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Background: Portal vein injury is an uncommon complication of endoscopic retrograde cholangiopancreatography (ERCP), for which stent malpositioning in the portal vein is very rare and can lead to fatal events. We report a case of biliary stent migration to the portal vein and a novel method for its safe removal under the guidance of portal angiography. Moreover, we reviewed the literature and summarized reports on the identification and management of this condition., Case Summary: A 59-year-old woman with pancreatic cancer presented with abdominal pain and a high fever 20 days after the placement of two plastic biliary stents under the guidance of ERCP. Blood cultures and laboratory tests revealed sepsis, which was treated with antibiotics. A contrast-enhanced computed tomography scan revealed that one of the biliary stents in the main portal vein was malpositioned. To safely remove the stent, portal angiography was performed to visualize the portal vein and to allow the management of any bleeding. The two stents were removed without obvious bleeding, and an uncovered self-expanding metal stent was placed in the common bile duct for drainage. The patient had an uneventful 6-month follow-up period, except for self-resolving portal vein thrombosis., Conclusion: The combination of endoscopic and angiographic techniques allowed uneventful management of stent malposition in the portal vein., Competing Interests: Conflict-of-interest statement: The authors declare that they have no conflicts of interest to disclose., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is a cause of acute-on-chronic liver failure (ACLF)., Aim: To investigate the risk factors of ACLF within 1 year after TIPS in patients with cirrhosis and construct a prediction model., Methods: In total, 379 patients with decompensated cirrhosis treated with TIPS at Nanjing Drum Tower Hospital from 2017 to 2020 were selected as the training cohort, and 123 patients from Nanfang Hospital were included in the external validation cohort. Univariate and multivariate logistic regression analyses were performed to identify independent predictors. The prediction model was established based on the Akaike information criterion. Internal and external validation were conducted to assess the performance of the model., Results: Age and total bilirubin (TBil) were independent risk factors for the incidence of ACLF within 1 year after TIPS. We developed a prediction model comprising age, TBil, and serum sodium, which demonstrated good discrimination and calibration in both the training cohort and the external validation cohort., Conclusion: Age and TBil are independent risk factors for the incidence of ACLF within 1 year after TIPS in patients with decompensated cirrhosis. Our model showed satisfying predictive value., Competing Interests: Conflict-of-interest statement: The Authors have no conflict of interest related to the manuscript., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objective: The investigation and research on the application status of Hepatic Venous Pressure Gradient (HVPG) is very important to understand the real situation and future development of this technology in China. Methods: This study comprehensively investigated the basic situation of HVPG technology in China, including hospital distribution, hospital level, annual number of cases, catheters used, average cost, indications and existing problems. Results: According to the survey, there were 70 hospitals in China carrying out HVPG technology in 2021, distributed in 28 provinces (autonomous regions and municipalities directly under the central Government). A total of 4 398 cases of HVPG were performed in all the surveyed hospitals in 2021, of which 2 291 cases (52.1%) were tested by HVPG alone. The average cost of HVPG detection was (5 617.2±2 079.4) yuan. 96.3% of the teams completed HVPG detection with balloon method, and most of the teams used thrombectomy balloon catheter (80.3%). Conclusion: Through this investigation, the status of domestic clinical application of HVPG has been clarified, and it has been confirmed that many domestic medical institutions have mastered this technology, but it still needs to continue to promote and popularize HVPG technology in the future.

Background: Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction can cause recurrent portal hypertension (PH)-related complications such as ascites and gastroesophageal variceal bleeding. Portography is invasive and costly limits its use as a screening modality., Purpose: To assess the clinical value of conventional ultrasound in combination with point shear wave elastography (pSWE) to predict TIPS dysfunction., Material and Methods: A total of 184 patients with cirrhosis scheduled for TIPS implantation were enrolled in this study and evaluated retrospectively. The splenoportal venous blood flow parameter, liver stiffness (LS), and spleen stiffness (SPS) were measured. Outcome measures included differences in portal vein velocity (PVV), splenic vein velocity (SPVV), LS, and SPS. The accuracy of change in PVV (ΔPVV), SPVV (ΔSPVV), and SPS (ΔSPS) to diagnose TIPS dysfunction was investigated., Results: TIPS dysfunction occurred in 28 of 184 patients (15.2%). Eighteen (64.3%) patients had shunt stenoses and 10 (35.7%) had shunt occlusion. Portal vein diameter (PVD), PVV, splenic vein diameter (SPVD), SPVV, LS, and SPS were not significantly different between the TIPS normal and TIPS dysfunction groups. Compared with the TIPS normal group, PVV and SPVV of the TIPS dysfunction group decreased significantly, whereas SPS increased significantly ( P  < 0.001). The values of areas under the receiver operating characteristic curves of ΔPVV, ΔSPVV, and ΔSPS for the diagnosis of TIPS dysfunction were 0.97, 0.96, and 0.87, respectively., Conclusion: pSWE showed a diagnostic efficacy comparable to conventional ultrasound for diagnosing TIPS dysfunction and can be used routinely after TIPS procedures.

Objective: To evaluate the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) and non-TIPS therapy (endoscopy and/or nonselective beta-blockers [NSBB]) in patients with cirrhosis and active variceal hemorrhage who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis., Methods: Medical records of cirrhotic patients who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis at five university hospitals in China between January 2011 and December 2018 were reviewed. Treatment outcomes were compared between the TIPS and the non-TIPS groups., Results: Treatment failure of variceal hemorrhage within 5 days was reported in six patients of the non-TIPS group (N = 70) and none of the TIPS group (N = 66) (P = .028). The TIPS group had a higher 1-year variceal rebleeding-free rate compared with the non-TIPS group (95.5% vs 60.0%, P < .001). One patient treated with TIPS and nine with non-TIPS therapy experienced rebleeding within 5 days and 6 weeks after the intervention (P = .009). The cumulative 1-year survival rate was higher in the TIPS group than in the non-TIPS group (93.9% vs 78.6%, P = .01). The TIPS group had a higher incidence of hepatic encephalopathy within one year compared with the non-TIPS group (18.2% vs 4.3%, P = .026)., Conclusion: For patients with cirrhosis and active variceal bleeding who do not respond to high-dose vasoactive agents and require a balloon tamponade for hemostasis, TIPS may be an appropriate treatment choice., (© 2021 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Objective: To explore pyrrolizidine alkaloid-induced hepatic sinusoidal obstruction syndrome (PA-HSOS) severity grading to predict the prognostic value for PA-HSOS patients treated with transjugular intrahepatic portosystemic shunt (TIPS). Methods: Clinical data of patients with PA-HSOS who were critically ill or had ineffective drug treatment and underwent TIPS treatment from December 2013 to September 2019 were retrospectively analyzed. PA-HSOS severity grading criteria in adult was quoted, revised and defined from the European Group for Blood and Marrow Transplantation (EBMT). The survival time, the rate of shunt dysfunction and the incidence of postoperative hepatic encephalopathy in different severity groups after TIPS were compared. Univariate Cox or Binomial Logistic regression analysis was used to evaluate the impact of each variable. Variables with P < 0.1 were regarded as statistically significant variables for the prognosis, and were introduced into Cox or Binomial Logistic regression hierarchical regression analysis as controlled covariates. PA-HSOS severity grading was analyzed as dummy variables. Results: A total of 102 patient data were collected, and the median follow-up time was 14.52 months. The difference in survival time of patients with different severity levels was statistically significant ( P = 0.023). The mortality risk in moderate patients was 1.575 times higher than that of mild patients (95% CI : 0.216-11.457, P = 0.654). The mortality risk of severe and very severe patients was 7.424 times higher than that of mild patients (95% CI : 1.612-34.197, P = 0.010). There was no statistically significant difference in postoperative hepatic encephalopathy recurrence rate and shunt dysfunction rate ( P > 0.05). Conclusion: PA-HSOS severity grading has prognostic value for PA-HSOS patients receiving TIPS treatment, and can be used as an important reference for guiding the timing of TIPS intervention.

Hepatic sinusoidal obstruction syndrome (HSOS) is a kind of hepatic vascular disease which is characterized by damage to hepatic sinusoidal endothelial cells, centrilobular hepatic vein and/or interlobular vein, resulting in stenosis or lumen occlusion, hepatic injury and acute sinusoidal portal hypertension. Generally, most patients with HSOS have mild manifestations, but in severely ill patients, the disease can lead to multiple organ dysfunction/failure, and the mortality rate can be as high as 70%-80%. Therefore, it is important to identify and treat HSOS as soon as possible. This paper introduces the current clinical diagnostic criteria of HSOS, including the Modified Seattle and Baltimore Criteria along with "Nanjing Criteria", and reviews their characteristics, scope of application and limitations.

Objectives: To investigate the value of liver stiffness in rats with various degrees of hepatic sinusoidal obstruction syndrome (HSOS) induced by monocrotaline by comparing liver histopathologic findings., Methods: Seventy rats were randomly divided into a control group (n = 10), a low-dose monocrotaline group (n = 30), and a high-dose monocrotaline group (n = 30). After successful modeling, the liver shear wave velocity (SWV) by Virtual Touch tissue imaging quantification (Siemens Medical Solutions, Mountain View, CA) and the alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin levels of the groups were obtained on days 3 and 5, and the intergroup differences were compared. Liver histopathologic characteristics were analyzed to evaluate the degrees of HSOS, and the scores were recorded., Results: On days 3 and 5, the total bilirubin, AST, and ALT, levels and liver SWV in the low- and high-dose groups were elevated; the portal vein velocity (PVV) of these groups was decreased compared with the control group; and the high-dose rats showed higher serum AST and ALT levels than the low-dose rats. The high-dose rats had a lower PVV than the low-dose rats at day 3. The liver SWV values had significant correlations with the histologic score and PVV. In a multivariate analysis, the liver SWV (β = 0.813; P < .001) was independently associated with the histopathologic score., Conclusions: Liver stiffness as measured by Virtual Touch tissue imaging quantification increases with the severity of HSOS and can be recommended as a marker for diagnosis and assessment of HSOS., (© 2018 by the American Institute of Ultrasound in Medicine.)

Background: A clinical pathway (CP) is a standardized approach for disease management. However, big data-based evidence is rarely involved in CP for related common bile duct (CBD) stones, let alone outcome comparisons before and after CP implementation., Aim: To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography (ERCP)., Methods: This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December 2017. The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care (non-pathway group, n = 467) and CP care (pathway group, n = 2196)., Results: At baseline, the main differences observed between the two groups were the percentage of patients with multiple stones ( P < 0.001) and incidence of cholangitis complication ( P < 0.05). The percentage of antibiotic use and complications in the CP group were significantly less than those in the non-pathway group [adjusted odds ratio (OR) = 0.72, 95% confidence interval (CI): 0.55-0.93, P = 0.012, adjusted OR = 0.44, 95%CI: 0.33-0.59, P < 0.001, respectively]. Patients spent lower costs on hospitalization, operation, nursing, medication, and medical consumable materials ( P < 0.001 for all), and even experienced shorter length of hospital stay (LOHS) ( P < 0.001) after the CP implementation. No significant differences in clinical outcomes, readmission rate, or secondary surgery rate were presented between the patients in the non-pathway and CP groups., Conclusion: Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS, hospital costs, antibiotic use, and complication rate., Competing Interests: Conflict-of-interest statement: The authors have no conflict of interests to declare.

Background and Aims: Hematopoietic stem cell transplantation related hepatic vein occlusive disease (HSCT-HVOD) has been researched extensively; however, little is known about the clinical features and treatment of pyrrolizidine alkaloid-induced HVOD (PA-HVOD). This retrospective single centre study examined the clinical and laboratory characteristics of 108 patients with acute PA-HVOD and explored the efficacy of anticoagulation and TIPS therapy., Methods: The study included 108 consecutive patients with PA-HVOD between July 2008 and June 2016. The clinical manifestations and the results of laboratory and imaging tests were evaluated. The survival rates of patients treated with different approaches were recorded., Results: Serum total bilirubin was <34.2 μmol/L (2 mg/dL) in approximately 40% of patients. More than 90% of patients were presented with hepatomegaly, uneven liver perfusion in the balance phase, compressive stenosis of the hepatic segmental inferior vena cava and decreased peak velocity of portal vein blood flow. Severe portal hypertension was observed in all patients undergoing HVPG examination or TIPS operation. Anticoagulation therapy with low molecular weight heparin combined with warfarin was significantly more effective than liver protection and supportive therapy, and TIPS further improved the prognosis of patients who did not respond to anticoagulation therapy. The total effective rate of the anticoagulation-TIPS ladder therapeutic strategy was 91%., Conclusions: Patients with PA-HVOD had different characteristics than those with HSCT-HVOD. Anticoagulation and TIPS treatment may be effective for patients with PA-HVOD., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

This study evaluated whether the stiffness of the liver and spleen, measured using the point shear wave elastography (pSWE) technique, correlates with portal venous pressure (PVP) and whether the result extends to estimate the diminishing change in PVP (ΔPVP) in patients with decompensated cirrhosis. We evaluated the data of 67 prospectively enrolled patients who underwent both transjugular intrahepatic portosystemic shunt (TIPS) and pSWE. The stiffness of liver and spleen were evaluated by measuring shear wave velocity (SWV) to determine the statistical correlation with PVP. We also analyzed whether change in SWV (ΔSWV) correlates with ΔPVP. The correlations were assessed with Spearman's rank correlation coefficients. Furthermore, receiver operating characteristic (ROC) curves were constructed to evaluate diagnostic capacity of ΔSWV. Spleen stiffness (SS) was positively correlated with PVP before and after TIPS (p < 0.002), although no correlation between liver stiffness and PVP was detected. A strong relationship between ΔSWV in SS and ΔPVP change in portal hypertension (r = 0.871) was also found in the overall population. The area under the ROC curve for the diagnosis of TIPS technical success was 0.869 and at a ΔSWV cut-off value of 0.36 m/s sensitivity was 77%. Measurement of SS can be used for non-invasive assessment and monitoring of PVP in patients with decompensated cirrhosis., (Copyright © 2017 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Gallbladder carcinoma (GBC) is a rare and highly aggressive disease. The diagnosis of this cancer is difficult due to its occult onset. Hence, GBC is often detected late and at an advanced stage. Although physicians and researchers are continually working to improve the treatment for advanced-stage disease, GBC is usually associated with short survival times. The present study describes a case of GBC that was first diagnosed with accompanying cholecystolithiasis at the time of cholecystectomy. Cancer relapse occurred 1.5 years after the cholecystectomy. Multidisciplinary collaboration was involved in the decision-making process for the treatment of this aggressive recurrence, and the survival time was successfully extended to 26 months. Importantly, high-grade intraepithelial neoplasia and positive margins had previously been detected post-cholecystectomy at a different institution, but were ignored. Relapse may have been preventable had the cancer been diagnosed when it was initially observed. Taken together, these findings suggest that multidisciplinary collaboration should be considered for the management of advanced GBC, whereby patients will benefit from improved survival times. Furthermore, it is recommended that samples obtained from patients undergoing cholecystectomy should more carefully analyzed for evidence of cancerous or precancerous tissues.

In this study the effects of S-adenosylmethionine (SAM) on experimental hepatic fibrotic rats induced by carbon tetrachloride (CCl(4)) and ethanol and the relevant potential mechanisms were explored. Hepatic fibrotic rat models were established with CCl(4) diluted in olive oil being drunk with 10% ethanol in water. SAM was used both for prevention and treatment. Histological evaluation was carried out by hematoxylin-eosin (HE) and Masson staining of hepatic samples. Serum biochemical assays showed that alanine aminotransferase (ALT) was increased and albumin (ALB) was decreased by CCl(4) and ethanol, and both effects were suppressed by preventing and treating use of SAM. The model control rats got significantly higher scores in fatty degeneration, lobular inflammation, and hepatocyte ballooning. A significant improvement was observed in the SAM-prevented rats and SAM-treated rats, which was consistent with the change of fibrosis scoring in each group. Smad3 was induced by CCl(4) and ethanol in the model control group, which was significantly down regulated by SAM. SAM reduced both total Smad3 and phospho-Smad3 in vitro. SAM had a protective effect on hepatic fibrosis in rats induced by CCl(4) combined with ethanol and the down-regulation of activity and expression of Smad3 were involved in the potential mechanisms.

Objective: To investigate the effects of S-adenosylmethionine (SAM) on the proliferation, adhesion, migration, invasion and apoptosis of activated human hepatic stellate cells (HSCs) and to explore the relevant potential mechanisms., Methods: Human HSCs LX-2 were cultured with SAM. The proliferation and adhesion were detected by CCK-8. Cell apoptosis rate were analyzed by flow cytometry, and cell migration and invasion were tested by the transwell assay. The expression of Rac1 and MMP-2 was identified by real-time PCR or Western blotting, and activated Rac1 was detected by GST pull-down assay. The activity of MMP-2 and MMP-9 was analyzed by substrate zymography., Results: The proliferation of LX-2 cells was inhibited by SAM, exhibiting a dose-dependent manner. Cell apoptosis rate induced by SAM was remarkably increased. SAM decreased the adhesion, migration and invasion of LX-2 cells. The expression and activation of Rac1 in LX-2 cells were significantly suppressed by SAM. In contrast, the activity of MMP-2 and MMP-9 was enhanced by SAM. SAM attenuated the up-regulated expression of Smad3/4 and Rac1 induced by TGF-β1., Conclusion: SAM inhibits the proliferation, adhesion, migration and invasion of LX-2 cells in vitro probably via attenuating the expression and activation of Rac1 and up-regulating MMP-2 and MMP-9 expression, which possibly provide a molecular basis for potential application of SAM in the therapy of liver fibrosis., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Aim: To investigate the prevalence of minimal hepatic encephalopathy (MHE) and to assess corresponding health-related quality of life (HRQoL) in hospitalized cirrhotic patients in China., Methods: This multi-center cross-sectional study included 16 teaching hospitals, which were members of "Hepatobiliary Cooperation Group, Society of Gastroenterology, Chinese Medical Association", from different areas of China carried out between June and October in 2011. All the eligible hospitalized cirrhotic patients (n = 538) were required to complete triplicate number connection tests combined with one digit symbol test for diagnosing MHE. Patients' clinical examination data were complemented by a modified questionnaire assessing HRQoL. Written informed consent was obtained from each patient., Results: Male was predominant (68.6%) in 519 patients who met the criteria of the study, with a mean age of 49.17 ± 11.02 years. The most common cause of liver cirrhosis was chronic hepatitis B (55.9%). The prevalence of MHE was 39.9% and varied by Child-Pugh-Classification score (CPC-A: 24.8%, CPC-B: 39.4% and CPC-C: 56.1%, P < 0.01). MHE (P < 0.01) and higher CPC scores (P < 0.01) were associated with a high HRQoL scores (reflecting poorer quality of life). The prevalence of MHE was proportionate to CPC (P = 0.01) and high quality of life scores (P = 0.01)., Conclusion: Hospitalized cirrhotic patients have a high prevalence of MHE that is proportionate to the degree of liver function and HRQoL impairment.

Context: Autologous hematopoietic stem cell transplantation (AHSCT) has the potential to induce clinical remission in patients with newly diagnosed type 1 diabetes., Objective: The objective of the study was to examine the impact of AHSCT on lymphocytes and pancreatic β-cell function., Design: This was a nonrandomized, open-label prospective study., Patients and Interventions: Thirteen patients with new onset of type 1 diabetes, 10 of them with diabetic ketoacidosis, were subjected to AHSCT with cryopreserved CD34(+) progenitor cells and followed up for 31-54 months., Main Outcome Measures: The numbers of different subsets of lymphocytes and the levels of serum cytokines, islet antibodies, C-peptide, and plasma glycosylated hemoglobin were longitudinally measured., Results: The numbers of different subsets of lymphocytes, except for CD8(+) T cells, in the patients before AHSCT were significantly lower than those in controls. However, all lymphocytes gradually recovered after AHSCT, accompanied by decreased levels of serum autoantibodies, IL-1, IL-17, and TNF-α. After AHSCT, 11 of 13 patients required significantly reduced doses of insulin for adequate glycemic control, accompanied by reduced levels of glycosylated hemoglobin but increased C-peptide concentrations. Three patients achieved exogenous insulin independence for 7-54 months. The survival of remaining β-cells was associated positively with the preexisting β-cell function but negatively with preexisting autoantibodies (P < 0.05). The numbers of infused CD34(+) cells were positively correlated with the concentrations of serum IL-10, IL-4, TGF-β, and fasting C-peptide but negatively correlated with the levels of serum TNF-α and insulin doses after AHSCT (P < 0.05)., Conclusion: AHSCT modulated lymphocytes and preserved β-cell function in Chinese patients with new onset of type 1 diabetes and diabetic ketoacidosis.

Objectives: To investigate the efficacy of interventional obstructive therapy for patients with liver cancer complicated with intrahepatic arteriovenous fistula., Methods: Forty-eight of 56 patients with liver cancer complicated with intrahepatic arteriovenous fistula, confirmed by angiography, were treated with interventional obstructive therapy. The manifestations of the angiography, abdominal distention, ascites, and 24 hour urine output of the patients were retrospectively analyzed., Results: (1) The arteriovenous fistula connected with the main branches of hepatic artery were embolized effectively by interventional method. (2) After the treatment, the abdominal distention alleviated remarkably (x2 =13.59, P < 0.01), the amount of ascites decreased, 24 hour urine output increased significantly (t = 13.57, P < 0.01) and quality of life improved. (3) The lifespan of the treated patients was prolonged after the embolization therapy., Conclusion: Interventional embolization is an effective palliative therapy for patients with liver cancer complicated with severe ascites and intrahepatic arteriovenous fistula. The good results of this therapy were associated with its effect in decreasing portal hypertension of the patients.