Transjugular intrahepatic portosystemic shunt in patients who have undergone liver transplantation.

PURPOSE: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension. MATERIALS AND METHODS: Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death. RESULTS: No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy. CONCLUSION: In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.

Optimizing CT portography: a prospective comparison of injection into the splenic versus superior mesenteric artery.

PURPOSE: To evaluate whether computed tomographic arterial portography (CTAP) is best performed with injections in the superior mesenteric artery (SMA) or the splenic artery. MATERIALS AND METHODS: Seventy-one studies were performed with injection into the SMA (n = 37) or splenic artery (n = 34) of 150 mL of contrast material at 1.5 mL/sec and 20-second delay for both groups. Images were reviewed for location and type of nontumoral perfusion abnormalities. The degree of liver parenchymal enhancement with each technique was compared. RESULTS: Fewer nontumoral perfusion defects were seen with splenic artery (65%) versus SMA (78%) injection. Visual differences in contrast enhancement with greater attenuation in dependent portions of the liver were seen with greater frequency with SMA (41%) than with splenic artery (24%) injection. Contrast enhancement that obscured detail in the right lobe was seen only with SMA injections (16%). Greater parenchymal enhancement (up to 18 HU) at all time intervals was seen with splenic artery injection. CONCLUSION: Because of greater parenchymal enhancement and fewer nontumoral perfusion abnormalities, splenic artery catheterization is the preferred technique for CTAP.

Bile leak after hepatic transplantation: cholangiographic features, prevalence, and clinical outcome.

PURPOSE: To evaluate cholangiographic features and prevalence of bile duct leaks in liver transplant recipients and correlate the different types of leaks with clinical outcomes. MATERIALS AND METHODS: For 6 years, 3,242 cholangiograms were obtained in 1,363 liver allografts in 1,306 patients. All cholangiograms with definite or suspected bile duct leaks, per the radiology reports, were retrospectively reviewed. RESULTS: Leaks were diagnosed in 59 allografts in 59 patients. The prevalence of leaks after liver transplantation, as depicted on cholangiograms, was 4.3% (59 of 1,363 grafts). Sixteen of 21 patients with anastomotic leaks needed 17 surgical repairs, four leaks were surgically drained without repair, and one was treated with percutaneous biliary catheter drainage. Twelve of 21 patients with T-tube exit-site leaks underwent T-tube drainage. Seven underwent surgical repair or drainage, one died, and one underwent retransplantation. Nine of 13 patients with leaks from bile duct necrosis required retransplantation. CONCLUSION: Bile duct leaks at biliary anastomoses and those resulting from bile duct necrosis have high morbidity, mortality, and graft loss rates and usually require surgical intervention. Most T-tube exit-site leaks heal with conservative treatment.

Hepatic parenchymal perfusion defects detected with CTAP: imaging-pathologic correlation.

To determine whether characteristics of focal hepatic parenchymal perfusion defects detected with computed tomographic arterial portography (CTAP) correlate with underlying pathologic processes, 245 perfusion defects detected with CTAP in 60 patients who subsequently underwent definitive hepatic surgery were characterized by shape, location within the liver, and relative attenuation value and were prospectively correlated with sectioned pathologic specimens. Of 177 round perfusion defects, 102 (58%) were malignant and 75 (42%) were benign. Only one (2%) of 53 peripheral wedge-shaped defects was malignant. All 15 peripheral flat defects were benign. Defects in characteristic locations anterior to the porta hepatis (n = 15) and adjacent to the intersegmental fissure (n = 7) were uniformly benign. While 83 (56%) of 147 soft-tissue attenuation defects were malignant, only four (6%) of 68 intermediate-attenuation defects were malignant. Although these characteristics of parenchymal perfusion defects aid in differentiation of benign from malignant processes, all other types of perfusion defects are nonspecific and may require biopsy.

Common bile duct calculi: updated experience with dissolution with methyl tertiary butyl ether.

The authors describe their experience with methyl tertiary butyl ether (MTBE) in a larger series of patients than previously reported in order to acquaint physicians with both its effectiveness for dissolution of common bile duct calculi and the limitations of its use. Ten patients with 13 biliary calculi underwent percutaneous stone dissolution treatment with the experimental cholesterol solvent, MTBE. Three stones completely dissolved within 30 minutes, seven were reduced in size, and three were visibly unaffected. All stones not completely dissolved were easily extracted by means of a stone basket except for one in a patient taken to surgery. Although MTBE perfusion is an effective technique for management of biliary calculi, practitioners should be aware that its use is quite time consuming and its odor difficult to control.

Percutaneous pancreaticobiliary biopsies in 173 patients using primarily ultrasound or fluoroscopic guidance.

Two hundred and one biopsies of the pancreas and/or extrahepatic bile ducts were performed in 173 patients using primarily ultrasound (US) or fluoroscopic guidance. Computed tomographic (CT) guidance was used twice. The success rate for detecting malignancy was 82.4%. Patients with primary ductal carcinoma had the lowest success rate. Seven complications occurred: five vasovagal reactions, one fever, and one acute pancreatitis in a patient with a normal variation, which resembled a mass. In this large series, aspiration biopsy of the pancreas and extrahepatic bile ducts proved to be a safe and reliable procedure that often can be performed on an outpatient basis. Fluoroscopic and US guidance are satisfactory for the majority of biopsies. CT guidance probably should be reserved for patients who undergo a repeat biopsy, or when US fails to adequately demonstrate the pancreas.

Refractory afferent loop problems: percutaneous transhepatic management of two cases.

Complications of the afferent loop are traditionally managed only by surgical revision. Transhepatic biliary drainage was used in the palliative treatment of two different afferent loop problems in critically ill patients for whom surgery was unsuccessful. Transcholecystic cholangiography was used to opacify the nondilated bile ducts and proved valuable for the transhepatic biliary catheterization procedure. There were no complications, and both patients showed clinical improvement.

Monooctanoin infusion and stone removal through the transparenchymal tract: use in 17 patients.

Seventeen patients underwent monooctanoin infusion and biliary stone removal through the percutaneous transhepatic biliary drainage tract. In the first five patients, monooctanoin was infused until the stone(s) became smaller or disappeared; basket extraction was not attempted until this reduction was observed. An average of 22 hospital days was required for the procedure. In the next 12 patients, basket extraction was attempted after as few as 3 days of infusion, without waiting for a reduction in stone size. After infusion, these stones became extremely friable, fragmented easily, and were atraumatically removed through the fresh liver tract. The average hospital stay for these patients was 7 days, with no complications. The ability of monooctanoin to soften some stones allows an earlier, more aggressive approach to stone removal through the transparenchymal tract without risk of soft-tissue laceration; use of the infusion significantly decreases the hospital stay.

Common bile duct obstruction: assessment by transcholecystic cholangiography.

Percutaneous transcholecystic cholangiography was performed in 20 patients. Fifteen patients had normal-sized bile ducts on sonograms and computed tomographic scans, and five had partial common bile duct obstruction. Gallbladder pressures were measured in 14 patients. In all cases the intrahepatic and extrahepatic bile ducts were well visualized. Only one clinically significant complication, bile peritonitis, occurred, and it was relieved by inserting a cholecystostomy catheter. Techniques as well as the potential indications for transcholecystic cholangiography are discussed. The authors believe the transcholecystic approach is a useful alternative to transhepatic cholangiography.