Sanjeeva Prasad Kalva

BACKGROUND The prolonged use of percutaneous cholecystostomy tubes (PCTs) in patients with acute cholecystitis, deemed inoperable, is fraught with complications. Transpapillary cholecystoduodenal stenting (TCDS) is an alternative technique that restores the physiologic outflow of bile, avoiding the need for an external drain. However, the long-term safety and efficacy of this approach remain unclear. We sought to prospectively assess the safety and efficacy of this procedure, performed via percutaneous or endoscopic approach, in high-risk patients presenting with acute cholecystitis. METHODS This prospective study included consecutive patients with acute cholecystitis and long-lasting, prohibitive surgical risk, in whom TCDS was offered at two partnering tertiary care centers between August 1, 2018, and December 31, 2022. Patients with a need for endoscopic retrograde cholangiopancreatography (ERCP) underwent ERCP-guided TCDS. In patients without a need for ERCP, a temporary PCT was followed by fluoroscopic-guided TCDS 4 weeks to 6 weeks later. Interval cholecystectomy was performed in patients who became surgical candidates later. All patients were followed up until January 1, 2023. RESULTS Transpapillary cholecystoduodenal stenting was successful in 67 (percutaneous in 45/50; endoscopic in 22/23) of 73 patients (92%) attempted. Over a median follow-up period of 17 months (7, 26), 10 patients (15%) developed stent blockage or migration; all but two had their stent successfully replaced. Five patients (7%) developed mild, self-limited pancreatitis. Five (7%) patients underwent interval cholecystectomy at a median time of 7 months. CONCLUSION Transpapillary cholecystoduodenal stenting is a safe and promising definitive alternative to chronic PCT in high-risk patients with acute cholecystitis that eliminates the discomfort and complications of long-term external drainage. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level V. Export

Purpose To determine if ultrasound Doppler velocities within transjugular portosystemic shunts/direct intrahepatic portosystemic shunts (TIPS/DIPS) differ based on the stent diameter (8 mm vs. 10 mm) and report typical flow velocities at defined locations along the stent in patients with a patent TIPS/DIPS on venography. Methods This study retrospectively analyzed a cohort of TIPS/DIPS recipients at a large tertiary care hospital from 2017 to 2022. Sixty-nine patient-entries with patent TIPS/DIPS venograms and available intervening Doppler US were identified (8 mm n = 41; men: 70.7%, mean age: 57.5 years [range: 36–75 years]; 10-mm n = 28; men: 50%, mean age: 50.2 years [range: 24–74 years]). Results The mean Doppler velocities were significantly different at the mid-stent (184.7 cm/s in 8 mm stents and 148.9 cm/s in 10 mm stents; p = 0.03, 95% CI 4.1–67.5) and hepatic-venous-end of the TIPS/DIPS (172.4 cm/s in 8 mm stents and 141.3 cm/s in 10 mm stents; p = 0.02, 95% CI 5.2–57.0). The mean Doppler velocities were not significantly different at the portal vein end of the TIPS (140.7 cm/s in 8 mm stents and 146.8 cm/s in 10 mm stents; p = 0.77, 95% CI − 34.6–46.8) or in the main portal vein (46.8 cm/s in 8 mm stents and 53.0 cm/s in 10 mm stents; p = 0.29, 95% CI − 5.4–17.9). Peak velocities occurred at the mid-TIPS location for the majority of patent 8 mm TIPS (n = 22) and at the portal-end of TIPS for the majority of 10 mm TIPS (n = 12). Conclusion Normal Doppler velocities within TIPS/DIPS differ depending on the shunt diameter. These findings demonstrate a need for specific Doppler screening thresholds in assessing TIPS/DIPS stents of differing calibers.

Purpose To assess the technical and clinical outcomes of percutaneous embolization for high-flow mesenteric vein to gonadal vein (MGV) portosystemic shunts. Methods In this HIPPA-compliant, review board-approved study, patients who underwent embolization of MGV shunts between 2011 and 2023 were included. Patient demographic data, embolization technique, clinical outcomes, and complications were retrieved from the electronic health records. Technical success was defined as complete occlusion of the shunt on follow-up imaging. Clinical outcomes assessed were resolution/improvement of hepatic encephalopathy, improvement in liver function, changes to liver volumes, and occurrence of adverse events. Results Eight patients (mean age 59.5, 75% female) with nine MGV shunts were included. The indications for shunt embolization included medically refractory hepatic encephalopathy, bleeding duodenal varices, and transplant liver dysfunction. The mean maximum shunt diameter was 23.3 mm. Embolization was most commonly performed with a combination of coils and N-butyl cyanoacrylate or vascular plugs. Complete MGV shunt thrombosis was achieved in 7/9 shunts post-embolization, and symptom improvement was noted in 7/8 patients. Child–Pugh scores improved post-embolization in 6/9 patients by a median of 3 points. Liver volumes also increased by a mean of 20.8 ± 17.7% post-embolization. Minor adverse events included new onset ascites, partial mesenteric/portal vein thrombosis, and new gastroesophageal varices without bleeding in four patients. Conclusion Embolization of MGV shunts is technically feasible and effective for treatment of hepatic encephalopathy and increasing hepatopetal portal perfusion. There was an improvement in Child–Pugh scores and an increase in liver volumes in the majority of patients post-embolization. Graphical Abstract