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Portal vein embolization prior to hepatectomy: Techniques, outcomes and novel therapeutic approaches

Matthew L. Hung , and Justin P. McWilliams

Abstract : Hepatectomy plays a pivotal role in the management of primary and secondary malignancies of the liver, and offers a curative option for the patient. Postoperative liver failure is a severe complication of liver resection, particularly for patients with underlying liver disease. Portal vein embolization (PVE) is a well-established preoperative technique that redirects blood flow to the anticipated remaining liver after resection in an effort to improve the functional hepatic reserve. PVE has improved the safety of hepatectomy and has extended surgical candidacy to patients who previously would have been ineligible for resection because of insufficient remnant liver volume. This article reviews the following aspects of PVE; indications, contra-indications, liver volumetry, approaches, embolization agents, recent outcomes data, and areas of active research including adjunctive therapies and temporary PVE.

A review of recent experience with transjugular intrahepatic portosystemic shunt creation using intravascular ultrasound

Steven D. Kao, and Edward Wolfgang Lee

Abstract : Portal vein access has historically been the most technically challenging step in the creation of transjugular intrahepatic portosystemic shunts (TIPSs). The use of intravascular ultrasound (IVUS) for guidance of portal vein access during TIPS creation has garnered much interest in recent years. Recent literature has suggested potential improvements in procedural metrics that may result from use of IVUS for TIPS. This review aims to provide historical context, detail technical advances and describe recent clinical experience with the use of IVUS for TIPS creation.

Transjugular intrahepatic portosystemic shunt trends in China: A brief review

Xiao JiangQiang, and ZhuGe YuZheng

Abstract : Transjugular intrahepatic portosystemic shunt (TIPS) is now considered as a major treatment option for cirrhotic patients with portal hypertension. Globally, it is getting markedly increase attention, and a similar phenomenon is occurring in China. On average, the number of TIPS procedures is increasing at a rate of 15% per year. Published research papers are also continuously growing every year. Similar but unique compared to western countries, most Chinese physicians follow Chinese specialized guidelines when treating patients with portal hypertension. In this review, we briefly introduce the history of TIPS in China, the present and the future of TIPS in China.

A new and improved transjugular intrahepatic portosystemic shunt (TIPS) stent graft: Controlled expansion

Harry Trieu, and Edward Wolfgang Lee

Abstract : Initial underdilation of transjugular intrahepatic portosystemic shunt (TIPS) stents has been a widely proposed and commonly practiced technique to balance portal hypertension relief and the adverse effects associated with excess shunting, especially hepatic encephalopathy. However, this technique has been scrutinized by a number of studies which have shown that underdilated TIPS stents tend to passively expand with time. The recently launched GORE® VIATORR® TIPS Endoprosthesis with Controlled Expansion (VIATORR CX®) may address this problem with its novel diameter control capabilities. This article reviews literature concerning passive expansion of initially underdilated TIPS stents and explores preliminary data investigating the use and efficacy of the VIATORR CX® endoprosthesis.

Portosystemic collateral pathways and interventions in portal hypertension

Murad Feroz Bandali, and Anirudh Mirakhur

Abstract : Pathologic increase in portal pressure can be caused by increased resistance to blood flow at the level of the portal vein (pre-hepatic), hepatic sinusoids (hepatic) or hepatovenous outflow (post-hepatic). This results in recruitment and dilatation of tiny portosystemic collateral pathways, diverting portal venous blood flow to low pressure systemic veins. Based on the location of the causative factor of portal venous resistance, different collateral pathways and shunts may develop, resulting in unique syndromes of portal hypertension and in-turn requiring unique treatment options. Knowledge of the common and less-common portosystemic collateral pathways have important implication for clinicians and interventionalists. The objective of this pictorial review is to illustrate the various collateral pathways using diagrammatic and conventional non-invasive and invasive radiologic examples. Additionally, we will briefly address minimally invasive interventional techniques used to treat the sequelae of portal hypertension.

Intraductal migration of necrotic hepatocellular carcinoma: A possible cause of obstructive cholangitis after chemoembolization

Hyo Jung Park, and Ji Hoon Shin

Abstract : Acute obstructive cholangitis due to the migration of necrotized tumor fragment(s) has been rarely reported after transarterial chemoembolization (TACE). We report an unusual case of it, which was demonstrated by computed tomography (CT) and endoscopic retrograde cholangiography. We suggest that in the setting of acute biliary obstruction after TACE with a CT-demonstrated new intraductal soft tissue lesion with or without a radiopaque portion, along with no or less visualization of a previous tumor located inside or near the duct, the possibility of intraductal migration of a necrotic tumor fragment should be considered. Both clinicians and radiologists should become familiar with this condition because it may be ignored or misinterpreted as biliary calculi.

Combined use of a two-channel endoscope and a flexible tip catheter for difficult biliary cannulation

Masaki Kuwatani, Yoshimasa Kubota, Shuhei Kawahata, Kimitoshi Kubo, Kazumichi Kawakubo, Hiroshi Kawakami , and Naoya Sakamoto

Abstract : A 69-year-old woman with jaundice was referred to our hospital. After a final diagnosis of pancreatic cancer with liver metastasis, we performed transpapillary biliary drainage with a covered self-expandable metal stent (SEMS). Three months later, we also placed an uncovered duodenal stent for duodenal stricture in a side-to-end fashion. Another month later, for biliary SEMS obstruction, we attempted a transpapillary approach. A duodenoscope was advanced and a guidewire was passed through the mesh of the duodenal stent into the bile duct with a flexible tip catheter, but the catheter was not. Thus, we exchanged the duodenoscope for a forward-viewing two-channel endoscope and used the left working channel with a flexible tip catheter. By adjusting the axis, we finally succeeded biliary cannulation and accomplished balloon cleaning for recanalization of the SEMS. This is the first case with successful biliary cannulation by combined use of a two-channel endoscope and a flexible tip catheter.

Percutaneous placement of H-configured triple biliary and enteral stents through a single access: A solution for complex bilio-enteric obstruction

Sunghun Park , and Auh Whan Park

Abstract : A 75-year-old male with recurrent pancreatic adenocarcinoma after a previous Whipple’s procedure presented with jaundice. The local advancement of the tumor caused obstructions of the common bile duct, intrahepatic bile duct hilum, and small bowel. Endoscopic stent insertion was precluded by the Roux-en-Y reconstruction. A successful transhepatic percutaneous single-access stenting of the whole biliary tree and intestine was achieved by H-configured triple stenting by combining T-configured dual stent placement in the biliary system with a duodenal stent insertion across the bottom of the anastomosis after looping a wire in the afferent limb. The ‘H-configured’ stents remained patent for 10 months without major or minor complications. This technique adds a new minimal-invasive and effective palliative option for patients with obstruction of a bilio-enteric anastomosis inaccessible to endoscopy.

Infectious peritonitis after endoscopic ultrasound-guided biliary drainage in a patient with ascites

Nozomi Okuno, Kazuo Hara , Nobumasa Mizuno, Takamichi Kuwahara, Hiromichi Iwaya, Masahiro Tajika, Tsutomu Tanaka, Makoto Ishihara, Yutaka Hirayama, Sachiyo Onishi, Kazuhiro Toriyama, Ayako Ito, Naosuke Kuraoka, Shimpei Matsumoto, Masahiro Obata, Muneji Yasuda, Yusuke Kurita, Hiroki Tanaka, and Yasumasa Niwa

Abstract : Summary of EventBacterial, mycotic peritonitis and Candida fungemia developed in a patient with moderate ascites who had undergone endoscopic ultrasound-guided biliary drainage (EUS-BD). Antibiotics and antifungal agent were administered and ascites drainage was performed. Although the infection improved, the patient’s general condition gradually deteriorated due to aggravation of the primary cancer and he died.Teaching PointThis is the first report to describe infectious peritonitis after EUS-BD. Ascites carries the potential risk of severe complications. As such, in patients with ascites, endoscopic retrograde cholangiopancreatography (ERCP) is typically preferred over EUS-BD or percutaneous drainage to prevent bile leakage. However, ERCP may not be possible in some patients with tumor invasion of the duodenum or with surgically altered anatomy. Thus, in patients with ascites who require EUS-BD, we recommend inserting the drainage tube percutaneously and draining the ascites before and after the intervention in order to prevent severe infection.