Innovations in endoscopic ultrasound for portal hypertension and its role in managing complications in clinical practice:Lessons learned from a tertiary referral public hospital

Portal hypertension(PH)poses significant challenges.This paper presents an innovative study on the utilization of endoscopic ultrasound(EUS)for both the diagnosis and management of PH.Conducted at Dr.Cipto Mangunkusumo National General Hospital in Jakarta,this retrospective case series included patients diagnosed with PH through clinical examination,imaging evaluation,and esophagogastroduodenoscopy.Exclusion criteria comprised a history of reduced blood consumption within the last 5 days,hepatocellular carcinoma,massive ascites,or elevated international normalized ratio(>1.4).EUS-guided portal pressure gradient(PPG)measurements were performed using an innovative standard manometer.The study involved 15 patients,with 14 having liver cirrhosis and 1 diagnosed with Budd–Chiari syndrome.Among them,nine patients experienced bleeding due to gastroesophageal varices.Small and large esophageal varices were identified in four and eight patients,respectively.Gastroesophageal varices type 1 were observed in two patients,and type 2 in four patients.Isolated gastric fundal varices type 1 were present in one patient.Based on EUS-PPG measurements,14 patients exhibited clinically significant portal hypertension.Seven patients underwent endoscopic band ligation and three underwent EUS-guided cyanoacrylate injection during the same session as the EUS-PPG measurement procedure.Notably,no adverse events,such as abdominal pain,perforation,or bleeding were observed during or after the procedure.EUS emerges as a promising and accurate tool for both diagnosis and management.

Serum markers for detecting histological features of autoimmune hepatitis and predicting prognosis in patients with antinuclear antibody-positive drug-induced liver injury

Aims:Although useful for distinguishing drug-induced liver injury(DILI)from autoimmune hepatitis(AIH),liver biopsy is an invasive examination,and the presence of antinuclear antibody(ANA)positivity in patients with DILI could lead to excessive use of biopsy.Hence,we aimed to identify screening markers for histological features of AIH in patients with ANA-positive DILI and verify their clinical outcomes after 1 year.Methods:This retrospective study included patients with ANA-positive DILI,who underwent liver biopsy between January 2017 and April 2022.Two pathologists identified histological features of AIH.We detected the independent indicators associated with histological features of AIH using logistic regression.We evaluated their diagnostic ability for histological features of AIH using the receiver operating characteristic curve.The followup period to determine clinical outcomes was 1 year after DILI onset.Theχ2 test or Fisher's exact test was used to compare categorical data and the Wilcoxon rank-sum test was used to compare continuous variables.Twosided p<0.05 was considered to indicate significance.Results:The final analysis included 125 patients with ANA-positive DILI,of whom 18 had AIH-like histology.Factors independently associated with AIH-like histology included globulin levels(odds ratio[OR]=1.154,95%confidence interval[CI]=1.046-1.288;p=0.006)and ANA titer≥1:1000(OR=3.531,95%CI=1.136-11.303;p=0.029).The optimal globulin cutoff indicating AIH-like histology was 31.8 g/L.This globulin level in combination with ANA titer≥1:1000(area under the curve=0.785,95%CI=0.738-0.832)provided a sensitivity of 100%and a specificity of 57%for indicating histological features of AIH in patients with ANA-positive DILI.During follow-up,more patients developed AIH in the group with AIH-like histology than in the group without AIH-like histology(35.3%vs.0,p<0.001).Conclusions:For patients with ANA-positive DILI and ANA titer≥1:1000 or globulin≥31.8 g/L,liver biopsy is recommended to determine the presence of histological features of AIH and guide further monitoring.

Nationwide survey analysis of esophagogastric varices in portal hypertension based on endoscopic management in China

Aims:The endoscopic treatment of esophagogastric varices is challenging,and the nationwide application of endoscopic therapies for various types of esophagogastric varices and different clinical scenarios remains unclear.This study investigated the use of endoscopic therapy for portal hypertension in China.Methods:This study used a questionnaire survey initiated by the Liver Health Consortium in China to investigate the use of endoscopic therapies for portal hypertension.Questionnaires were released online from January 30,2023 to February 28,2023 and filled out by chief physicians or senior instructors responsible for endoscopic therapies in participating hospitals across 31 provinces(autonomous regions and municipalities)in China.Comparisons of guideline adherence between primary and referral medical centers were performed using the chi‐square test or Fisher's exact test.Results:In total,836 hospitals participated in the survey.For primary and secondary prophylaxis of esophagogastric variceal bleeding(EGVB),adherence to the national guidelines was 72.5%(606/836)and 39.2%(328/836),respectively.Significant differences were observed in the rate of adherence between the primary and referral centers for primary(79.9%[111/139]vs.71.0%[495/697],p=0.033)and secondary prophylaxis(27.3%[38/139]vs.41.6%[290/697],p=0.002).Of the hospitals,78.2%(654/836)preferred endoscopic therapies for acute EGVB,and the timing of endoscopy was usually within 12 h(48.5%,317/654)and 12-24 h(36.9%,241/654)after bleeding.Endoscopic therapy was more likely to be the first choice of treatment for acute EGVB in referral centers than in primary centers(82.6%[576/697]vs.56.1%[78/139],p<0.001).Regarding the management of gastroesophageal varices type 2 and isolated gastric varices type 1,the most prevalent procedures were cyanoacrylate injection combined with sclerotherapy(48.2%[403/836]and 29.9%[250/836],respectively);however,substantial hospitals preferred clip-assisted therapies(12.4%[104/836]and 26.4%[221/836],respectively).Nonselective beta‐blockers were routinely used in 73.4%(614/836)of hospitals during the perioperative period of EGVB management,and propranolol(88.8%,545/614)and carvedilol(37.5%,230/614)were the most widely used nonselective beta-blockers.Conclusions:This survey clarified that various endoscopic procedures have been implemented nationwide in China.Participating hospitals have actively performed emergent endoscopy for acute EGVB;however,these hospitals do not adequately follow recommendations regarding primary and secondary prophylaxis of EGVB.In the future,standardizing the selection of endoscopic procedures and improving compliance with guidelines is crucial.

Sequential or simultaneous transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma within the Milan criteria:A retrospective real-world study

Aims:Few studies have investigated differences in sequential transarterial chemoembolization(TACE),radiofrequency ablation(RFA),and simultaneous RFA-TACE for the treatment of hepatocellular carcinoma(HCC)using the Milan criteria.This study explored the differences in safety and prognosis between sequential TACE-RFA and simultaneous RFA-TACE.Methods:This retrospective real-world study included 109 patients with HCC within the Milan criteria who underwent sequential TACE-RFA(n=75)or simultaneous RFA-TACE(n=34)at the Eastern Hepatobiliary Surgery Hospital between January 2017 and 2021.Postoperative complications,length of hospital stay,and long-term prognosis were compared.The median follow-up duration of these patients was 39.1 months.Overall survival(OS)and time to tumor recurrence(TTR)curves were plotted using the Kaplan−Meier method and were compared using the logarithmic rank test.Independent risk factors for OS and tumor recurrence(TR)were analyzed using the Cox risk regression model.Results:Multivariate analysis showed that tumor diameter>3 cm(hazard ratio[HR]:2.201,95%confidence interval[CI]:1.106-4.378,p=0.025;HR:2.236,95%CI:1.271-3.934,p=0.005,respectively)and alphafetoprotein(AFP)>400μg/L(HR:2.362,95%CI:1.195-4.668,p=0.013;HR:1.798,95%CI:1.048-3.086,p=0.033,respectively)were independent risk factors for OS and TTR,whereas the presence of multiple tumors(HR:2.352,95%CI:1.127-4.907,p=0.023)was an independent risk factor for TTR.Simultaneous RFA-TACE did not have an effect on OS or TTR.After propensity score-matched,comparable results were obtained and RFATACE still had no effect on OS or TTR.No significant differences were observed in grade III/IV complications(2/75[2.7%]vs.1/34[2.9%],p=1.000)between the two groups.However,the RFA-TACE group had fewer complications than the TACE-RFA group(24/34[70.6%]vs.66/75[88.0%],p=0.026).The RFA-TACE group had a shorter hospital stay and less total cost during hospitalization compared with the TACE-RFA group(6.0 vs.10.0 days,p<0.001;30,000 vs.35,000 CNY,p<0.001).Conclusions:For HCC within the Milan criteria,there was no significant difference in OS and TTR between RFA-TACE and TACE-RFA.However,RFA-TACE could reduce all-grade complications and shorten the length of hospital stay compared with TACE-RFA.Therefore,simultaneous RFA-TACE may be considered for patients with HCC and good liver function falling within the Milan criteria.

Role of post-hepatectomy portal hypertension in predicting the outcome of hepatocellular carcinoma after curative resection

Aims:Portal venous pressure frequently increases after a major hepatectomy.We aimed to assess the outcomes of patients with hepatocellular carcinoma(HCC)with different post-hepatectomy portal pressure statuses and the predictive factors correlated with prognosis and post-hepatectomy portal hypertension(PHPH).Methods:Data from consecutive patients who underwent curative-intent hepatectomy for HCC at the Eastern Hepatobiliary Surgery Hospital and Mengchao Hepatobiliary Hospital of Fujian Medical University between January 2008 and December 2016 were retrospectively analyzed.Patients were followed up until March 1,2022.PHPH was defined as new-onset portal hypertension(PH)in patients without preoperative PH within 1 month of hepatectomy.Patients were classified into two groups according to the presence or absence of PHPH:non-PH and PHPH.The clinicopathological characteristics were compared between the two groups.Univariate and multivariate analyses were used to identify independent risk factors for early and late recurrence of HCC,overall survival(OS),and PHPH.Results:Disease-free survival rates were significantly higher in the non-PH group(n=1068)than those in the PHPH group(n=423)(62.0%,39.0%,and 31.0%vs.46.2%,24.5%,and 19.3%at 1,3,and 5 years,respectively;all p<0.001).The 1-,3-,and 5-year OS rates were 91.0%,66.4%,and 51.4%in the non-PH group and 80.0%,48.9%,and 32.6%in the PHPH group,respectively(all p<0.001).Multivariate analysis revealed that PHPH was independently associated with early recurrence of HCC and poor OS(hazard ratio[HR]1.476,95%confidence interval[CI]1.279–1.704,p<0.001 and HR 1.601,95%CI 1.383–1.853,p<0.001,respectively).Furthermore,hepatitis B virus infection,cirrhosis,preoperative alanine aminotransferase>40 U/L,and major hepatectomy were identified as independent risk factors for PHPH.Conclusions:PHPH was associated with early recurrence of HCC and poor OS but not with late recurrence.Therefore,PHPH may be an attractive target for therapeutic interventions and follow-up surveillance to improve prognosis.

Dual neovascular targets of vascular endothelial growth factor receptors and platelet-derived growth factor receptor ameliorate thioacetamide induced liver fibrosis in rats

Aims:Neovascularization plays a crucial role in liver fibrosis(LF),and blocking vascular endothelial growth factor receptors(VEGFR)has been shown to improve fibrosis.The aim of our study was to investigate the role of dual neovascularization targets,VEGFR,and platelet-derived growth factor receptor(PDGFR),in ameliorating fibrosis.Methods:In vitro,we observed the effects of apatinib(APA)(a VEGFR inhibitor)and donafenib(DON)(a VEGFR and PDGFR inhibitor)on the activation,proliferation,and apoptosis of hepatic stellate cells(HSCs)from rats and humans.In vivo,we established a thioacetamide(TAA)-induced liver fibrosis rat model to explore the antifibrosis effect of APA and DON.We used the method of random table to randomly divide the rats into 4 groups.We detected the expression of angiogenesis-related proteins using Western blot and immunohistochemistry.Results:APA and DON inhibited the proliferation and activation of HSCs,promoted apoptosis of HSCs,and arrested the S phase of the cell cycle in vitro.We also found that DON had a stronger inhibitory effect on HSCs.In vivo,APA and DON ameliorated liver fibrosis,reduced collagen deposition andα-SMA expression in rats,and DON had a stronger improvement effect.APA and DON downregulated the expression of VEGFR2 while inhibiting the phosphorylation of Akt and ERK1/2.DON can act through both VEGF and PDGF pathways,whereas APA can only act through the VEGF pathway.Conclusion:Antiangiogenesis is a promising approach for the treatment of fibrosis.Compared with a single-target drug(APA),the dual-target drug(DON)can achieve better therapeutic effects.

Global status and trends in hepatitis B virus DNA mutation research from 2003 to 2022:A comprehensive bibliometric view

Aims:Hepatitis B virus(HBV)is an enveloped DNA virus belonging to the Hepadnaviridae family.It is a significant contributor to the prevalence of chronic liver disease on a global scale.Mutations in HBV DNA can affect the diagnosis,treatment,and prognosis of patients with chronic hepatitis B.Although numerous studies on HBV DNA mutations have been conducted,few bibliometric studies have been performed to date.This study aimed to analyze changes in scientific output to gain a better understanding of the current research status and identify potential new research directions in the field of HBV DNA mutation.Methods:Relevant studies published between 2003 and 2022 were retrieved from the Web of Science Core Collection database.CiteSpace version 6.1.R6 was used to construct network maps to evaluate collaborations among countries,institutions,authors,journals,and keywords.Results:In total,1508 publications over the past 20 years were obtained,mainly from China,the United States,and Japan.The major research institutions in China included the University of Hong Kong,Fudan University,and Peking University.Lai Ching Lung was the most productive author,whereas Anna Suk-Fong Lok was the most frequently co-cited author.The keyword“HBsAg”was the strongest burst keyword in recent years,indicating possible future study trends.Conclusions:This bibliometric analysis intuitively revealed the overall research status of HBV DNA mutations,providing valuable information for researchers,funding agencies,and policymakers to explore the current research status,research hotspots,and new directions for future research.

Progress in the diagnosis and treatment of graft fibrosis after liver transplantation

Liver transplantation(LT)is considered one of the best treatments for patients with end-stage liver diseases.However,some patients with no significant clinical manifestations or abnormal laboratory tests still experience graft fibrosis during postoperative follow-up,which is often recognized by graft histopathology.Graft fibrosis can lead to graft dysfunction,thereby reducing the survival time of the recipient and even requiring retransplantation.Currently,noninvasive methods are widely applied in the assessment of hepatic and allograft fibrosis.Although both noninvasive diagnostic models based on laboratory examination indicators and elastography technology that can quantify liver stiffness have some value in the evaluation of fibrosis,the diagnostic accuracy and characteristics of these various methods vary and cannot replace liver biopsy completely.In recent years,some liver-protective drugs and proprietary Chinese traditional medicines have been proven to delay or reverse chronic liver fibrosis.Nevertheless,their efficacy and safety for LT recipients need to be further verified.This article reviews the diagnosis and treatment of graft fibrosis after LT to provide a reference for improving the overall survival rate of LT recipients.

Tumor budding is a meaningful prognostic marker in patients with hepatocellular carcinoma after curative hepatectomy

Aim:Tumor budding(TB)has excellent prognostic value in many solid tumors,but there is little research on it in hepatocellular carcinoma(HCC).This study assessed the prognostic value of TB in patients with HCC who received hepatectomy.Methods:This retrospective study included 210 patients with HCC who received curative hepatectomy at the First Affiliated Hospital of Xi'an Jiaotong University,between 2016 and 2018.TB was evaluated on hematoxylin-and eosin-stained slides according to the criteria established by the 2016 International Tumor Budding Consensus Conference.t-tests,Chi-squared tests,and rank-sum tests were used to correlate the extent of TB with clinicopathological parameters.Prognostic analysis was performed using Cox regression models and the Kaplan–Meier method.Results:The positive detection rate of TB was 45.2%(95/210)in 210 patients with HCC.Patients positive for TB always exhibit lower tumor differentiation,higher hepatitis B virus DNA levels,and more severe liver fibrosis.Multivariate Cox analysis identified TB(hazard ratio[HR]:2.232,95%confidence interval[CI]:1.479–3.368,p<0.001)as an independent prognostic factor for patients'recurrence-free survival(RFS),similar to tumor size(HR:1.070,95%CI:1.070–1.142,p=0.042)and satellite nodule(HR:2.266,95%CI:1.298–3.956,p=0.004).Kaplan–Meier analysis also demonstrated that TB-positive patients had a significantly worse RFS.Interestingly,subgroup analysis revealed that among HCC patients with negative microvascular invasion(MVI),TB was also strongly associated with RFS(HR:3.206,95%CI:1.667–6.168,p<0.001).These findings suggest that TB may serve as a supplemental prognostic biomarker for HCC-negative MVI.Conclusions:TB is an adverse prognostic biomarker for HCC,particularly in patients negative for MVI.TB evaluation should be considered in the postoperative pathological examination of HCC in clinical practice.

Endoscopic ultrasound-guided portal pressure gradient identifies patients with previously undiagnosed clinically significant portal hypertension

Aims:Portal hypertension(PH)is a complication of cirrhosis that leads to hepatic decompensation.Assessing the portal pressure gradient(PPG)provides valuable information for disease assessment,staging,and prognosis.In this study,we aimed to report the utilization of endoscopic ultrasound(EUS)-guided PPG(EUS-PPG)measurements in a real-world setting.Methods:This retrospective analysis included patients at a tertiary care center who underwent EUS-PPG between February 2021 and May 2022.The most common indication was to establish or exclude the diagnosis of cirrhosis,followed by an assessment of surgical risk in the setting of suspected cirrhosis.Extensive demographic and clinical data were collected,and statistical analysis was performed using the Student's t test.Results:Eighteen patients underwent EUS-PPG.Technical success was achieved in 17 of the 18 patients.No complications were observed.The mean scores of Child-Pugh,Model for End-Stage Liver Disease-Sodium,and Fibrosis-4 scores were 5.1±0.5,9.0±3.0,and 3.7±4.5,respectively.Of the 18 patients,two presented with esophageal varices and six with portal hypertensive gastropathy.The mean PPG was 5.8±4.5 mmHg,and five patients exhibited clinically significant PH(CSPH).Of the 18 patients,15 underwent concurrent EUS-liver biopsy,which was 100%successful and provided diagnostic histology for all patients.The PPG data led to changes in the clinical management of 17 patients.Conclusions:EUS-PPG is safe and technically feasible.The Child-Pugh score did not correlate well with the presence of CSPH;however,PPG measurements resulted in changes in the management of almost all patients.Larger studies correlating EUS-PPG with other assessments of liver diseases are required.

Endovascular embolization for upper gastrointestinal bleeding due to portal hypertension caused by a superior mesenteric arteriovenous fistula

To the Editor,Upper gastrointestinal bleeding(UGIB)caused by portal hypertension is not uncommon in clinical practice,but UGIB caused by superior mesenteric arteriovenous fistula(SMAVF)is extremely rare.The primary etiologies of SMAVF are associated with traumatic or iatrogenic injury,and congenital lesions.1,2 Although many patients remain asymptomatic after unrecognized injury to the superior mesenteric artery(SMA)for many years,most previous studies reported delayed presentation of persistent epigastric pain,vomiting and nausea,ascites,mesenteric ischemia,or bleeding.The incidence of SMAVF is 0.09%,with a mortality rate of 39%–77%.3 Thus,prompt diagnosis and treatment are very important to prevent morbidity and mortality.

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Application of subharmonic-aided pressure estimation in a patient with giant hepatic cyst:A case report

Giant hepatic cysts may lead to impaired liver function by compressing surrounding tissue,resulting in symptoms such as nausea or portal hypertension.Subharmonic-aided pressure estimation(SHAPE)offers a noninvasive method for quantitatively estimating pressure and monitoring interstitial fluid pressure.A 55-year-old female patient with giant hepatic cysts was admitted to our hospital with elevated protein electrophoretic gamma levels,likely caused by compression of important liver vessels by the cysts.Before surgery,B-mode ultrasound(BMUS)revealed multiple anechoic cystic lesions with thin,smooth walls in the right lobe.In SHAPE,the curve of the portal vein was lower than that of the hepatic vein,which is absolutely different from a healthy volunteer in our previous SHAPE study.It suggested that the patient may have had portal hypertension.Three days after laparoscopic fenestration and drainage of hepatic cysts,the size of the largest cyst had decreased on BMUS and protein electrophoretic gamma levels had normalized.While the curve of the portal vein remained lower than that of the hepatic vein,the difference between them had decreased compared to presurgery levels.SHAPE shows promise as a tool for noninvasively estimating portal hypertension and improving prognosis assessment in patients.

One-year status of hepatic venous pressure gradient measurement from 85 hospitals in China

Aims:Surveys and research on the applications of the hepatic venous pressure gradient(HVPG)are important for understanding the current status and future development of this technology in China.This article aimed to investigate the status of hepatic venous pressure gradient measurement in China in 2022.Methods:We investigated the overall status of HVPG technology in China-including hospital distribution,hospital level,annual number of cases,catheters used,average cost,indications,and current challenges by using online questionnaire.By counting the number and percentages of cases of these results,we hope to clarify the current status of HVPG measurements in China.Results:According to the survey,85 hospitals in China used HVPG technology in 2022 distributed across 29 provinces.A total of 4989 HVPG measurements were performed in all of the surveyed hospitals in 2022,of which 2813 cases(56.4%)were measured alone.The average cost of HVPG measurement was 5646.8±2327.9 CNY.Of the clinical teams who performed the measurements(sometimes multiple per hospital),94.3%(82/87)used the balloon method,and the majority of the teams(72.4%,63/87)used embolectomy catheters.Conclusions:This survey clarified the clinical application status of HVPG in China and confirmed that some medical institutions in China have established a foundation for this technology.It is still necessary to continue promoting and popularizing this technology in the future.

Treatment strategy for erythropoietic protoporphyria accompanied by severe abdominal pain and liver injury

To the Editor,Erythropoietic protoporphyria(EPP)is a genetic disease caused by a lack of the enzyme ferrochelatase(FECH)in the heme biosynthesis pathway due to genetic defects.FECH deficiency is caused by a deleterious FECH variant in transposition to the frequently occurring hypomorphic allele or by the presence of biallelic pathogenic variants.1 EPP could lead to abnormal production and excretion of protoporphyrin IX,2 causing clinical manifestations such as skin damage and liver injury.3–5.

Ten important original articles in the field of cirrhosis and portal hypertension from China

To the Editor,The number of patients with liver disease exceeds 400 million in China.1 All types of hepatitis can progress to cirrhosis,and the severity of portal hypertension is a crucial factor affecting patients'clinical prognosis.2 In 2022,Chinese scientific researchers have made progress in the field of cirrhosis and portal hypertension.Accordingly,the“Top 10 Original Research in Cirrhosis and Portal Hypertension from China in 2022”project was initiated by the Chinese Portal Hypertension Alliance(CHESS).

Comparison of patients with hepatitis B virus-associated hepatocellular carcinoma:Data from two hospitals from Turkey and China

Aims:There are many studies on the incidence of hepatitis B virus(HBV)-associated hepatocellular carcinoma(HCC),but very little is known about the HCC features in different populations.The study aimed to compare characteristics in two cohorts of patients with HBV-associated hepatocellular carcinoma from Turkey and China.Methods:Data on patients with HBV-associated HCC diagnosed by imaging or liver biopsy were retrospectively collected from Shandong Provincial Hospital(n=578)and Inonu University Hospital(n=359)between January 2002 and December 2020,and the liver function and HCC characteristics were compared.Continuous variables were compared using Student's t-test or Mann-Whitney U test and categorical variables were compared using the χ^(2) test or Fisher's exact test.Results:The patients in the Turkish cohort had significantly worse Child-Pugh scores(Child-Pugh A:38.3%vs.87.9%;Child-Pugh B:40.3%vs.11.1%;Child-Pugh C:21.4%vs.1.0%;p<0.001)and significantly higher levels of aspartate aminotransferase(66.5[38.0−126.0]vs.36.0[27.0-50.0]IU/L;p<0.001),alanine aminotransferase(47.5[30.0−87.3]vs.33.0[24.0−45.0]IU/L;p<0.001),total bilirubin(20.8[13.7−39.3]vs.17.9[13.8−24.0]mg/dL;p<0.001),and lower albumin levels(32.0[26.0-39.0]vs.40.0[36.1-43.8]g/L;p<0.001)than patients in Chinese cohort.The tumor characteristics showed the Barcelona Clinic Liver Cancer(BCLC)score(BCLC 1:5.1%vs.71.8%;BCLC 2:48.7%vs.24.4%;BCLC 3:24.4%vs.3.8%;BCLC 4:21.8%vs.0;all p<0.001),maximum tumor diameter(5.0[3.0-9.0]vs.3.5[2.5−6.0]cm;p<0.001),alpha-fetoprotein values(27.7 vs.13.2 ng/mL;p<0.001),and percentage of patients with portal vein tumor thrombus(33%vs.6.1%;p<0.001)were all significantly worse in the Turkish cohort compared with Chinese cohort.Conclusions:HBV-associated HCC from the Turkish cohort had worse liver function and more aggressive clinical characteristics than patients from the Chinese cohort.

Status of transjugular intrahepatic portosystemic shunt for portal hypertension in China:A national survey analysis

Aim:The transjugular intrahepatic portosystemic shunt(TIPS)procedure has been performed in China for 30 years,but our understanding of the status and difficulties associated with the use of TIPS for portal hypertension is incomplete.This study aims to investigate the current situation of the use of TIPS for portal hypertension,which should aid the development of TIPS in China.Methods:This study involved a questionnaire survey,initiated by the China Portal Hypertension Alliance(CHESS)to investigate the use of TIPS for portal hypertension in China.Questionnaires were released on the Internet between August 16,2022 and September 16,2022.Detailed information was collected from 545 hospitals contracted by the CHESS in China,which performed TIPS surgery in 2021.Results:The 545 hospitals covers the majority of hospitals in China that conduct TIPS intervention.In the survey,a total of 13,527 TIPS interventions were carried out with 94.1%(498/545)of them had a system of routine follow‐up after TIPS.The majority(42.6%[232/545])believed that the main indication of TIPS was the control of acute bleeding.Overall,48.1%(262/545)carried out early or pre‐emptive TIPS,53.0%(289/545)carried out TIPS for cavernous transformation of the portal vein,and 81.0%(441/545)chose routine embolization of collateral circulation during operation.Most used coils(97.0%[475/490])and biological glue(72.0%[353/490])as embolic materials,and 78.5%(428/545)routinely performed intraoperative portal pressure gradient measurements.When selecting TIPS stents,57.1%(311/545)chose viator‐specific stents,and 57.2%(312/545)chose conventional anticoagulation after TIPS.Conventional anticoagulation after TIPS is over a time interval of 3–6 months(55.4%[173/312]).The limitation of TIPS surgery is mainly its cost(72.3%[394/545])and insufficient understanding of the procedure by doctors in other related departments(77.4%[422/545]).Most of the hospital teams accept the use of domestic instruments in TIPS surgery(92.7%[505/545]).Conclusions:This survey shows that TIPS is an essential part of the treatment of portal hypertension in China.TIPS is widely used in Chinese patients with portal hypertension,and this survey presents a more comprehensive picture of the options and difficulties encountered in the implementation of TIPS.In the future,it is necessary to promote TIPS technology and further standardize surgical indications,routine operations,and instrument application.

The relationship between sarcopenia,multidimensional frailty,and malnutrition cluster and long-term mortality in hospitalized patients with cirrhosis

Aim:Sarcopenia,multidimensional frailty,and malnutrition represent common debilitating conditions in the context of cirrhosis,linked to a variety of dismal outcomes.We aimed to clarify their overlap and cumulative impact on long-term mortality in hospitalized patients with cirrhosis.Methods:Consecutive patients with cirrhosis were prospectively recruited from January 2018 to December 2020.The diagnosis of sarcopenia,multidimensional frailty,and malnutrition was standardized according to the consensus definition and our well-documented criteria.The prevalence of the respective debilitating condition and the concurrence of this comorbidity were calculated.Results:In total,253 patients with cirrhosis aged 64 years with a female predominance(52.4%)were recruited.Sarcopenia was present in 20.9%(53/253),multidimensional frailty in 12.6%(32/253),and malnutrition in 44.7%(113/253)of the entire cohort.Approximately half of the patients had at least one debilitating condition(127/253).Sarcopenia and malnutrition co-existed in 33 nonfrail patients(13.0%)and multidimensional frailty and malnutrition in eight nonsarcopenic patients(3.2%).Fifteen(5.9%)subjects had all three debilitating conditions,namely malnutrition,sarcopenia,and frailty(MSF)group.The proportions of males,infections,and ascites were significantly higher in the MSF group.Patients in the MSF group had the highest levels of neutrophil-to-lymphocyte ratio and creatinine.The 2-year mortality rates in patients with three debilitating conditions,two conditions,one condition,and no conditions were 60.0%,23.8%,21.4%,and 13.5%,respectively.Multivariate Cox regression indicated the long-term mortality risk was approximately four-fold higher among patients in the MSF group compared to those with no conditions.Conclusions:A fraction of patients with cirrhosis exhibited comorbidities of sarcopenia,multidimensional frailty,and malnutrition,linked to a higher risk of long-term mortality.

Subharmonic aided pressure estimation in portal hypertension:A noninvasive ultrasound-based technique to assess portal pressure gradient

Portal hypertension(PH)is a clinical syndrome,characterized by elevated pressure gradient between portal vein and inferior vena cava.These elevated pressures gradient due to increased vascular resistance and/or increased volume of blood flowing through the portal vein circulation,results in blood outflow difficulty from portal vein to hepatic veins and inferior vena cava.