Percutaneous transhepatic obliteration and percutaneous transhepatic sclerotherapy for intractable hepatic encephalopathy and gastric varices improves the hepatic function reserve

Abstract

Abstract. Percutaneous transhepatic obliteration (PTO) and percutaneous transhepatic sclerotherapy (PTS) are widely performed as an emergency measure in cases of variceal hemorrhage and intractable hepatic encephalopathy. The PTO/PTS technique is capable of directly blocking the blood supply in cases in which balloon-occluded retrograde transvenous obliteration (B-RTO) is not effective, or in cases with complicated collateral flow. Although PTO/PTS is not currently the first choice due to the invasiveness of transhepatic puncture, this procedure can modify the blood flow in an antegrade manner. The present study examined the changes in hepatic function reserve following PTO/PTS for intractable hepatic encephalopathy and/or gastric varices. In total, the study included 37 patients (mean age, 61.75±12.77 years; age range, 32-88 years; male to female ratio, 23:14) with a variety of gastrorenal shunts, or B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts. The patients underwent PTO/PTS by embolizing a microcoil or injection of a sclerosing agent (5% ethanolamine oleate iopamidol). Alterations in hepatic function reserve prior to and following the procedure were compared. The patients were treated for hepatic encephalopathy in 11 patients, gastric varices in 19 patients, and both conditions in 7 patients. The results indicated that the blood ammonia level improved from 135.76±75.23 mg/dl to 88.00±42.16 and 61.81±33.75 mg/dl at 3 and 6 months after therapy, respectively. In addition, the Child-Pugh score improved from 8.48±2.01 prior to therapy to 7.70±1.84 and 7.22±2.01 at 3 and 6 months after the procedure, respectively. Although there was a concern that PTO/PTS may cause complications due to an increase in portal venous pressure (PVP) arising from shunt occlusion, no severe complications were observed. In conclusion, for patients with various gastrorenal shunts or those with B-RTO-intractable hepatic encephalopathy and gastric varices without gastrorenal shunts, PTO/PTS can improve the antegrade blood flow to the liver, as demonstrated by improvement in the hepatic function reserve.

A case of esophagojejunal varices rupture after proximal gastrectomy with double-tract reconstruction

“…Furthermore, the recurrence rate after PTO is higher than after endoscopic treatment because the original PTO technique using stainless-steel coils makes collateral circulation to the varices [15,16]. However, the PTO technique is being developed with a microcatheter or microcoil [17]. We have applied this new technique in our case and have been able to superselectively obliterate the varices themselves as well as their feeding vein.…”

Post-operative care of interventional therapy for 40 liver cancer patients with obstructive jaundice

“…Therefore, it is difficult for patients to sustain repeated puncture since it has relatively severe damage on liver functions. This is the main cause for hepatic encephalopathy (Edula & Pyrsopoulos, ; Ishikawa et al., ).…”

Gastric variceal hemorrhage treated with percutaneous transhepatic embolization with balloon-occluded antegrade transvenous obliteration

“…2 It was decided to proceed with accessing the gastric variceal feeders via a transhepatic approach as it is simpler compared to the retrograde access via the renal vein and this technique is well described in the Japanese literature. 3 Once these afferent or feeding vessels are identified, they can be coiled off easily and sclerotherapy can be performed via any of these branches in an antegrade fashion. Prior to sclerotherapy, the out flow should be blocked, which is performed by inflating a balloon in the gastrorenal shunt as in standard BRTO procedure.…”