Letters to the Editor

of TIPS for hepatic hydrothorax. Of the 79 papers identified, 8 studies including a total of 208 patients were identified with relevant clinical details (1,3–9). Short-term ( < day 45) mortality of patients undergoing TIPS for hepatic hydrothorax ranged from 0% to 29%. When data from these studies were pooled, short-term mortality was 16.8%. TIPS insertion is a therapeutic option for patients with refractory hydrothorax. These data emphasize the potential for harm and the need for careful patient selection to minimize early mortality. ACKNOWLEDGMENTS Dr R. Parker, Dr I.A. Rowe, and Dr D.D. Houlihan are in receipt of Medical Research Council Clinical Research Training Fellowships. Dr M.J. Armstrong is in receipt of a Wellcome Trust Clinical Research Training Fellowship. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES 1. Dhanasekaran R, West JK, Gonzales PC et al. Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis. Am J Gastroenterol 2010;105:635–41. 2. Boyer TD, Haskal ZJ, American Association for the Study of Liver Diseases. The role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in the management of portal hypertension. Hepatology 2010;51:1–16. 3. Strauss RM, Martin LG, Kaufman SL et al. Transjugular intrahepatic portal systemic shunt (TIPS) for the management of symptomatic cirrhotic hydrothorax. Am J Gastroenterol 1994;89:1520–2. 4. Gordon FD, Anastopoulos HT, Crenshaw W et al. The successful treatment of symptomatic, refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt. Hepatology 1997;25:1366–9. 5. Jeffries MA, Kazanjian S, Wilson M et al. Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax. Liver Transpl Surg 1998;4:416–23. 6. Siegerstetter V, Deibert P, Ochs A et al. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients. Eur J Gastroenterol Hepatol 2001;13:529–34. 7. Spencer EB, Cohen DT, Darcy MD. Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax. J Vasc Interv Radiol 2002;13:385–90. 8. Núñez O, García A, Rincón D et al. Percutaneous intrahepatic portosystemic shunting as a treatment for refractory hepatic hydrothorax. Gastroenterol Hepatol 2002;25:143–7. 9. Wilputte JY, Goffette P, Zech F et al. The outcome after transjugular intrahepatic portosystemic shunt (TIPS) for hepatic hydrothorax is closely related to liver dysfunction: a long-term study in 28 patients. Acta Gastroenterol Belg 2007;70:6–10.

© 2013 by the American College of Gastroenterology

1

Centre for Liver Research and NIHR Biomedical Research Unit, Institute for Biomedical Research, University of Birmingham, Birmingham, UK; 2 Liver and Hepatobiliary Unit, Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK. Correspondence: Diarmaid D. Houlihan, MB, PhD, Centre for Liver Research and NIHR Biomedical Research Unit, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, UK. E-mail: [email protected]

2.

3.

4.

Response to Houlihan et al. 5.

Renumathy Dhanasekaran, MD1 and Hyun S. Kim, MD1 6.

doi:10.1038/ajg.2013.300

To the Editor: We apologize for the oversight and resultant errors in Table 5 in our paper “Transjugular intrahepatic portosystemic shunt for symptomatic refractory hepatic hydrothorax in patients with cirrhosis” (1). In the actual text of the article, the reference to the table does correctly state that “Comparable rates of 20–25% early mortality have been reported in other studies (12, 13, 14, 18) (Table 5)” (2–5). However, the 30-day mortality column in Table 5 has errors as noted by Parker et al. (6). We have corrected the numbers and attached a new version below. One of the studies in the original Table 5 by Siegerstetter et al. (7) only reported 6-month mortality (15%) and not 30-day mortality, so we removed it from the corrected table. Fortunately, the errors have not been committed in the analysis of the results of our study and they do not change the conclusion of our study.

7.

for symptomatic refractory hepatic hydrothorax. Am J Gastroenterol 2010;105:635-41. Strauss RM, Martin LG, Kaufman SL et al. Transjugular intrahepatic portal systemic shunt for the management of symptomatic cirrhotic hydrothorax. Am J Gastroenterol 1994;89:1520–2. Gordon FD, Anastopoulos HT, Crenshaw W et al. The successful treatment of symptomatic, refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt. Hepatology 1997;25:1366–9. Jeffries MA, Kazanjian S, Wilson M et al. Transjugular intrahepatic portosystemic shunts and liver transplantation in patients with refractory hepatic hydrothorax. Liver Transpl Surg 1998;4:416–23. Spencer EB, Cohen DT, Darcy MD. Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax. J Vasc Interv Radiol 2002;13:385–90. Parker R, Armstrong MG, Rowe IA et al. Estimated short-term mortality following tips insertion for patients with hepatic hydro thorax. Am J Gastroenterol 2013;108:1806–7 (this issue). Siegerstetter V, Deibert P, Ochs A et al. Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt: long-term results in 40 patients. Eur J Gastroenterol Hepatol 2001;13:529–34.

1

Division of Interventional Radiology and Image Guided Medicine, Department of Radiology, Emory University School of Medicine, Atlanta, Georgia, USA. Correspondence: Hyun S. Kim, MD, Division of Interventional Radiology and Image Guided Medicine, Department of Radiology, Emory University School of Medicine, 1364 Clifton Road, Atlanta, Georgia 30322, USA. E-mail: [email protected]

Incidence and Natural Course of Portal Vein Thrombosis in Cirrhosis Marco Senzolo, MD, PhD1 and J.C. García-Pagán, MD, PhD2

CONFLICT OF INTEREST

The authors declare no conflict of interest.

doi:10.1038/ajg.2013.291

REFERENCES 1. Dhanasekaran R, West J, Gonzales PC et al. Transjugular intrahepatic portosystemic shunt

To the Editor: We have read with interest the recent article by Maruyama et al. (1) on

Table 5. Comparison with different studies Author

N

Mean follow-up (months)

Favorable clinical response (%)

30-Day mortality (%)

Strauss (18), 1994

5

10.4

40

0

Gordon (12), 1997

24

7.2

79

21

Jeffries (13), 1998

12

5.8

58

25

Spencer (14), 2002

21

7.2

57

29

Current study

73

25.3

79

19

The American Journal of GASTROENTEROLOGY

1807

1808

Letters to the Editor

the incidence and natural course of portal vein thrombosis (PVT) in viral cirrhosis. Despite the interest of the study being the third to report incidence of PVT in cirrhotics, it presents several inconsistencies and drawbacks in design and data analysis. First, reported incidence of PVT included six patients with only splenic vein thrombosis, thus being 36/150, 24%. Moreover, the occurrence of PVT is strangely not equally distributed during the follow-up, with a 12.8% incidence in the first years and about 2% per year during the followup. This is in contrast with the current knowledge of a greater prevalence of PVT in patients with more advanced liver disease. Second, patients were recruited for the study during 11 years, and it is stated that Doppler ultrasonography (US) were performed at least every 6–12 months. However, surprisingly, the median number of US per patient was only 4.4, leading to a period of time covered of a maximum of 4 years. Third, correlation of flows at US Doppler at inclusion with occurrence of PVT after years from the initial evaluation is unlikely due to changing hemodynamics in cirrhotic patients overtime. Fourth, it is difficult to understand why patients were tested for prothrombotic disorders at the beginning of the enrollment in the study (in year 1998 the potential role of these alterations in cirrhosis was still not defined). Fifth, US is characterized by diagnostic limitations, especially in extra-hepatic segments of PV or other splanchnic veins. Sixth, worsening of PVT has been described in only 1/23 patients, data very different from previous studies that described progression of PVT in 48–75% of cases at 2 years (2,3). Finally, the way that data on PVT and survival was analyzed does not allow to conclude that PVT does not have an impact on survival. Kaplan–Meyer curve of survival is faulty because the number of patients plotted in the figure is 156 and not 150, and survival was considered from the enrollment in the study. Therefore, for example a patient developing PVT after 7 years of follow-up and dying 1 month after it is considered as being alive for 7 years and 1 month. In conclusion, we believe that the interpretation of the described data is difficult and no recommendations can be drawn The American Journal of GASTROENTEROLOGY

according to the results of the present manuscript. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES 1. Maruyama H, Okugawa H, Takahashi M et al. De novo portal vein thrombosis in virus-related cirrhosis: predictive factors and long-term outcomes. Am J Gastroenterol 2013;108:568–74. 2. Luca A, Caruso S, Milazzo M et al. Natural course of extrahepatic nonmalignant partial portal vein thrombosis in patients with cirrhosis. Radiology 2012;265:124–32. 3. Senzolo M, M Sartori T, Rossetto V et al. Prospective evaluation of anticoagulation and transjugular intrahepatic portosystemic shunt for the management of portal vein thrombosis in cirrhosis. Liver Int 2012;32:919–27. 1

Multivisceral Transplant Unit, Department of Surgical and Gastroenterological Sciences, Padua University Hospital, Padua, Italy; 2 Hepatic Hemodynamic Laboratory, Liver Unit, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), CIBERehd, University of Barcelona, The Hospital Clínic, Barcelona, Spain. Correspondence: Marco Senzolo, MD, PhD, Multivisceral Transplant Unit, Department of Surgical Oncological and Gastroenterological Sciences, University Hospital of Padua, Via Giustiniani 2, 35128 Padua, Italy. E-mail: [email protected]

Response to Senzolo and García-Pagán Hitoshi Maruyama, MD, PhD1 doi:10.1038/ajg.2013.298

To the Editor: We appreciate the interest of Senzolo and García-Pagán (1) in our recent work. The study was properly performed and the data were correctly analyzed, though the total number of patients with portal vein thrombosis in figure 3 (n = 48) was typing error (It should be 42). Most of your comments depend on the characteristics of the cohort and study design based on retrospective setting. In fact, the distribution and detectability of thrombus might be influenced by the diagnostic performance of imaging tool, and it may not be always easy to detect thrombus in the extrahepatic portal vein

by Doppler ultrasonography. However, the study was done consistently throughout the study period by the experienced physician. Relatively stable and less progressive condition was a typical course of portal vein thrombosis. Although we understand some of the data are not consistent with your previous works, it cannot be denied the possibility of heterogeneity in the natural course of portal vein thrombosis. Nonetheless, we acknowledge the limitations of our retrospective study. The data need to be validated in the study with prospective setting. CONFLICT OF INTEREST

The author declares no conflict of interest. REFERENCE 1. Senzolo M, García-Pagán JC. Incidence and natural course of portal vein thrombosis in cirrhosis. Am J Gastroenterol 2013;108:1807–8 (this issue). 1

Department of Gastroenterology, Chiba University Graduate School of Medicine, Chiba, Japan. Correspondence: Hitoshi Maruyama, MD, PhD, Department of Gastroenterology, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuou-ku, Chiba 260-8670, Japan. E-mail: [email protected]

Overlap Between Postprandial Distress Syndrome and Epigastric Pain Syndrome in The DIAMOND Study Jan Tack, MD, PhD1 and Florencia Carbone, MSc2 doi:10.1038/ajg.2013.295

To the Editor: We read with interest the report in the April 2013 issue of the American Journal of Gastroenterology on the symptom overlap between postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) of the Rome III functional dyspepsia (FD) classification (1). In this paper, Vakil and colleagues used the database of the Diamond VOLUME 108 | NOVEMBER 2013 www.amjgastro.com

Incidence and natural course of portal vein thrombosis in cirrhosis.

Incidence and natural course of portal vein thrombosis in cirrhosis. - PDF Download Free
90KB Sizes 0 Downloads 0 Views