Surgical treatment of portal hypertension is classified into three categories: 1) shunt operations including portocaval shunt and selective shunt that can detour portal venous blood; 2) non-shunt operations such as Hassab's operation and esophageal transection that can decompress esophago-gastric varices by esophago-upper gastric devascularization; 3) other procedures including splenectomy, liver transplantation and mesoportal bypass. Although endoscopic or IVR treatment has become the first choice for esophago-gastric varices, splenectomy and Hassab's operation are still in need in non-surgically intractable cases. Furthermore, these procedures are increasingly performed by minimally invasive surgery using laparoscopy or robotics. Finally, the decision of timing of liver transplantation is critically important in cases of portal hypertension from end-stage liver disease.

Bleeding from the puncture site is a serious complication that can occur during percutaneous transhepatic interventions. We experienced a patient showing serious postoperative bleeding from the puncture site. Thus, we have reviewed and improved the procedure for puncture tract embolization. According to the conventional method, a paste-like embolic gel created from gelatin sponges and contrast agents were injected into the puncture tract through a guiding sheath for angiography. There were instances, however, where the procedure was not stable, such as the sheath unexpectedly coming out too early or embolization agent leaking into the portal vein, resulting in inadequate status of the embolization agent. Thus, we introduced a parallel insertion of a guide wire of 0.035 inch and micorcatheter into the sheath; initially, a metallic coil was placed within the tract via the catheter, followed by the injection of embolization agent. Leaving the guidewire within the catheter stabilized the behavior of the sheath. Moreover, the use of metallic coils minimized the outflow of embolization agents into the portal vein, allowing for stable filling of the tract with embolization agents, and enhancing its occlusive properties. The synergistic effect of metabolic coils and a paste-like embolic gels resulted in a robust embolization. Thus, this method has been evaluated as a safe and reliable tract embolization technique.

Tolvaptan, vasopressin V2-receptor antagonist, is an effective treatment for refractory ascites due to cirrhosis, whereas it is indicated for hyponatremia in Western countries. We investigated the association early changes in serum sodium concentration after starting tolvaptan with the prognosis. A total of 78 cirrhotic patients without hepatocellular carcinoma, who were treated with tolvaptan for refractory ascites, were enrolled. The therapeutic effect was defined as a weight loss of 1.5 kg or more after 7 days. Baseline serum sodium concentration was not associated with treatment response, but it significantly increased after 6 hours and 24 hours regardless of treatment response. Hyponatremia was observed in 37.2% before starting tolvaptan, but it decreased to 17.6% after 24 hours. Multivariate analysis revealed that serum sodium concentration after 24 hours was associated with the prognosis, along with liver function and furosemide dosage. In particular, hyponatremia after 24 hours had a poor prognosis regardless of the therapeutic effect on ascites. In conclusion, our study revealed that hyponatremia was observed in approximately 40% of patients with decompensated liver cirrhosis with refractory ascites and improved early regardless of the therapeutic effect of tolvaptan, but hyponatremia after 24 hours after starting tolvaptan was significantly associated with poor prognosis.

Background: Treatment such as balloon-occluded retrograde rransvenous obliteration (BRTO) and percutaneous transhepatic obliteration (PTO) have been performed for conditions like esophageal varices and hepatic encephalopathy. We have empirically conducted these procedures only in patients with Child-Pugh (CP) class C cirrhosis up to 12 points. The outcomes and tolerability of these interventions were retrospectively investigated.

Methods: Nineteen patients with CP class C cirrhosis up to 12 points, undergoing a total of 22 BRTO and/or PTO procedures from 2007 to 2021, were included in the study. We compared the pre-treatment and 2-3 months post-treatment liver function, assessed long-term survival as a measure of effectiveness, and evaluated tolerability based on postoperative hospital stay and complications.

Results: Gastric varices disappeared in all patients after treatment, and hepatic encephalopathy improved in 94.1% of patients. Significant improvements were observed in liver function indicators such as CP score. The 1-year and 2-year survival rates were 77.2% and 50.0%, respectively, with a median survival of 784 days. Some patients experienced increased ascites postoperatively, but the average postoperative hospital stay was 21.5 days.

Conclusions: Even in patients with Child-Pugh class C cirrhosis, interventions like BRTO and PTO can be performed if the score is up to 12 points; however, careful perioperative management is essential thereafter.