjected for hepatectomy, where a facility of ICG-r15% is not available. However, further studies are needed to validate our findings in cirrhotic only patients.

Predictors and Outcomes of Post-transjugular Intrahepatic Portosystemic Shunt Liver Failure in Patients with Cirrhosis.

BACKGROUND: Post-transjugular intrahepatic portosystemic shunt (TIPS) liver failure (PTLF) is a serious complication of TIPS procedure with poor patient prognosis. This study tried to investigate the incidence of PTLF following elective TIPS procedure and evaluated possible predictive factors for the same. METHODS: A retrospective analysis of patients who underwent elective TIPS placement between 2012 and 2022 and was conducted to determine development of PTLF (≥ 3-fold bilirubin and/or ≥ 2-fold INR elevation from the baseline) within 30 days following TIPS procedure. Medical record review was done and factors predicting development of PTLF and the 90-day transplant-free survival was determined. RESULTS: Thirty of 352 (8.5%) patients developed PTLF within 30 days of TIPS (mean age 54.2 ± 9.8 years, 83% male). The etiology of cirrhosis was related to non-alcoholic steatohepatitis (NASH) in 50%, alcohol in 33.3%, and hepatitis B/C virus infection in 16.7% of the patients. The mean Child-Turcotte-Pugh (CTP) score was 9.5 ± 1.2 and mean model for end stage liver disease (MELD) score was 14.6 ± 4.5 at the time of admission in patients who developed PTLF. The indication for TIPS was recurrent variceal bleed in 50% (15 of 30) and refractory ascites in 46.7% (14 of 30) patients with PTLF. Multivariate analysis identified prior HE (OR 6.1; CI 2.57-14.5, p < 0.0001) and higher baseline CTP score (OR 1.47; CI 1.07-2.04; p = 0.018) as predictors of PTLF. PTLF was associated with significantly lower 90-day transplant-free survival, as compared to patients without PTLF (40% versus 96%, p < 0.001). CONCLUSION: Almost 10% of patients with cirrhosis develop post-TIPS liver failure and is associated with significant early mortality and morbidity. Higher baseline CTP score and prior HE were identified as predictors for PTLF.

Role of Interventional Radiology (IR) in vascular emergencies among cirrhotic patients.

Gastrointestinal hemorrhage remains one of the most common causes of morbidity and mortality among patients with liver cirrhosis. Mostly, these patients bleed from the gastroesophageal varices. However, nonvariceal bleeding is also more likely to occur in these patients. Because of frequent co-existing coagulopathy, cirrhotics are more prone to bleed from a minor vascular injury while performing percutaneous interventions. Ultrasound-guided bedside vascular access is an essential procedure in liver critical care units. Transjugular portosystemic shunts (TIPS) with/without variceal embolization is a life-saving measure in patients with refractory variceal bleeding. Whenever feasible, balloon-assisted retrograde transvenous obliteration (BRTO) is an alternative to TIPS in managing gastric variceal bleeding, but without a risk of hepatic encephalopathy. In cases of failed or unfeasible endotherapy, transarterial embolization using various embolic agents remains the cornerstone therapy in patients with nonvariceal bleeding such as ruptured hepatocellular carcinoma, gastroduodenal ulcer bleeding, and procedure-related hemorrhagic complications. Among various embolic agents, N-butyl cyanoacrylate (NBCA) enables better vascular occlusion in cirrhotics, even in coagulopathy, making it a more suitable embolic agent in an expert hand. This article briefly entails the different interventional radiological procedures in vascular emergencies among patients with liver cirrhosis.

Real-Time Shear Wave Elastography for Determining the Ideal Site of Liver Biopsy in Diffuse Liver Disease.

Objectives The objective of the study was to identify accurate site of liver biopsy under ultrasound and elastography guidance and compare the shear wave elastography (SWE) and transient elastography (TE) diagnostic accuracy with histopathological correlation. Methods This was a prospective single-center study where patients scheduled for nonfocal liver biopsy were divided into two groups (group U: ultrasound; group E elastography) by sequential nonrandom selection of patients. Elastography was performed before the biopsy and biopsies from the maximum stiffness segment were taken. Results There was no significant difference of intersegmental liver stiffness with mean velocity; however, biopsy segment velocities show significant difference with mean liver stiffness suggestive of heterogenous distribution of fibrosis. The rho ( r ; Spearman's correlation) value between biopsy segments and mean velocities shows excellent correlation. The diagnostic performance of TE was good for fibrosis stages F2, F3, and F4, while SWE was fair for the diagnosis of fibrosis stages F1 and F2 and fairly equal for the diagnosis stages F2 and F3. Area under the curve (AUC) values in differentiating mild (F1) or no fibrosis from significant fibrosis (≥F2) were 95.5 with cutoff value of at least 1.94 m/s. Conclusions The diagnostic performance of SWE is comparable with TE in liver fibrosis staging and monitoring. Fibrosis is heterogeneously distributed in different segments of the right lobe liver. Therefore, elastography at the time of biopsy may help in defining the accurate site for biopsy and improve histopathological yield in detecting liver fibrosis in patients with chronic liver disease. Advances in Knowledge Elastography-guided biopsy is helpful to determine the ideal site of biopsy.

Comparison of Balloon-Occluded Thrombolysis with Catheter-Directed Thrombolysis in Patients of Budd-Chiari Syndrome with Occluded Direct Intrahepatic Portosystemic Shunt.

Objectives Direct intrahepatic portosystemic shunt (DIPS) stent placement is an effective treatment for patients with Budd-Chiari syndrome (BCS); however, thrombotic occlusion of DIPS stent remains a cause of concern. The purpose of this study is to describe a novel technique of balloon-occluded-thrombolysis (BOT) for occluded DIPS stent, and compare it with the conventional catheter-directed-thrombolysis (CDT). Methods In this retrospective study, the hospital database was searched for BCS patients who underwent DIPS revision for thrombotic stent occlusion between January 2015 and February 2021. Patients were divided into CDT group and BOT group. The groups were compared for technical success, total dose of thrombolytic agent administered, duration of hospital stay, and primary assisted stent patency rates at 1- and 6-month follow-up. Results CDT was performed in 12 patients, whereas 21 patients underwent BOT. Complete recanalization was achieved in 66.7% (8 of 12) patients of CDT group as compared to 81% (17 of 21) patients of BOT group (nonsignificant difference, p = 0.420). BOT group had a short hospital stay (1.8 ± 0.7 vs. 3.5 ± 1.0 days) and required less dose of thrombolytic agent ([2.2 ± 0.4]x10 5 IU versus [8.3 ± 2.9]x10 5 IU of urokinase) as compared to the CDT group and both differences were statistically significant ( p < 0.001). Further, 6-month patency rate was higher in BOT group as compared to CDT group ( p = 0.024). Conclusion The novel BOT technique of DIPS revision allows longer contact time of thrombolytic agent with the thrombi within the occluded stent. This helps in achieving fast recanalization of thrombosed DIPS stent with a significantly less dose of thrombolytic agent required, thus reducing the risk of systemic complications associated with thrombolytic administration.

Association of Serum ɣ-Glutamyl Transpeptidase Levels With Overall Survival in Intermediate and Advanced Hepatocellular Carcinoma Treated With Transarterial Chemoembolization.

Introduction: This article aims to evaluate the prognostic significance of pretreatment serum É£-glutamyl transpeptidase (GGT) levels in patients with intermediate (BCLC B) and advanced stage (BCLC C) hepatocellular carcinoma receiving transarterial chemoembolization (TACE) as first-line treatment. Methods: In this single-center retrospective study, a total of 608 patients with BCLC B and BCLC C class were included who received TACE as first-line treatment modality. Patients were divided into low and high GGT groups based on a cutoff value of pretreatment serum GGT levels calculated by receiver operating curve. Overall survival was evaluated with Kaplan-Meier method, and intergroup significance was calculated by log-rank test for overall patients, each BCLC B and BCLC C group. Univariate and multivariate analysis were used for significance for prognostic factors. Results: Median follow-up time was 20, 22, and 9 months for overall patients, BCLC B, and BCLC C group, respectively. Optimal cut value for GGT was calculated at 90.5 U/L. One-year and 3-year survival rates were 84.2% and 27.9% in low GGT, 49.4% and 8.6% in high-GGT group for overall patients. Multivariate analysis in overall patients showed Child-Pugh B (HR,1.801; 95%CI, 1.373-2.362, P < .001), ascites (1.393, 1.070-1.812; P = .014), multiple tumors (1.397, 1.137-1.716; P = .001), AST >40 (1.407, 1.095-1.808; P = .008), albumin <3.2 (.735, .612-.884; P = .001), AFP > 400 (1.648, 1.351-2.011; P < .001), high GGT (2.009, 1.631-2.475; P < .001), or receipt of chemo/ablation (.463, .377-.569; P < .001) as independent risk factors for overall survival. Serum GGT levels and AFP showed significant correlation in between with significance coefficient of .155 (P < .001). Conclusion: Elevated pretreatment serum GGT level was feasible and promising independent prognostic marker for overall survival in intermediate and advanced stage hepatocellular carcinoma patients treated with TACE.

Percutaneous ablative therapies for hepatocellular carcinoma in the caudate lobe of the liver: efficacy and outcome.

OBJECTIVE: To assess the efficacy and outcomes of percutaneous ablative therapies for hepatocellular carcinoma (HCC) in the caudate lobe. METHODS: Patients within Milan criteria, who underwent thermal ablation (RFA/MWA) for HCC were analyzed. Based on the inclusion-criteria, patients were categorized in two groups. Group-1 (caudate-lobe HCC) and Group-2 (non-caudate-lobe HCC). Both the groups were analyzed for technical success (TS), local tumor progression (LTP), disease-free survival (DFS), and overall survival (OS) were compared between both the groups. Predictive factors for LTP, DFS, or OS in the study cohort were analyzed using appropriate statistical analyses. RESULTS: Twenty-one patients qualified to be in Group-1 while 130 patients fulfilled the criteria for Group-2. TS of 90.5 and 97.7% was seen after the first session of ablation for Group-1 and group-2 respectively, while a TS of 95.2% (Group-1) and 100% (Group-2) was achieved after second session. The right-intercostal-approach was used in 66.7% (n = 14) and the anterior-epigastric-approach was used in 33.3% (n = 7) of patients having caudate-lobe HCC. Procedure-related complications in both the groups were comparable. Although, statistically insignificant, LTP in the Group-1 (19.5%, n = 4) was twice that of non-caudate lobe HCC (8.5%, n = 11). The cumulative DFS rate was better in Group-2 while OS in both groups were comparable. Multivariate analysis showed: tumor size and ablative margin of 5 mm being independent predictors of LTP after percutaneous-ablation of caudate-lobe HCC. CONCLUSION: Ablative therapies for HCC in caudate lobe is feasible and safe with comparable LTP and OS to non-caudate lobe HCC. Tumor size >2 cm and lack of 5 mm ablative margin are independent predictors of LTP. ADVANCES IN KNOWLEDGE: 1. Percutaneous ablation of caudate lobe HCC is feasible using anterior epigastric approach or right intercostal approach. 2. These approaches may allow a safe and effective ablation of caudate lobe HCC with results comparable to non-caudate HCC ablation.

Safety and Efficacy of Transjugular Intrahepatic Portosystemic Shunt for Non-tumoral Cirrhotic Portal Vein Thrombosis Not Responding to Anticoagulation Therapy.

OBJECTIVES: To evaluate the feasibility, safety, and efficacy of add-on transjugular-intrahepatic-portosystemic shunt (TIPS) for portal vein recanalization (PVR) in cirrhotic patients with non-tumoral chronic portal vein thrombosis (PVT) after 6 months of monitored anticoagulation therapy (ACT). METHODS: We conducted a retrospective search of the hospital database for patients who underwent TIPS for persistent PVT despite 6 months of ACT (January 2011 to August 2021). These patients were compared to control group (ACT group; no TIPS but continued on ACT). Post-TIPS periodic assessment was done to look for clinical outcome, PVR (using contrast-enhanced CT scan), and complications. RESULTS: A total of 90 patients were analyzed. Thirty-six patients in TIPS group and 54 patients in ACT group. TIPS was successfully performed in all patients. TIPS group showed complete recanalization of portal vein in 77.8%, partial recanalization in 16.7%, and stable thrombus in 5.5% of the patients. TIPS thrombosis was seen in 3 patients, all underwent successful endovascular thrombolysis. Seven patients developed post-TIPS hepatic encephalopathy and were managed conservatively. In contrast, no patient in ACT group achieved PVR on 12-month follow-up. After propensity score matching, patients in TIPS group showed significantly lower incidence of variceal re-bleeding (22.2% vs. 77.8%, p = 0.03) and refractory ascites (11.1% vs. 51.9%, p < 0.01) with significantly better 12-month survival as compared to ACT group (88.9% vs. 69.4%, p = 0.04). CONCLUSION: TIPS in cirrhotic patients with PVT result in superior recanalization rates, better control of ascites, and variceal re-bleeding resulting in better survival. TIPS may be considered a preferred therapy after anticoagulation failure. CLINICAL IMPACT: TIPS is associated with good technical and clinical success in patients of cirrhosis with PVT and should be considered in patients not responding to ACT.

Role of Inferior Vena Cava (IVC) Recanalization in Patients with Back Pain, Secondary to IVC Obstruction in Budd-Chiari Syndrome.

PURPOSE: To study the prevalence of back pain in patients of Budd-Chiari syndrome (BCS) with inferior vena cava (IVC) obstruction, and to evaluate the role of IVC recanalization in resolution of back pain. METHODS: All patients with BCS and IVC obstruction who underwent IVC recanalization between January 2018 and October 2022 were included. Patients with degenerative spine disease or other identifiable causes for back pain were excluded; remaining patients were assessed for the presence of back pain. In patients with back pain, pain relief was assessed at 24 h following IVC recanalization. RESULTS: Fifty-eight patients with BCS and IVC occlusion were identified, of which six with degenerative spine diseases were excluded. Of the remaining 52 patients, 34 (65.4%) had back pain, with pain score between 3 and 9. Engorged epidural venous plexus on preprocedural imaging (p = 0.002), and degree of luminal narrowing (p = 0.021) had a significant association with back pain. Twenty-nine of thirty-four patients (85.3%) with back pain had pain relief immediately following IVC recanalization, more so in patients with engorged epidural venous plexus on preprocedural imaging (p < 0.001). CONCLUSION: Back pain is one of the under-reported symptoms of IVC obstruction in BCS. IVC recanalization by IVC angioplasty with or without stenting relieves back pain due to the decompression of engorged epidural veins.

Splenic Stiffness Is the Best Predictor of Clinically Significant Varices in Children With Portal Hypertension.

BACKGROUND AND AIMS: We studied splenic stiffness measurement (SSM) by transient elastography (TE) and portal hemodynamics parameters (PHDp) on Doppler as predictors of clinically significant varices (CSV) in children. METHODS: All children of 6 months to 18 years of age with portal hypertension (PHT) (chronic liver disease, CLD and non-cirrhotic portal hypertension, NCPH) were enrolled. TE for spleen (SSM) and liver (liver stiffness measurement, LSM) and PHDp by Doppler ultrasonography were measured. Noninvasive indices for PHT were calculated. CSV were defined as esophageal varices ≥grade 2 and/or gastric varix. Binary logistic regression analysis (LRA) and receiver operating characteristic statistics were applied. RESULTS: A total of 150 (120 CLD and 30 NCPH) children formed the study cohort. Prevalence of CSV was higher in NCPH than CLD [73.3% vs 53.3%, Odd's ratio (OR) 2.369, P = 0.04]. On LRA, SSM was found to be the only independent predictor of CSV in children with CLD [OR 1.19 (95% Confidence Interval (CI) 1.018-1.16), P = 0.000] as well as in NCPH [OR 1.088 (95% CI 1.018-1.16), P = 0.013]. This model improved prediction of CSV in CLD from 52.5% to 83.9% and in NCPH from 73.3% to 86.7%. In children with CLD, SSM at a cut-off ≥27.6 kPa and in NCPH, SSM at a cut-off ≥29.5 kPa predicted CSV. In children with CLD, SSM correlated with LSM ( R = 0.610, P <0.001) and with noninvasive PHT indices except aspartate aminotransferase-to-platelet ratio index. CONCLUSION: SSM is the best noninvasive predictor of CSV in childhood CLD and NCPH and can be used as screening test for endoscopy in children with PHT.

Emergent rescue transjugular intrahepatic portosystemic shunt within 8 h improves survival in patients with refractory variceal bleed.

BACKGROUND: Transjugular-intrahepatic portosystemic-shunt (TIPS) and SX-Ella stent Danis (DE stent) are available rescue therapies for refractory variceal bleeding in cirrhosis. Any delay in appropriate therapy is associated with high mortality. Determining the best timing for rescue TIPS is crucial and largely unknown. METHODS: Cirrhotic patients with refractory variceal bleed (n = 121) who underwent rescue TIPS within 24-h (n = 66) were included. Their early rebleed (upto 42 days) rate, 6-week and 1-year survival were compared with matched patients who underwent rescue DE stent (n = 55). Outcomes based on timing of TIPS (within 8-h/8-24 h) were also analyzed. RESULTS: At baseline, patients who received rescue DE stent were sicker with higher MELD score (27.6 ± 8.3 vs. 22.3 ± 7.9; p = 0.001), active bleeding at endoscopy (54.5% vs. 34.8%; p = 0.03) compared to TIPS-group. After propensity score matching, adjusting for MELD-Na score and non-bleed complications, DE patients (n = 34) had higher mortality at 6-week (17/34; 50%) and 1-year (29/34; 85.3%) compared to TIPS-group (20.6% and 38.2%, respectively; both p < 0.02), with higher rebleeding rate (10/34; 29.4% vs. 1/34; 2.9%, p = 0.003). Rescue TIPS placed within 8-h compared with 8-24 h had lower 6-week (48.6% vs. 12.9%; p = 0.003) and 1-year mortality (62.9% vs. 16.1%, p = 0.001) despite comparable rebleed rates (2/31; 6.5% vs. 2/35;5.7%; p = 0.90). Post-TIPS Portal pressure gradient at 6-weeks and 1-year was comparable between survivors and non-survivors. Active bleeding at endoscopy [HR = 11.8; 95% CI 2.96-47.53], presence of AKI [HR = 5.8; 95% CI 1.92-17.41], MELD-Na > 24 [HR = 1.1; 95% CI 1.0-1.17], mean arterial pressure > 64.5 mmHg [HR = 0.8; 95% CI 0.75-0.92] independently predicted 6-week mortality in rescue TIPS-group. CONCLUSIONS: Rescue TIPS placement preferably within 8-h of refractory variceal bleed improves short- and long-term survival. It provides better outcome than DE stent for control of bleeding and prevention of rebleeding, even in patients with high MELD-Na score.

Post-transjugular Intrahepatic Portosystemic Shunt Hepatic Encephalopathy: Sarcopenia Adds Insult to Injury.

BACKGROUND: Hepatic encephalopathy, which is a serious complication, and sarcopenia are undesirable consequences in cirrhosis. Transjugular intrahepatic portosystemic shunt increases the risk of hepatic encephalopathy. We investigated the effect of sarcopenia on the incidence of post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy. METHODS: Clinical data of patients who underwent transjugular intrahepatic portosystemic shunt were extracted retrospectively. Computed tomography images at L3 level of scans performed prior to transjugular intrahepatic portosystemic shunt were analyzed to assess skeletal muscle index-expressed as skeletal muscle area (cm2)/ height (m2). RESULTS: Of 210 patients who underwent transjugular intrahepatic portosystemic shunt, complete information was available in 79 [male: 68 (86%); age: 50.5 ± 11.2 years; Child-Turcotte-Pugh score: 8.81 ± 1.23; etiology-alcohol: 44 (56%), non-alcoholic steatohepatitis: 16 (20%), others: 19 (24%); transjugular intrahepatic portosystemic shunt indication-ascites: 56 (71%); bleed: 23 (29%); sarcopenics: 42 (53%)]. Post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy developed in 29 (37%) patients. In patients who developed hepatic encephalopathy, both serum ammonia [177.6 ± 82.5 vs. 115.5 ± 40.5 µg/dL, P =.008] and prevalence of sarcopenia [69% vs. 44%; P =.02; odds ratio (95% CI): 2.8 (1.08-7.4), P =.02] were higher, with sarcopenics having 3 times higher risk of hepatic encephalopathy and 8 times higher risk of multiple episode of hepatic encephalopathy [31% vs. 5.4%; odds ratio (95% CI): 8.2 (1.68- 40.5), P =.009]. In multivariate analysis, age [odds ratio (95% CI): 1.05 (1.001-1.11), P =.047], serum albumin [odds ratio (95% CI): 0.162 (0.05-0.56), P =.004], and skeletal muscle index [odds ratio (95% CI): 0.925 (0.89-0.99), P =.017] were independently associated with post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy. CONCLUSIONS: Sarcopenia is present in nearly half of the cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt, which increases the risk of a single episode of hepatic encephalopathy by 3-fold and that of multiple episodes of hepatic encephalopathy by 8-fold after transjugular intrahepatic portosystemic shunt procedure. Increased skeletal muscle index is associated with decreased risk of hepatic encephalopathy.

Embryonal Rhabdomyosarcoma of the Biliary Tree as a Differential in a Paediatric Patient Presenting with Biliary Dilatation: Not Always a Choledochal Cyst.

Rhabdomyosarcoma is a soft tissue malignant musculoskeletal tumour and is the most prevalent soft-tissue sarcoma in the paediatric population. Although, Embryonal RMS of the biliary tree is a rare entity, however, it is the most common cause of paediatric malignant obstructive jaundice. We present a 4-year-old child who had symptoms of obstructive jaundice and palpable liver. The non-contrast magnetic resonance imaging and magnetic resonance cholangiopancreatography (MRCP) features were consistent with choledochal cyst. However, contrast enhanced computed tomography and PET CT images revealed biliary RMS as the differential diagnosis. Percutaneous biopsy followed by histopathology confirmed the diagnosis of embryonal biliary RMS. Since embryonal rhabdomyosarcoma is uncommonly recorded in the literature and can mimic the appearance of a choledochal cyst, this case report emphasises the necessity of keeping embryonal RMS as a differential in paediatric cases of obstructive jaundice.

Role of contrast-enhanced ultrasound with Perfluorobutane in lesion detection, guidance for microwave ablation, and response assessment of hepatocellular carcinoma.

PURPOSE: To evaluate role of perfluorobutane in guiding microwave ablation of HCC and to compare treatment response at 3 h of ablation using contrast-enhanced US (CEUS) with Sonazoid with 1-month follow-up contrast-enhanced CT/MRI. METHODS: This was a single center prospective study and consecutive patients planned for microwave ablation of HCC from October to November 2021 were enrolled. Pre-procedure CEUS were performed using Sonazoid in both vascular and Kupffer phase and number of Kupffer defects compared with gray scale US. Precise needle placement of microwave applicator was done in the Kupffer phase. 3 hours post ablation CEUS was repeated to evaluate response assessment using Liver Imaging Reporting and Data System Treatment Response criteria (LR TR). One-month follow-up imaging was done using multiphasic CECT/dynamic CEMRI and comparison was done with post procedure CEUS.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 5 Given name: [Manoj Kumar] Last name [Sharma]. Author 6 Given name: [Shiv Kumar] Last name [Sarin]. Also, kindly confirm the details in the metadata are correct. all the names and affiliations are correct RESULTS: A total of 26 patients (24 males and 2 females, mean age 61.38 ± 9.76 years) having 40 lesions, of mean tumor diameter 21.4 ± 7.7 mm, underwent CEUS and ablation. Most common etiology for cirrhosis was viral hepatitis, followed by non-alcoholic steatohepatitis (NASH). Four (10%) additional lesions (which were seen on pre-procedure imaging) were detected in Kupffer phase over gray scale US. All lesions showed complete response in the immediate post procedure CEUS. Technique efficacy at 1-month was 95% according to the LR TR criteria.Please check the edit made in article title and amend if necessary.The edit is correct and appropriatePlease check and confirm that the authors and their respective affiliations have been correctly identified and amend if necessary.All the names and their respective affiliations are correct CONCLUSION: CEUS with Sonazoid is an excellent modality for precise needle placement for ablation due to stable nature and excellent lesion visibility of Kupffer phase.

Transarterial Chemoembolization (TACE) Combined With Sorafenib versus TACE in Patients With BCLC Stage C Hepatocellular Carcinoma - A Retrospective Study.

Objective: Advanced-stage hepatocellular carcinoma is a heterogeneous group with limited treatment options. TACE has been advocated recently by various study groups. The purpose of this study was to evaluate if TACE in combination with sorafenib, as well as TACE alone, was safe and efficacious in treating BCLC stage C HCC. Methods: A retrospective evaluation of the clinical data of 78 patients with BCLC stage C HCC who received either TACE-sorafenib (TS) combination therapy or TACE monotherapy as their first treatment was done. The two groups were compared in terms of radiological tumor response 1 month after the intervention. The two groups were also compared in terms of time to progression (TTP), overall survival (OS), and adverse events. Results: The disease control rate (44.9% and 25.8%, respectively, P = 0.09) was higher in the TS combination group than in the TACE monotherapy group after 1 month of treatment. The TS combination group had significantly superior TTP and OS than the TACE group (TTP was 4.6 and 3.1 months, respectively, P = 0.001), and OS was 10.1 and 7.8 months, respectively, P < 0.001). The TACE-S group had a greater cumulative survival time at 6 months, 9 months, and 1 year than the TACE group (97.9%, 51.1%, 25.7% vs. 90.4%, 51.6%, and 0%, respectively). Conclusion: TS combination therapy in advanced-stage (BCLC-C) HCC significantly improved disease control rate, TTP, and OS compared with TACE alone, without any significant increase in adverse reactions.

Clinical Outcomes of Transcatheter Arterial Embolization Using N-butyl-2-cyanoacrylate (NBCA) in Cirrhotic Patients.

Purpose: To evaluate the clinical outcomes of transcatheter arterial embolization (TAE) with n-butyl-2-cyanoacrylate (NBCA) for treatment of bleeding in cirrhotic patients. Materials and methods: A total of 35 cirrhotic patients (26 men, 9 women; mean age, 48.4 ± 11.1) who underwent TAE with NBCA for bleeding from January 2011 to December 2020 were retrospectively analysed. Only cirrhotic patients with active arterial bleeding confirmed on computed tomography (CT) were included. Fifteen patients were hemodynamically unstable before embolization procedure, and coagulopathy was observed in 32 patients. The mean MELD score and Child Pugh score were 24 ± 9.9 and 9.9 ± 2.2, respectively. The mean haemoglobin level and mean number of RBC units transfused before embolization were 7.4 ± 1.4 g/dL and 10.2 ± 4, respectively. The technical, clinical success rate and 30-day mortality rate were evaluated. Results: Technical success and clinical success rates were achieved in 100% and 82.8% of patients, respectively. Overall 30-day mortality rate was 48%. No major complications related to the embolization procedure was seen. Only the greater number of RBC units transfused before the embolization procedure (OR = 1.81, 95% CI = 1.17-2.80, P = 0.007) was significantly associated with clinical failure. Greater number of RBC units transfused (OR = 1.53, 95% CI: 1.00-2.34, P = 0.004) and higher Child Pugh score (OR 2.44, 95% CI 1.26-4.71, P = 0.008) were significantly associated with higher 30-day mortality rate. Conclusion: Transcatheter arterial embolization using NBCA can be used as the effective treatment option for bleeding in cirrhotic patients which has a high technical and clinical success despite the grave prognosis associated with cirrhosis.

Caudate lobe amebic abscesses: percutaneous image-guided aspiration or drainage.

BACKGROUND: Amebic liver abscess is the most common type of liver abscess on a worldwide basis, with caudate lobe being a relatively uncommon location for its occurrence. Abscess in caudate lobe of liver is often considered a challenging location for image-guided percutaneous drainage due to its difficult-to-access location along with close relationship with major vessels at porta hepatis. PURPOSE: This study aims to demonstrate safety and efficacy of percutaneous drainage for caudate lobe amebic abscess. MATERIALS AND METHODS: In this retrospective study, hospital database was electronically searched for patients having caudate lobe amebic abscess that underwent percutaneous catheter drainage/needle aspiration (PCD/PNA) between January 2016 and January 2021. The etiology, risk factors, microbiology, complications, different approaches for PCD/PNA, and their outcome were studied and reported. RESULTS: Of 30 patients having caudate lobe amebic abscess treated with PCD/PNA, solitary caudate lobe abscess was seen in 29, whereas one patient had more than one abscesses in caudate lobe. Contained and free intraperitoneal rupture of the abscess were seen in 9 (30%) and one patient, respectively. Ten (32%) patients had associated vascular thrombosis, while 2 patients were found to have abscess-biliary communication. Twenty-six (86.7%) patients were treated with PCD, while remaining 4 (13.3%) with PNA. On Univariate analysis, factors such as volume, multilocularity, and contained rupture of the abscess were found to be significantly increasing the duration of percutaneous drainage (PCD), while only multilocularity (p value 0.007) continued to show statistical significance on Multivariate analysis. Venous thrombosis and duration of catheter drainage were the two factors found to have significant influence on the length of hospital stay on Univariate as well as Multivariate analysis (p value 0.05 and 0.001, respectively). The rates of catheter manipulation were also significantly higher in patients with abscess showing complex internal configuration (heteroechoic contents and/or multilocularity). Technical and clinical success rates of 100% and 96.7% were achieved through percutaneous interventions (PCD/PNA), despite the complex location of abscesses and associated complications, with no incidence of vascular injury. CONCLUSION: Liver abscess in caudate lobe can be accessed by different routes for percutaneous drainage, despite being surrounded by large vessels and its deep location, without major complications. Thus, PCD/PNA may be considered as a first-line therapy for the management of caudate lobe amebic abscesses in adjunct to medical therapy.

Transarterial Chemoembolization in Unresectable Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Tertiary Care Center Experience.

Background Portal vein tumor thrombosis (PVTT) is a common complication of hepatocellular carcinoma (HCC) occurring in 30 to 40% of cases. The presence of PVTT in HCC is regarded as an advanced disease that confers poor prognosis and survival. Transarterial chemoembolization (TACE) has traditionally been considered to be contraindicated in cases of PVTT, due to the risk of hepatic infarction, and further deteriorate liver function. We evaluated safety, technical efficacy, and outcomes of TACE in HCC with PVTT. Methods From search results of the hospital database, out of 652 patients who underwent TACE for HCC, 73 patients of HCC with PVTT were retrospectively evaluated. Post-TACE tumor response by computed tomography (CT)/magnetic resonance imaging (MRI) imaging as per modified response evaluation criteria in solid tumors (mRECIST) criteria, if any occurrence of acute hepatic failure was assessed. Prognostic factors influencing survival were also determined. Results In our study population, the mean age of the patients was 58 years. The 12- and 24-month survival rates were 59 and 14%, respectively, with an overall median survival of 12.3 months. A total of 58.9% patients had branch portal vein tumor thrombus and 41.1% had tumor thrombus in the main portal vein. We did not encounter any mortality or acute liver failure following TACE in a 30-day period. Both univariate and multivariate analysis revealed Child-Pugh score ( p = 0.01) and the extent of tumoral thrombus ( p 0.004) as a significant prognostic factor. Patients with branch PVTT, no ascites, and Child-Pugh A had better survival than those having main portal vein tumor thrombus, ascites, and Child-Pugh B. Conclusion Our study concluded that TACE can achieve good disease control and improved survival in HCC with portal vein invasion despite being considered as a relative contraindication. Technical expertise, selection of patients, such as superselective catheterization and preserved liver function, are the key factors for a safe therapeutic procedure. Child-Pugh score and extent of portal vein invasion were the significant prognostic factors determining survival.