GI Surgery – Liver
AGA Clinical Practice Update on Managing Portal Vein Thrombosis in Cirrhotic Patients: Expert Review
3 Jan, 2025 | 10:00h | UTCIntroduction: 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:
- No Routine Screening: Asymptomatic patients with compensated cirrhosis do not require regular screening for PVT in the absence of suggestive clinical changes.
- 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.
- Hypercoagulability Testing: Extensive thrombophilia workup is not indicated unless there is family or personal history of thrombotic events, or associated laboratory abnormalities.
- 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.
- 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.
- 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.
- Chronic Cavernous PVT: Anticoagulation is generally not advised in patients with long-standing (>6 months) complete occlusion and well-formed collateral channels.
- Variceal Screening: Perform endoscopic screening or ensure prophylaxis for varices. Avoid delays in initiating anticoagulation, as timeliness is essential for better recanalization outcomes.
- 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.
- 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.
- 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 | UTCStudy 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):
M-A | Percutaneous catheter drainage superior to needle aspiration for liver abscess treatment success
9 Aug, 2023 | 15:12h | UTC
Nonrandomized Controlled Trial | Long-term survival of 80% in selected colorectal cancer patients post liver transplant
1 Aug, 2023 | 14:20h | UTCLong-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
Selected patients with liver-only CRLM and favorable pre-transplant prognostic scoring have long-term OS comparable to conventional indications for LT, providing a potential curative treatment option in patients otherwise offered only palliative treatments https://t.co/Xso5R7IDsX pic.twitter.com/uwEWijcrBp
— JAMA Surgery (@JAMASurgery) July 26, 2023
Fluorescence-guided surgery: comprehensive review
18 May, 2023 | 13:34h | UTCFluorescence-guided surgery: comprehensive review – BJS Open
Commentary on Twitter
Find all you ever wanted to know about the current state of fluorescence-guided surgery 🟢🔬🔪in our latest comprehensive review by @BJSurgery editor @paulo_sutt et al. Absolutely worth reading!https://t.co/Tgrj4UvOzV@BJSAcademy @juliomayol @young_bjs #SoMe4Surgery #MedTwitter pic.twitter.com/ReArdO1LOs
— BJS Open (@BjsOpen) May 17, 2023
EASL-ILCA Clinical practice guidelines on the management of intrahepatic cholangiocarcinoma
9 May, 2023 | 14:47h | UTC
Commentary on Twitter
🆕#CPG in press❕
EASL-ILCA Clinical Practice Guidelines on the management of #IntrahepaticCholangiocarcinoma
🆓Find it here👉https://t.co/buM8rgBU1F@EASLedu@EASLnews#iCCA#LiverTwitter pic.twitter.com/raR983x0qk
— Journal of Hepatology (@JHepatology) April 20, 2023
Review | Multidisciplinary management in the treatment of intrahepatic cholangiocarcinoma
28 Apr, 2023 | 13:03h | UTC
Perspective | Liver transplantation for patients with severe acute on chronic liver failure: it is time to change paradigms
25 Apr, 2023 | 14:37h | UTC
Commentary on Twitter
Liver #Tx in severe acute on chronic failure
➡️ #ICU care crucial in ACLF-3
➡️ improve referrals to LT centers & pre-LT workup
➡️ to decide to put pt on waitlist consider donor shortage/collective utility of LT
➡️ identifying transplantability window
🖇️ https://t.co/VZxDyZ1k74 pic.twitter.com/6YOcd5rzMu— Intensive Care Medicine (@yourICM) April 19, 2023
Overcoming size disparity in liver transplant access: prioritizing smaller donors for smaller candidates
3 Apr, 2023 | 13:41h | UTCAssociation 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
In this study, liver waitlist candidates with the smallest body surface areas had a disadvantage due to size. Prioritizing allocation of smaller liver donors to smaller candidates may help overcome this disparity. https://t.co/p5F76Hgzm0
— JAMA Surgery (@JAMASurgery) March 30, 2023
Review | Platelet aggregation inhibitors and anticoagulants in gastroenterological and visceral surgical procedures
1 Mar, 2023 | 14:03h | UTC
Post-transplant biliary complications: advances in pathophysiology, diagnosis, and treatment
3 Feb, 2023 | 14:01h | UTC
M-A | Major complications and mortality after resection of intrahepatic cholangiocarcinoma
3 Feb, 2023 | 13:43h | UTC
M-A | Impact of perioperative steroid administration in patients undergoing elective liver resection
19 Jan, 2023 | 14:00h | UTC
ERAS Guidelines for perioperative care for liver surgery.
1 Nov, 2022 | 12:16h | UTCRelated:
Complete List of Enhanced Recovery After Surgery (ERAS) Society Guidelines
Systematic Review | Contrast‐enhanced ultrasound for the diagnosis of hepatocellular carcinoma in adults with chronic liver disease.
5 Sep, 2022 | 14:13h | UTC
Meta-analysis of observational studies | In patients with hepatocellular carcinoma, intraoperative blood salvage during liver transplantation appears safe.
30 Aug, 2022 | 12:03h | UTC
Review | New concepts in the treatment of hepatocellular carcinoma.
24 Aug, 2022 | 13:56h | UTCNew concepts in the treatment of hepatocellular carcinoma – UEG Journal
Review | Acute liver failure management and liver transplantation.
15 Aug, 2022 | 11:41h | UTCCAQ 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 | UTCLenvatinib 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 | UTCSurvival 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
Commentary on Twitter
Recurrent #HCC after resection: re-resect or ablate?
📰#systematicreviewRedo-Resection has:
– ⏫Morbidity 17% vs 3%
– ⏫ recurrence free survival (HR 0.79)
– ⚖️ overall survival (HR 0.93 (0.83-1.04))https://t.co/WWwsHNkNQ9#SoMe4Surgery #some4hpb@SEIQuirurgica @asgbi pic.twitter.com/h4apdpY7eh— BJS Open (@BjsOpen) May 6, 2022
M-A | Evidence on indications and techniques to increase the future liver remnant in children undergoing extended hepatectomy.
22 Jul, 2022 | 11:33h | UTC
Review | Liver biopsy in patients with alcohol-associated liver disease with acute-on-chronic liver failure.
22 Jul, 2022 | 11:28h | UTC
Cystic liver lesions: a pictorial review.
18 Jul, 2022 | 10:48h | UTCCystic 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