Enfermedad vascular porto sinusoidal: una causa inusual de sangrado digestivo / Porto sinusoidal vascular disease: an unusual cause of digestive bleeding

RESUMEN La hipertensión portal (HTP) se define como el aumento de la presión a nivel de la vena porta por encima de 5 mmHg, siendo la causa más frecuente la cirrosis hepática. Dentro de las causas intrahepáticas presinusoidales de HTP con compromiso venular portal se describe a la que tradicionalmente fue conocida como hipertensión portal no cirrótica idiopática (HPNCI) teniendo como requisitos excluir aquellos pacientes que no presentaban HTP, así como aquellos con presencia de cirrosis hepática y trombosis venosa portal (TVP). Actualmente se han replanteado los criterios diagnósticos de esta entidad, y su denominación, siendo conocida como enfermedad vascular porto sinusoidal (EVPS) además no excluye a los pacientes con HTP o presencia de enfermedad hepática de base. La biopsia hepática continúa siendo el gold estándar para su diagnóstico. Las manifestaciones clínicas son derivadas de la HTP y el manejo es similar a las complicaciones que se presentan como en los pacientes con cirrosis hepática. Se presenta el caso de un paciente varón quien debuta con cuadro de sangrado digestivo, con hallazgos de varices esofágicas en la endoscopia alta además de estudio de hepatopatía viral, autoinmune y de depósitos negativos, con biopsia hepática concluyente de Enfermedad vascular portosinusoidal.

ABSTRACT Portal hypertension (PHT) is defined as an increase in pressure at the level of the portal vein above 5 mmHg, the most common cause being liver cirrhosis. Among the presinusoidal intrahepatic causes of PHT with portal venular involvement, what was traditionally known as idiopathic non-cirrhotic portal hypertension (NCIH) is described, with the requirements of excluding those patients who did not present PHT, as well as those with the presence of liver cirrhosis and thrombosis. portal venous vein (PVT). Currently, the diagnostic criteria for this entity have been reconsidered, and its name, being known as porto-sinusoidal vascular disease (PSVD), also does not exclude patients with PHT or the presence of underlying liver disease. Liver biopsy continues to be the gold standard for diagnosis. The clinical manifestations are derived from PHT and the management is similar to the complications that occur in patients with liver cirrhosis. The case of a male patient is presented who presents with symptoms of digestive bleeding, with findings of esophageal varices in upper endoscopy in addition to a study of viral, autoimmune liver disease and negative deposits, with a conclusive liver biopsy of porto-sinusoidal vascular disease.

Efficacy of percutaneous transhepatic variceal embolization alone or in combination with partial splenic embolization in treatment of portal hypertensive hemorrhage in liver cirrhosis： A Meta-analysis / 临床肝胆病杂志

ObjectiveTo investigate the efficacy of percutaneous transhepatic variceal embolization （PTVE） alone or in combination with partial splenic embolization （PSE） in the treatment of portal hypertensive hemorrhage in liver cirrhosis through a meta-analysis. MethodsThis study was conducted according to PRISMA guideline， with a PROSPERO registration number of CRD42023396690. Wanfang Med Online， CNKI， CBM， VIP Databases， PubMed， Embase， the Cochrane Library， and Web of Science databases were searched for articles on PTVE alone or in combination with PSE in the treatment of portal hypertensive hemorrhage in liver cirrhosis published up to December 23， 2022. The articles were selected based on inclusion and exclusion criteria， and related data were extracted. The RevMan 5.4.1 statistical analysis software was used to perform the meta-analysis. ResultsEight articles were finally included， with a total sample size of 592 cases， among which there were 316 cases in the PTVE+PSE group and 276 cases in the PTVE group. The meta-analysis showed that compared with the PTVE group， the PTVE+PSE group had significantly lower postoperative portal vein pressure （standardized mean difference ［SMD］=-1.75， 95% confidence interval ［CI］： -2.33 to -1.16， P<0.05）， postoperative diameter of the portal vein （SMD=-0.87， 95%CI： -1.64 to -0.10， P<0.05）， postoperative rebleeding rate （odds ratio ［OR］=0.17， 95%CI： 0.11 — 0.28， P<0.05）， mortality rate （OR=0.13， 95%CI： 0.04 — 0.37， P<0.05）， and incidence rate of postoperative portal hypertensive gastrointestinal disease （OR=0.17， 95%CI： 0.07 — 0.45， P<0.05］， as well as a significantly higher postoperative platelet level （SMD=0.79， 95%CI： 0.52 — 1.06， P<0.05）， while there were no significant differences between the two groups in the incidence rates of postoperative ascites. ConclusionCompared with PTVE alone， PTVE combined with PSE can effectively reduce the rebleeding rate and mortality rate of portal hypertensive hemorrhage in liver cirrhosis， the incidence rate of portal hypertensive gastrointestinal disease， and portal vein pressure， and it can also shorten the diameter of the portal vein and increase platelet level. Therefore， it is an effective interventional method for the treatment of portal hypertension hemorrhage in liver cirrhosis.

Investigation and analysis of the current status of transjugular intrahepatic portosystemic shunt treatment for portal hypertension in China / 中华放射学杂志

Objective:To investigate the current situation of the use of transjugular intrahepatic portosystemic shunt (TIPS) for portal hypertension, which should aid the development of TIPS in China.Methods:The China Portal Hypertension Alliance (CHESS) initiated this study that comprehensively investigated the basic situation of TIPS for portal hypertension in China through network research. The survey included the following: the number of surgical cases, main indications, the development of Early-TIPS, TIPS for portal vein cavernous transformation, collateral circulation embolization, intraoperative portal pressure gradient measurement, commonly used stent types, conventional anticoagulation and time, postoperative follow-up, obstacles, and the application of domestic instruments.Results:According to the survey, a total of 13 527 TIPS operations were carried out in 545 hospitals participating in the survey in 2021, and 94.1% of the hospital had the habit of routine follow-up after TIPS. Most hospitals believed that the main indications of TIPS were the control of acute bleeding (42.6%) and the prevention of rebleeding (40.7%). 48.1% of the teams carried out early or priority TIPS, 53.0% of the teams carried out TIPS for the cavernous transformation of the portal vein, and 81.0% chose routine embolization of collateral circulation during operation. Most of them used coils and biological glue as embolic materials, and 78.5% of the team routinely performed intraoperative portal pressure gradient measurements. In selecting TIPS stents, 57.1% of the hospitals woulel choose Viator-specific stents, 57.2% woulel choose conventional anticoagulation after TIPS, and the duration of anticoagulation was between 3-6 months (55.4%). The limitation of TIPS surgery was mainly due to cost (72.3%) and insufficient understanding of doctors in related departments (77.4%). Most teams accepted the domestic instruments used in TIPS (92.7%).Conclusions:This survey shows that TIPS treatment is an essential part of treating portal hypertension in China. The total number of TIPS cases is far from that of patients with portal hypertension. In the future, it is still necessary to popularize TIPS technology and further standardize surgical indications, routine operations, and instrument application.

Construction of a risk prediction model for overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with hepatitis B cirrhosis and portal hypertension / 临床肝胆病杂志

ObjectiveTo investigate the influencing factors for overt hepatic encephalopathy （OHE） in patients with hepatitis B cirrhosis after transjugular intrahepatic portosystemic shunt （TIPS）， and to construct an individualized risk prediction model. MethodsA total of 302 patients with hepatitis B cirrhosis who underwent TIPS in Department of Gastroenterology， The General Hospital of Western Theater Command， from January 2017 to December 2021 were enrolled， and according to the presence or absence of OHE after surgery， they were divided into non-OHE group with 237 patients and OHE group with 65 patients. The two groups were compared in terms of general data， laboratory markers， Child-Turcotte-Pugh （CTP） score， MELD combined with serum sodium concentration （MELD-Na） score， and albumin-bilirubin （ALBI） score before surgery. The independent-samples t test or the Mann-Whitney U test was used for comparison of continuous data between two groups， and the chi-square test was used for comparison of categorical data between two groups. The univariate and multivariate logistic regression analyses were used to identify the influencing factors for OHE after TIPS in patients with hepatitis B cirrhosis， and independent influencing factors were used to construct a nomogram model. The receiver operating characteristic （ROC） curve analysis and the calibration curve analysis were used to evaluate the discriminatory ability and calibration of the model， and the decision curve analysis and the clinical impact curve （CIC） were used to evaluate the clinical effectiveness of the model . ResultsAge （odds ratio ［OR］=1.035， 95% confidence interval ［CI］： 1.004‍ ‍—‍ ‍1.066， P<0.05）， white blood cell count （WBC）/platelet count （PLT） ratio （OR=33.725， 95%CI： 1.220‍ ‍—‍ ‍932.377， P<0.05）， international normalized ratio （INR） （OR=5.149， 95%CI： 1.052‍ ‍—‍ ‍25.207， P<0.05）， and pre-albumin （PAB） （OR=0.992， 95%CI： 0.983‍ ‍—‍ ‍1.000， P<0.05） were independent predictive factors for OHE after TIPS in patients with hepatitis B cirrhosis. The nomogram model constructed based on age， WBC/PLT ratio， INR， and PAB had an area under the ROC curve of 0.716 （95%CI： 0.649‍ ‍—‍ ‍0.781）， with a sensitivity of 78.5% and a specificity of 56.1%. ConclusionThe nomogram model constructed based on age， WBC/PLT ratio， INR， and PAB can help to predict the risk of OHE after TIPS in patients with hepatitis B cirrhosis.

Colangiopatía hipertensiva portal por transformación portal cavernomatosa de origen no cirrótica: a propósito de un caso

La colangiopatía portal hace referencia a anomalías colangiográficas que se producen en pacientes con cavernomatosis portal, siendo progresiva, cursando con enfermedad biliar sintomática y anomalías graves de las vías biliares. Y, representa una complicación infrecuente de la hipertensión portal. Se describe el caso de un hombre de 53 años, con historia de larga data de hipertensión portal nocirrótica y cavernomatosis portal, quien presentó un episodio de enfermedad biliar obstructiva sintomática, y en estudios se documentó tejido fibrótico de extensión periportal ascendente con compresión extrínseca del colédoco distal y dilatación de la vía biliar extra e intrahepática. Por lo que se procedió a colangiopancreatografía retrógrada endoscópica, realizándose tratamiento paliativo, con papilotomía pequeña y colocación de endoprótesis biliar plástica, siendo exitoso por ausencia de complicaciones procedimentales, y mejoría clínica y parámetros bioquímicos. Finalmente, recibiendo de alta con indicación de seguimiento prioritario para recambios periódicos de endoprótesis biliares, y valoración por hepatología. La colangiopatía portal es una entidad rara que debe sospecharse en sujetos con hipertensión portal de origen no-cirrótico, con hallazgos imagenológicos de estenosis, angulaciones o dilataciones segmentarias, su tratamiento debe ser individualizado, y la terapia endoscópica es de elección en enfermedad biliar sintomática.

Portal cholangiopathy refers to cholangiographic abnormalities occurring in patients with portal cavernomatosis, being progressive, presenting with symptomatic biliary disease and severe biliary tract abnormalities. And, it represents an infrequent complication of portal hypertension. We describe the case of a 53-year-old man with a long history of non-cirrhotic portal hypertension and portal cavernomatosis, who presented an episode of symptomatic obstructive biliary disease, and studies documented fibrotic tissue of ascending periportal extension with extrinsic compression of the distal common bile duct and dilatation of the extra and intrahepatic biliary tract. Therefore, endoscopic retrograde cholangiopancreatography was performed, and palliative treatment with small papillotomy and placement of a plastic biliary endoprosthesis was successful due to the absence of procedural complications, and clinical improvement and biochemical parameters. Finally, the patient was discharged with indication of priority follow-up for periodic replacement of biliary stents, and evaluation by hepatology. Portal cholangiopathy is a rare entity that should be suspected in subjects with portal hypertension of non-cirrhotic origin, with imaging findings of stenosis, angulations or segmental dilatations, its treatment should be individualized, and endoscopic therapy is of choice in symptomatic biliary disease.

Application prospect of endoscopic ultrasound-guided portal pressure gradient measurement / 临床肝胆病杂志

Portal pressure measurement plays an important role in the diagnosis and evaluation of portal hypertension, and at present, there is still no unified method for the assessment of portal vein pressure. With the wide application of endoscopic ultrasound in digestive system diseases, endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) measurement was included in the research agenda of the 2021 Baveno-VII conference, thus attracting widespread attention of scholars. This article reviews portal pressure measurement techniques, the development of EUS-PPG measurement technique, and two commonly used methods for EUS-PPG measurement in China and globally and elaborates on the application prospect of EUS-PPG measurement technique. A number of studies around the world have shown that EUS-PPG measurement technique is a direct, minimally invasive, simple, accurate, and radiation-free technique with strong clinical operability, and it is an important supplement to portal pressure measurement methods and may gradually become one of the main methods for portal pressure measurement.

Guidelines on the management of esophagogastric variceal bleeding in cirrhotic portal hypertension / 临床肝胆病杂志

In order to standardize the diagnosis, treatment and management of esophagogastric variceal bleeding (EVB) in cirrhotic portal hypertension, the Chinese Society of Hepatology, Chinese Society of Gastroenterology, and Chinese Society of Digestive Endoscopology of Chinese Medical Association organized relevant experts, reviewed domestic and international latest progress in clinical research on EVB in cirrhotic portal hypertension, and followed the evidence of evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guideline provides recommendations for the diagnosis, treatment and management of EVB in cirrhotic portal hypertension and aims to improve the level of clinical treatment of EVB in cirrhotic portal hypertension.

Advances in the application of nonselective β-receptor blockers in treatment of liver cirrhosis / 临床肝胆病杂志

Nonselective β-receptor blockers (NSBBs) are first-line drugs for the prevention and treatment of complications in cirrhotic patients with portal hypertension and are widely used in the primary and secondary prevention of esophagogastric variceal bleeding. In recent years, studies have shown that in patients with clinically significant portal hypertension (CSPH), NSBBs can used to prevent liver decompensation events besides variceal bleeding, such as ascites and hepatic encephalopathy. However, in patients without CSPH, current research evidence does not support the use of NSBBs. Although reliable data currently support the use of NSBBs in end-stage liver cirrhosis, there are still drug safety issues in patients with refractory ascites and spontaneous bacterial peritonitis, and further studies are needed to explore the dose and timing of administration. This article reviews the clinical research advances in the use of NSBBs (especially carvedilol) in patients with liver cirrhosis and summarizes the therapeutic window used reasonably in the whole-course management of liver cirrhosis, so as to provide a basis for clinical decision-making.

Current research status of spleen stiffness measurement in predicting portal hypertension and its complications in patients with liver cirrhosis / 临床肝胆病杂志

Liver stiffness measurement (LSM) has been widely used in predicting portal hypertension in clinical practice, and in recent years, spleen stiffness measurement (SSM) has also become a diagnostic tool. Studies have shown that SSM can predict portal hypertension and its complications such as esophagogastric variceal bleeding in patients with chronic liver diseases and assist in the risk stratification management of portal hypertension and esophagogastric variceal bleeding. It can accurately predict clinically significant portal hypertension, high-risk esophageal and gastric varices, decompensation rate, and mortality rate in patients with chronic liver diseases. At present, SSM data in most studies are obtained by detection using the liver equipment FibroScan Ⓡ (SSM@50 Hz). FibroScan Ⓡ 630 is a new scanner dedicated for SSM with a special mode for SSM (SSM@100 Hz). This article elaborates on the significance of SSM in predicting portal hypertension and briefly introduces the advantages and disadvantages of the new equipment for SSM.

Hemodynamic characteristics of proper hepatic artery and portal vein in patients after splenectomy and devascularization / 临床肝胆病杂志

Objective To investigate the characteristics of hemodynamics of proper hepatic artery and portal vein after splenectomy and devascularization. Methods The clinical data of 103 patients with portal hypertension who underwent splenectomy and devascularization in the Capital Medical University-Affiliated You'an Hospital from April 2014 to February 2019 were retrospectively analyzed. Their hemodynamics of the proper hepatic artery and portal vein were recorded before and 1 week-, and 1-, 3-, 6-, 12-, and 24-months after surgery and then statistically analyzed. Continuous data with normal distribution were compared using paired-samples t test. Results Compared with the before surgery data, the portal vein diameter, portal vein flow, maximum velocity, and average velocity of the portal vein were all significantly decreased 1-week-, 1-, 3-, 6-, 12-, and 24-months after splenectomy and devascularization (all P < 0.05). The blood flow and velocity of the proper hepatic artery was significantly increased 1 week and 1 month after surgery (all P < 0.05); however, there was no statistically significant difference at 3-, 6-, 12-, and 24-months after surgery. Conclusion The diameter, flow, and flow velocity of the portal vein after splenectomy and devascularization were significantly lower than those before surgery, whereas the proper hepatic artery flow and flow velocity were increased within 1 month after surgery and then returned back to the pre-surgery levels 3 months after surgery.

Efficacy of transjugular intrahepatic portosystemic shunt in treatment of primary biliary cholangitis with portal hypertension / 临床肝胆病杂志

Objective To investigate the long-term efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of primary biliary cholangitis (PBC) with portal hypertension. Methods A retrospective analysis was performed for 102 patients who received TIPS in Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2015 to August 2021, and these patients were divided into PBC group with 41 patients and viral hepatitis cirrhosis group with 81 patients. Related indicators were collected, including routine blood test results, liver and renal function, coagulation function, portal vein thrombosis, hepatic encephalopathy, and etiology of TIPS treatment shortly after admission, preoperative portal venous pressure, and stents used in surgery, and Child-Pugh score was calculated. Follow-up data were collected and analyzed, including postoperative upper gastrointestinal rebleeding, stent dysfunction, hepatic encephalopathy, and the data on survival and prognosis. The independent samples t -test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of continuous data with skewed distribution between two groups; the chi-square test was used for comparison of categorical data between two groups. The Kaplan-Meier method was used for survival analysis, and the log-rank test was used for survival difference analysis. Results In the PBC group and the viral hepatitis cirrhosis group, the median percentage of reduction in portal venous pressure after surgery was 33.00% and 35.00%, respectively, and there was no significant difference between the two groups ( P > 0.05). At the end of follow-up, there were no significant differences between the PBC group and the viral hepatitis cirrhosis group in stent dysfunction rate (14.63% vs 24.69%, χ 2 =1.642, P > 0.05), upper gastrointestinal rebleeding rate (17.07% vs 24.69%, χ 2 =0.917, P > 0.05), the incidence rate of overt hepatic encephalopathy (12.20% vs 7.41%, χ 2 =0.289, P > 0.05), and disease-specific death rate (14.63% vs 9.88%, χ 2 =0.229, P > 0.05). Conclusion For PBC patients with portal hypertension, TIPS can achieve the same efficacy as the treatment of portal hypertension caused by viral hepatitis cirrhosis and can also effectively reduce portal hypertension without increasing the incidence rate of complications and disease-specific death rate. Therefore, it is a safe and effective treatment method.

Clinical features of myeloproliferative neoplasms with portal hypertension as the main manifestation / 临床肝胆病杂志

Objective To investigate the clinical features, liver histological features, and diagnostic and treatment methods for patients with myeloproliferative neoplasms (MPN) with portal hypertension as the main manifestation. Methods A retrospective analysis was performed for related data of the patients who attended the hospital due to portal hypertension and were finally diagnosed with MPN in Liver Research Center, Beijing Friendship Hospital, from January 2019 to February 2022, including clinical manifestation, liver pathological features, treatment, and follow-up results. Results Nine patients were included in this study, and all the patients had splenomegaly and esophageal and gastric varices, while portal vein thrombosis was observed in eight patients. All patients had normal or slightly abnormal liver function and routine blood test results. Six patients underwent liver biopsy, without the formation of fibrous septum and pseudolobule, and hepatic extramedullary hematopoiesis was observed in two patients. All nine patients underwent bone marrow biopsy and genetic testing, among whom six had essential thrombocythemia and three had primary myelofibrosis, and genetic testing revealed JAK - 2V617F gene mutation in seven patients and CALR gene mutation in two patients. Conclusion MPN is one of the rare causes of portal hypertension and has the clinical manifestations of esophageal and gastric varices, splenomegaly, and even megalosplenia, without the manifestations of hypersplenism such as leukopenia and thrombocytopenia. Detection of the JAK - 2V617F and CALR genes can improve the diagnostic rate of MPN.

Association between spontaneous portosystemic shunt and hepatorenal syndrome in liver cirrhosis / 临床肝胆病杂志

ObjectiveTo investigate the association between spontaneous portosystemic shunt （SPSS） and hepatorenal syndrome （HRS） in patients with liver cirrhosis. MethodsA retrospective analysis was performed for 93 patients with SPSS from Dezhou Hospital， Qilu Hospital of Shandong University， from January 2015 to January 2022， and the patients were followed up for 12 months with the onset of HRS as the observation endpoint. According to the presence or absence of HRS， the 93 patients with SPSS were divided into HRS group with 38 patients （40.86%） and non-HRS group with 55 patients （59.14%）， and the two groups were compared in terms of clinical data， laboratory data， complication， and shunt diameter. Based on the maximum shunt vein diameter of 1.5 cm， the 93 patients with SPSS were divided into high shunt group with 52 patients （55.91%） and low shunt group with 41 patients （44.09%）， and with the onset of HRS as the observation endpoint， the two groups were compared in terms of the incidence rate of HRS and survival time curve. The independent-samples t test was used for comparison of normally distributed continuous data with homogeneity of variance between two groups， and the chi-square test was used for comparison of categorical data between two groups. The receiver operating characteristic （ROC） curve was used to predict cut-off values， the Kaplan-Meier curve was used for comparison of survival time， and the Log-rank test was used to compare the differences in survival curves. The multivariate Cox regression analysis was used to investigate risk factors. ResultsCompared with the non-HRS group， the HRS group had significant increases in Child-Pugh score， Child-Pugh class， MELD score， serum creatinine， blood urea nitrogen， alanine aminotransferase， aspartate aminotransferase， maximum shunt vein diameter， the incidence rates of hepatic encephalopathy and spontaneous bacterial peritonitis， and the degree of ascites， as well as significant reductions in main portal vein diameter， serum sodium and albumin （all P<0.05）. Compared with the low shunt group， the high shunt group had a significant increase in the incidence rate of HRS （51.92% vs 26.83%， χ²=5.974， P=0.015） and a significant reduction in the time to the onset of HRS （Log-rank P=0.033）. A maximum shunt vein diameter of >1.5 cm （hazard ratio ［HR］=1.123， 95% confidence interval ［CI］： 1.041‍ ‍—‍ ‍1.211， P=0.003）， an increase in MELD score （HR=1.205， 95%CI： 1.076‍ ‍—‍ ‍1.437， P=0.039）， a reduction in serum albumin （HR=0.890， 95%CI： 0.814‍ ‍—‍ ‍0.974， P=0.011）， an increase in the degree of ascites （HR=2.099， 95%CI： 1.066‍ ‍—‍ ‍4.130， P=0.032）， and spontaneous bacterial peritonitis （HR=2.259， 95%CI： 1.020‍ ‍—‍ ‍5.003， P=0.045） were independent risk factors for the onset of HRS in SPSS patients. ConclusionThere is an association between SPSS and HRS， and shunt diameter >1.5 cm was an independent risk factor for HRS in SPSS patients， which should be taken seriously and require early intervention in clinical practice.

Clinical features of idiopathic non-cirrhotic portal hypertension: An analysis of 74 patients / 临床肝胆病杂志

Objective Idiopathic non-cirrhotic portal hypertension (INCPH) is a rare cause of portal hypertension, and this study aims to analyze the clinical features of patients with INCPH, and to assist in diagnosis and differential diagnosis. Methods A total of 74 patients who were hospitalized in Beijing YouAn Hospital from January 2019 to July 2022 and were diagnosed with INCPH were enrolled, and 332 patients with liver cirrhosis who were hospitalized during the same period of time were enrolled as control group. Demographic data, laboratory markers, gastroscopy, liver elasticity, pathological examination, and complications were recorded and compared between the two groups. The receiver operating characteristic (ROC) curve was used to investigate the ability of liver stiffness measurement (LSM), aspartate aminotransferase-to-platelet ratio index (APRI), and fibrosis-4 (FIB-4) in the differential diagnosis of INCPH, and the DeLong test was used to compare the area under the ROC curve (AUC). The independent-samples t test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. Results Among the patients with INCPH, 46.55% had no obvious symptoms at disease onset and 43.24% were misdiagnosed with liver cirrhosis. Compared with the patients with liver cirrhosis, the patients with INCPH had a significantly higher proportion of patients with gastrointestinal bleeding (62.16% vs 41.27%, χ 2 =10.67, P < 0.01) and a significantly lower proportion of patients with moderate-to-severe ascites (16.21% vs 29.82%, χ 2 =34.98, P < 0.01), and there were few patients with hepatic encephalopathy. As for pathology, 89.19% (66/74) of the INCPH patients manifested as typical occlusive portal vein disease. The statistical analysis showed that compared with the patients with liver cirrhosis, the patients with INCPH had significantly better liver function parameters, MELD score, and Child-Pugh score and significantly lower LSM [9.05(7.18-12.33) vs 25.32(16.21-47.23), Z =-8.41, P < 0.01], APRI score [0.70(0.41-1.28) vs 1.35(0.80-2.39), Z =-6.21, P < 0.01], and FIB-4 index [2.99(1.62-4.81) vs 6.68(4.06-10.42), Z =-8.39, P < 0.01]. LSM, FIB-4, and APRI had a good ability in differentiating INCPH from liver cirrhosis, and in particular, LSM had an AUC of up to 0.92 (95% confidence interval: 0.87-0.96), with a sensitivity of 92.68% and a specificity of 81.60%. Conclusion INCPH patients tend to have an insidious onset, a relatively high incidence rate of portal hypertension-related complications, and relatively good liver function, especially the patients with LSM < 14.5 kPa. The possibility of INCPH should be considered for such patients in clinical practice.

Risk factors for pulmonary infection after laparoscopic surgery in treatment of hepatocellular carcinoma with liver cirrhosis and portal hypertension / 临床肝胆病杂志

Objective To investigate the incidence rate of pulmonary infection after laparoscopic surgery and related risk factors in patients with hepatocellular carcinoma (HCC) comorbid with liver cirrhosis and portal hypertension (PHT). Methods A retrospective analysis was performed for the clinical data of 105 HCC patients with liver cirrhosis and PHT who underwent laparoscopic surgery in Beijing Ditan Hospital, Capital Medical University, from January 2017 to February 2022. A total of 30 factors that might cause pulmonary infection were recorded, including general information, disease factors, surgical factors, and postoperative factors. Postoperative recovery was observed and the occurrence of pulmonary infection was recorded. The chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups, and the multivariate logistic regression analysis was used to investigate the independent risk factors for pulmonary infection. Results Among the 105 patients, 66 underwent laparoscopic devascularization combined with hepatectomy and 39 underwent laparoscopic devascularization combined with radiofrequency ablation (RFA). The surgery was successful for all patients, with no case of conversion to laparotomy or unscheduled reoperation. No death was observed within 30 days after surgery and during hospitalization, with a median length of hospital stay of 20 days (range 14-25 days). The incidence rate of pulmonary infection was 25.71% (27/105). Smoking (odds ratio [ OR ]=3.362, 95% confidence interval [ CI ]: 1.282-8.817, P =0.014), MELD score ( OR =3.801, 95% CI : 1.007-14.351, P =0.049), tumor location ( OR =1.937, 95% CI : 1.169-3.211, P =0.010), surgical procedure ( OR =0.006, 95% CI : 0.001-0.064, P =0.000), intraoperative infusion volume ( OR =4.871, 95% CI : 1.211-19.597, P =0.026), and postoperative pleural effusion ( OR =9.790, 95% CI : 1.826-52.480, P =0.008) were independent risk factors for pulmonary infection. Conclusion There is a relatively high risk of pulmonary infection in HCC patients with liver cirrhosis and PHT undergoing laparoscopic surgery. Postoperative pleural effusion is the high risk factor for pulmonary infection, and devascularization combined with RFA can significantly reduce the risk of pulmonary infection. It is recommended to strengthen preoperative rehabilitation, perioperative liver function maintenance, intraoperative damage control, and goal-oriented fluid therapy and reduce postoperative fluid accumulation in the third space, so as to reduce the incidence rate of pulmonary infection.

The mechanism of action of partial splenic artery embolization in treatment of liver cirrhosis and hypersplenism / 临床肝胆病杂志

Hypersplenism is a common complication caused by liver cirrhosis and portal hypertension, and at present, splenectomy and partial splenic artery embolization (PSE) are the main methods for the treatment of hypersplenism. Splenectomy has a marked effect in the treatment of hypersplenism and can significantly improve the clinical symptoms of patients with hypersplenism. Compared with splenectomy, PSE causes partial splenic parenchymal infarction and thus achieve similar clinical efficacy as partial splenectomy while preserving the spleen and its function. Although PSE is an effective method for the treatment of hypersplenism, there are few reports on the effect of PSE on liver fibrosis, immunity, and liver regeneration in China and globally. This article summarizes the common causes of hypersplenism, the mechanism of PSE in the treatment of hypersplenism, the therapeutic effect of different embolization methods and materials, and the effect of PSE on liver fibrosis, immunity, and liver regeneration, so as to provide a theoretical basis and new ideas for the clinical treatment of hypersplenism.

Influencing factors for portal vein thrombosis after laparoscopic splenectomy and azygopor-tal disconnection / 中华消化外科杂志

Objective:To investigate the influencing factors for portal vein thrombosis after laparoscopic splenectomy and azygoportal disconnection (LSD).Methods:The retrospective case-control study was conducted. The clinicopathological data of 106 patients with portal hypertension, type B viral hepatitis and cirrhosis who were admitted to Clinical Medical College of Yangzhou University from September 2014 to January 2017 were collected. There were 83 males and 23 females, aged (51±11)years. All patients underwent LSD. Observation indicators: (1) incidence of postoperative thrombosis and treatment; (2) influencing factors for portal vein thrombosis after LSD. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Univariate analysis was conducted by corres-ponding statistic methods. Multivariate analysis was conducted by Logistic stepwise regression model with forward method. Results:(1) Incidence of postoperative thrombosis and treatment. All 106 pati-ents were followed up in the postoperative 1 month. During the follow-up period, 35 patients had thrombosis occurred in main and intrahepatic branches of portal vein, including 23 cases with thrombosis occurred in main portal vein, 1 case with thrombosis occurred in intrahepatic right branches of portal vein, 5 cases with thrombosis occurred in main and intrahepatic right branches of portal vein, 5 cases with thrombosis occurred in main and intrahepatic left branches of portal vein, 1 case with thrombosis occurred in intrahepatic left branches of portal vein. Of the 35 patients with portal vein thrombosis, 17 cases were treated with warfarin and 18 cases were treated with aspirin. (2) Influencing factors for portal vein thrombosis after LSD. Results of multivariate analysis showed that preoperative portal vein diameter was an independent factor influencing portal vein thrombosis after LSD ( odds ratio=1.559, 95% confidence interval as 1.200-2.027, P<0.05). Conclusion:Preoperative portal vein diameter is an independent factor influencing portal vein thrombosis after LSD .

Application value of peri-gastric devascularization without dissociation of esophagus for portal hypertension / 中华消化外科杂志

Objective:To investigate the application value of peri-gastric devasculariza-tion without dissociation of esophagus for portal hypertension.Methods:The retrospective and descriptive study was conducted. The clinical data of 94 patients with portal hypertension who were admitted to three medical centers, including 75 cases in the People′s Hospital of Ningxia Hui Autonomous Region, 12 cases in the People′s Hospital of Wuhai and 7 cases in the People′s Hospital of Wuzhong, from July 2018 to December 2022 were collected. There were 68 males and 26 females, aged 46(range, 21-70)years. All 94 patients underwent peri-gastric devascularization without dissociation of esophagus. Observation indicators: (1) intraoperative condition; (2) postoperative complications; (3) follow-up. Measurement data with normal distribution were represented as Mean± SD, and measure-ment data with skewed distribution were represented as M(range). Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Results:(1) Intraoperative condition. All 94 patients underwent surgery success-fully without operation death, including 82 cases receiving open surgery and 12 cases receiving laparoscopic surgery. The operation time and volume of intraoperative blood loss were (183±85)minutes and 289(range, 158-560)mL, respectively, for the 94 patients. (2) Postoperative complications. Of 94 patients, early portal vein thrombosis occurred in 24 cases, intra-abdominal infection occurred in 2 cases, hepatic encephalopathy occurred in 1 case, pulmonary embolism occurred in 1 case, intra-abdominal hemorrhage requiring operation to stop bleeding occurred in 1 case and pleural effusion requiring drainage occurred in 1 case. All patients with postoperative complications were cured after treatment. None of the 94 patient had postoperative esophageal complications such as odynophagia or dysphagia. (3) Follow-up. All 94 patients were followed up for 38(range, 6-60)months. Of the 45 patients with paraesophageal vein, there were 36 cases of thinner and 9 cases of occlusion of the distal subphrenic paraesophageal vein after surgery, respectively. Cases with esophageal varices disappearance, cases with mild and moderate residual of esophageal varices, cases with severe residual of esophageal varices, cases with recurrence of esophageal varices, cases with esophageal varices bleeding were 7, 70, 9, 4, 4 in the 94 patients after surgery. Cases with esophageal varices disappearance was 7 in the 45 patients with paraesophageal vein, versus 0 in the 49 patients without paraesophageal vein, showing a significant difference between them ( P<0.05). Of 94 patients, 17 cases developed postoperative late portal vein thrombosis and cavernous transformation, 7 cases developed liver cancer, 1 case had hepatic encephalopathy, and 6 cases died. Conclusion:Peri-gastric devascularization without dissociation of esophagus is safe and feasible for the treatment of portal hypertension.

The value of new inflammation index in predicting portal vein thrombosis in cirrhotic patients with portal hypertension / 中国医师杂志

Objective:To explore the value of a new inflammatory index in predicting portal vein thrombosis in cirrhotic patients with Portal hypertension.Methods:This study was a single center cross-sectional study. The patients with portal hypertension who underwent portal vein computed tomography (CT) examination and hepatic vein pressure gradient (HVPG) measurement in the Minhang District Central Hospital of Shanghai from January 2019 to February 2023 due to cirrhosis were included. They were divided into thrombosis group and non thrombosis group according to whether portal vein thrombosis was combined or not. The predictive value of Monocyte lymphocyte ratio (MLR), neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR) and systemic immune inflammatory index (SII) for portal vein thrombosis was determined by logistic regression analysis and receiver operating characteristic (ROC) curve.Results:A total of 122 patients were ultimately included and were divided into a thrombus group of 20 and a non thrombus group of 102 based on portal vein CT results. The MLR and PLR of patients in the thrombotic group were significantly higher than those in the non thrombotic group ( P=0.038 7, P=0.040 7). There was no significant difference in hemoglobin, platelets, leukocytes, neutrophils, lymphocytes, monocyte, NLR, SII, albumin, alanine aminotransferase (ALT), total bilirubin, creatinine, prothrombin time, D-dimer, and C-reactive protein between the two groups (all P>0.05). The diagnosis model of portal vein thrombosis was constructed by logistic regression model. It was found that the area under the ROC of MLR combined with D-dimer and ascites was 0.900, the sensitivity was 0.850, and the specificity was 0.431. Conclusions:The new inflammatory index (including MLR and PLR) is significantly increased in cirrhotic patients with portal vein thrombosis. MLR combined with D-dimer and ascites can predict portal vein thrombosis in cirrhotic patients.

Analysis of risk factors causing early postoperative portal vein thrombosis after salvage devascularization for failed endoscopic therapy / 中华肝胆外科杂志

Objective:To study the risk factors of early postoperative portal vein thrombosis (PVT) after salvage devascularization for failed endoscopic therapy.Methods:A retrospective analysis was conducted on the clinical data of 525 cirrhotic patients who underwent pericardial devascularization for portal hypertension and esophagogastric variceal bleeding at the Department of General Surgery, Beijing Ditan Hospital, Capital Medical University from January 2012 to January 2022. There were 435 males and 90 females, aged 47(37, 58) years old. These patients were divided into two groups based on whether PVT occurred after devascularization: the PVT group ( n=225) and the non-PVT group ( n=300). Clinical data including gender, age, portal vein diameter and postoperative platelet elevation level (PPEL) were studied and the related factors of PVT were analyzed by univariate analysis. Factors with statistically significant differences were included in logistic regression analysis. Results:Univariate analysis showed that the significant risk factors of PVT were the scores of the model of end-stage liver disease, platelets, portal vein diameter, endoscopic therapy, operation duration, surgical bleeding volume, intraoperative blood transfusion and PPEL on the first and third postoperative days (all P<0.05). Multivariate analysis showed that portal vein diameter ≥13 mm ( OR=6.000, 95% CI: 3.418-10.533), endoscopic injection ( OR=1.894, 95% CI: 1.196-2.998), operation duration ≥ 180 min ( OR=8.520, 95% CI: 5.333-13.554), PPEL ≥ 20×10 9/L on the first postoperative day ( OR=2.125, 95% CI: 1.306-3.456) and PPEL≥50×10 9/L on the third postoperative day ( OR=1.925, 95% CI: 1.192-3.109) increased the risk of PVT (all P<0.05). Conclusion:The diameter of portal vein, endoscopic treatment, operation duration and PPEL on the first and third days after operation were independent risk factors of early postoperative PVT development.