Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established interventional treatment for complications of portal hypertension. Post-TIPS transient or persistent acute bilirubin elevation (ABE) is common, possibly due to impairment of portal perfusion. The outcomes of patients with ABE is not clear.

Aims & Methods

This study investigates the incidence, clinical outcomes, and prognostic factors associated with ABE in cirrhotic patients undergoing TIPS. Between January 2009 and November 2022, 1,287 patients (882 men, 405 women; mean age, 52 years) were included in this retrospective analysis. ABE was defined as a total serum bilirubin level exceeding 85.5 μmol/L (5 mg/dL) within one week after TIPS. Statistical analyses included the Kaplan-Meier method, log-rank test, multivariate Cox regression, and stepwise regression.

Results

Post-TIPS ABE occurred in 67 patients (5.2%). Patients with ABE had significantly higher baseline Child-Pugh scores (8.39 ± 1.62 vs. 7.41 ± 1.54, P < 0.001) and MELD scores (13.98 ± 4.13 vs. 10.72 ± 2.99, P < 0.001). Refractory ascites as the TIPS indication was more frequent in the ABE group (17.91% vs. 7.21%, P = 0.001). ABE was associated with a significantly higher incidence of hepatic encephalopathy (HE): 62.7% vs. 38.3% at 1 year and 80.6% vs. 62.8% at 5 years (P = 0.042). During follow-up, 441 patients died, with causes including liver failure (n = 129), gastrointestinal bleeding (n = 100), sepsis (n = 16), multi-organ dysfunction (MOD) (n = 41), hepatocellular carcinoma (HCC) (n = 43), and other or unknown causes (n = 112). Survival rates were significantly lower in the ABE group: 1-year (52.2% vs. 85.2%), 3-year (34.3% vs. 68.3%), and 5-year (25.4% vs. 46.6%) (P < 0.001). Multivariate analysis identified ABE (hazard ratio [HR]: 2.09; 95% confidence interval [CI]: 1.41–3.10; P < 0.001), age (HR: 1.05; 95% CI: 1.04–1.06; P < 0.001), albumin level (HR: 0.95; 95% CI: 0.94–0.97; P < 0.001), pre-TIPS grade 4 HE (HR: 1.93; 95% CI: 1.19–3.14; P = 0.008), presence of HCC (HR: 1.81; 95% CI: 1.24–2.65; P = 0.002), baseline MELD score (HR: 1.09; 95% CI: 1.04–1.14; P < 0.001), and change in MELD score (HR: 1.08; 95% CI: 1.06–1.11; P < 0.001) as independent predictors of post-TIPS mortality.

Conclusion

AEB is not rare in cirrhotic patients undergoing TIPS and is associated with an increased risk of HE and mortality. Risk factors for post-TIPS mortality include AB, older age, higher and fluctuating MELD scores, concurrent HCC, severe pre-TIPS HE, and lower albumin levels. Early identification, close monitoring, and prompt management of complications are essential to improving clinical outcomes and reducing the risk of liver failure after TIPS.

Introduction

Biodegradable pancreaticobiliary stents provide an alternative to conventional stents and avoid the need for a repeat procedure for endoscopic removal. While use is not currently widespread in the United Kingdom, accepted indications for insertion include bile leaks, prophylaxis of post-ERCP pancreatitis and as a bridge to cholecystectomy after bile duct clearance. Evidence from small studies suggest biodegradable stents are safe and cost effective, however there are few prospective studies to guide best practice. Complications of biodegradable stents are also not well understood with limited, if any, data describing issues specific to these types of stent. In our hospital trust, biodegradable stents have been in use since 2019 and this study aims to describe trends in use including complications and provide a comprehensive summary experience to date.

Aims & Methods

The electronic record of all patients in two hospitals within Manchester foundation trust who underwent insertion of a biodegradable pancreaticobiliary stent were reviewed. The study period was between March 2019 and April 2023. Patient demographics, type of stent, indication for stent insertion, readmissions and repeat ERCP data was collected on review of each patient’s record.

Results

During the study period 66 Biodegradable stents were inserted in 63 patients of which 48 were pancreatic and 18 biliary. All pancreatic stents were inserted for post-ERCP pancreatitis prophylaxis, whilst 5 biliary stents were performed for bile leaks and 13 for biliary drainage post-ERCP. A total of 9 patients were readmitted within 6 months for a pancreaticobiliary related complications including cholangitis (n=3), cholecystitis (n=2), post-ERCP pancreatitis (n=2), biliary obstruction (n=1) and persistent bile leak (n=1). In total, 10 patients underwent repat ERCP within 6 months. In one patient, the biodegradable stent was noted at ERCP to be in situ ERCP 5 months after insertion. Over 94% (n=17) of all biliary stents were performed in the first year of study, although the majority of these were inserted in 1 of the 2 study centres.

Conclusion

To our knowledge this is the largest series of patients undergoing biodegradable stent insertion in the United Kingdom. In this study, the most common indication for the insertion of a biodegradable stent was post-ERCP pancreatitis prophylaxis. As the study period progressed pancreatic stents became by far the most commonly inserted stent. In fact, only 1 biliary stent was placed in the final 3 years of the study period, demonstrating a trend towards the use of pancreatic biodegradable stents versus biliary stents. This may represent differences in clinical practice, services provided over time (e.g Spyglass or ‘hot’ cholecystectomies) or simply endoscopist preference. The study suggests that biodegradable stents are safe and effective with only 10 patients undergoing a further ERCP in 6 months. Therefore, a significant proportion of patients were able to avoid a second procedure thus providing a benefit in both risk and cost.

Disclosure

None

Introduction

Endoscopic interventions in children require specialized training and expertise due to unique anatomy and physiology challenges. Pancreaticobiliary endoscopies represent highlighted procedures in this population due to the often-unusual indications and the inherent high risk of complications.

Aims & Methods

The current work demonstrates our experience in pancreaticobiliary endoscopy in the pediatric population. We retrospectively analyzed data on all patients <18 years old who underwent endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS) from 2021 to the present days at our department. We collected demographical data, indications, procedural findings, interventions, and complications.

Results

Overall, 19 ERCPs and 7 EUS procedures were performed on 24 children with regular endoscopes. 15 were males, and the mean age was 10.7 years (±4.7). Indications for ERCP included bile duct stones, benign stricture, pancreatic divisum and disconnected duct syndrome. Successful intervention was carried out in 18 cases, while there was one case of unsuccessful deep pancreatic duct cannulation due to abnormality of the duct. There was one case of perforation (Stapfer II), which was effectively managed endoscopically by placing a fully covered self-expanding metallic stent. 1 case of mild post-ERCP acute pancreatitis occurred following ERCP. EUS was performed for chronic pancreatitis, pancreatic cystic neoplasia, acute necrotizing pancreatitis, biliary compression and polycystic pancreas. 3 tissue acquisitions were done and one EUS-guided transluminal drainage was established. There were no complications.

Conclusion

To our knowledge, this is the most comprehensive domestic dataset of pancreaticobiliary endoscopies in children. Our findings imply that ERCP and EUS are effective diagnostic and treatment modalities in pediatric patients with acceptable safety profiles.

Introduction

Acute upper gastrointestinal (UGI) bleeding is a common medical emergency among the elderly. There is limited data on the management and outcomes of non-variceal UGI bleeding in the elderly in India.

Aims & Methods

We aimed to study clinical presentation, endoscopic findings, and outcomes in elderly patients with acute non-variceal UGI bleeding. All elderly patients (≥ 60 years of age) who presented with acute UGI bleed and were admitted for the same from 2021 to 2022 were retrospectively analysed. Baseline characteristics, blood transfusions before and after endoscopy, endoscopic diagnosis and therapy, AIMS65 score, complete Rockall score, and outcomes such as in-hospital re-bleeding and mortality were recorded.

Results

Of the 399 patients who had acute non-variceal UGI bleed, 309 patients aged <60 years were excluded. Of the 90 patients studied, the mean age of presentation was 69.8 ± 7.35 years, with 81.1% males. The most common presentation was melena (30%). Forty-one (45.5%) patients had a history of antiplatelet and anticoagulant use. The most common endoscopic finding was gastric ulcer (54.4%), followed by duodenal ulcer (22.2%), gastroesophageal junction ulcer (7.7%), Mallory-Weiss tear (6.6%), duodenal diverticular bleed (2.2%). The majority of ulcers were Forrest III (43.3%), followed by Forrest IIa (23.3%) and IIc (18.3%). Around 65% of patients with non-variceal UGI bleeds did not require endotherapy. Dual endotherapy was done in 25.5.5% of patients. Triple endotherapy was done in two patients. AIMS65 score was 1 in 50% of patients and 2 in 24.5% of patients. The majority (81.1%) of patients had a complete Rockall score of 3-7, indicating a moderate risk of re-bleeding and mortality. All the 90 patients were discharged without any mortality.

Conclusion

Our study showed that gastric ulcer was the most common cause of acute non-variceal UGI bleeding in the elderly, and melena was the most common presentation. Early endoscopic therapy may reduce blood transfusion requirements, in-hospital re-bleeding, and mortality.