Reply to: “Hepatic encephalopathy and survival after transjugular intra-hepatic portosystemic shunt: Do spontaneous portosystemic shunts matter?”

Overt hepatic encephalopathy (OHE) may negatively impact the quality of life of patients and their caregivers, and our study aimed to investigate whether episodic OHE following a transjugular intrahepatic portosystemic shunt (TIPS) procedure adversely affects survival rates. Our findings suggest that episodic post-derivative OHE does not affect patient survival. On the contrary, we found that the development of persistent OHE leads to worse survival rates, particularly in patients with more advanced liver disease. 1 In our opinion, the discrepancy in the prognostic impact of episodic OHE between our patients who underwent TIPS and those reported in the literature who did not receive TIPS, 2 as observed by Zhang and colleagues, 3 could be explained by the prevention of further portal hypertensive decompensating events. 4 This is likely to prevent further impairment of liver function and the occurrence of systemic complications that ultimately affect the survival of patients with cirrhosis. Recent studies corroborate this hypothesis, indicating no significant difference in the incidence of OHE between patients who underwent TIPS and control groups across various indications in patients with cirrhosis. 5 We read with great interest the pertinent comments to our paper by Zhang and colleagues. While we agree that an analysis of the significance of spontaneous porto-systemic shunts (SPSS) in these patients would have been of interest, these data are not currently available in our case series. The concurrent embolization of large SPSS during the TIPS procedure offers a promising approach to reduce the quantity of blood rerouted to the systemic circulation, but in our opinion should be supported by additional controlled studies. 6 In the centers participating in our study, the embolization of the SPSS at the time of TIPS is performed only if SPSS are still visualized following distal contrast injection and particularly in patients showing fundal gastric varices, ectopic gastric varices, or ectopic non-gastric varices. Notably, none of the patients included in our study underwent embolization of any SPSS. Another point to consider is that the presence of SPSS, especially if large, is closely correlated with more advanced degrees of liver failure and rates of development of OHE. 7 Therefore, a potential limit of SPSS embolization could be that patients who would benefit the most from their closure might be excluded from TIPS placement due to higher degrees of hepatocellular failure. 8 Zhang et al. also comment on the high rate of OHE in our cohort. We would like to point out, first, that the rates of OHE in our study are in line with most of the available literature. 9 , 10 Second, by design, our study required a close follow-up of included patients with careful neuropsychological assessment and concomitant meticulous education of caregivers on identifying potential OHE-related symptoms. This was to minimize the underdiagnoses of grade II OHE but may have led to the diagnosis of OHE cases that might have been missed on a conventional follow-up. The interventional approach to the management of portal hypertension is rapidly evolving. The combination of different techniques including TIPS should be explored in adequately selected patients to tailor the best therapeutic approach to tackle this deadly complication of cirrhosis. This is particularly warranted since the available literature currently does not clearly demonstrate a survival advantage in patients undergoing SPSS embolization, as acknowledged by the authors of the letter.