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GI Surgery – Liver

AGA Clinical Practice Update on Managing Portal Vein Thrombosis in Cirrhotic Patients: Expert Review

3 Jan, 2025 | 10:00h | UTC

Introduction: This summary highlights key recommendations from an AGA expert review on portal vein thrombosis (PVT) in cirrhotic patients. PVT is common in cirrhosis, with an estimated five-year incidence of around 11%, and may worsen portal hypertension and elevate mortality. Management is challenging because of limited evidence, the potential complications of both PVT and anticoagulation, and significant heterogeneity regarding clot characteristics, host factors, and cirrhosis severity. This review presents the latest guidance on identifying clinically relevant PVT, selecting anticoagulation, and considering endovascular interventions, including TIPS (transjugular intrahepatic portosystemic shunt).

Key Recommendations:

  1. No Routine Screening: Asymptomatic patients with compensated cirrhosis do not require regular screening for PVT in the absence of suggestive clinical changes.
  2. Imaging Confirmation: When Doppler ultrasound reveals suspected PVT, contrast-enhanced CT or MRI is recommended to confirm the diagnosis, exclude malignancy, and characterize clot extent and occlusion.
  3. Hypercoagulability Testing: Extensive thrombophilia workup is not indicated unless there is family or personal history of thrombotic events, or associated laboratory abnormalities.
  4. Intestinal Ischemia Management: Patients who develop PVT with evidence of intestinal ischemia should receive prompt anticoagulation and, ideally, multidisciplinary team care involving gastroenterology, hepatology, interventional radiology, hematology, and surgery.
  5. Observation of Minor or Recent Thrombi: In cirrhotic patients without ischemia, with recent (<6 months) thrombi that are <50% occlusive, close imaging follow-up every three months is a reasonable option to track potential spontaneous clot regression.
  6. Anticoagulation for Significant PVT: Consider anticoagulation for more extensive or obstructive (>50%) recent PVT, especially if the main portal vein or mesenteric vessels are involved. Candidates for liver transplantation and those with inherited thrombophilia may derive additional benefit.
  7. Chronic Cavernous PVT: Anticoagulation is generally not advised in patients with long-standing (>6 months) complete occlusion and well-formed collateral channels.
  8. Variceal Screening: Perform endoscopic screening or ensure prophylaxis for varices. Avoid delays in initiating anticoagulation, as timeliness is essential for better recanalization outcomes.
  9. Choice of Anticoagulant: Vitamin K antagonists, low-molecular-weight heparin, and direct oral anticoagulants (DOACs) are all viable options in cirrhosis. DOACs may be appropriate in well-compensated (Child-Turcotte-Pugh class A or certain class B) cirrhosis but should be avoided in class C. Treatment selection should consider patient preferences, monitoring feasibility, and risk of bleeding.
  10. Duration of Therapy: Reassess clot status with cross-sectional imaging every three months. Continue anticoagulation for transplant-eligible individuals who show partial or complete recanalization, and consider discontinuation in nonresponders after six months if futility is evident.
  11. TIPS Revascularization: Portal vein revascularization using TIPS may be pursued in patients who have other TIPS indications (like refractory ascites or variceal bleeding) or to improve transplant feasibility by recanalizing portal flow.

Conclusion: PVT in cirrhosis remains a complex clinical issue requiring careful evaluation of clot extent, timing, and the potential need for transplantation. The recommendations presented here underscore prompt imaging, timely anticoagulation for high-risk thrombi, and individualized therapy based on Child-Turcotte-Pugh classification and bleeding risk. When necessary, multidisciplinary collaboration is key to achieving optimal patient outcomes. Prospective randomized trials and standardized classifications of PVT will be instrumental in refining future guidelines.

Reference:
Davis JPE, Lim JK, Francis FF, Ahn J. AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients With Cirrhosis: Expert Review. Gastroenterology. 2024. DOI: http://doi.org/10.1053/j.gastro.2024.10.038

 


RCT: Laparoscopic hemihepatectomy for primary or metastatic cancer offers faster recovery and improved quality of life compared to open surgery – J Clin Oncol

25 May, 2024 | 18:52h | UTC

Study Design and Population: This study was a multicenter, randomized controlled, patient-blinded, superiority trial involving adult patients undergoing major liver resection (hemihepatectomy) primarily for cancer. Conducted across 16 European hospitals from November 2013 to December 2018, it included 352 patients who were randomized, with 332 completing the surgery—166 each in the laparoscopic and open surgery groups.

Main Findings: The primary outcome, time to functional recovery, was significantly shorter for the laparoscopic group, averaging 4 days compared to 5 days for the open surgery group (P < .001). Quality of life assessments showed higher scores for global health status and body image in the laparoscopic group. Although major complication rates were similar between the two groups, the laparoscopic approach demonstrated a notable advantage in the secondary cancer-specific outcome of time to adjuvant systemic therapy, which was significantly shorter compared to the open surgery group.

Implications for Practice: The findings suggest that laparoscopic hemihepatectomy not only enhances functional recovery and quality of life but also accelerates the initiation of adjuvant therapy in cancer patients without compromising safety or oncological outcomes. This evidence supports the broader adoption of laparoscopic techniques in major liver resections, particularly for cancer-related surgeries, to improve postoperative recovery and patient well-being.

 

Reference (link to abstract – $ for full-text):

Fichtinger RS et al. (2024). Laparoscopic Versus Open Hemihepatectomy: The ORANGE II PLUS Multicenter Randomized Controlled Trial. Journal of Clinical Oncology. DOI: 10.1200/JCO.23.01019.

 


M-A | Percutaneous catheter drainage superior to needle aspiration for liver abscess treatment success

9 Aug, 2023 | 15:12h | UTC

Percutaneous catheter drainage versus percutaneous needle aspiration for liver abscess: a systematic review, meta-analysis and trial sequential analysis – BMJ Open

 


Nonrandomized Controlled Trial | Long-term survival of 80% in selected colorectal cancer patients post liver transplant

1 Aug, 2023 | 14:20h | UTC

Long-Term Survival, Prognostic Factors, and Selection of Patients With Colorectal Cancer for Liver Transplant: A Nonrandomized Controlled Trial – JAMA Surgery (link to abstract – $ for full-text)

 

Commentary on Twitter

 


Fluorescence-guided surgery: comprehensive review

18 May, 2023 | 13:34h | UTC

Fluorescence-guided surgery: comprehensive review – BJS Open

 

Commentary on Twitter

 


EASL-ILCA Clinical practice guidelines on the management of intrahepatic cholangiocarcinoma

9 May, 2023 | 14:47h | UTC

EASL-ILCA Clinical Practice Guidelines on the management of intrahepatic cholangiocarcinoma – Journal of Hepatology

 

Commentary on Twitter

 


Review | Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma

28 Apr, 2023 | 13:03h | UTC

Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma – CA: A Cancer Journal for Clinicians

 


Perspective | Liver transplantation for patients with severe acute on chronic liver failure: it is time to change paradigms

25 Apr, 2023 | 14:37h | UTC

Liver transplantation for patients with severe acute on chronic liver failure: it is time to change paradigms – Intensive Care Medicine

 

Commentary on Twitter

 


Overcoming size disparity in liver transplant access: prioritizing smaller donors for smaller candidates

3 Apr, 2023 | 13:41h | UTC

Association of Body Surface Area With Access to Deceased Donor Liver Transplant and Novel Allocation Policies – JAMA Surgery (free for a limited period)

Invited Commentary: Addressing Size-Based Disparities in Liver Transplant – JAMA Surgery (free for a limited period)

 

Commentary on Twitter

 


Review | Platelet aggregation inhibitors and anticoagulants in gastroenterological and visceral surgical procedures

1 Mar, 2023 | 14:03h | UTC

Platelet Aggregation Inhibitors and Anticoagulants in Gastroenterological and Visceral Surgical Procedures – Deutsches Ärzteblatt international

Related: Management of antiplatelet therapy in patients undergoing elective invasive procedures. Proposals from the French Working Group on perioperative haemostasis (GIHP) and the French Study Group on thrombosis and haemostasis (GFHT). In collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR)

 


Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment

3 Feb, 2023 | 14:01h | UTC

Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment – BMJ Open Gastroenterology

 


M-A | Major complications and mortality after resection of intrahepatic cholangiocarcinoma

3 Feb, 2023 | 13:43h | UTC

Major complications and mortality after resection of intrahepatic cholangiocarcinoma: A systematic review and meta-analysis – Surgery

 


M-A | Impact of perioperative steroid administration in patients undergoing elective liver resection

19 Jan, 2023 | 14:00h | UTC

Impact of perioperative steroid administration in patients undergoing elective liver resection: meta-analysis – BJS Open

 


ERAS Guidelines for perioperative care for liver surgery.

1 Nov, 2022 | 12:16h | UTC

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022 – World Journal of Surgery

Related:

Complete List of Enhanced Recovery After Surgery (ERAS) Society Guidelines

Top 100 Most-Cited Articles on Enhanced Recovery After Surgery: A Bibliometric Analysis and Visualized Study – Frontiers in Surgery

 


Systematic Review | Contrast‐enhanced ultrasound for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease.

5 Sep, 2022 | 14:13h | UTC

Contrast‐enhanced ultrasound for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease – Cochrane Library

Summary: How accurate are contrast-enhanced ultrasound scans for detecting hepatocellular carcinoma? – Cochrane Library

 


Meta-analysis of observational studies | In patients with hepatocellular carcinoma, intraoperative blood salvage during liver transplantation appears safe.

30 Aug, 2022 | 12:03h | UTC

Safety of Intraoperative Blood Salvage During Liver Transplantation in Patients With Hepatocellular Carcinoma: A Systematic Review and Meta-analysis – Annals of Surgery

 


Review | New concepts in the treatment of hepatocellular carcinoma.

24 Aug, 2022 | 13:56h | UTC

New concepts in the treatment of hepatocellular carcinoma – UEG Journal

 


Review | Acute liver failure management and liver transplantation.

15 Aug, 2022 | 11:41h | UTC

CAQ Corner: Acute liver failure management and liver transplantation – Liver Transplantation

 


RCT | Lenvatinib combined with transarterial chemoembolization as first-line treatment for advanced hepatocellular carcinoma.

5 Aug, 2022 | 13:50h | UTC

Lenvatinib Combined With Transarterial Chemoembolization as First-Line Treatment for Advanced Hepatocellular Carcinoma: A Phase III, Randomized Clinical Trial (LAUNCH) – Journal of Clinical Oncology (link to abstract – $ for full-text)

Commentary: Adding TACE to Lenvatinib Boosts Survival in Advanced Liver Cancer — In China-based trial, overall survival in first-line improved by 6 months versus lenvatinib alone – MedPage Today (free registration required)

 


Case-Control Study | Survival benefit of living-donor liver transplant.

4 Aug, 2022 | 13:59h | UTC

Survival Benefit of Living-Donor Liver Transplant – JAMA Surgery

Commentaries:

Just How Low a Model for End-stage Liver Disease Score Benefits From Living-Donor Liver Transplant? – JAMA Surgery (free for a limited period)

Low MELD Score No Barrier to Long Survival After Living-Donor Transplant — End-stage liver disease patients with scores as low as 11 achieved survival of 13 years or beyond – MedPage Today (free registration required)

 


M-A | Repeat hepatic resection vs. percutaneous ablation for the treatment of recurrent hepatocellular carcinoma.

4 Aug, 2022 | 13:27h | UTC

Repeat hepatic resection versus percutaneous ablation for the treatment of recurrent hepatocellular carcinoma: meta-analysis – BJS Open

 

Commentary on Twitter

 


M-A | Evidence on indications and techniques to increase the future liver remnant in children undergoing extended hepatectomy.

22 Jul, 2022 | 11:33h | UTC

Evidence on Indications and Techniques to Increase the Future Liver Remnant in Children Undergoing Extended Hepatectomy: A Systematic Review and Meta-Analysis of Individual Patient Data – Frontiers in Pediatrics

 


Review | Liver biopsy in patients with alcohol-associated liver disease with acute-on-chronic liver failure.

22 Jul, 2022 | 11:28h | UTC

Liver Biopsy in Patients With Alcohol-Associated Liver Disease With Acute-on-Chronic Liver Failure – Journal of Clinical and Experimental Hepatology

 


Cystic liver lesions: a pictorial review.

18 Jul, 2022 | 10:48h | UTC

Cystic liver lesions: a pictorial review – Insights into Imaging

 


Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases.

12 Jul, 2022 | 11:48h | UTC

Hypertensive disorders in pregnancy complicated by liver rupture or hematoma: a systematic review of 391 reported cases – World Journal of Emergency Surgery

 


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