Safety and efficacy of transjugular intrahepatic portosystemic shunt therapy for symptomatic portal biliopathy
Year: 2023
Type: article
Abstract: Portal biliopathy (PB) is characterized by an abnormality in the extrahepatic biliary system in patients with chronic portal vein occlusion or cavernous transformation of the portal vein. It is a rare biliary complication secondary to portal hypertension.1 Symptomatic PB refers to recurrent cholangitis and chronic cholestasis with pain caused by biliary strictures or stones. The management of symptomatic PB is limited to case reports, including endoscopic, interventional radiology, and surgical procedures. Transjugular intrahepatic portosystemic shunt (TIPS), an effective therapy for portal hypertension, has been indicated for the cavernous transformation of the portal vein in patients with cirrhosis; however, its role in the management of PB remains unclear. This study aimed to evaluate the efficacy of covered TIPS in patients with symptomatic PB. Patients with symptomatic PB who underwent TIPS between January 2017 and June 2022 were retrospectively screened using a prospectively maintained database. The study protocol was approved by the Ethics Committee of Nanjing Drum Tower Hospital. Informed consent was obtained from all the patients. Laboratory examinations and imaging tests, such as abdominal computed tomography, doppler ultrasonography, and magnetic resonance cholangiopancreatography, were performed. Obstructive jaundice or cholangitis are considered necessary symptoms of symptomatic PB. Outcomes included technical success, procedure-related complications, cholangitis recurrence, portal hypertension complication recurrence, and overall survival. Data are described as frequencies and percentages, means and standard deviations, or medians (ranges), as appropriate. The Statistical Package for Social Sciences (version 22.0, SPSS, IBM, Chicago, IL, USA) was used for statistical analysis. In total, six patients were analyzed. All six patients experienced recurrent cholangitis before undergoing TIPS therapy. The patient characteristics are shown in Supplementary Table S1. Portal vein thrombosis in four patients was secondary to noncirrhotic causes, including leukemia and abdominal surgery, while two patients had liver cirrhosis and a history of splenectomy. Beta-blockers were not administered to these patients. Three patients underwent endoscopic retrograde cholangiopancreatography (ERCP) before TIPS, while two patients suffered from severe hemobilia. Two patients had a history of esophagogastric variceal bleeding and underwent endoscopy. Among them, two patients received percutaneous transhepatic cholangial drainage (PTCD)–TIPS–ERCP continuation treatment because of severe intrahepatic bile duct dilatation combined with severe esophagogastric varices (Figure 1). Technical success was achieved in five patients with TIPS. All procedures were performed using a RUPS-100 (COOK) under local anesthesia. Indirect portal vein angiography combined with the introduction of a microcatheter into the hepatic artery as a marker was used in three patients, while a balloon-marked portal vein through a percutaneous transhepatic approach was used in three patients. One patient suffered biliary injury due to a puncture of the portal vein; however, no clinically significant adverse events were observed. All patients had 8-mm VIATORR stents (W. L. Gore & Associates) inserted. The average portosystemic gradient decreased from 23 to 10 mmHg. No major procedure-related complications were observed. No patients experienced variceal bleeding or recurrent cholangitis up to 1 year after the procedure. Two patients underwent an additional ERCP after TIPS for biliary strictures that did not cause hemobilia. One patient had TIPS dysfunction and underwent stent revision 6 months after the initial procedure. No overt hepatic encephalopathy occurred in this cohort. In this study, we report case series describing TIPS therapy for the management of PB. The goal of treating symptomatic PB is to resolve biliary complications and reduce portal pressure,2, 3 which might be a novel indication for TIPS.4 TIPS improves peribiliary vascular plexus varicosis in treating PB and makes therapeutic ERCP safer by reducing the risk of hemobilia.5 However, the TIPS procedure may be rather difficult because of the cavernous transformation of the portal vein and biliary dilatation. In our cohort, the continuation of PTCD-TIPS-ERCP was an effective and safe strategy for complicated PB accompanied by severe esophagogastric varices and biliary dilatation. PTCD compresses the biliary dilatation to reduce the risk of TIPS, whereas TIPS resolves portal hypertension and reduces the risk of ERCP. Portal vein puncture and recanalization during TIPS for PB were difficult. Transsplenic and transhepatic approaches and indirect portal vein angiography were all effective for guidance.6, 7 During follow-up, no patient developed overt hepatic encephalopathy or liver failure, which is the main drawback of TIPS therapy in patients with decompensated cirrhosis and poor liver function. Therefore, TIPS appears to be a safe and effective method for resolving the recurrence of cholangitis and portal hypertension which improves the prognosis of patients with symptomatic PB. Feng Zhang and Xixuan Wang performed data curation. Feng Zhang, Ming Zhang, and Xixuan Wang developed the formal analysis. Feng Zhang and Yuzheng Zhuge provided funding. Feng Zhang, Wei Zhang, and Ming Zhang performed the experiments. Feng Zhang, Xixuan Wang, and Wei Zhang developed the methodology. Yuzheng Zhuge wrote, reviewed, and revised the manuscript. Wei Zhang performed the validation. Lei Wang and Yuzheng Zhuge provided conceptualization and supervision. All the authors have read and approved the final manuscript. None. The authors declare no conflict of interest. None. The study protocol was approved by the Ethics Committee of Nanjing Drum Tower Hospital and informed consent was obtained from all the patients. The data used to support the findings of this study are included within the article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
Source: Portal hypertension & cirrhosis
DOI: 10.1002/poh2.54
Authors: Feng Zhang, Xixuan Wang, Wei Zhang, Ming Zhang, Lei Wang, Yuzheng Zhuge
Language: English
Subfield: Hepatology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4386966974