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Garbuzenko DV. Milestones to optimize of transjugular intrahepatic portosystemic shunt technique as a method for the treatment of portal hypertension complications. World J Hepatol 2024; 16:891-899. [DOI: 10.4254/wjh.v16.i6.891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/10/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
This editorial describes the milestones to optimize of transjugular intrahepatic portosystemic shunt (TIPS) technique, which have made it one of the main methods for the treatment of portal hypertension complications worldwide. Innovative ideas, subsequent experimental studies and preliminary experience of use in cirrhotic patients contributed to the introduction of TIPS into clinical practice. At the moment, the main achievement in optimize of TIPS technique is progress in the qualitative characteristics of stents. The transition from bare metal stents to extended polytetrafluoroethylene–covered stent grafts made it possible to significantly prevent shunt dysfunction. However, the question of its preferred diameter, which contributes to an optimal reduction of portal pressure without the risk of developing post-TIPS hepatic encephalopathy, remains relevant. Currently, hepatic encephalopathy is one of the most common complications of TIPS, significantly affecting its effectiveness and prognosis. Careful selection of patients based on cognitive indicators, nutritional status, assessment of liver function, etc., will reduce the incidence of post-TIPS hepatic encephalopathy and improve treatment results. Optimize of TIPS technique has significantly expanded the indications for its use and made it one of the main methods for the treatment of portal hypertension complications. At the same time, there are a number of limitations and unresolved issues that require further randomized controlled trials involving a large cohort of patients.
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Larrue H, Allaire M, Weil-Verhoeven D, Barge S, Thabut D, Payance A, Moga L, Jézéquel C, Artru F, Archambeaud I, Elkrief L, Oberti F, Roux C, Laleman W, Rudler M, Dharancy S, Laborde N, Minello A, Mouillot T, Desjonquères E, Wandji LCN, Bourlière M, Ganne-Carrié N, Bureau C. French guidelines on TIPS: Indications and modalities. Liver Int 2024. [PMID: 38758295 DOI: 10.1111/liv.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/19/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024]
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) has become essential in the treatment or prevention of portal hypertension-related complications. In the early 1990s, the primary indication was refractory bleeding. It is now proposed for the treatment of ascites for the prevention of bleeding and in patients with vascular diseases of the liver. Thus, there are a growing number of patients being treated with TIPS all over the world. The broadening of indications, the involvement of multiple stakeholders, the need for an accurate selection, the positioning in relation to transplantation and the lack of standardization in pre-therapeutic assessment, in the procedure itself and in the follow-up have led the board of the French Association for the Study of the Liver to establish recommendations.
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Affiliation(s)
- Hélène Larrue
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
| | - Manon Allaire
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Delphine Weil-Verhoeven
- Service d'Hépatologie et Soins intensifs digestifs, CHU Jean Minjoz, Besançon, France
- Université de Franche-Comté, CHU Besançon, EFS, INSERM, UMR RIGHT, Besançon, France
| | - Sandrine Barge
- Service d'Hépato-gastro-entérologie, Centre Hospitalier Intercommunal de Créteil, Creteil, France
| | - Dominique Thabut
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Audrey Payance
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | - Lucile Moga
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de recherche sur l'inflammation, Inserm, UMR 1149, Université de Paris, Paris, France
| | | | - Florent Artru
- Service des Maladies du Foie, CHU Rennes, Rennes, France
| | - Isabelle Archambeaud
- Hépato-Gastro-Entérologie et Assistance Nutritionnelle-Institut des Maladies de l'Appareil Digestif (IMAD), CHU Nantes-Inserm CIC 1413, Nantes, France
| | - Laure Elkrief
- Service d'Hépato-Gastroentérologie, Hôpital Trousseau, CHRU de Tours et Faculté de Médecine de Tours, Tours, France
| | - Frédéric Oberti
- Service d'Hépato-Gastroentérologie, CHU Angers, Angers, France
| | - Charles Roux
- Service de Radiologie Intervent.ionnelle, AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Wim Laleman
- Service de Gastroentérologie et Hépatologie, Hôpital Universitaire Gasthuisberg, KU Leuven, Louvain, Belgium
| | - Marika Rudler
- Service d'Hépato-gastroentérologie, Hôpital Universitaire Pitié-Salpêtrière, AP-HP Sorbonne Université, Paris, France
| | - Sébastien Dharancy
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, 2 Rue Michel Polonovski, Lille, France
| | - Nolwenn Laborde
- Gastro-Entérologie, Hépatologie, Nutrition, Maladies Héréditaires du Métabolisme Pédiatriques, Centre de Compétence Maladies Rares du Foie, Hôpital des Enfants, CHU, Toulouse, France
| | - Anne Minello
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Thomas Mouillot
- Service D'hépato-Gastroentérologie et Oncologie Médicale, CHU F. Mitterrand, Dijon, France
| | - Elvire Desjonquères
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France
| | - Line Caroll Ntandja Wandji
- Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, University of Lille, Lille, France
| | - Marc Bourlière
- Département d'Hépatologie et Gastroentérologie, Hôpital Saint Joseph, Marseille, France
| | - Nathalie Ganne-Carrié
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, Université de Paris, Paris, France
| | - Christophe Bureau
- Service d'Hépatologie Hopital Rangueil CHU Toulouse et Université Paul Sabatier, Toulouse, France
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Kaplan DE, Ripoll C, Thiele M, Fortune BE, Simonetto DA, Garcia-Tsao G, Bosch J. AASLD Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis. Hepatology 2024; 79:1180-1211. [PMID: 37870298 DOI: 10.1097/hep.0000000000000647] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Affiliation(s)
- David E Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA USA
| | - Cristina Ripoll
- Internal Medicine IV, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Maja Thiele
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark; Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Brett E Fortune
- Department of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Jaime Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS) and CIBERehd, University of Barcelona, Spain
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Shung DL, Laine L. Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management. Aliment Pharmacol Ther 2024; 59:1062-1081. [PMID: 38517201 DOI: 10.1111/apt.17949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/27/2023] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes. AIMS To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases. METHODS We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals. RESULTS Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. CONCLUSIONS Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.
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Affiliation(s)
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut, USA
- West Haven Veterans Affairs Medical Center, West Haven, Connecticut, USA
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Kalo E, Read S, George J, Roberts SK, Majumdar A, Ahlenstiel G. Attitudes towards transjugular intrahepatic portosystemic shunt (TIPS) in Australia: a national survey of TIPS centres. BMJ Open Gastroenterol 2024; 11:e001308. [PMID: 38519047 DOI: 10.1136/bmjgast-2023-001308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/20/2024] [Indexed: 03/24/2024] Open
Abstract
BACKGROUND Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive therapeutic option to treat the sequelae of portal hypertension. It is unclear whether current international recommendations are reflected in current clinical practice across Australia and the extent of variations in care. This study aimed to address this gap in knowledge and benchmark the current landscape of TIPS services in Australia against international guidelines. METHODS We designed a 42-item questionnaire according to practice-based recommendations and standards of international guidelines to investigate current landscape of TIPS service across four key domains: (1) service provision, (2) patient selection and indications, (3) best procedure practice, and (4) postoperative care. RESULTS Gastroenterologist/hepatologists from 23 major liver centres (67.6%) across Australia currently performing TIPS completed the questionnaire. Between 2017 and 2020, there were 456 elective TIPS insertions. Units offering TIPS service had a low median number of TIPS insertions (n=7 per annum). More than half of respondents (56.5%) did not have institutional clinical practice protocols. There was marked variation in practices across institutions in terms of TIPS indications and patient selection. Despite variations, the success rate of elective TIPS was high at 91.7% (79-100%), with 86.6% (29-100%) for rescue TIPS. There was significant variation in postoperative follow-up and care. CONCLUSION Current TIPS practice in Australia varies significantly across institutions. There is a need for a national consensus clinical practice guidelines to improve access and minimise unwarranted variation. A national registry for TIPS could measure, monitor, and report on quality of clinical care and patient outcomes.
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Affiliation(s)
- Eric Kalo
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Scott Read
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
| | - Jacob George
- Faculty of Medicine, Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
- Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Avik Majumdar
- Victorian Liver Transplant Unit, Austin Health, Heidelberg, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Golo Ahlenstiel
- Blacktown Mt Druitt Clinical School and Research Centre, Western Sydney University, Blacktown, New South Wales, Australia
- Blacktown Hospital, Blacktown, New South Wales, Australia
- Westmead Institute for Medical Research Storr Liver Centre, Westmead, New South Wales, Australia
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Gwon DI. AASLD Practice Guidance on the Use of TIPS, Variceal Embolization, and Retrograde Transvenous Obliteration in the Management of Variceal Hemorrhage. Cardiovasc Intervent Radiol 2024; 47:403-404. [PMID: 38334852 PMCID: PMC10920477 DOI: 10.1007/s00270-023-03654-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 12/16/2023] [Indexed: 02/10/2024]
Affiliation(s)
- Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Gralnek IM, Garcia-Pagan JC, Hernández-Gea V. Challenges in the Management of Esophagogastric Varices and Variceal Hemorrhage in Cirrhosis - A Narrative Review. Am J Med 2024; 137:210-217. [PMID: 38128860 DOI: 10.1016/j.amjmed.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
Over the past decade, significant advancements in pharmacological, endoscopic, and radiographic treatments have emerged in the management of patients with cirrhosis and esophagogastric varices or variceal hemorrhage. These advances have been in several areas, including the role of screening and primary prophylaxis (preventing an initial variceal bleed), evaluation and management of acute esophagogastric variceal hemorrhage, and in preventing variceal rebleeding. Therefore, we believe there is a need for an updated, evidence-based "narrative review" on this important clinical topic that will be relevant for internists, hospitalists, intensive care unit physicians, and those in training. We believe the guidance presented in this narrative review will enhance daily medical practice of health care professionals and has the potential to improve quality of care for these complex patients.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel; Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel.
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, Universitat de Barcelona University of Barcelona, Barcelona, CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain
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Villanueva C. The hidden face of preemptive TIPS. Hepatology 2024; 79:535-537. [PMID: 38085849 DOI: 10.1097/hep.0000000000000714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Càndid Villanueva
- Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
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Wong YJ, Teng M, Sim A, Thet HM, Teoh X, De Roza MA, Sen Kew G, Koh JH, Loi PL, Lim K, Kang G, Kuang J, Low EXS, Ho JL, Cher LYG, Sze K, Wong GW, Kwek BYA, Yang WL, Abraldes JG, Chang J. Full adherence to cirrhosis quality indicators is associated with lower mortality in acute variceal bleeding: Nationwide audit. Hepatology 2024:01515467-990000000-00764. [PMID: 38381716 DOI: 10.1097/hep.0000000000000793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/23/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND AND AIMS Acute variceal bleeding (AVB) is a major complication in patients with cirrhosis. Using a nationwide AVB audit, we performed a nested cohort study to determine whether full adherence to the AVB quality indicator (QI) improves clinical outcomes in patients with cirrhosis and AVB. APPROACH AND RESULTS We assessed real-world adherence to AVB QI among patients with cirrhosis admitted for AVB in all public hospitals in Singapore between January 2015 and December 2020. Full adherence was considered when all 5 QIs were fulfilled: prophylactic antibiotics, vasoactive agents, timely endoscopy, endoscopic hemostasis during index endoscopy, and nonselective beta-blockers after AVB. We compare 6-week mortality between the full adherence and suboptimal adherence groups using a propensity-matched cohort.A total of 989 patients with AVB were included. Full adherence to all AVB QI was suboptimal (56.5%). Analysis of the propensity-matched cohort with comparable baseline characteristics showed that full adherence was associated with a lower risk of early infection (20.0% vs. 26.9%), early rebleeding (5.2% vs. 10.2%), and mortality at 6 weeks (8.2% vs. 19.7%) and 1 year (21.3% vs. 35.4%) ( p <0.05 for all). While full adherence was associated with a lower 6-week mortality regardless of the MELD score, nonadherence was associated with a higher 6-week mortality despite a lower predicted risk of 6-week mortality. Despite high adherence to the recommended process measures, patients with CTP-C remain at a higher risk of rebleeding, 6-week and 1-year mortality. CONCLUSIONS Full adherence to the AVB QI should be the target for quality improvement in patients with cirrhosis.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Clinical Program, SingHealth, Singapore
- Liver unit, Division of Gastroenterology & Hepatology, University of Alberta, Canada
| | - Margaret Teng
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Alyssa Sim
- Department of Gastroenterology & Hepatology, Tan Tock Seng General Hospital, Singapore
| | - Htay Myat Thet
- Department of Medicine, Division of Gastroenterology & Hepatology, Ng Teng Fong Hospital, Singapore
| | - Xuhui Teoh
- Department of General Medicine, Division of Gastroenterology, Khoo Teck Puat Hospital, Singapore
| | | | - Guan Sen Kew
- Department of Medicine, Woodlands Health, Singapore
| | - Jia Hong Koh
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Pooi Ling Loi
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Kai Lim
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Garrett Kang
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
| | - Jonathan Kuang
- Department of Gastroenterology & Hepatology, Tan Tock Seng General Hospital, Singapore
| | - En Xian Sarah Low
- Department of Medicine, Division of Gastroenterology & Hepatology, Ng Teng Fong Hospital, Singapore
| | | | - Liu Yuan Gabriel Cher
- Department of General Medicine, Division of Gastroenterology, Khoo Teck Puat Hospital, Singapore
| | - Kenny Sze
- Department of General Medicine, Division of Gastroenterology, Khoo Teck Puat Hospital, Singapore
| | - Guan Wee Wong
- Department of Medicine, Division of Gastroenterology & Hepatology, Ng Teng Fong Hospital, Singapore
| | - Boon Yew Andrew Kwek
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Clinical Program, SingHealth, Singapore
| | - Wei Lyn Yang
- Department of Gastroenterology & Hepatology, Tan Tock Seng General Hospital, Singapore
| | - Juan G Abraldes
- Liver unit, Division of Gastroenterology & Hepatology, University of Alberta, Canada
| | - Jason Chang
- Duke-NUS Academic Clinical Program, SingHealth, Singapore
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
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Di Cola S, Lapenna L, Gazda J, Fonte S, Cusi G, Esposito S, Mattana M, Merli M. Role of Transjugular Intrahepatic Portosystemic Shunt in the Liver Transplant Setting. J Clin Med 2024; 13:600. [PMID: 38276106 PMCID: PMC10816519 DOI: 10.3390/jcm13020600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation is currently the only curative therapy for patients with liver cirrhosis. Not all patients in the natural course of the disease will undergo transplantation, but the majority of them will experience portal hypertension and its complications. In addition to medical and endoscopic therapy, a key role in managing these complications is played by the placement of a transjugular intrahepatic portosystemic shunt (TIPS). Some indications for TIPS placement are well-established, and they are expanding and broadening over time. This review aims to describe the role of TIPS in managing patients with liver cirrhosis, in light of liver transplantation. As far as it is known, TIPS placement seems not to affect the surgical aspects of liver transplantation, in terms of intraoperative bleeding rates, postoperative complications, or length of stay in the Intensive Care Unit. However, the placement of a TIPS "towards transplant" can offer advantages in terms of ameliorating a patient's clinical condition at the time of transplantation and improving patient survival. Additionally, the TIPS procedure can help preserve the technical feasibility of the transplant itself. In this context, indications for TIPS placement at an earlier stage are drawing particular attention. However, TIPS insertion in decompensated patients can also lead to serious adverse events. For these reasons, further studies are needed to make reliable recommendations for TIPS in the pre-transplant setting.
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Affiliation(s)
- Simone Di Cola
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Jakub Gazda
- 2nd Department of Internal Medicine, PJ Safarik University and L. Pasteur University Hospital in Kosice, 040 11 Kosice, Slovakia;
| | - Stefano Fonte
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Giulia Cusi
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Samuele Esposito
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Marco Mattana
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy; (S.D.C.); (L.L.); (S.F.); (G.C.); (S.E.); (M.M.)
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Zou X, Liu L, Tan F, Tang H, Hu D, Li Z, Wang Q, Shen Y. Non-contrast-enhanced MR angiography of left gastric vein in patients with gastroesophageal varices: morphology and blood supply analysis. Eur Radiol 2023:10.1007/s00330-023-10497-3. [PMID: 38133674 DOI: 10.1007/s00330-023-10497-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/07/2023] [Accepted: 10/29/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES To investigate the feasibility of non-contrast-enhanced MR angiography (NCE-MRA) in evaluating the morphology and blood supply of left gastric vein (LGV) in patients with gastroesophageal varices. METHODS Between March 2021 and October 2022, patients with gastroesophageal varices and who underwent NCE-MRA were retrospectively reviewed. In order to evaluate the blood supply of LGV, superior mesenteric vein (SMV) and splenic vein (SV) were visualized separately by using inflow-sensitive inversion recovery sequence. Two radiologists independently assessed the image quality, determined the origination and the blood supply of LGV, and measured the diameter of LGV. The origination and diameter of LGV were compared between NCE-MRA and contrast-enhanced CT. Differences in blood supply were compared between LGVs with different originations. RESULTS A total of 53 patients were enrolled in this study and the image quality was categorized as good or excellent in 52 patients. No significant differences were observed in visualizing the origination and the diameter of LGV between NCE-MRA and contrast-enhanced CT (p > .05). The blood supply of LGV was related to its origination (p < .001). Most LGVs with SV origination were supplied by SV. If LGV was originated from the portal vein (PV), about 70% of them were supplied by both SV and SMV. Compared with LGVs with SV origination, LGVs with PV origination showed more chance to receive blood from SMV (p < .001). CONCLUSION Non-contrast-enhanced MR angiography appears to be a reliable technique in evaluating the morphology and blood supply of LGV in patients with gastroesophageal varices. CLINICAL RELEVANCE STATEMENT Non-contrast-enhanced MR angiography provides valuable information for the management of gastroesophageal varices. Especially, it benefits patients with renal insufficiency. KEY POINTS • Non-contrast-enhanced MR angiography using inflow-sensitive inversion recovery technique can be used for evaluating not only morphology as CT but also blood supply of left gastric vein. • The blood supply of left gastric vein is related to its origination and left gastric vein with portal vein origination shows more chance to receive blood from superior mesenteric vein.
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Affiliation(s)
- Xianlun Zou
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Lisi Liu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Fangqin Tan
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Hao Tang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Qiuxia Wang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
| | - Yaqi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Avenue, Wuhan, 430030, Hubei, China.
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Friis KH, Thomsen KL, Laleman W, Montagnese S, Vilstrup H, Lauridsen MM. Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis. J Clin Med 2023; 13:14. [PMID: 38202028 PMCID: PMC10779844 DOI: 10.3390/jcm13010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.
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Affiliation(s)
- Karina Holm Friis
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
| | - Karen Louise Thomsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, 3000 Leuven, Belgium
| | - Sara Montagnese
- Department of Medicine, University of Padova, 35122 Padova, Italy
| | - Hendrik Vilstrup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Mette Munk Lauridsen
- Department of Gastroenterology and Hepatology, University Hospital of Southern Denmark, Finsensgade 35, 6700 Esbjerg, Denmark
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Ge J, Sun S, Owens J, Galvez V, Gologorskaya O, Lai JC, Pletcher MJ, Lai K. Development of a Liver Disease-Specific Large Language Model Chat Interface using Retrieval Augmented Generation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.10.23298364. [PMID: 37986764 PMCID: PMC10659484 DOI: 10.1101/2023.11.10.23298364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background Large language models (LLMs) have significant capabilities in clinical information processing tasks. Commercially available LLMs, however, are not optimized for clinical uses and are prone to generating incorrect or hallucinatory information. Retrieval-augmented generation (RAG) is an enterprise architecture that allows embedding of customized data into LLMs. This approach "specializes" the LLMs and is thought to reduce hallucinations. Methods We developed "LiVersa," a liver disease-specific LLM, by using our institution's protected health information (PHI)-complaint text embedding and LLM platform, "Versa." We conducted RAG on 30 publicly available American Association for the Study of Liver Diseases (AASLD) guidelines and guidance documents to be incorporated into LiVersa. We evaluated LiVersa's performance by comparing its responses versus those of trainees from a previously published knowledge assessment study regarding hepatitis B (HBV) treatment and hepatocellular carcinoma (HCC) surveillance. Results LiVersa answered all 10 questions correctly when forced to provide a "yes" or "no" answer. Full detailed responses with justifications and rationales, however, were not completely correct for three of the questions. Discussions In this study, we demonstrated the ability to build disease-specific and PHI-compliant LLMs using RAG. While our LLM, LiVersa, demonstrated more specificity in answering questions related to clinical hepatology - there were some knowledge deficiencies due to limitations set by the number and types of documents used for RAG. The LiVersa prototype, however, is a proof of concept for utilizing RAG to customize LLMs for clinical uses and a potential strategy to realize personalized medicine in the future.
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Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Steve Sun
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| | - Joseph Owens
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| | - Victor Galvez
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
| | - Oksana Gologorskaya
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
- Bakar Computational Health Sciences Institute, University of California – San Francisco, San Francisco, CA
| | - Jennifer C. Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California – San Francisco, San Francisco, CA
| | - Mark J. Pletcher
- Department of Epidemiology and Biostatistics, University of California – San Francisco, San Francisco, CA
| | - Ki Lai
- UCSF Health Information Technology, University of California – San Francisco, San Francisco, CA
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