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Definition of SPSS: we need to speak the same language

2020; Elsevier BV; Volume: 73; Issue: 2 Linguagem: Inglês

10.1016/j.jhep.2020.03.012

1600-0641

Oana Nicoară-Farcău, Xiaoze Wang, Xuefeng Luo,

Hepatitis Viruses Studies and Epidemiology

We read with great interest the recent international multicenter retrospective study published in Journal of Hepatology by Praktiknjo et al., assessing the impact of total cross-sectional spontaneous portosystemic shunt (SPSS) area (TSA) on outcomes in patients with cirrhosis.[1]Praktiknjo M. Simon-Talero M. Romer J. Roccarina D. Martinez J. Lampichler K. et al.Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis.J Hepatol. 2020; 72: 1140-1150Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar The authors found that a TSA >83 mm2 was associated with an increased risk of overt hepatic encephalopathy and mortality. This study, as well as their previous prominent work,[2]Simon-Talero M. Roccarina D. Martinez J. Lampichler K. Baiges A. Low G. et al.Association between portosystemic shunts and increased complications and mortality in patients with cirrhosis.Gastroenterology. 2018; 154: 1694-1705.e4Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar shed light on the role of SPSS in the prognosis of cirrhosis, a role which should not be neglected. Nevertheless, we believe that there are still some issues that need clarification. Firstly, there is no consensual definition of SPSS in the literature. SPSSs refer to, as the name implies, all the potential portosystemic collaterals that divert the flux from the portal vein into the systemic circulation.[3]Saad W.E. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure.Tech Vasc Interv Radiol. 2013; 16: 60-100Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar,[4]Arora A. Rajesh S. Meenakshi Y.S. Sureka B. Bansal K. Sarin S.K. Spectrum of hepatofugal collateral pathways in portal hypertension: an illustrated radiological review.Insights Imaging. 2015; 6: 559-572Crossref PubMed Scopus (21) Google Scholar In patients with portal hypertension, esophageal and paraesophageal varices are primarily supplied by the left gastric vein and drain into the systemic circulation via the azygos/hemiazygos veins, therefore fitting this definition. In the current study, as well as in several other studies,[1]Praktiknjo M. Simon-Talero M. Romer J. Roccarina D. Martinez J. Lampichler K. et al.Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosis.J Hepatol. 2020; 72: 1140-1150Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,[2]Simon-Talero M. Roccarina D. Martinez J. Lampichler K. Baiges A. Low G. et al.Association between portosystemic shunts and increased complications and mortality in patients with cirrhosis.Gastroenterology. 2018; 154: 1694-1705.e4Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar,[5]Laleman W. Simon-Talero M. Maleux G. Perez M. Ameloot K. Soriano G. et al.Embolization of large spontaneous portosystemic shunts for refractory hepatic encephalopathy: a multicenter survey on safety and efficacy.Hepatology. 2013; 57: 2448-2457Crossref PubMed Scopus (140) Google Scholar they were not considered as SPSSs and were excluded from analysis. However, esophageal and/or paraesophageal varices were considered SPSSs in other studies.[6]Zardi E.M. Uwechie V. Caccavo D. Pellegrino N.M. Cacciapaglia F. Di Matteo F. et al.Portosystemic shunts in a large cohort of patients with liver cirrhosis: detection rate and clinical relevance.J Gastroenterol. 2009; 44: 76-83Crossref PubMed Scopus (45) Google Scholar,[7]Nagaoki Y. Aikata H. Daijyo K. Teraoka Y. Honda F. Nakamura Y. et al.Risk factors for exacerbation of gastroesophageal varices and portosystemic encephalopathy during treatment with nucleos(t)ide analogs for hepatitis B virus-related cirrhosis.Hepatol Res. 2018; 48: 264-274Crossref PubMed Scopus (2) Google Scholar As such, the ambiguity of the definition makes it difficult to interpret the results and compare between different studies. In contrast, gastrorenal shunt (GRS) is widely accepted as SPSS. In general, GRS is common and occurs in 80%–85% of patients with gastric varices.[3]Saad W.E. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure.Tech Vasc Interv Radiol. 2013; 16: 60-100Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Since GRS can be found both in the presence or absence of gastric varices, it is not clear if the authors included all GRS in this paper. In addition, the authors state that the gastroesophageal and rectal varices were not measured because of their appearance as a network of collaterals. Although we agree that measuring at this level is technically more challenging, the largest diameter of afferent portal venous feeders of esophageal, gastric and rectal varices could be easily identified, as in the case of the umbilical vein (Fig. 1). Interestingly, the authors found no difference in the rate of bleeding between patients with large and small TSA. Although the prevalence and type of gastroesophageal varices were not described, this finding may be attributed to the absence of follow-up imaging. In other words, portosystemic collaterals and varices may change over time and be influenced by the progression or aggressiveness of the disease,[8]Berzigotti A. Merkel C. Magalotti D. Tiani C. Gaiani S. Sacerdoti D. et al.New abdominal collaterals at ultrasound: a clue of progression of portal hypertension.Dig Liver Dis. 2008; 40: 62-67Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar therefore the predictive value of baseline portosystemic collaterals for the risk of variceal bleeding may be limited. The association between left gastric vein with the size of esophageal varices and the bleeding risk has been assessed in previous studies.[9]Zhou H.Y. Chen T.W. Zhang X.M. Zeng N.L. Zhou L. Tang H.J. et al.Diameters of left gastric vein and its originating vein on magnetic resonance imaging in liver cirrhosis patients with hepatitis B: association with endoscopic grades of esophageal varices.Hepatol Res. 2014; 44: E110-E117Crossref PubMed Scopus (5) Google Scholar,[10]Adithan S. Venkatesan B. Sundarajan E. Kate V. Kalayarasan R. Color Doppler evaluation of left gastric vein hemodynamics in cirrhosis with portal hypertension and its correlation with esophageal varices and variceal bleed.Indian J Radiol Imaging. 2010; 20: 289-293Crossref PubMed Scopus (12) Google Scholar Including gastroesophageal varices in the measurement would have an impact on the bleeding risk assessment. In conclusion, we propose to use the term portosystemic collaterals to define all the vessels that divert the blood from the portal system to bypass the liver and drain into the systemic circulation and include all of them for analysis. The adoption of this term and the agreement on a uniform nomenclature is an essential requirement for future studies. Oana Nicoară-Farcău manuscript draft. Xiaoze Wang image preparation. Xuefeng Luo manuscript draft. The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details. Download .pdf (.16 MB) Help with pdf files disclosures.pdf Total area of spontaneous portosystemic shunts independently predicts hepatic encephalopathy and mortality in liver cirrhosisJournal of HepatologyVol. 72Issue 6PreviewSpontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that the presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, the presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcomes in patients with liver cirrhosis. Full-Text PDF Open AccessReply to: “Definition of SPSS: we need to speak the same language”: Computer-assisted image processing for better quantificationJournal of HepatologyVol. 73Issue 2PreviewWe appreciate the interest of Nicoară-Farcău et al. in our recent multicenter study published in Journal of Hepatology.1 Full-Text PDF