RPS 2409 - Hepato-biliary interventions in benign conditions

Author Block: P. Marra¹, D. Barnés Navarro², L. F. Fernández Rodríguez³, G. Barbiero⁴, S. Mcguirk⁵, C. Gonzalez-Junyent², T. Hernández Cabrero³, M. C. Minà⁴, S. Sironi¹; ¹Bergamo/IT, ²Barcelona/ES, ³Madrid/ES, ⁴Padova/IT, ⁵Birmingham/UK
Purpose: Percutaneous transhepatic cholangiography (PTC), billioplasty and biliary drainage are routine treatments for benign strictures after pediatric liver transplantation (pLT). This multicentric study evaluated the efficacy and safety of biodegradable biliary stents.
Methods or Background: ELLA (Ella-CS Ltd) is self-expandable stent made of polydioxanone which degrades in 3-6 months. We evaluated a total of 81 patients (39 females, median age 4 y/o; 42 males, median age 5 y/o) with benign biliary strictures developed after pLT in five European centers. All the patients underwent percutaneous bilioplasty followed by ELLA stent placement between October 2014 and March 2024. Stricture features and treatment timing were assessed. Efficacy in terms of freedom from stricture recurrence and safety in terms of complications were analyzed.
Results or Findings: Regarding stricture features, 42.7% of strictures had and extension <1 cm, 57.3% ≥1 cm; 69.7% of patients had strictures at the hepaticojejunostomy, 2.5% had intrahepatic strictures and 28% had both intrahepatic and anastomotic strictures. The time between PTC and stent placement varied from 0 to 744 days (median of 36 days, IQR 61 days) with maintainance of a drainage; 53/81 (65.4%) patients underwent additional bilioplasty sessions before ELLA placement. Successful stent placement was achieved in 100% of cases and complications occurred in 23.5% of cases, all minor, mostly infectious cholangitis. Eighteen patients had a stricture recurrence (22.2%) during a median follow-up of 784 days (IQR 1200 days); of these, 55.6% were retreated with ELLA.
Conclusion: Biodegradable self-expandable biliary stent are be safe and effective for the treatment of benign biliary strictures after pLT. Further studies investigating factor predisposing to stent failure with standardized protocols are required to define the ideal candidates and the best timing for stenting.
Limitations: Retrospective design; variable protocols among centers
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Comitato Etico of Bergamo - Multicenter ELLA

Author Block: P. Marra, R. Muglia, F. S. Carbone, L. Dulcetta, L. D'Antiga, S. Sironi; Bergamo/IT
Purpose: Portal hypertension resulting from extrahepatic portal vein obstruction (EHPVO) in children has been managed primarily through Meso-Rex bypass. The aim of the study is to report a preliminary series of patients who underwent attempts at portal vein recanalization (PVR) prior to other types of intervention.
Methods or Background: A cohort of consecutive patients with EHPVO from 2021-2024 was retrospectively collected. After transjugular wedge hepatic venography for the study of the native intrahepatic portal system, percutaneous PVR was attempted via transhepatic and/or transplenic access. Clinical and procedural data, technical and clinical success, complications and follow up data were recorded. Technical success was considered at least the partial revascularization of the native portal system.
Results or Findings: Fifteen patients (7 males; median age 8 years) with severe portal hypertension due to EHPVO underwent 20 percutaneous transhepatic (n=1), transplenic (n=12) or simultaneous transhepatic/transplenic (n=7) attempts at portal vein recanalization. Rex vein was judged patent ad wedge hepatic venography in 2/15 (13%). Successful recanalization was achieved in 9/15 patients (60%). No major adverse events were observed. After successful angioplasty, 8/9 patients required metal stenting to obtain sustained patency. None of the failed patients was considered eligible for Meso-Rex bypass and underwent TIPS (n=2), splenectomy (n=1), surgical shunt (n=1). Two patients were followed-up without further interventions. After a median follow-up of 6 months patency of the main portal vein was demonstrated in all the patients who achieved PVR, with clinical and laboratory improvement of portal hypertension.
Conclusion: Our preliminary experience suggests that 60% of children with EHPVO can restore the portal flow by endovascular treatment, even with obliterated Rex vein. Thanks to its low invasiveness, PVR may be regarded as the primary intervention, before considering surgery.
Limitations: Retrospective study with limited sample
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: EC of Bergamo - Portal-01

Author Block: A. Princi, P. Marra, F. S. Carbone, L. Dulcetta, R. Muglia, S. Sironi; Bergamo/IT
Purpose: TIPS creation with the standard technique may be challenging in children with low body weight, unusual anatomy, and liver grafts. This study analyses different approaches for TIPS creation in a retrospective cohort of paediatric patients.
Methods or Background: The retrospective single-centre cohort included 47 patients who received TIPS either with the standard (sTIPS; n:30 median age 10 years IQR8-16) or with a transhepatic/transplenic ‘’hybrid’’ (hTIPS; hTIPS n:17 13y IQR7-16) approaches from 2005 to 2023. Inclusion criteria were age ≤ 18 years or liver graft transplanted in paediatric age. All the variables between the sTIPS and the hTIPS group were compared.
Results or Findings: Technical, hemodynamic, and clinical success were 100%, 100%, and 83% in sTIPS (8 permanent, 22 as bridge) while 100%, 97%, and 81% in hTIPS (10 permanent, three bridge). Patients with liver grafts were 4 (13%) in the sTIPS and 5 in the hTIPS (30%) groups, respectively. Portal cavernoma, acute portal vein thrombosis, and Budd-Chiari syndrome were significantly more prevalent in the hTIPS group (76% vs 33%, p<0.05). Indications were comparable. Covered stents were respectively employed in 90% sTIPS and 88% hTIPS, with primary-assisted patency of 100% and 93% after a median follow-up of 34 and 14 months (IQR 21-52 and 12-20). Complications included one hemoperitoneum in each group conservatively managed, one liver failure (hTIPS group) requiring urgent transplantation and one septic shock (sTIPS group). Eight shunt dysfunctions in sTIPS and 3 in hTIPS were all successfully treated.
Conclusion: In a retrospective cohort of children, hybrid techniques for TIPS creation achieved high success rates comparable to the standard technique despite unfavourable baseline characteristics. Further studies may investigate the role of these approaches in expanding TIPS indication for complex scenarios in paediatric patients.
Limitations: Retrospective nature.
Funding for this study: None.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: Not applicable.

Author Block: F. Schön, T. Helmberger, M. Berning, S. F. U. Blum, C. Radosa, S. Löck, R-T. Hoffmann, J-P. Kühn; Dresden/DE
Purpose: To investigate early laboratory changes following Transjugular Intrahepatic Portosystemic Shunt (TIPS) and their associations with short-term mortality.
Methods or Background: TIPS procedures from 2017 to 2023 were enrolled retrospectively. Laboratory parameters (INR, ALAT, ASAT, GGT and bilirubin) were assessed once pre-procedurally, on post-procedural days 1 or 2, and once again between days 5 and 7. Percentage changes from baseline were calculated for each parameter. Temporal changes of the parameters were assessed using Kruskal-Wallis tests, and comparisons regarding 30-day mortality were evaluated using Mann-Whitney U tests.
Results or Findings: A total of 245 TIPS procedures (161 men, mean age 59.8 +/- 10.9 years) were enrolled, with a technical success rate of 95.5% (234/245). All laboratory parameters significantly increased post-procedurally (p < 0.001). ALAT and ASAT revealed the highest increase within the first two post-procedural days (+374 +/- 1118%, and +450 +/- 1079%, respectively), followed by decreases on days 5-7 (+279 +/- 568%, and +125 +/- 233%, respectively). Patients who died within 30 days (n = 17) had significantly higher baseline INR (p = 0.009), ASAT (p = 0.014) and bilirubin (p = 0.011), while GGT was lower (p = 0.012). 30-day mortality was associated with a higher increase of ASAT and GGT on days 1/2 (+1361 +/- 2202% vs. +415 +/- 954%, p = 0.029; and +56 +/- 101% vs. +21 +/- 51%, p = 0.034, respectively).
Conclusion: TIPS significantly impacts liver function, with marked early increases of ALAT and ASAT levels. Pronounced increase of laboratory parameters within the first two post-procedural days might help to identify high-risk patients in terms of short-term mortality.
Limitations: Retrospective study design with a relatively small number of patients.
Funding for this study: Not applicable.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The present study was approved by the local ethics committee (BO-EK-501122023).

Author Block: U. Koç, C. Aydın, M. Özdemir; Ankara/TR
Purpose: We aimed to evaluate cases of giant liver hydatid cysts.
Methods or Background: Between December 2020 and January 2023, out of 100 liver hydatid cysts treated with the percutaneous approach in our interventional radiology department, 35 cases were more than 10 cm in one of the diameters. These giant hydatid cysts were treated with the catheterization approach which includes trochar style puncture, aspiration of the cavity, and installation with hypertonic saline solution. Then, ethanol installation of the cyst is the next step if the cavity is not connected with the biliary tree.
Results or Findings: Out of 35 patients, 27 (78%) patients were treated successfully with catheter approach solely without the need of ERCP related interventions. 8 patients (22%) needed further interventions with ERCP because of cystobiliary fistula; 2 out of 8 patients had biliary passage confirmed after contrast installation at catheterization. Other 6 patients did not have opaque drainage into the biliary system, rather they were suspected of having a fistula because of yellow content or biochemistry showing high bilirubin. These 8 patients had extended days of external catheter duration, about 20 days on average; while other patients had the external catheter removed approximately 2 days later. 1 patient had to go through cystectomy operation because of insufficient drainage after repeated ERCP interventions, and this patient had the longest hospitalization duration of 100 days; whilst other ERCP patients had 20 days of hospitalization on average.
Conclusion: Giant hydatid cysts are manageable with a percutaneous approach. Cystobiliary fistula must be kept in mind especially for the giant hydatid cysts, since size is an important predictor for this communication.
Limitations: As a limitation, this study did not compare the method with others, but a future study will address this.
Funding for this study: None
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: None

Author Block: E. D. L. A. Salazar Perez, E. E. Lozada Hernandez, B. E. E. Retamoza Rojas; Leon/MX
Purpose: This meta-analysis examines the incidence of bleeding in patients undergoing biliary diversion via two alternatives to ERCP: percutaneous and endoscopic methods. The analysis aims to establish a foundation for identifying the most suitable treatment by evaluating effectiveness and safety. The primary goal of managing biliary tract obstruction is to achieve safe and effective drainage, with proper patient selection and diagnosis being essential for determining the best procedure.
Methods or Background: Eleven studies were analyzed regarding the incidence of bleeding, pancreatitis, and reinterventions associated with endoscopic or percutaneous biliary drainage procedures from January 2010 to 2023. The evaluated aspects included sensitivity, risk of bias ratio, odds ratio, and their 95% confidence interval using a random-effects model, with effects considered statistically significant if the confidence interval was at 95%. The I² statistic was calculated to assess heterogeneity. Bias analysis was reported using funnel plot tables. Data processing was performed using the R programming language within the RStudio environment (version 4.1.0 CRAN). Any p-value less than 0.05 was considered statistically significant.
Results or Findings: The study evaluated complications and reinterventions for two techniques of biliary diversion: the percutaneous method, involving 2,058 patients from 11 studies, and the endoscopic method, with 7,959 patients. The overall odds ratio for bleeding was 1.81 (95% CI 0.43-7.60), with heterogeneity (I² = 74%). For acute pancreatitis, the overall odds ratio was 0.15 (95% CI 0.05-0.47) with p = 0.03. Reinterventions showed an odds ratio of 0.25, with a wide confidence interval [0.06; 1.51], reflecting high heterogeneity and variability among the studies.
Conclusion: The percutaneous technique, as a first-line option compared to many other emerging techniques, remains the ideal choice in many referral centers for diseases presenting with biliary tract obstruction, showing minimal complication rates.
Limitations: Heterogeneity.
Funding for this study: There is no funding or conflict of interest.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The registration for the approval of the hospital was the CEI-004-2022

Author Block: H. N. Lee¹, S-J. Park², Y. Cho³, S. Lee¹; ¹Cheonan/KR, ²Ansan/KR, ³Gangneung/KR
Purpose: To compare the clinical outcomes of separate versus single tract techniques and to investigate predictors of complications during percutaneous radiologic gastrostomy with single gastropexy.
Methods or Background: Between January 2018 and January 2024, 241 consecutive patients (mean age: 68.8 ± 13.5 years; male: 73.4%) who underwent percutaneous radiologic gastrostomy with single gastropexy were enrolled. The patients were divided into two groups based on the anchoring method: the separate tract group (n = 136) and the single tract group (n = 105).
Results or Findings: The technical success rate was 99.3% in the separate tract group and 98.1% in the single tract group (p = 0.582). Four patients (3.81%) in the single tract group experienced intra-procedural anchor dislodgment. In 3 of these cases, technical success was achieved by deploying a second anchor. The 30-day complication rate was 12.5% in the separate tract group and 15.2% in the single tract group (p = 0.324). There was no procedure-related mortality. BMI (odds ratio 0.885, p = 0.021) was a negative predictor, while unfavorable anatomy on CT (odds ratio 2.4, p = 0.033) was a positive predictor for complication.
Conclusion: Although anchor dislodgment was a complication unique to the single tract technique, the two groups showed no significant difference in overall clinical outcomes. This study highlights that BMI and CT findings are more crucial predictors of complications than the choice of technique.
Limitations: The retrospective nature of the study leads to several biases.
Funding for this study: This study was not supported by any funding.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The Institutional Review Board of tertiary care hospitals approved this retrospective study and waived written informed consent for using clinical and imaging data.