North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension.

Complications of portal hypertension, including ascites, gastrointestinal bleeding, hepatic hydrothorax, and hepatic encephalopathy, are associated with significant morbidity and mortality. Despite few high-quality randomized controlled trials to guide therapeutic decisions, transjugular intrahepatic portosystemic shunt (TIPS) creation has emerged as a crucial therapeutic option to treat complications of portal hypertension. In North America, the decision to perform TIPS involves gastroenterologists, hepatologists, and interventional radiologists, but TIPS creation is performed by interventional radiologists. This is in contrast to other parts of the world where TIPS creation is performed primarily by hepatologists. Thus, the successful use of TIPS in North America is dependent on a multidisciplinary approach and technical expertise, so as to optimize outcomes. Recently, new procedural techniques, TIPS stent technology, and indications for TIPS have emerged. As a result, practices and outcomes vary greatly across institutions and significant knowledge gaps exist. In this consensus statement, the Advancing Liver Therapeutic Approaches group critically reviews the application of TIPS in the management of portal hypertension. Advancing Liver Therapeutic Approaches convened a multidisciplinary group of North American experts from hepatology, interventional radiology, transplant surgery, nephrology, cardiology, pulmonology, and hematology to critically review existing literature and develop practice-based recommendations for the use of TIPS in patients with any cause of portal hypertension in terms of candidate selection, procedural best practices and, post-TIPS management; and to develop areas of consensus for TIPS indications and the prevention of complications. Finally, future research directions are identified related to TIPS for the management of portal hypertension.

Percutaneous Ultrasound Guided Gastrostomy Tube Placement: A Prospective Cohort Trial.

BACKGROUND: To compare the safety and efficacy of percutaneous ultrasound guided gastrostomy (PUG) tube placement with traditional fluoroscopic guided percutaneous gastrostomy tube placement (PRG). METHODS: A prospective, observational, non-randomized cohort trial was performed comparing 25 consecutive patients who underwent PUG placement between April 2020 and August 2020 with 25 consecutive patients who underwent PRG placement between February 2020 and March 2020. Procedure time, sedation, analgesia requirements, and complications were compared between the two groups in non-inferiority analysis. RESULTS: Technical success rates were 96% in both groups (24/25) of procedures. Ninety-two percent of patients in the PUG cohort were admitted to the ICU at the time of G-tube request. Aside from significantly more COVID-19 patients in the PUG group (P < .001), there was no other statistically significant difference in patient demographics. Intra-procedure pain medication requirements were the same for both groups, 50 micrograms of IV fentanyl (P = 1.0). Intra-procedure sedation with IV midazolam was insignificantly higher in the PUG group 1.12 mg vs 0.8 mg (P = .355). Procedure time trended toward statistical significance (P = .076), with PRG being shorter than PUG (30.5 ± 14.1 minutes vs 39.7 ± 17.9 minutes). There were 2 non-device related major complications in the PUG group and 1 major and 1 minor complication in the PRG group. CONCLUSION: PUG is similar in terms of complications to PRG gastrostomy tube placement and a safe method for gastrostomy tube placement in the critically ill with the added benefits of bedside placement, elimination of radiation exposure, and expanded and improved access to care.

Evaluation of a three-session biliary dilation protocol following transplant-related biliary stricture in pediatric patients.

To evaluate whether a serial biliary dilation protocol improves outcomes and decreases total biliary drainage time for biliary strictures following pediatric liver transplantation. From 2006 to 2016, 213 orthotopic deceased and living related liver transplants were performed in 199 patients with a median patient age of 3.1 years at a single pediatric hospital. Patients with biliary strictures were managed by IR or surgically by the transplant team. Patients managed by IR were divided into two groups. The first group was managed with a standardized three-session protocol consisting of dilation every two weeks for three dilations. The second group was managed clinically with varying number and interval of dilations as determined by a multidisciplinary team. The location of biliary stricture, duration of drainage, number of balloon dilations, balloon diameter, time interval between dilations, and success of percutaneous treatment were recorded. Thirty-four patients developed biliary strictures. Thirty-one patients were managed with percutaneous intervention. Three strictures could not be crossed and were converted to operative management. Ten patients were managed in the three-session protocol, and 18 patients were managed in the clinically treated group. There was no significant difference in clinical success rates between groups, 80% and 61%, respectively. The three-session protocol group trended toward a lower total biliary drain indwell time (median 49 days) compared with the clinically treated group (median 89 days), P = .089. Our study suggests that a three-session dilation protocol following transplant-related biliary stricture may decrease total biliary drainage time for some patients.

Single-Institution Experience with Irreversible Electroporation for T4 Pancreatic Cancer: First 50 Patients.

BACKGROUND: Irreversible electroporation (IRE) for treatment of locally advanced pancreatic tumors is garnering increasing attention. This study was conducted to determine perioperative morbidity and mortality for locally advanced pancreatic cancer. METHODS: Prospective data of 50 consecutive patients receiving IRE for T4 lesions at a single tertiary center were analyzed. The primary end point was Clavien-Dindo complications at 90 days, and the secondary outcomes were survival and recurrence. RESULTS: A total of 50 patients underwent 53 IRE procedures for primary treatment (n = 29) or margin extension (n = 24), and 47 patients had adenocarcinoma. Six patients died within 90 days after the procedure (5 in the primary control group). Mortality occurred a median of 26 days (range, 8-42 days) after the procedure. Five patients in both the margin-extension and primary control groups experienced grade 3 or 4 morbidity (p = 0.739). The incidences of grades 3 to 5 complications did not differ significantly based on the adjustable parameters of IRE, tumor size, or primary treatment versus margin extension. After a median follow-up period of 8.69 months [interquartile range (IQR), 0.26-16.26 months], the median overall survival period for the primary control group was 7.71 months [95 % confidence interval (CI), 6.03-12.0 months) and was not reached in the margin-extension group (p = 0.01, log-rank). CONCLUSIONS: At the authors' center, the mortality rate after IRE was higher than reported in other series, with the majority occurring in the primary control group. Major morbidity trended around upper gastrointestinal bleeding, visceral ulcerations/perforations, and portal vein thromboses. This favors further investigation of the safety and efficacy of IRE.

Neonatal hepatic mesenchymal hamartoma causing cardiac failure and disseminated intravascular coagulopathy.

Even with advance prenatal diagnostic tools, differentiating among specific types of hepatic masses continues to challenge many physicians. Here, we report a neonate with life-threatening hepatic mass, cardiac failure, and disseminated intravascular coagulopathy, which clinically resembled hepatic hemangioma. A hepatic mesenchymal hamartoma was detected by postmortem pathology.

Transarterial chemoembolization for primary hepatocellular carcinoma in patients at high risk.

PURPOSE: Transarterial chemoembolization (TACE) has become a standard treatment option for patients with unresectable hepatocellular carcinoma (HCC). This retrospective study evaluated the safety and efficacy of TACE in patients at high risk with increased serum bilirubin level, low serum albumin level, poor hepatic reserve, or compromised hepatopetal flow in the portal vein (PV). MATERIALS AND METHODS: A total of 52 patients underwent 65 high-risk procedures. Thirty patients treated with 38 procedures (57.7% of patients and 58.5% of procedures) had serum bilirubin levels of 2-3 mg/dL (ie, moderate elevation) and 22 patients treated with 27 procedures (42.3% and 41.5%) had a serum bilirubin level of at least 3 mg/dL (ie, considerable elevation). Forty patients (76.9%) had serum albumin levels less than 3.5 mg/dL. Thirteen recipients of 15 procedures (25% and 20%) had portal diversion or obstruction. Twenty-four patients (46.2%) had a Child-Pugh (CP) score of 8 or less and 28 patients (53.8%) had a CP score of at least 9 at the time of TACE. Thirty patients (57.7%) had focal tumors and 22 patients (42.3%) had multifocal or infiltrative disease. Superselective chemoembolization could be performed in 37 procedures (56.9%); lobar chemoembolization was performed in the remaining 28 (43.1%). RESULTS: The 30-day mortality rate was 7.7% and the procedure-related morbidity rate was 10.8%. Patients with multifocal disease and lobar embolization had significantly higher mortality rates (P=.03). Individual factors such as serum bilirubin, serum albumin, and PV flow did not affect outcomes significantly. The 1- and 2-year survival rates in patients with focal disease were 67.9% and 37.7%, respectively, compared with 19.6% and 0% in patients with multifocal disease (P<.0001). CONCLUSIONS: TACE in patients considered at high risk does not necessarily incur a higher incidence of morbidity or mortality. Patient selection should be based on extent of disease, and these tumors should be treated selectively at a segmental level if possible.

Preoperative angiography with embolization and radiofrequency ablation as novel adjuncts to safe surgical resection of a large, vascular sacrococcygeal teratoma.

Sacrococcygeal teratomas (SCTs) can present a challenging problem and can be associated with significant perinatal morbidity and mortality. A female child was born at 36 weeks' gestation with a large, vascular Type 1 SCT originally identified by prenatal ultrasound. A CT scan showed two large feeding vessels arising from both internal iliac arteries that were successfully embolized during angiography. A radiofrequency probe was then used to ablate a zone between normal tissue and the tumor. The SCT was subsequently surgically excised with minimal blood loss. This case is presented to illustrate two useful and previously unreported postnatal adjuncts to the surgical treatment of massive, hypervascular sacrococcygeal tumors.

Recurrent TIPS thrombosis after polyethylene stent-graft use and salvage with polytetrafluoroethylene stent-grafts.

Increasing data support the use of polytetrafluoroethylene (PTFE) stent-grafts for de novo and revision transjugular intrahepatic portosystemic shunt (TIPS) applications. Animal experiments have indicated that polyethylene terephthalate (PET) stent-grafts provide no improvement or actually worsen TIPS patency compared with controls, but human TIPS experience with PET grafts is more limited. Herein we describe three patients who underwent de novo creation of TIPS with PET-covered stent-grafts at outside institutions, which resulted in immediate and recurring TIPS thromboses despite repeated thrombectomies. After the failed TIPS were revised with PTFE stent-grafts, the presenting symptoms resolved and uninterrupted patency was achieved.

Radiofrequency ablation for hemobilia secondary to hepatocellular carcinoma.

Hemobilia is a rare manifestation of hepatic malignancies. The current treatment of choice for hemobilia is transcatheter hepatic arterial embolization. However, there have been only two published reports that describe the use of hepatic arterial embolization for hemobilia caused by hepatic neoplasms. In addition, this procedure is occasionally unsuccessful in the treatment of hemobilia. A case in which hemobilia caused by hepatocellular carcinoma was successfully treated with percutaneous radiofrequency tumor ablation after several failed hepatic arterial embolizations is described in this report.