Introduction
EUS-guided portal pressure gradient measurement (EUS-PPGm) would be a useful procedure in patients with liver diseases (1). However, there is scarcely data on the clinical relevance of this EUS-guided procedure.
Aims & Methods
We report our experience on EUS-PPGm focus on safety, clinical relevant findings, technical drawbacks and how to overcome them.
We used a therapeutic echoendoscope and a 25G dedicated needle as previously reported (1, 2). To minimize the risk of infection, periprocedural antibiotherapy was administered and the working channel of the echoendoscope was flushed with povidone-iodine.
Results
EUS-PPGm was performed in 30 patients, median age 42±3 yo. Indications: assessment of NAFLD, 25 patients; idiopathic portal hypertension, 3 patients; evaluation for curative therapy in hepatocellular carcinoma (HCC), 2 patients. Anticoagulants were withdrawn in 4 patients. EUS-guided bilobar liver biopsies (EUS-BLB) were also immediately performed in 26 patients (87%) with a 19G needle. EUS-PPGm was successfully obtained in 25/30 patients (83%). EUS-PPGm was >5 mmHg in 14/25 cases (56%). In idiopathic portal hypertension 3/3 patients. In NAFLD 10/22 patients (45%) without endoscopic and/or ultrasonographic signs of portal hypertension and without liver fibrosis on EUS-BLB. Mean time to obtain EUS-PPGm was 21±2 minutes. Mean time for EUS-PPGm plus EUS-BLB was 45±2 minutes. Idiopathic portal hypertension was assessed by this procedure with the complementary information given by the EUS-BLB. In the 2 patients with HCC, one patient did not have reliable results and, in the other, EUS-PPGm was useful ruling out portal hypertension and the patient was referred to curative surgery that was successfully carried out.
Technical drawbacks: In 5 cases (17%) EUS-PPGm was not obtained due to non-reliable measurements in 4 cases probably due to excesive use of the elevator and up&down wheel of the echoendoscope and bending of the needle, that would be avoided. In the fifth case the EUS-PPGm was not performed for exacerbating breathing movements that precluded the procedure for safety concerns. We experienced difficulty in punctioning the hepatic and the portal vein in one and two cases, respectively, having to transverse these vessels and repositioning the needle in the lumen of these veins. In one case the 25G needle passed in close proximity to the hepatic artery. We think dedicated 25G needles have more flexibility and penetrability than larger caliber needles and, probably could lead for a safer and easier procedure and could be more accurate in the puncture of narrow vessels in liver cirrhosis (3).
Adverse events: A self-limited bleeding from the cardias was immediately observed after one EUS-PPGm in a patient with idiopathic portal hypertension. One mild epigastric pain 2 day after a combined procedure was observed. No other adverse events were registered one month later.
Conclusion
EUS-guided PPGm, even when combined with EUS-BLB, seems safe providing useful clinical information. Almost half of patients affected with NAFLD have portal hypertension diagnosed precociously in reversible stages providing a useful tool in precision Medicine, especially in the setting of obesity pandemic. Idiopathic portal hypertension was confirmed by this procedure with the complementary information provided by the EUS-BLB. In the patient with HCC, EUS-PPGm rule out portal hypertension and allowed for curative surgery. There are technical aspects related to the needle and the position of the echoendoscope that could be useful to know to improve the safety and accuracy of this procedure.
References
(1) Samarasena J, Chang KJ. Endo-hepatology: A new paradigm. Endosc Ultrasound. 72018. p. 219-22.
(2) Hashimoto R, Chang KJ. Endoscopic ultrasound guided hepatic interventions. Dig Endosc. 2021;33(1):54-65.
(3) Romero-Castro, R; Carmona-Soria, I; Jimenez-Garcia, VA; et al. Endoscopic ultrasound-guided portal pressure gradient measurement: Improving its safety overcoming technical drawbacks. Endoscopy (In press).
Disclosure
Rafael Romero-Castro is consultant to Cook Medical since February, 28th, 2023.
