Endo-hepatology: Why should we do endoscopic ultrasound-guided interventions to the liver that we could do through the skin?

Effects of endoscopic gastric plication on portal pressure gradient in a patient with nonalcoholic steatohepatitis cirrhosis.

Introduction: EUS-guided portal pressure gradient (PPG) measurement and EUS guided liver biopsies are well tolerated procedures under anesthesia, but it is unclear which anesthesia modality, monitored anesthesia care (MAC) or general anesthesia (GA), is superior for performing these cases. We aimed to describe our centers’ experiences and approach to EUS-guided PPG and liver biopsy from an anesthesia perspective and compared the two anesthesia modalities in terms of procedure duration, efficacy, and safety. Methods: This was a retrospective review of all consecutive patients who underwent EUS-guided PPG measurement and/or liver biopsies at a single tertiary center between June 2021 and May 2022. All procedures were done with an anesthesiologist attending and/or a resident/nurse. After initial experience with GA, our center largely switched to MAC for these cases. In the last 40 cases, 82% were done with MAC. Demographic data, scope time, anesthesia time, technical success rate, and adverse events post procedure for each patient were noted. Statistical analysis was performed using student t-testing. Results: We have a total of 73 patients who underwent EUS guided PPG measurement and/or liver biopsy, with 30 (54%) having undergone only PPG measurement. The mean age was 51, with 56 (77%) patients being female and mean BMI as 37. The clinical indication for most patients 60 (82%) in undergoing the EUS procedure was for evaluation of underlying NAFLD/NASH. No differences in basic demographics was found between the MAC and GA cohorts. The mean scope time for MAC vs GA was 38.2 ± 14.2 and 47.3 ± 14.5 minutes respectively for patients who underwent both EUS-PPG and liver biopsy. The timing of endoscopy was comparable between the two modalities (p=0.013). The mean anesthesia time for MAC vs GA was 57.1 ± 14.9 and 81.6 ± 14.9 minutes respectively, with MAC being shorter by 25 minutes (p= < 0.001). Similar comparisons were made for patients who underwent EUS-PPG alone. Technical success was 100% for all cases, and there was only one reported adverse event of a patient who reported transient shortness of breath post-extubation from GA who underwent EUS-PPG alone. This was resolved within a few hours with close monitoring. (Table) Conclusion: Our results show that MAC was superior in terms of anesthesia time as compared to GA. Both anesthesia modalities demonstrated excellent and comparable safety and efficacy. Table 1. - Procedure and Anesthesia time for EUS guided PPG measurement and Liver Biopsy Table a EUS guided PPG measurement (with liver biopsy) Mean Mac(n=20) GA (N=23) p value Procedure time (mins) 38.2 ± 14.2 47.3 ± 14.5 0.013 Anesthesia time (mins) 57.1 ± 14.9 81.6 ± 14.9 Table b EUS guided PPG measurement (without liver biopsy) Mean MAC (N=13) GA (N=17) p value Procedure time (mins) 37.7 ± 14.5 46.9 ± 14.5 0.011 Anesthesia time (mins) 58.1 ± 15.5 81.9 ± 15.5 < 0.001 Table c Mean intubation time with GA (n=23 )( with liver biopsy) 66.3 ± 14.6 Mean intubation time in minutes with GA (n= 17) ( without liver biopsy) 66 ± 15.3

Risk stratification in liver disease includes liver elastography (LE) and portal pressure gradient (PPG) measurement. We examined the efficacy and safety of endoscopic ultrasound (EUS)-liver biopsy (EUS-LB) and the correlation between EUS-PPG and EUS-LE in patients with liver disease. This is a prospective and retrospective, single-center study. Data from patients who underwent concomitant EUS-LE, EUS-PPG, and EUS-LB were analyzed. Histologically, significant fibrosis (SF) was considered F2-F4, non-significant fibrosis (NSF) as F0-F1, advanced fibrosis (AF) as F3-F4, and non-advanced fibrosis (NAF) as F0-F2. In total, 25 patients underwent EUS-PPG measurement; 60% were male (mean age, 60 years). EUS-LE and EUS-LB were performed in 88% and 96% of patients, respectively (the technical success rate was 100%). The mean number of portal tracts was 14.3. Histological diagnosis was achieved in all patients; 67% had SF. The mean EUS-LE was 24.1 kPa, and the mean PPG was 4.6 mmHg. Portal hypertension (PH; PPG >5 mmHg) and clinically significant PH (PPG >10 mmHg) were found in 44% and 12%, respectively. Patients with SF had a higher mean PPG (5.9 vs 2.8 mmHg; p = 0.003) and mean shear wave measurement (SWM; 30.0 vs 15.6 kPa; p = 0.02) compared to the NSF group. Patients with AF had a higher mean PPG (6.0 vs 3.4 mmHg; p = 0.01) and mean SWM (32.0 vs 18.8 kPa; p = 0.04) compared to the NAF group. There were no significant adverse events. Concomitant EUS-LB and PPG is safe. EUS-PPG and EUS-LE correlate with the degree of fibrosis on histology. Larger studies are needed to optimize their values in clinical practice.

Objective To evaluate the feasibility and safety of endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) measurement in the normal porcine model. Methods Four pigs, 2 male and 2 female, aged 8-12 months, weighing 20-30 kg were selected in the experiment. Under general anesthesia and EUS guidance, a 22 G fine needle connected to electrocardiograph monitor with a central vein pressure manometer was used to puncture and measure pressures in the portal vein (PV) and hepatic vein (HV) or inferior vena cava (IVC). Pressures were measured three times for each vessel and the mean pressure was recorded. The PPG was recorded as the difference between the PV pressure and HV or IVC pressure. Vital signs during and after the procedure and operation-related complications were monitored. Results EUS-PPG measurement was successful in all targeted vessels. The PV pressure, HV or IVC pressure, and PPG was 11.0±1.0 mmHg(1 mmHg=0.133 kPa), 7.3±1.1 mmHg and 3.8±0.9 mmHg, respectively. No adverse event occurred. Conclusion EUS-PPG measurement has a high successful rate and reliable accuracy and safety reflecting the portal vein pressure. Key words: Endosonography; Hypertension, portal; Portal pressure gradient; Hepatic venous pressure gradient

Endoscopic ultrasound (EUS) has evolved from a diagnostic to an interventional modality, allowing precise vascular access and therapy. EUS-guided vascular access of the portal vein has received increasing attention in recent years as a diagnostic and therapeutic tool. EUS-guided portal pressure gradient directly measures the hepatic vein portal pressure gradient and is crucial for understanding of liver function and prognostication of liver disease. EUS facilitates the sampling of portal venous blood to obtain circulating tumor cells (CTCs) in pancreatobiliary malignancies. This technique aids in the diagnosis and staging of cancers. EUS-guided interventions have a substantial potential for diagnosing portal vein tumor thrombus (PVTT) in patients with hepatocellular carcinoma. EUS-guided coil and glue embolization have higher efficacy for the treatment of gastric varices than direct endoscopic glue. Pseudoaneurysm (PsA), a rare vascular complication of acute and chronic pancreatitis, is typically managed with interventional radiology (IR)-guided embolization and surgery. EUS is increasingly used in specialized centers for non-variceal gastrointestinal bleeding, particularly for pseudoaneurysm-related bleeding. There is limited data on EUS-guided intervention for bleeding ectopic varices, rectal varices and Dieulafoy lesions, but it is becoming more widely accepted. In this extensive review, we evaluated both current and potential future applications of EUS-guided vascular interventions, including EUS-guided gastric variceal bleed therapy, rectal and ectopic varices, pseudoaneurysmal bleeding, splenic artery embolization, portal pressure gradient measurement, portal vein sampling for CTCs, fine needle aspiration of PVTT, intrahepatic portosystemic shunt placement, liver tumor ablation and EUS-guided cardiac intervention.

Liver-directed therapies such as resection, ablation, and embolization offer potentially curative options for patients with primary and metastatic liver tumors as part of multidisciplinary oncology care. However, these treatments pose significant hepatic decompensation risks, particularly with underlying liver disease and chemotherapy-associated steatohepatitis. Accurate assessment of liver function and portal hypertension (PH) is critical for candidate selection. While Child-Pugh score and model for end-stage liver disease are commonly used, they have substantial limitations. Hepatic venous pressure gradient (HVPG) measurement remains the gold standard for assessing PH but is invasive and not widely available. Endoscopic ultrasound (EUS) guided portal pressure gradient (PPG) measurement has emerged as a promising minimally invasive alternative. EUS-PPG demonstrates excellent technical success rates, safety profile, and correlation with HVPG in early studies. By providing direct portal pressure measurement, EUS-PPG offers several advantages over existing methods for prognostication and risk stratification prior to liver-directed therapies, particularly in detecting presinusoidal hypertension. Furthermore, it has potential applications in assessing response to neoadjuvant treatments and guiding adjuvant therapies. However, research is needed to validate its predictive performance and cost-effectiveness in larger prospective cohorts and to establish its accuracy compared to non-invasive assessment of liver function.

Endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) measurement (EUS-PPG) is a novel technique demonstrated to be safe and feasible. We aimed to: (i) validate the technique against transjugular hepatic venous pressure gradient (TJ-HVPG) measurement; and (ii) evaluate the utility of preoperative EUS-PPG in patients with established or suspected cirrhosis undergoing abdominal surgery. This single-center prospective study was performed between May 2021 and August 2022. Patients planned for abdominal surgery with established or suspected cirrhosis or portal hypertension were recruited. All patients underwent preoperative EUS-PPG and TJ-HVPG measurements. EUS-PPG was performed using a linear echoendoscope and a 25G needle attached to a manometer. Our primary outcome was the correlation between EUS-PPG and TJ-HVPG measurements. Secondary outcomes included the influence on pre-surgical management, 90-day postsurgical mortality, correlation with noninvasive markers and patient-reported procedural preference. Ten patients (F: 5; mean age: 63) underwent EUS-PPG and TJ-HVPG measurements. EUS-PPG measurement was successful in nine patients (90%), with the median pressure gradient strongly correlated between the EUS-PPG (median = 6.65 mmHg; IQR:1.2-15.3) and transjugular measurements (median = 6.5 mmHg; IQR:4.3-12), (R = 0.895; p = 0.001). Three patients had clinically significant portal hypertension (CSPH) based on EUS-PPG and six patients underwent uncomplicated surgeries, including one patient with EUS-PPG proven CSPH who underwent pre-surgical TIPS. There was no 90-day mortality. Patients preferred the EUS-PPG over the TJ-HVPG approach, with significantly higher VAS (9.0 (IQR:8.8-10) versus 5.0 (IQR:4.0-6.0); p < 0.01). EUS-PPG is highly feasible, safe, is preferred by patients and correlates strongly with TJ-HVPG. Preoperative EUS-PPG is a promising decision-making tool associated with reduced postoperative complications.

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide with the prevalence approaching 90% in patients with obesity. Nonalcoholic steatohepatitis (NASH) is an aggressive form of NAFLD with an increased risk of cirrhosis. The treatment for NASH is limited to lifestyle modification. Case Description/Methods: Our patient was a 68-year-old woman with obesity and compensated NASH cirrhosis. She underwent an attempted Roux-en-Y gastric bypass, which was aborted due to cirrhosis. Transient elastography suggested cirrhosis with liver stiffness of 17 kPa. This case represents the convergence of endobariatrics and endohepatology. Specifically, we demonstrate the use of endoscopic gastric plication (EGP) to treat obesity and NASH in a patient with cirrhosis, as well as the application of endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) measurement to monitor its changes following EGP. Prior to EGP, she underwent EUS-guided PPG measurement. Specifically, a transgastric transhepatic puncture with a 25-gauge fine needle aspiration needle into the hepatic vein was achieved. The manometer and needle were flushed with heparinized saline solution. The manometer reading rose and plateaued. The process was repeated at least two more times and the average manometer number represented hepatic venous pressure (HVP). The needle was slowly withdrawn under Doppler. Subsequently, the portal vein was punctured, and the same steps repeated to measure the portal vein pressure (PVP). In this case, the average HVP and PVP were 17 mmHg and 28.5 mmHg. Therefore, her PPG prior to EGP was 11.5 mmHg. The patient then underwent an EGP procedure. The first set of plications was placed in the distal gastric body perpendicular to the length of the stomach to reduce its width. The second and third sets of plications were placed longitudinally to shorten the gastric length. The last set of plications was then placed at the proximal gastric body to further reduce its width. At 9 months, her weight decreased from 279 to 255 pounds, representing an 8.6% weight loss. Her liver stiffness decreased from 17 to 7.6 kPa, suggesting regression from stage 4 to stage 2 fibrosis. A follow-up PPG showed a PPG of 8 mmHg, representing a 30% reduction. Discussion: This case demonstrates the safety and efficacy profile of EGP for the treatment of compensated NASH cirrhosis with improvement in liver fibrosis and PPG. Watch video at https://bit.ly/3i0axL1.

EUS-guided portal pressure gradient measurement: a promising tool in noncirrhotic portal hypertension

Chronic liver disease (CLD) is still a major problem, where the disease progression will lead to liver cirrhosis (LC) or hepatocellular carcinoma (HCC). Portal hypertension (PH) management and loco-regional therapy for HCC have become the cornerstones in advanced liver disease management. Recently, there are studies looking at the potential role of interventional endoscopic ultrasound (EUS) in liver diseases. EUS may be useful in vascular changes of the digestive wall evaluation, performing dynamic assessment of hemodynamic changes, predicting variceal bleeding and rebleeding risk, and assessing the pharmacological effects. In PH management, EUS-guided vascular therapy—which revolves around glue injection, endovascular coil placement/embolization, and combination of both—has shown promising results. As a diagnostic modality for liver cancer, the implementation of EUS in liver diseases is currently not only limited to liver biopsy (EUS-LB) but also in shear-wave elastography (SWE) and portal pressure gradient measurement, as well as portal vein sampling. The application of EUS-guided radiofrequency ablation (EUS-RFA) and tumor injection can also overcome the limitations shown by both modalities without EUS. Nevertheless, establishing EUS as a firm diagnostic and therapeutic modality is still challenging since the performance of interventional EUS requires high expertise and adequate facilities.

665 EUS-GUIDED PORTAL PRESSURE GRADIENT MEASUREMENT SAFELY PERFORMED WITH EUS-GUIDED LIVER BIOPSY: ENDOHEPATOLOGY IN PRACTICE

Background and Objectives:Interventional endoscopic ultrasound (EUS) is a promising novel approach for intravascular interventions. The aim of this study was to assess the feasibility and safety of a EUS-guided intrahepatic portosystemic shunt (EGIPS) with portal pressure gradient measurement in a live porcine model.Methods:The left hepatic vein (LHV) or the inferior vena cava (IVC) was punctured with a needle that advanced into the portal vein (PV). A guidewire was then inserted into the PV, and a needle knife was used to create an intrahepatic fistula between LHV and PV. Portal pressure was recorded. The fistula was dilated with a balloon and a biliary metal stent was deployed between LHV and PV under sonographic and fluoroscopic observation. A portocavography validated the patency of the stent. Necropsies were realized after euthanasia.Results:Portosystemic stenting was achieved in 19/21 pigs. Final portocavography confirmed stent patency between PV and LHV or IVC in 17 pigs (efficacy of 81%): Four stents were dysfunctional as two were thrombosed and two were poor positioned. Portal pressure was documented before and after shunting in 20/21 pigs. Necropsies revealed that 19/21 procedures were transesophageal and two were transgastric. Hemoperitoneum and pneumothorax were found in one pig and hemothorax was found in two pigs. Morbidity was 14.2% (3/21 animals).Conclusion:EGIPS was feasible in 91% of cases, functional in 81%, with 14.2% per procedure morbidity. EGIPS still needs to be assessed in portal hypertension pig models with longer follow-up before being considered as an alternative when the transjugular intrahepatic portosystemic shunt fails.

"One stop" liver-focused endoscopy: EUS-guided portal pressure gradient measurement technique.

Endoscopic ultrasonography

Mo1280 EUS-GUIDED PORTAL PRESSURE GRADIENT MEASUREMENT CAN BE SAFELY COMBINED WITH LIVER BIOPSY DURING A SINGLE ENDOSCOPIC PROCEDURE