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©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
Segmental intrahepatic cholestasis as a technical complication of the transjugular intrahepatic porto-systemic shunt
Julian Nikolaus Bucher, Marcus Hollenbach, Steffen Strocka, Gereon Gaebelein, Michael Moche, Thorsten Kaiser, Michael Bartels, Albrecht Hoffmeister
Julian Nikolaus Bucher, Department of Surgery, Munich University Hospital at Großhadern, Bavaria, Munich 81377, Germany
Marcus Hollenbach, Medical Department II–Gastroenterology, Hepatology, Infectious Diseases, Pulmonology, University of Leipzig Medical Center, Saxony, Leipzig 04103, Germany
Steffen Strocka, Department of Diagnostic and Interventional Radiology, University of Leipzig Medical Center, Saxony, Leipzig 04103, Germany
Gereon Gaebelein, Department of General, Visceral, Vascular and Pediatric Surgery, University of Saarland, Saarland, Homburg 66421, Germany
Michael Moche, Department of Diagnostic and Interventional Radiology, Bavaria, Nuernberg 90411, Germany
Thorsten Kaiser, Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig Medical Center, Saxony, Leipzig 04310, Germany
Michael Bartels, Department for General and Visceral Surgery, Helios Park-Klinikum Leipzig, Saxony, Leipzig 04289, Germany
Albrecht Hoffmeister, Medical Department II–Gastroenterology, Hepatology, Infectious Diseases, Pulmonology, University of Leipzig Medical Center, Leipzig 04103, Saxony, Germany
Author contributions: Bucher JN and Hoffmeister A designed research; Bucher JN, Strocka S, Gaebelein G, Moche M, Kaiser K, and Bartels M performed research; Strocka S and Moche M contributed analytic tools; Bucher JN and Hollenbach M analyzed data; Bucher JN, Hollenbach M and Hoffmeister A wrote the paper.
Institutional review board statement: The study was reviewed and approved for publication by our Institutional Reviewer.
Informed consent statement: Not applicable, weaver of informed consent due to retrospective study, Ethical Committee consented that no informed consent statement is necessary.
Conflict-of-interest statement: There is no conflict of interest associated with any of the senior author or other co-authors contributed their efforts in this manuscript. All the authors have no conflict of interest related to the manuscript.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at marcus.hollenbach@web.de.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Marcus Hollenbach, MD, Postdoc, Senior Researcher, Senior Scientist, Gastroenterologist, Medical Department II–Gastroenterology, Hepatology, Infectious Diseases, Pulmonology, University of Leipzig Medical Center, Liebigstraße 20, Leipzig 04103, Saxony, Germany. marcus.hollenbach@web.de
Telephone: +49-341-9712362 Fax: +49-341-9712209
Received: July 31, 2019
Peer-review started: July 31, 2019
First decision: August 27, 2019
Revised: September 25, 2019
Accepted: November 7, 2019
Article in press: November 7, 2019
Published online: November 21, 2019
BACKGROUND
Segmental intrahepatic cholestasis caused by transjugular intrahepatic portosystemic shunt (TIPS) (SIC-T), is a rare complication of this technique and only referred by case reports. Thus, we conducted a systematic, retrospective analysis to provide evidence regarding prevalence and consequences of this TIPS-induced bile duct compression.
AIM
To assess prevalence and outcome of SIC-T in a large TIPS-cohort.
METHODS
In this retrospective cohort study, we screened the institutional databases for all consecutive patients that were treated by TIPS-placement or TIPS-revision between January 2005 and August 2013. We analyzed radiologic images for signs of biliary congestion. Cases that were indicative of SIC-T were reviewed by two independent radiologists and additional patient data was collected. Descriptive statistics of patient demographics, indications for TIPS and procedural details were registered. Logistic regression analysis was performed to identify predictors for the development of SIC-T.
RESULTS
We analyzed 135 cirrhotic patients who underwent TIPS (mean age 55 years, 79% male gender). Etiology of cirrhosis was alcohol in most cases and indications for TIPS were mainly refractory ascites and recurrent variceal bleeding. TIPS revision was necessary in 31 patients. We identified 4 cases (2.9%) of SIC-T in direct proximity of the TIPS-stent. Diagnosis was confirmed by CT-scan, MRI or endoscopic retrograde cholangio pancreaticography (ERCP). In two patients TIPS was implanted via the right and in one through the medial hepatic vein. One patient received TIPS-prolongation by multiple revisions. Most patients were asymptomatic but one cholangitic abscess necessitated a transhepatic drain. Logistic regression analysis identified TIPS-placement other than from medial hepatic vein to right portal vein as risk factor (OR 21.0) for SIC-T.
CONCLUSION
SIC-T ads to (mostly late) complications in the interventional treatment of cirrhotic portal hypertensions and can lead to cholangitic abscesses. Patients, particularly with multiple interventions, should be screened for SIC-T.
Core tip: Segmental intrahepatic cholestasis (SIC-T) is a rare and mostly late complication of transjugular intrahepatic portosystemic shunt (TIPS). Detection of SIC-T is performed by a combination of clinical, radiological and laboratory analyses. In the majority of patients, SIC-T requires no intervention but can lead to cholangitic abscesses. SIC-T contributes to late complications of TIPS-procedure. TIPS placement other than from the medial hepatic vein is an important risk factor for SIC-T development. Patients with atypical TIPS placements should be screened for SIC-T.
