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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.
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Doença Hepática Terminal , Derivação Portossistêmica Transjugular Intra-Hepática , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Doença Hepática Terminal/complicações , Índice de Gravidade de Doença , Cirrose Hepática/complicações , Hemorragia , Ascite/etiologia , Resultado do TratamentoRESUMO
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.
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Varizes Esofágicas e Gástricas , Derivação Portossistêmica Transjugular Intra-Hepática , Humanos , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Varizes Esofágicas e Gástricas/terapia , Varizes Esofágicas e Gástricas/complicações , Emergências , Radiologia Intervencionista , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Hemorragia Gastrointestinal/diagnóstico por imagem , Hemorragia Gastrointestinal/terapia , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico por imagem , Resultado do TratamentoRESUMO
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.
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Técnicas de Imagem por Elasticidade , Varizes Esofágicas e Gástricas , Hipertensão Portal , Varizes , Humanos , Criança , Baço/patologia , Hipertensão Portal/complicações , Hipertensão Portal/diagnóstico por imagem , Fígado/patologia , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Varizes Esofágicas e Gástricas/etiologia , Endoscopia Gastrointestinal , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico por imagem , Cirrose Hepática/patologiaRESUMO
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.
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Derivação Portossistêmica Transjugular Intra-Hepática , Trombose , Trombose Venosa , Humanos , Veia Porta/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Estudos Retrospectivos , Ascite/tratamento farmacológico , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/etiologia , Trombose Venosa/terapia , Cirrose Hepática/patologia , Trombose/tratamento farmacológico , Hemorragia , Resultado do Tratamento , Anticoagulantes/efeitos adversosRESUMO
BACKGROUND: The aim of the study was to study the four week patency rates of the reconstructed neo middle hepatic vein specifically using the explant portal vein (PV) in right hemiliver live donor liver transplantation (LDLT). We hypothesized that short term patency of the neo-MHV should result in good graft and patient outcomes. METHODS: Pre, intra and post operative variables were prospectively collected for 88 consecutive patients undergoing right hemiliver LDLT from January 2014 to October 2015. RESULTS: Explant PV was used to reconstruct neo-MHV in 76 (86.4%, 76/88) patients. Neo MHV patency rate at 28 days with explant PV was 89.4% (59/66) and with other conduit (PTFE) was 90.9% (10/11). All occlusions were detected after 7 days. There was no impact of the patency of the neo-MHV on the incidence of early allograft dysfunction, sepsis, rejection, morbidity or mortality, despite the contribution of the anterior sector to the graft volume being more than 50% in close to two-thirds of patients. CONCLUSION: The reconstructed neo-MHV has excellent short term patency rates at 4 weeks. Perhaps due to the absence of early occlusions, there was no impact on graft or patient outcomes in the study population.
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Veias Hepáticas/cirurgia , Transplante de Fígado/métodos , Doadores Vivos , Veia Porta/cirurgia , Grau de Desobstrução Vascular , Procedimentos Cirúrgicos Vasculares , Adolescente , Adulto , Idoso , Estudos de Viabilidade , Feminino , Sobrevivência de Enxerto , Veias Hepáticas/diagnóstico por imagem , Veias Hepáticas/fisiopatologia , Humanos , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Veia Porta/diagnóstico por imagem , Veia Porta/fisiopatologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Adulto JovemRESUMO
Circumportal pancreas is a congenital fusion anomaly of the pancreas where the pancreatic tissue from the uncinate process, anomalously encases the portal vein and/or the superior mesenteric vein. Depending upon the level of the pancreatic annulus the variant can be classified into three subtypes-suprasplenic, infrasplenic or mixed; and each subtype exhibits either an anteportal or retroportal main pancreatic duct. Limited literature is available on this intriguing anomaly primarily because of its relatively low prevalence in humans (published prevalence rates vary from 0.2 to 2.5 %), probable lack of awareness among medical professionals and its generally symptomless course. In an attempt to appraise the embryological basis, clinicoradiological manifestations and potential surgical implications of circumportal pancreas, literature published in English was searched using PubMed and information collated so as to provide up-to-date information on this relatively understudied entity. The anomaly by itself remains innocuous but its preoperative recognition in those undergoing pancreatic resection bears decisive influence on planning and selecting apposite surgical resection planes as inadvertent duct injury can lead to pancreatic fistula.
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Diagnóstico por Imagem , Pâncreas/anormalidades , Humanos , Veias Mesentéricas/anormalidades , Pâncreas/embriologia , Pâncreas/cirurgia , Pancreaticoduodenectomia , Veia Porta/anormalidades , PrevalênciaRESUMO
Synchronous double malignancies involving different organs are relatively rare and uncommon finding. We report an interesting case of double malignancy in which a patient exhibited synchronous two separate carcinomas, pancreatic and hepatocellular carcinoma (HCC). Patient was a 64-year-old male who presented primarily with symptoms pertaining to the biliary obstruction and ultrasound of abdomen revealing pancreatic head mass. HCC was detected incidentally during the investigations for carcinoma pancreas.
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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.
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OBJECTIVES: Salvage TIPS is indicated in patients with active endoscopically uncontrollable variceal bleeding. TIPS alone is not effective in management of gastric varices and BRTO requires favourable variceal anatomy. Concomittant placement of a TIPS stent with antegrade variceal embolisation leads to control of gastric variceal bleeding with no significant increase in portal pressure. MATERIALS AND METHODS: A single centre retrospective observational study where patients with active uncontrollable gastric variceal bleeding were included in the study. Technical success of the procedure, 5-day rebleed, 6-weeks and 6-months survival as well as other additional outcomes were evaluated. RESULTS: A total of 18 patients were included in the study. Technical success was 100% and significant non-target embolisation was seen in 0% patients. 6 week and 6 month survival rates were 66.67% with an overall survival of 108.786 days (censored at 180 days). 5 day rebleed rate was 11.1%. A significant difference in CTP score (p = 0.03), MELD Na score (p = 0.022), requirement of intubation (p = 0.038), hemoglobin levels (p = 0.042), hematocrit value (p = 0.018), PRBC infusion required prior to and after the procedure (p = 0.045, 0.044) and presence of refractory shock (p = 0.013) was observed between the survival and the mortality group. Post variceal bleeding hemoglobin levels, MAP and MELD-Na scores were significant predictors of mortality. CONCLUSION: TIPS in adjunct to antegrade transvenous embolisation is a safe and effective modality for management of active uncontrolled gastric variceal bleeding in patients with variceal anatomy unfavourable for performing RTO.
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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.
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Carcinoma Hepatocelular , Verde de Indocianina , Cirrose Hepática , Neoplasias Hepáticas , Fígado , Tomografia Computadorizada por Raios X , Humanos , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/patologia , Carcinoma Hepatocelular/complicações , Verde de Indocianina/administração & dosagem , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/complicações , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico por imagem , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tamanho do Órgão , Fígado/diagnóstico por imagem , Fígado/patologia , Idoso , Adulto , Corantes/administração & dosagem , Doença Hepática Terminal/complicações , Doença Hepática Terminal/etiologia , Doença Hepática Terminal/diagnóstico por imagem , Correlação de DadosRESUMO
Background/Aims: To study the association of infertility in patients with Budd Chiari syndrome, radiological aspects of the disease determining infertility and to see if there are improved chances of conception following radiological intervention. Methods: Retrospective search of the hospital records was done and patients with Budd Chiari syndrome, who underwent radiological intervention between January 2016 till October 2021 were initially included. Patients outside the reproductive age group, unmarried patients, patients who did not attempt conception or attempted for less than 1 year and patients having other causes of infertility were excluded. 90 patients were assessed for presence of primary or secondary infertility using infertility questionnaire. In patients with infertility, conception during 1-year follow-up period following radiological intervention, was assessed. Results: 146 patients underwent radiological intervention for Budd Chiari syndrome in the study period. 56 patients meeting the exclusion criteria were excluded from the study and subsequently 90 patients were assessed for infertility. 16.7% (15/90) of our patients with Budd Chiari syndrome had infertility, of which 7 were male, and 8 were female. Infertility is more common in younger age group (mean - 28.8 ± 4.2 years) (P < 0.001). In females, presence of pelvic venous congestion on preprocedural imaging showed significant association with infertility (P < 0.001). 6 (40%) out of 15 of patients with infertility conceived during a 1-year follow-up period after radiological intervention. Conclusion: Infertility is a common in patients with Budd Chiari syndrome, with a prevalence of 16.7%. Pelvic venous congestion is associated with women having infertility. Radiological interventions play important role in management of Budd Chiari and may help to overcome infertility in these patients.
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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.
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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.
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Hepatic visceral larva migrans (VLM) refers to a condition characterized by granulomatous liver lesions containing eosinophils and inflammatory cells associated with migration of second-stage larvae of certain nematodes such as toxocara canis. The typical imaging findings described in the literature include small, ill-defined, oval or elongated, low-attenuating nodules with fuzzy margins, non-spherical shape, and absent or insignificant rim enhancement on contrast-enhanced CT scan. The present series in contrast depicts a new imaging manifestation of hepatic VLM presenting as confluent and clustered complex cystic liver lesions. Pre-treatment imaging studies including contrast-enhanced CT/MRI of three patients are presented. One of the patients underwent liver resection while post-treatment follow-up scan at 6 months in the remaining two displayed regression of the lesions with antihelminthic treatment.
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Eosinofilia/parasitologia , Abscesso Hepático/parasitologia , Adolescente , Adulto , Feminino , Humanos , Larva Migrans Visceral , Hepatopatias Parasitárias , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-IdadeRESUMO
The authors describe the case of a 44-year-old male with chronic liver disease in whom celiacomesenteric trunk (CMT) was incidentally detected on routine multidetector row computed tomography of abdomen. The CMT (measuring approximately in diameter 12.3 mm) divided into celiac trunk and superior mesenteric artery (SMA) (measuring approximately 7.5 and 7.2 mm, respectively). The celiac trunk further divided into common hepatic, left gastric, and right inferior phrenic and splenic arteries. The common hepatic artery gave off gastroduodenal arteries before continuing as hepatic artery proper. The SMA was seen running down, deep to the neck of the pancreas to supply the midgut. The incidence and clinical implications of this vascular variation are discussed with a review of the relevant literature.
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Artéria Celíaca/anormalidades , Imageamento Tridimensional , Achados Incidentais , Artéria Mesentérica Superior/anormalidades , Tomografia Computadorizada Multidetectores/métodos , Adulto , Artéria Celíaca/diagnóstico por imagem , Doença Crônica , Humanos , Hepatopatias/diagnóstico por imagem , Masculino , Artéria Mesentérica Superior/diagnóstico por imagemRESUMO
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.
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Varizes Esofágicas e Gástricas , Derivação Portossistêmica Transjugular Intra-Hepática , Varizes , Humanos , Hemorragia Gastrointestinal/cirurgia , Hemorragia Gastrointestinal/complicações , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Varizes/complicações , Cirrose Hepática/etiologia , Resultado do TratamentoRESUMO
Introduction: This article aims to evaluate the prognostic significance of pretreatment serum ɣ-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.
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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.
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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.
Assuntos
Encefalopatia Hepática , Derivação Portossistêmica Transjugular Intra-Hepática , Sarcopenia , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/epidemiologia , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Sarcopenia/complicações , Estudos Retrospectivos , Cirrose Hepática/complicações , Resultado do TratamentoRESUMO
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.