Endoscopic Cyanoacrylate Injection Versus Balloon-Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial.

BACKGROUND AND AIMS: The optimal treatment for gastric varices (GVs) is a topic that remains open for study. This study compared the efficacy and safety of endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous obliteration (BRTO) to prevent rebleeding in patients with cirrhosis and GVs after primary hemostasis. APPROACH AND RESULTS: Patients with cirrhosis and history of bleeding from gastroesophageal varices type 2 or isolated gastric varices type 1 were randomized to cyanoacrylate injection (n = 32) or BRTO treatment (n = 32). Primary outcomes were gastric variceal rebleeding or all-cause rebleeding. Patient characteristics were well balanced between two groups. Mean follow-up time was 27.1 ± 12.0 months in a cyanoacrylate injection group and 27.6 ± 14.3 months in a BRTO group. Probability of gastric variceal rebleeding was higher in the cyanoacrylate injection group than in the BRTO group (P = 0.024). Probability of remaining free of all-cause rebleeding at 1 and 2 years for cyanoacrylate injection versus BRTO was 77% versus 96.3% and 65.2% versus 92.6% (P = 0.004). Survival rates, frequency of complications, and worsening of esophageal varices were similar in both groups. BRTO resulted in fewer hospitalizations, inpatient stays, and lower medical costs. CONCLUSIONS: BRTO is more effective than cyanoacrylate injection in preventing rebleeding from GVs, with similar frequencies of complications and mortalities.

Comparison of Concanavalin a-Induced Murine Autoimmune Hepatitis Models.

BACKGROUND/AIMS: Autoimmune hepatitis (AIH) is a chronic necroinflammatory disease of the liver whose pathogenic mechanisms have not yet been elucidated. Moreover, the current treatment used for the vast majority of AIH patients is largely dependent on immunosuppressant administration and liver transplantation. However, research on the pathogenesis of AIH and effective new treatments for AIH have been hampered by a lack of animal models that accurately reproduce the human condition. METHODS: AIH models created by concanavalin A (ConA) injections at different times and doses. The levels of ALT, AST, LDH and inflammatory cytokines were examined at various times after 20 mg/kg ConA was administered by ELISA using commercially available kits. Moreover, liver pathological changes were observed by flow cytometry (FCM) and H&E staining. RESULTS: Our experiments demonstrated that the levels of ALT, AST, LDH and several inflammatory cytokines, including TNF-α, IFN-γ, and IL-6, were higher in the 20 mg/kg 12 h ConA group than in the other groups. Importantly, the numbers of activated CD4+ and CD8+ T lymphocytes in the blood, spleen and liver were calculated. These results showed that ConA (20 mg/kg for 12 h)-induced hepatitis was similar to that in clinical AIH patients. Furthermore, we found that the number of MDSCs in the blood was significantly increased in the ConA (20 mg/kg for 12 h) group compared with controls. Our findings indicated that ConA (20 mg/kg for 12 h)-induced hepatitis could be used as an experimental murine model that mirrors most of the pathogenic properties of human type I AIH. CONCLUSION: This model [ConA (20 mg/kg for 12 h)] provides a valuable tool for studying AIH immunopathogenesis and rapidly assessing novel therapeutic approaches.

Transjugular intrahepatic portosystemic shunt creation: three-dimensional roadmap versus CO2 wedged hepatic venography.

OBJECTIVES: The blind portal vein puncture remains the most challenging step during transjugular intrahepatic portosystemic shunt (TIPS) creation. We performed a prospective randomised clinical trial to compare three-dimensional (3D) roadmap with CO2 wedged hepatic vein portography for portal vein puncture guidance. METHODS: Between March 2017 and May 2017, 30 patients were enrolled and randomly allocated to the study group (3D roadmap) or the control group (CO2 wedged hepatic vein portography). RESULTS: Technical success of TIPS procedures was achieved in all 30 patients. The mean number of needle passes was significantly lower in the study group (2.0 ± 1.0) compared to the control group (3.7 ± 2.5; p = 0.021). A total of six (40%) patients in the study group and three (20%) in the control group required only one puncture for the establishment of TIPS. There were no significant differences in total fluoroscopy time (p = 0.905), total procedure time (p = 0.199) and dose-area product (p = 0.870) between the two groups. CONCLUSIONS: 3D roadmap is a safe and technically feasible means for portal vein puncture guidance during TIPS creation, equivalent in efficacy to CO2 wedged hepatic vein portography. This technique could reduce the number of needle passes, thereby simplifying the TIPS procedure. KEY POINTS: • 3D roadmap can be used to guide portal vein puncture. • Compared with CO 2 venography, 3D roadmap reduced the number of needle passes. • 3D roadmap has a potential to simplify the TIPS procedure.

Emergency Transjugular Intrahepatic Portosystemic Shunt: an Effective and Safe Treatment for Uncontrolled Variceal Bleeding.

BACKGROUND: Uncontrolled variceal bleeding (VB) remains a great challenge for clinical treatment. Emergency transjugular intrahepatic portosystemic shunt (TIPS) is a salvage procedure, but unsatisfactory clinical outcomes and a high incidence of complications have been reported. This study aimed to investigate the effect and safety of emergency TIPS performed in our institution during recent years. METHODS: Fifty-eight consecutive cirrhotic patients with uncontrolled VB who underwent emergency TIPS from March 2009 to November 2017 in our hospital were followed until the last clinical evaluation, liver transplantation (LT), or death. RESULTS: Overall, 5, 36, and 17 patients belonged to Child-Pugh class A, B, and C, respectively. TIPS was successfully performed in 57 (98.3%) patients at 89.5 h (mean) after initial bleeding. After TIPS, bleeding ceased in 52 (91.2%) patients, and 51 (89.5%) patients had a portal pressure gradient below 12 mmHg. Only one (1.8%) major procedure-related complication occurred without any clinical consequences, and no procedure-related deaths occurred. During follow-up, 55 hepatic encephalopathy (HE) episodes occurred in 19 (33.3%) patients, and the median time of the first HE episode was 3.1 months. Seven (12.3%) patients experienced shunt dysfunction after 8.7 months (median). The 6-week, 1-year, and 2-year variceal rebleeding rates were 10.5%, 17.1%, and 20.0%, respectively. The LT-free survival rates at 6 weeks, 1 year, and 2 years were 87.7%, 81.8% and 73.6%, respectively. CONCLUSION: Our study highlights the fact that emergency TIPS could be effective for patients with liver cirrhosis and uncontrolled VB with few potential complications.

Clinical Efficacy of Transjugular Intrahepatic Portosystemic Shunt Created with Expanded Polytetrafluoroethylene-Covered Stent-Grafts: 8-mm Versus 10-mm.

PURPOSE: Conflicting data exist regarding the appropriate shunt diameter for transjugular intrahepatic portosystemic shunt (TIPS) creation in cirrhotic patients. This study was designed to compare the clinical efficacy of TIPS using stent-grafts with 8- and 10-mm diameters. METHODS: In this retrospective study, cirrhotic patients who underwent TIPS technical successfully for the prevention of variceal rebleeding from December 2011 to June 2015 were included. Thirty-four patients with 8-mm TIPS and 380 patients with 10-mm TIPS were identified. Propensity score matching method produced 32 patients in each group for comparison. RESULTS: Baseline characteristics between two groups were comparable. There was no significant difference in variceal rebleeding rate between the two groups. The cumulative incidence of variceal rebleeding after 1 and 3 years was 6.4% and 35.5% in the 8-mm group, respectively, and 14.2% and 24.9% in the 10-mm group, respectively (P = 0.663). 8-mm TIPS conferred a significant decrease in hepatic encephalopathy (HE) rate compared with the 10-mm TIPS (16.1 vs. 32.6% at 1 year, 27.8 vs. 53.2% at 3 years, P = 0.034). The cumulative survival rates were similar between the two groups: 93.3% and 79.6% at 1 and 3 years, respectively, in the 8-mm TIPS group vs. 87.3% and 72.1% at 1 and 3 years, respectively, in the 10-mm TIPS group (P = 0.451). CONCLUSION: The placement of 8-mm TIPS was sufficient to decompress the portal hypertension and prevent variceal rebleeding. The use of the 8-mm stent-graft can decrease HE rates compared with 10-mm stent-graft, although no survival benefit was observed.

Underestimated Male Prevalence of Primary Biliary Cholangitis in China: Results of a 16-yr cohort study involving 769 patients.

For primary biliary cholangitis (PBC), a sex ratio was reported to be significantly lower than previously cited in the West; we sought to evaluate sex ratio and long-term outcomes in PBC by studying a PBC cohort at a high-volume hospital from January 2001 to July 2016. A retrospective analysis including 769 PBC patients was conducted. The gender ratio was 6.1:1. Of the patients, 30.6% had one or more extrahepatic autoimmune (EHA) conditions. The proportion of patients with decompensated PBC at diagnosis increased from 25.0% in period 1 to 47.0% in period 4 (p < 0.05). Of the 420 patients without complications on presentation, the Kaplan-Meier estimate revealed distinct outcomes between non-cirrhotic PBC and cirrhotic PBC, with estimated mean survival times of 145.1 months and 104.5 months, respectively (p < 0.001). According to a subgroup analysis, gender and anti-mitochondrial antibody (AMA) status did not affect long-term prognosis, whereas patients with EHA conditions showed better prognoses. This study reveals evolving trends in male prevalence similar to their Western counterparts. Cirrhotic PBC patients were distinct from those with non-cirrhotic PBC at diagnosis based on difference in long-term outcome.