Transjugular Intrahepatic Portosystemic Shunt Procedure Research Articles

Ascities after Liver Cirrhosis Diagnosis and Treatment

Ascities after Liver Cirrhosis Diagnosis and Treatment

Transjugular intrahepatic portosystemic shunt: A promising therapy for recompensation in cirrhotic patients.

This is a retrospective study focused on recompensation after transjugular intrahepatic portosystemic shunt (TIPS) procedure. The authors confirmed TIPS could be a treatment for recompensation of patients with cirrhosis according to Baveno VII. The paper identified age and post-TIPS portal pressure gradient as independent predictors of recompensation in patients with decompensated cirrhosis after TIPS. These results need to be validated in a larger prospective cohort.

Higher In-Hospital Mortality among Asian Americans Undergoing Transjugular Intrahepatic Portosystemic Shunt Procedure

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to alleviate portal hypertension in patients with decompensated liver cirrhosis. While prior research highlighted racial disparities in TIPS, Asian Americans were not included in the investigation. This study aimed to investigate disparities in the immediate postprocedural outcomes among Asian American patients who underwent TIPS. Methods: The study identified Asian American and Caucasian patients who underwent TIPS in the National Inpatient Sample from Q4 2015–2020. Preprocedural factors, including demographics, comorbidities, primary payer status, and hospital characteristics, were matched by 1:2 propensity-score matching between the groups. In-hospital outcomes after TIPS were examined. Results: There were 6,658 patients who underwent TIPS with 128 (1.92%) Asian Americans and 4,574 (68.70%) Caucasians, where 218 Caucasians were matched to all Asian Americans. Asian Americans had higher in-hospital mortality (14.06% vs. 7.34%, p = 0.04) and higher total hospital charge (253,756 ± 37,867 vs. 163,391 ± 10,265 US dollars, p = 0.02). The occurrence of hepatic encephalopathy, acute kidney injury, transfers out to other hospital facilities, and length of stay did not differ between cohorts. Conclusion: Despite their heightened risk for cirrhosis, Asian Americans are significantly underrepresented in TIPS and had higher in-hospital mortality after TIPS. This highlights the need for enhanced access to diagnosis and treatment care of liver cirrhosis for Asian Americans.

The smoker's paradox in transjugular intrahepatic portosystemic shunt procedure: A national inpatient sample analysis from 2015 to 2020

ObjectivesTransjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Smoking can adversely impact liver function and has been shown to influence liver-related outcomes. This study aimed to examine the impact of smoking on the immediate outcomes of TIPS procedure. Materials and MethodThe study compared smokers and non-smokers who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015 to 2020. Multivariable analysis was used to compare the in-hospital outcomes post-TIPS. Adjusted pre-procedural variables included sex, age, race, socioeconomic status, indications for TIPS, liver disease etiologies, comorbidities, and hospital characteristics. ResultsCompared to non-smokers, smokers had lower risks of in-hospital mortality (7.36% vs 9.88 %, aOR 0.662, p < 0.01), acute kidney injury (25.57% vs 33.66 %, aOR 0.68, p < 0.01), shock (0.45% vs 0.98 %, aOR 0.467, p = 0.02), and transfer out to other hospital facilities (11.35% vs 14.78 %, aOR 0.732, p < 0.01). There was no difference in hepatic encephalopathy or bleeding. Also, smokers had shorter wait from admission to operation (2.76±0.09 vs 3.17±0.09 days, p = 0.01), shorter length of stay (7.50±0.15 vs 9.89±0.21 days, p < 0.01), and lower total hospital cost (148,721± 2,740.7 vs 204,911±4,683.5 US dollars, p < 0.01). Subgroup analyses revealed consistent patterns among both current and past smokers. ConclusionThis study compared the immediate outcomes of smokers and non-smokers after undergoing the TIPS procedure. Interestingly, we observed a smokers’ paradox, where smoker patients had better outcomes following TIPS. The underlying causes for this smoker's paradox warrant further in-depth exploration.

Quantifying Residual Rivaroxaban Plasma Concentration after Antagonization with Andexanet Alfa: A Difficult Task in Routine Clinical Practice.

We describe the case of a 38-year-old man with a history of chronic portal vein thrombosis who presented with abdominal pain after a transjugular intrahepatic portosystemic shunt procedure. Under anticoagulation therapy with rivaroxaban, he experienced active splenic bleeding, leading to hemodynamic instability. Emergency interventions, including andexanet alfa and nanoparticle administration, successfully stopped the bleeding. However, routine tests showed persistently high rivaroxaban levels despite reversal with andexanet alfa. This case report shows that next to standard anti-Xa activity assay, high-performance liquid chromatography is as well unreliable in this regard. In contrast, viscoelastic tests might better serve as indicators of the efficacy of the reversal. The availability of modified anti-Xa tests is urgently needed, to monitor the effects of andexanet alfa reversal.

Development of a new Cox model for predicting long-term survival in hepatitis cirrhosis patients underwent transjugular intrahepatic portosystemic shunts.

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a procedure that can effectively treat complications of portal hypertension, such as variceal bleeding and refractory ascites. However, there have been no specific studies on predicting long-term survival after TIPS placement. To establish a model to predict long-term survival in patients with hepatitis cirrhosis after TIPS. A retrospective analysis was conducted on a cohort of 224 patients who underwent TIPS implantation. Through univariate and multivariate Cox regression analyses, various factors were examined for their ability to predict survival at 6 years after TIPS. Consequently, a composite score was formulated, encompassing the indication, shunt reasonability, portal venous pressure gradient (PPG) after TIPS, percentage decrease in portal venous pressure (PVP), indocyanine green retention rate at 15 min (ICGR15) and total bilirubin (Tbil) level. Furthermore, the performance of the newly developed Cox (NDC) model was evaluated in an internal validation cohort and compared with that of a series of existing models. The indication (variceal bleeding or ascites), shunt reasonability (reasonable or unreasonable), ICGR15, postoperative PPG, percentage of PVP decrease and Tbil were found to be independent factors affecting long-term survival after TIPS placement. The NDC model incorporated these parameters and successfully identified patients at high risk, exhibiting a notably elevated mortality rate following the TIPS procedure, as observed in both the training and validation cohorts. Additionally, in terms of predicting the long-term survival rate, the performance of the NDC model was significantly better than that of the other four models [Child-Pugh, model for end-stage liver disease (MELD), MELD-sodium and the Freiburg index of post-TIPS survival]. The NDC model can accurately predict long-term survival after the TIPS procedure in patients with hepatitis cirrhosis, help identify high-risk patients and guide follow-up management after TIPS implantation.

Association between endotoxemia and blood no in the portal circulation of cirrhotic patients: results of a pilot study.

Pathophysiology of portal vein thrombosis (PVT) in cirrhosis is still not entirely understood. Elevated levels of lipopolysaccharides (LPS) in portal circulation are significantly associated with hypercoagulation, increased platelet activation and endothelial dysfunction. The aim of the study was to investigate if LPS was associated with reduced portal venous flow, the third component of Virchow's triad, and the underlying mechanism. Serum nitrite/nitrate, as a marker of nitric oxide (NO) generation, and LPS were measured in the portal and systemic circulation of 20 patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) procedure; portal venous flow velocity (PVV) was also measured in each patient and correlated with NO and LPS levels. Serum nitrite/nitrate and LPS were significantly higher in the portal compared to systemic circulation; a significant correlation was found between LPS and serum nitrite/nitrate (R = 0.421; p < 0.01). Median PVV before and after TIPS was 15 cm/s (6-40) and 31 cm/s (14-79), respectively. Correlation analysis of PVV with NO and LPS showed a statistically significant negative correlation of PVV with portal venous NO concentration (R = - 0.576; p = 0.020), but not with LPS. In vitro study with endothelial cells showed that LPS enhanced endothelial NO biosynthesis, which was inhibited by L-NAME, an inhibitor of NO synthase, or TAK-242, an inhibitor of TLR4, the LPS receptor; this effect was accomplished by up-regulation of eNOS and iNOS. The study shows that in cirrhosis, endotoxemia may be responsible for reduced portal venous flow via overgeneration of NO and, therefore, contribute to the development of PVT.

CBCT-based three-dimensional dual-phase vascular image fusion: anovel technique for interventional real-time TIPS guidance.

Due to the invisibility of the portal vein (PV), how to puncture the PV accurately and safely in transjugular intrahepatic portosystemic shunt (TIPS) creation remains achallenge of the procedure. We aimed to provide the first evaluation of the safety, feasibility, and efficiency of cone beam computed tomography (CBCT)-based three-dimensional (3D) dual-phase vascular image fusion for interventional real-time guided PV puncture during TIPS procedures. From January 2021 to May 2021, 13patients undergoing TIPS were prospectively enrolled in this study. Images of the hepatic artery (HA) and PV in 3D were acquired and overlaid on interventional fluoroscopy images in adual-phase display mode for real-time PV puncture guidance. The number of PV puncture attempts, puncture time, overlaid image accuracy, dose area product, fluoroscopy time, and interventional complications were recorded. Portal vein puncture guided by CBCT-based 3D dual-phase vascular image fusion was successfully performed on 92.3% (12/13) patients. The mean number of PV puncture attempts was 1.8 ± 0.7 (1-3). The mean puncture time and fluoroscopy time was 3.5 ± 1.2 (2-6) min and 25.1 ± 9.4 (15-45) min, respectively. The mean dose area product was 39.49 ± 7.88 (28.81-52.87) mGym2. The error between the reference position of the fusion image and the interventional PV angiography image was less than 0.5 cm. No interventional complication was observed. Our results show that 3D dual-phase vascular image fusion might be asafe and feasible technique for interventional real-time guided PV puncture during TIPS. This novel technique might help to reduce the number of PV puncture attempts and the puncture time as well as lower the risks of interventional complications.

Disparity Among African Americans in Transjugular Intrahepatic Portosystemic Shunt Procedure: A National Inpatient Sample Analysis from 2015 to 2020.

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Racial disparities were present in TIPS where numerous studies suggested African American patients experience higher in-hospital mortality rates. However, the incidence of post-TIPS surgical complications, such as HE, has yet to be examined among African Americans. Therefore, this study aimed to provide a comprehensive examination of the disparities in TIPS procedures among African American patients. The study compared African American and Caucasian patients who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015-2020 after ICD-10 change. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were examined and multivariable analysis was used to assess outcomes correcting preoperative variables with p < 0.1. Compared to Caucasians, African Americans had higher in-hospital mortality (16.18 vs 8.22%, aOR 1.781, p < 0.01), hepatic encephalopathy (33.09 vs 27.44%, aOR 1.300, p = 0.05), and acute kidney injury (45.59 vs 29.60%, aOR 2.019, p < 0.01). Using the generalized linear model, African Americans have longer length of stay (11.04 ± 0.77days vs 8.54 ± 0.16days, p < 0.01). Despite a higher prevalence of cirrhosis, African Americans continue to have marked underrepresentation in TIPS procedures in recent years. Their underrepresentation, in conjunction with higher mortality, morbidity, and increased comorbidity conditions, could imply disparity in accessing care. This finding underscores the necessity for improved access to diagnostic and therapeutic services for African Americans with liver cirrhosis.

Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting.

Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS "towards transplant" can offer advantages in terms of ameliorating a patient's clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting.

Transjugular intrahepatic portosystemic shunt for portal hypertension with chronic portal vein occlusion

PurposeThis study aims to evaluate the long-term patency of transjugular intrahepatic portosystemic shunt (TIPS) and determine the predictors of shunt dysfunction in patients with chronic portal vein occlusion (CPVO). MethodThis retrospective study was conducted from December 2010 to December 2020 in patients with portal hypertension and CPVO. Patients were followed up from initial TIPS insertion to December 2022 or death. Details of TIPS procedure, adverse events and clinical outcomes were recorded. The cumulative rate of shunt patency was calculated by the Kaplan-Meier method and compared by using the log-rank test. Independent predictors of shunt dysfunction were calculated with the Cox regression model. A nomogram comprising independent variables was developed to enhance the predictive accuracy of shunt patency. ResultsOne hundred six patients (mean age, 45.3 years ± 13.6; 71 males and 35 females) were enrolled in the study. TIPS procedure was technically successful in 100 of 106 patients (94.3 %). The primary shunt patency rates for all 100 patients were 78.9 %, 74.7 %, 67.2 %, and 62.4 % at 6, 12, 24, and 36 months, respectively, and the overall shunt patency rates were 88.9 %, 86.8 %, 83.6 %, and 81.2 % at 6, 12, 24, and 36 months, respectively. Independent predictor of shunt dysfunction were inadequate inflow from superior mesenteric vein or splenic vein (the maximum diameter < 8 mm) and platelet count ≥ 300 × 109/L. The developed nomogram is a simple tool for accurately predicting shunt patency. ConclusionsIn patients with CPVO, inadequate inflow and high platelet count are important factors for TIPS dysfunction.

Analysis of transjugular intrahepatic portosystemic shunt by hemodynamic simulation.

Transjugular intrahepatic portosystemic shunt (TIPS), which artificially creates a portocaval shunt to reduce portal venous pressure, has gradually become the primary treatment for portal hypertension (PH). However, there is no prefect shunting scheme in TIPS to balance the occurrence of postoperative complications and effective haemostasis. To construct cirrhotic PH models and compare different shunting schemes in TIPS. Three cases of cirrhotic PH with different liver volumes were selected for enhanced computed tomography scanning. The models for different shunting schemes were created using Mimics software, and following FLUENT calculation, all the models were imported into the software computational fluid dynamic-post for processing. In each shunting scheme, the differences in portal vein pressure, hepatic blood perfusion and blood flow from the superior mesenteric vein in the shunt tract were compared. The coefficient G was adapted to evaluate the advantages and disadvantages. (1)Concerning the precise location of the shunt tract, the wider the diameter of the shunt tract, the lower the pressure of the portal vein and the lesser the hepatic blood perfusion. Meanwhile, the pressure drop objective was not achieved with the 6 mm-diameter shunting scheme. (2)The 8 mm-diameter shunting scheme through the left portal vein (LPV) had the highest coefficient G. The 8 mm-diameter shunting scheme through the LPV may demonstrate a superior effect and prognosis in TIPS procedures.

A streamlined controlled-expansion covered tapered stent for TIPS in the treatment of PHT

Transjugular intrahepatic portosystemic shunt (TIPS) relieves cirrhotic complications by reducing portacaval pressure gradient (PCG), but it lacks precision in achieving a targeted post-TIPS PCG simply through diameter adjustment of equal diameter stents. This study aimed to present a controlled-expansion, streamlined, and covered tapered stent, and examined its effects on pressure reduction compared with equal- diameter stents. Twenty-four patients who underwent standardized 8-mm stent TIPS implantation at West China Hospital from December 2017 to February 2021 were included in the current study. Virtual equal-diameter stent graft with different diameter and streamlined tapered stents were created in the post-TIPS 3-dimentional models reconstructed based on computed tomography angiography data. The numerical simulation showed that only two patients achieved targeted post-TIPS PCG consistent with the clinical invasive measurement. When 6-mm and 10-mm equal-diameter stents were employed, simulated post-TIPS PCGs for most patients remained outside the safe range, and recirculating flow was observed at the stent-portal vein anastomosis. In contrast, the use of the new streamlined taper stent resulted in post-TIPS PCGs within the 10–12 mmHg range for 17 out of 24 patients, with no recirculating flow observed at the anastomotic sites. In conclusion, the streamlined tapered stent could pose an effective solution to the problem that the big jump depressurization between two different equal-diameter stents and it would improve the hemodynamics in the region near the PV-stent anchorage. Therefore, the streamlined tapered stent may present a superior alternative for TIPS procedure.

Advanced chronic renal disease is an independent risk factor for inpatient mortality following transjugular intrahepatic portosystemic shunt procedure.

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate portal hypertension in patients with decompensated liver cirrhosis. However, the risks and outcomes associated with TIPS in patients with advanced chronic kidney disease (CKD) remain uncertain. This study aimed to investigate the perioperative outcomes of TIPS procedures in patients with advanced CKD using the National Inpatient Sample (NIS) database, a comprehensive all-payer inpatient database in the US. The study identified patients who underwent TIPS procedures in the NIS database from Q4 2015 to 2020. Patients with advanced CKD were identified using specific ICD-10-CM codes, and they were compared to patients without CKD. Preoperative variables, including demographics, indications for TIPS, comorbidities, APR-DRG subclass, primary payer status, and hospital characteristics, were noted. Perioperative outcomes were examined by multivariable logistic regression. A total of 248 patients with advanced CKD and 5511 patients without CKD undergoing TIPS procedures were identified in the NIS database. Compared to non-CKD, patients with advanced CKD had higher mortality (13.70% vs. 8.60%, aOR = 1.56, P = 0.03), acute kidney injury (51.21% vs. 29.34, aOR = 1.46, P < 0.01), transfer out (25.00% vs. 12.84%, aOR = 1.88, P < 0.01), and length of stay over 7 days (64.11% vs. 38.97%, aOR = 2.34, P < 0.01). However, there was no difference in hepatic encephalopathy (31.85% vs. 27.19%, aOR = 1.12, P = 0.42). Advanced CKD patients undergoing TIPS are at higher risk of mortality and AKI compared to patients without CKD; HE was mildly elevated but NS. Long-term prognosis of patients with advanced CKD who had TIPS is needed in future studies.

Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis.

Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.

Hepatic venous pressure gradient: Inaccurately estimates portal venous pressure gradient in alcoholic cirrhosis and portal hypertension.

Portal hypertension (PHT) in patients with alcoholic cirrhosis causes a range of clinical symptoms, including gastroesophageal varices and ascites. The hepatic venous pressure gradient (HVPG), which is easier to measure, has replaced the portal venous pressure gradient (PPG) as the gold standard for diagnosing PHT in clinical practice. Therefore, attention should be paid to the correlation between HVPG and PPG. To explore the correlation between HVPG and PPG in patients with alcoholic cirrhosis and PHT. Between January 2017 and June 2020, 134 patients with alcoholic cirrhosis and PHT who met the inclusion criteria underwent various pressure measurements during transjugular intrahepatic portosystemic shunt procedures. Correlations were assessed using Pearson's correlation coefficient to estimate the correlation coefficient (r) and determination coefficient (R2). Bland-Altman plots were constructed to further analyze the agreement between the measurements. Disagreements were analyzed using paired t tests, and P values < 0.05 were considered statistically significant. In this study, the correlation coefficient (r) and determination coefficient (R2) between HVPG and PPG were 0.201 and 0.040, respectively (P = 0.020). In the 108 patients with no collateral branch, the average wedged hepatic venous pressure was lower than the average portal venous pressure (30.65 ± 8.17 vs. 33.25 ± 6.60 mmHg, P = 0.002). Hepatic collaterals were identified in 26 cases with balloon occlusion hepatic venography (19.4%), while the average PPG was significantly higher than the average HVPG (25.94 ± 7.42 mmHg vs 9.86 ± 7.44 mmHg; P < 0.001). The differences between HVPG and PPG < 5 mmHg in the collateral vs no collateral branch groups were three cases (11.54%) and 44 cases (40.74%), respectively. In most patients, HVPG cannot accurately represent PPG. The formation of hepatic collaterals is a vital reason for the strong underestimation of HVPG.

Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives

Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis.

Role of erector spinae plane block in transjugular intrahepatic portosystemic shunt procedure: A randomized controlled trial

ABSTRACT Background Anesthesia for transjugular intrahepatic portosystemic shunt (TIPS) for lowering raised portal pressure is clinically challenging. As patients, candidates for TIPS are medically complex due to chronic liver disease, adding to remote area anesthesia’s complexities. Multimodal analgesia, including erector spinae plane block (ESPB), can improve anesthesia quality with patient satisfaction. Methods Fifty-six patients scheduled for TIPS, aged 18–60 years and with Child classification A or B, were randomly allocated into two groups. The ESPB group experienced ESPB (n = 24), while the control group was introduced with sedation spontaneously breathing (n = 24). Primarily, we investigated the records of the hemodynamic profile and analgesia nociceptive index (ANI). As a secondary aim, we recorded the opioid consumption, complication incidence, and patient and interventional radiologist satisfaction scores. Results Heart rate was significantly lower in the ESPB group at the beginning of the procedure, liver puncture, and balloon dilatation events, while there were no significant differences in mean blood pressure. Analgesia assessment by ANI was significantly higher in the ESPB group indicating adequate analgesia. Opioid consumption was significantly lower in the ESPB group than in the control group. Statistical analysis for patient satisfaction showed better results in the ESPB group, while the surgeon satisfaction score showed no significant statistical differences. Conclusion ESPB could be recommended as an alternative to analgesia in TIPS and its vulnerable patients to improve safety by reducing sedation-related morbidity and complications with improving the patient’s degree of satisfaction.

Safety and Effectiveness of a Novel Tips Access Set with Steerable Cannula in a Swine Model

PurposeThis study aimed to assess the safety, effectiveness, and feasibility of the Liverty™ transjugular intrahepatic portosystemic shunt (TIPS) access set, which has an ergonomic handle that allows for in situ cannula tip deflection and a distal steerable cannula angle, versus the COOK® Rosch-Uchida Transjugular Liver Access Set (RUPS-100) in healthy pigs.MethodsTwelve pigs randomly underwent TIPS with the Liverty™ set or the RUPS-100 set. Three interventionalists performed 4 TIPS procedures, 2 with each set. The primary outcome was procedural success, defined as successful establishment of the intrahepatic portosystemic shunt and stent placement.ResultsThe shunt was successfully established in 11 pigs. The procedural success was achieved in all 6 pigs in the Liverty™ group and 5 out of 6 pigs for the RUPS-100 group (Fisher exact test, P > 0.999). The mean duration of puncture was shorter in the Liverty™ group versus the RUPS-100 group (12.3 ± 4.5 min vs. 16.2 ± 8.5 min), but without significant statistical difference (two sample t test, P = 0.359). The cannula angle was adjusted 69% of passes in the Liverty™ group, which was significantly higher than that in the RUPS-100 group (12%, P = 0.004). Overall, the TIPS procedural performance was comparable between the groups. Both sets were safe. No intraabdominal hemorrhage, vascular injuries, tissue or organ injuries, porto-biliary fistula, biliary peritonitis, and infection or abscess occurred in either group.ConclusionThe Liverty™ set is safe and has similar procedural metrics to the COOK® RUPS-100 set. It allows in situ adjustment of the angle of the stiffening cannula without increasing procedure time and lessens the occurrences of periprocedural complications.Graphical

Co-Relation between MELD Scoring System prior Living Donor Liver Transplantation and Occurrence of Post-Transplant Biliary Complications

Background Liver transplantation is considered the treatment of choice for patients with end stage liver disease who have failed standard medical and surgical therapy. The development of liver transplantation has revolutionized the field of hepatology and greatly improved the outlook of patients suffering from various liver diseases. The Model for EndStage Liver Disease, or MELD, is a scoring system for assessing the severity of chronic liver disease. It was initially developed to predict mortality within three months of surgery in patients who had undergone a transjugular intrahepatic portosystemic shunt (TIPS) procedure and was subsequently found to be useful in determining prognosis and prioritizing for receipt of a liver transplant. This score is now used by the United Network for Organ Sharing (UNOS) and Eurotransplant for prioritizing allocation of liver transplants instead of the older Child-Pugh score. Biliary tract complications are abundantly occurring post-operative, and they may include a variety of scenarios, as biliary leakage, ischemic bile duct injuries, and biliary stenosis. Aim of the Work Aim of the work is to study the relation between the Model of End Stage Liver Disease (MELD) scoring system and the occurrence of post liver transplantation biliary complications. Patients and Methods A combined retrospective and prospective cohort study was carried out. We retrospectively analyzed the available database of all patients that underwent LDLT, at Ain Shams Center of Organ Transplantation (ASCOT), during the period from January 2013 till May 2019, and suffered from post-operative biliary complications during the first 3 months Post-operative and correlated it with their MELD score before the operation. To do so, we studied 50 patients that are aged more than or equal 18 years old, any gender, that underwent living donor liver transplantation. We excluded patients with cholestatic liver disease and patients that underwent preoperative biliary intervention. All patients were subjected to complete history taking and thorough clinical examination, full laboratory workup, full radiological workup, post-operative cholangiography and Endoscopic retrograde colangio-pancreatography if needed.