Surgery-assisted transmesenteric transjugular intrahepatic portosystemic shunt for esophagogastric bleeding in patients with cavernous transformation of the portal vein

Abstract

This editorial provides commentary on the study by Wu et al, which investigates a novel intervention for a challenging clinical scenario: Transjugular intrahepatic portosystemic shunt (TIPS) placement with the assistance of surgery in patients with cavernous transformation of the portal vein. The authors compared surgically assisted TIPS (SATIPS) in 54 patients to endoscopic sclerotherapy in 53 patients. While 3-month survival rates were similar (94.4% vs 92.5%), a significant difference emerged at 6 months, with survival rates of 94.4% for SATIPS vs 73.6% for endoscope sclerotherapy. The SATIPS group also demonstrated significantly lower incidences of liver failure, esophagogastric bleeding, and hepatic encephalopathy at 6 months. However, the SATIPS procedure was not without risk, as four patients experienced major complications, including intraoperative hemorrhage. The study concludes that SATIPS is an effective alternative for cavernous transformation of the portal vein patients with esophagogastric bleeding, but its findings must be interpreted in light of its limitations. This research represents a significant contribution to the field.

Key Words: Portal hypertension; Esophagogastric variceal bleeding; Cavernous transformation of the portal vein; Transjugular intrahepatic portosystemic shunt; Abdominal surgery

Core Tip: This study suggests that for patients with cavernous transformation of the portal vein and esophagogastric bleeding, surgically assisted transjugular intrahepatic portosystemic shunt offers a survival advantage over endoscopic sclerotherapy at six months, with lower rates of liver failure, rebleeding, and hepatic encephalopathy. However, the surgically assisted transjugular intrahepatic portosystemic shunt carries a risk of serious complications, such as intraoperative hemorrhage and wound infection, which must be weighed against its benefits.

INTRODUCTION

We read with great interest the article by Wu et al[1], published in the World Journal of Gastroenterology. The authors present a large, retrospective, multicenter study investigating the clinical efficacy of minilaparotomy-assisted transmesenteric transjugular intrahepatic portosystemic shunt (TIPS) for managing esophagogastric variceal bleeding in cirrhotic patients with cavernous transformation of the portal vein (CTPV) and portal hypertension. This work represents a significant and informative contribution to the specialty.

Portal hypertension is defined by an increase in the portal pressure gradient to more than 5 mmHg. This gradient, measured between the portal vein and the inferior vena cava, typically results from obstruction at the hepatic sinusoids or other sites, most commonly due to cirrhosis[2,3]. A portal pressure gradient greater than or equal to 10 mmHg is clinically significant, as it is associated with the development of complications such as gastroesophageal varices, ascites, variceal hemorrhage, and hepatic encephalopathy. These events pose serious risks to patient survival and significantly impair quality of life[2]. CTPV is a rare condition with diverse etiologies and clinical presentations. It often originates from portal vein thrombosis, for which predisposing factors include chronic liver disease (e.g., cirrhosis), local or systemic inflammatory diseases, neoplasms, and myeloproliferative disorders[2-5]. Over time, a thrombosed portal vein may attempt to recanalize. This process leads to the development of multiple small collateral vessels within and around the occluded vein. As some of these vessels dilate and others thrombose, a network of channels forms, resulting in the characteristic appearance of CTPV[4,6]. This transformation increases resistance to portal inflow, exacerbating portal hypertension and creating a vicious cycle. The management of severe portal hypertension and its complications is complex. The primary goals are to reduce portal pressure and prevent sequelae such as gastroesophageal variceal bleeding, liver failure, and hepatic encephalopathy. Beyond comprehensive medical therapy, several interventional procedures are commonly employed. These include endoscopic sclerotherapy and variceal ligation, percutaneous transhepatic variceal embolization, balloon-assisted antegrade transvenous obliteration, balloon-occluded retrograde transvenous obliteration, portal vein stent placement, and the TIPS procedure[7-9].

TIPS is an established and widely used procedure that provides immediate reduction in portal pressure. It is highly effective at alleviating variceal bleeding and refractory ascites, thereby improving quality of life and increasing lifespan[8-11]. However, the conventional TIPS procedure becomes unfeasible when vascular access is obstructed by portal vein thrombosis, tumor invasion, or CTPV. These conditions alter the anatomy of the portal vein and its branches, and may also affect the superior mesenteric vein. Attempting a standard TIPS under these circumstances significantly increases the risk of intraoperative hemorrhage and other severe complications[9-12]. To address these challenges, several modified TIPS techniques have been developed. These include: Transjugular extrahepatic portosystemic shunt, involving direct portal vein puncture from the inferior vena cava[13]; surgically assisted TIPS (SATIPS), which combines abdominal surgery with the TIPS procedure[14,15]; percutaneous transhepatic balloon-assisted TIPS[16]; transjugular intrahepatic collateral-systemic shunt[17]; and transjugular splenocaval shunt[18]. These modified approaches have been demonstrated to be effective and safe alternatives for managing patients with complex portal vein abnormalities and portal hypertension-related gastroesophageal varices, gastroesophageal variceal hemorrhage, ascites, hepatic encephalopathy, and other complications[14-18].

Since its development in the late 1980s, the core principle of TIPS has remained the placement of an expandable metal stent between a hepatic vein and an intrahepatic branch of the portal vein to decompress the portal system[7]. The procedure’s success is highly dependent on the interventional radiologist’s skill and a favorable anatomy of the portal and hepatic veins. The presence of thrombus, tumor, or CTPV presents a substantial obstacle. To enhance the success rate and prevent complications, several guidance techniques are employed. These include using duplex ultrasound to guide to place markers in the branches of the portal vein or superior mesenteric vein to guide the puncture[19], or performing an abdominal surgical assistance to facilitate access[14,15,20].

The combination of superior mesenteric vein surgical access and TIPS for managing gastroesophageal variceal bleeding resulted from cirrhotic portal hypertension was first reported by Rozenblit and Del Guercio[14] in 1993 in a patient with a patent portal vein. Subsequently, Jalaeian et al[15] described its application in a more complex case: A 41-year-old man with hepatitis C-related cirrhosis, CTPV, and recurrent esophageal variceal bleeding[15]. After an initial failed attempt at conventional TIPS, the procedure was successfully performed via direct cannulation of an ileal vein under minilaparotomy. This surgical access allowed for lysis and aspiration of the thrombus, followed by portal vein stenting. Post-treatment endoscopy showed near-resolution of the esophageal varices and portal hypertensive gastropathy. The patient’s clinical condition improved significantly, and portal pressure remained stable without significant elevation for nine months.

A similar technique was employed by Pelizzo et al[20] for a 16-year-old girl with CTPV and recurrent short-interval esophageal variceal bleeding. They performed a minilaparotomy-assisted transmesenteric antegrade portal recanalization followed by TIPS. Through a transverse minilaparotomy in the right lower abdomen, the ileocolic vein was isolated to gain access to the superior mesenteric vein. The patient’s postoperative recovery was uneventful, and follow-up computed tomography and endoscopy demonstrated markedly alleviated signs and symptoms within one month. These case reports indicate that minilaparotomy-assisted transmesenteric TIPS is a feasible, effective, and safe alternative for patients with challenging portal vein anatomy due to CTPV or other pathologies. However, it is important to note that the evidence is currently limited to individual case reports, which may affect the generalizability of the findings. Consequently, further investigation with larger cohort studies is necessary to validate the efficacy and safety of this combined surgical and interventional approach.

CURRENT SITUATION AND CHALLENGES OF SAFETY OF MINILAPAROTOMY

In the study by Wu et al[1], 54 patients with portal hypertension and CTPV who had been ineffective in TIPS were treated with SATIPS, which included ligation of distal branch of the small intestinal vein trough abdominal surgery. Their outcomes were compared with 53 patients with portal hypertension and CTPV who had been ineffective in TIPS and managed with prophylactic endoscopic sclerotherapy. The results demonstrated that SATIPS significantly reduced portal pressure gradient compared to pre-procedure measurements. Furthermore, the SATIPS group showed significantly higher survival rates and a lower incidence of rebleeding at the 6-month follow-up. Specifically, while the 3-month survival rates were comparable between the SATIPS and sclerotherapy groups (94.4% vs 92.5%, respectively), a significant difference emerged at 6 months (94.4% vs 73.6%). The incidence of complications also favored the SATIPS group. At 3 months, significant differences were observed in rates of esophagogastric rebleeding (5.6% vs 37.7%) and hepatic encephalopathy (3.7% vs 17.0%); the difference in liver failure was not statistically significant (3.7% vs 9.4%, P = 0.26). At 6 months, the differences remained significant for all measured complications: Liver failure (3.7% vs 18.9%), esophagogastric rebleeding (9.3% vs 47.2%), and hepatic encephalopathy (7.4% vs 26.4%). Procedure-related complications in the SATIPS group included intraoperative massive hemorrhage (two patients), postoperative abdominal wound infection (one patient), and stent stenosis with associated rupture and bleeding at the superior mesenteric vein puncture site (one patient). In conclusion, this study demonstrates that SATIPS can significantly reduce the incidence of esophagogastric variceal rebleeding, hepatic encephalopathy, and liver failure in this high-risk patient population. These improved outcomes are associated with a significant survival benefit at six months. The strengths of this study include its case-control design and relatively large sample size, with satisfactory outcomes reported for the SATIPS procedure. However, several limitations and errors warrant consideration, as they may affect the interpretation and generalizability of the findings. The main points are as follows.

Imprecise terminology

The term “gastrointestinal bleeding” is used throughout the manuscript. This is imprecise, as the study specifically addresses esophagogastric variceal bleeding in cirrhotic patients with portal hypertension. The venous varices in cirrhotic patients with portal hypertension occur mainly in the esophagus and stomach and commonly forms of variceal bleeding are esophageal and gastric variceal bleeding and, far less commonly, rectal variceal bleeding[21]. The more general term may lead to misinterpretation of the patient population and clinical context.

Inaccurate study aim in abstract

The abstract states, “For patients with CTPV, there were no optimal treatment”. This is misleading, as the study’s aim was to investigate a treatment for esophagogastric variceal bleeding in patients with CTPV, not to treat CTPV itself. This statement misaligns with the paper’s actual objective.

Insufficient methodological detail for control group

The “Materials and Methods” section lacks a description of the endoscopic sclerotherapy procedure performed on the 53 control patients. As this is a distinct procedure performed by a different clinical team at a different department, a brief outline of its technique is necessary for reproducibility and comparative understanding.

Unclear patient enrollment and initial management

The manuscript would benefit from clarifications regarding several methodological points. It states that 107 patients were admitted with active bleeding, but it does not specify whether their enrollment was consecutive, selective, or randomized. Additionally, the techniques used for initial hemostasis before definitive therapy (SATIPS or prophylactic endoscope sclerotherapy) are not described. This is a critical point, as the study outcomes reflect the prevention of re-bleeding, not the control of the index bleed; this distinction should be explicitly addressed. To this end, providing a detailed diagram and description elucidating the guidewire navigation across the cavernous transformation would greatly improve the clarity and reproducibility of the reported SATIPS procedure.

Inconsistent manufacturer citation format

The citations for medical devices [e.g., “(HR China), (Ke Rui Chi, China), (COOK United States, Poco United States), and (Ke Rui Chi China, ev3 United States)”] are inconsistent and do not follow standard formatting conventions. A uniform style (e.g., “Manufacturer, City, Country”) should be applied for professionalism and clarity.

Unsubstantiated statistical claim

The “Statistical analysis” section mentions that “Factors influencing advantages were assessed through logistic analysis”, yet no corresponding methods, results, or data tables are presented. This claim should be supported with data or removed.

Incomplete exclusion criteria

The “Materials and methods” section does not provide a comprehensive list of exclusion criteria. Details on comorbid conditions or other factors that would preclude patients from receiving either treatment are essential to assess the study population’s generalizability.

Omission of Child-Pugh classification

The Child-Pugh classification is a critical prognostic indicator for cirrhotic patients with variceal bleeding. Its absence from the patient baseline characteristics (Table 2) limits the ability to assess the comparability of the two treatment groups and the severity of the underlying liver disease.

Poorly described tables

Table 1 lacks categorical item, descriptive, and references of original sources, making it difficult for readers to interpret the data presented. All tables should be self-explanatory.

Missing hematological parameters

Baseline hematological parameters (erythrocyte, leukocyte, and platelet counts) are absent from Table 2. These values are relevant to surgical and TIPS eligibility and are associated with postoperative complications; their inclusion is important for a complete clinical profile.

Need for body mass index

Table 2 presents patient height and weight separately. For standardized clinical assessment, body mass index should be calculated and presented in place of, or in addition to, these raw metrics.

Incomplete presentation of complication data

Tables 3 and 4 present complication rates as percentages without the corresponding raw numbers of patients (n). Providing both is a standard practice for transparency and allows readers to verify the calculations.

Missing unit for portal vein pressure

Table 5 lists portal vein pressure and portal pressure gradient without specifying the unit of measurement (e.g., cmH₂O, mmHg, or kPa). This omission renders the data uninterpretable.

Absence of control group complications

The “Results” section details complications in the SATIPS group but does not report complications associated with endoscopic sclerotherapy in the control group. A complete comparative analysis requires a full account of adverse events in both cohorts.

Unjustified surgical step

The methods describe ligating “the distal branch of the small intestinal vein”, but the rationale and clinical implications of this step are not discussed. The “Discussion” section should address the purpose and potential impact of this maneuver.

Irrelevant cost and stay comparisons

The “Discussion” includes unsupported comparisons of hospitalization costs and length of stay between SATIPS, traditional TIPS, and endoscopic therapy. Since cost and stay were not study objectives or measured outcomes, these speculative statements are unnecessary and should be removed.

Unsupported claims of “success rate”

The terms “success rate” (core tip) and “The high success rate” (Discussion) are used without being defined in the methods or supported by results. If technical success is a key endpoint, it must be explicitly defined and reported. Otherwise, these claims should be deleted.

Inaccurate conclusion

The conclusion states that “SATIPS demonstrates unique advantages in treating portal vein spongiosis”. This is incorrect; the procedure is used to treat the complications of portal hypertension (variceal bleeding) in patients with this condition, not the venous transformation itself. The conclusion should be rephrased to accurately reflect the study’s findings.

CONCLUSION

This research makes a significant contribution by demonstrating that SATIPS is a viable and effective intervention for esophagogastric variceal bleeding in patients with CTPV. Key findings include a significant reduction in esophagogastric rebleeding rates and an associated survival benefit compared to endoscopic sclerotherapy. Acknowledging the technical challenges and specific complications of SATIPS is crucial; future work must aim to improve its safety profile. With the rising prevalence of non-alcoholic fatty liver disease, there is a growing incidence of non-hepatitis B/C related cirrhosis. This poses a new clinical challenge, for which SATIPS is a particularly beneficial treatment given the otherwise limited therapeutic options. Finally, while this study offers compelling evidence, its retrospective nature and the limitations noted earlier underscore the necessity of a prospective randomized controlled study for definitive validation.