Liver cirrhosis has long been considered a point of no return, with limited hope for recovery. However, recent advancements, particularly the Baveno VII criteria and the utilization of transjugular intrahepatic portosystemic shunt (TIPS), have illuminated the concept of hepatic recompensation. In this editorial we comment on the article by Gao et al published in the recent issue. This editorial provides a comprehensive overview of the evolution of understanding cirrhosis, the criteria for recompensation, and the efficacy of TIPS in achieving recompensation. We discuss key findings from recent studies, including the promising outcomes observed in patients who achieved recompensation post-TIPS insertion. While further research is needed to validate these findings and elucidate the mech-anisms underlying recompensation, the insights presented here offer renewed hope for patients with decompensated cirrhosis and highlight the potential of TIPS as a therapeutic option in their management.

Hepatic recompensation is firstly described in the Baveno VII criteria, which requires the fulfillment of strict criteria. First, a primary cause of cirrhosis must be addressed, suppressed, or cured. Second, complications of liver cirrhosis, including ascites, encephalopathy, and variceal hemorrhage, must disappear without any intervention. Finally, liver function indicators must be improved. Moreover, without addressing/suppressing/curing cirrhosis and improvement in liver synthetic function, complications, including ascites and variceal hemorrhage can be improved by a transjugular intrahepatic portosystemic shunt (TIPS), which is not evidence of hepatic recompensation. Therefore, on the basis of the definition of hepatic recompensation, TIPS does not achieve hepatic recompensation.

OBJECTIVE: To determine the relationship between clinical, procedural, hospital, and physician characteristics with the duration of the transjugular intrahepatic portosystemic shunt (TIPS) procedure.
METHODS: This retrospective study included patients over 18 years of age who underwent an initial TIPS procedure between January 2005 and August 2020. Exclusion criteria were TIPS performed outside the institution and failed TIPS placement. A total of 154 records were included. Regression analyses were used to identify predictors of procedural duration.
RESULTS: The mean age at TIPS placement was 57 years. Seventy percent of patients were male and non-Hispanic whites (80.5%). The mean duration of the TIPS procedure was 169 minutes (SD: 78). Procedural duration was shorter when the etiology of cirrhosis was viral (mean: 144 min, SD: 84, p=0.008); the reason for TIPS was ascites (152, SD: 66, p=0.01); and the procedure did not require additional access (153 min, SD: 67, p=<.0001). The main clinical predictor of procedural duration was baseline bilirubin (Beta coefficient (β): 5.6 min, p=0.0007). In multivariable linear models, in those patients that did not require additional access, bilirubin (β: 4.9 min, p=0.005), etiology of cirrhosis, and physician experience were the main predictors of TIPS procedure duration. The effect of baseline bilirubin on procedural duration increased in the ascites group (β: 19.5 minutes, p=0.006), especially when additional access was not required.
CONCLUSIONS:  The study demonstrates an association between baseline bilirubin, etiology of cirrhosis, and physician experience with the duration of the TIPS procedure. The mechanism underlying the positive association between baseline bilirubin and procedural time is possibly related to the degree of liver fibrosis.

BACKGROUND: Gut microbiota (GM) affects the progression and response to treatment in liver diseases. The GM composition is diverse and associated with different etiologies of liver diseases. Notably, alterations in GM alterations are observed in patients with portal hypertension (PH) secondary to cirrhosis, with hepatitis B virus (HBV) infection being a major cause of cirrhosis in China. Thus, understanding the role of GM alterations in patients with HBV infection-related PH is essential.
OBJECTIVE: To evaluate GM alterations in patients with HBV-related PH after transjugular intrahepatic portosystemic shunt (TIPS) placement.
METHODS: This was a prospective, observational clinical study. There were 30 patients (with a 100% technical success rate) recruited in the present study. Patients with esophagogastric variceal bleeding due to HBV infection-associated PH who underwent TIPS were enrolled. Stool samples were obtained before and one month after TIPS treatment, and GM was analyzed using 16S ribosomal RNA amplicon sequencing.
RESULTS: One month after TIPS placement, 8 patients developed hepatic encephalopathy (HE) and were assigned to the HE group; the other 22 patients were assigned to the non-HE group. There was no substantial disparity in the abundance of GM at the phylum level between the two groups, regardless of TIPS treatment (all, P > 0.05). However, following TIPS placement, the following results were observed: (1) The abundance of Haemophilus and Eggerthella increased, whereas that of Anaerostipes, Dialister, Butyricicoccus, and Oscillospira declined in the HE group; (2) The richness of Eggerthella, Streptococcus, and Bilophila increased, whereas that of Roseburia and Ruminococcus decreased in the non-HE group; and (3) Members from the pathogenic genus Morganella appeared in the HE group but not in the non-HE group.
CONCLUSIONS: Intestinal microbiota-related synergism may predict the risk of HE following TIPS placement in patients with HBV-related PH. Prophylactic microbiome therapies may be useful for preventing and treating HE after TIPS placement.

UNASSIGNED: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure to alleviate portal hypertension in patients with decompensated liver cirrhosis. While prior research highlighted racial disparities in TIPS, Asian Americans were not included in the investigation. This study aimed to investigate disparities in the immediate postprocedural outcomes among Asian American patients who underwent TIPS.
UNASSIGNED: The study identified Asian American and Caucasian patients who underwent TIPS in the National Inpatient Sample from Q4 2015-2020. Preprocedural factors, including demographics, comorbidities, primary payer status, and hospital characteristics, were matched by 1:2 propensity-score matching between the groups. In-hospital outcomes after TIPS were examined.
UNASSIGNED: There were 6,658 patients who underwent TIPS with 128 (1.92%) Asian Americans and 4,574 (68.70%) Caucasians, where 218 Caucasians were matched to all Asian Americans. Asian Americans had higher in-hospital mortality (14.06% vs. 7.34%, p = 0.04) and higher total hospital charge (253,756 ± 37,867 vs. 163,391 ± 10,265 US dollars, p = 0.02). The occurrence of hepatic encephalopathy, acute kidney injury, transfers out to other hospital facilities, and length of stay did not differ between cohorts.
UNASSIGNED: Despite their heightened risk for cirrhosis, Asian Americans are significantly underrepresented in TIPS and had higher in-hospital mortality after TIPS. This highlights the need for enhanced access to diagnosis and treatment care of liver cirrhosis for Asian Americans.

OBJECTIVE: Transjugular intrahepatic portosystemic shunt (TIPS) is a catheter-based, minimally invasive procedure to reduce portal hypertension. The aim of the study was to investigate dysfunction and mortality after TIPS and to identify factors associated with these events.
METHODS: A retrospective analysis of 834 patients undergoing TIPS implantation in a single center from 1993-2018 was performed. Cumulative incidence curves were estimated, and frailty models were used to assess associations between potentially influential variables and time to dysfunction or death.
RESULTS: 1-, 2-, and 5-year mortality rates were 20.9% (confidence interval (CI) 17.7-24.1), 22.5% (CI 19.1-25.8), and 25.0% (CI: 21.1-28.8), 1-year, 2-year, and 5-year dysfunction rates were 28.4% (CI 24.6-32.3), 38.9% (CI 34.5-43.3), and 52.4% (CI 47.2-57.6). The use of covered stents is a protective factor regarding TIPS dysfunction (hazard ratio (HR) 0.47, CI 0.33-0.68) but does not play a major role in survival (HR 0.95, CI 0.58-1.56). Risk factors for mortality are rather TIPS in an emergency setting (HR 2.78, CI 1.19-6.50), a previous TIPS dysfunction (HR 2.43, CI 1.28-4.62), and an increased Freiburg score (HR 1.45, CI 0.93-2.28).
CONCLUSIONS: The use of covered stents is an important protective factor regarding TIPS dysfunction. Whereas previous TIPS dysfunction, emergency TIPS implantation, and an elevated Freiburg score are associated with increased mortality. Awareness of risk factors could contribute to a better selection of patients who may benefit from a TIPS procedure and improve clinical follow-up with regard to early detection of thrombosis/stenosis.
UNASSIGNED: The use of covered stents reduces the risk of dysfunction after transjugular intrahepatic portosystemic shunt (TIPS). TIPS dysfunction, emergency TIPS placement, and a high Freiburg score are linked to higher mortality rates in TIPS patients.
CONCLUSIONS: The risk of dysfunction is higher for uncovered stents compared to covered stents. Transjugular intrahepatic portosystemic shunt dysfunction increases the risk of instantaneous death after the intervention. A higher Freiburg score increases the rate of death after the intervention. Transjugular intrahepatic portosystemic shunt implantations in emergency settings reduce survival rates.

UNASSIGNED: The objective of this study was to investigate the effect of neutrophil-to-lymphocyte ratio (NLR) on the survival of cirrhotic patients with esophagogastric variceal bleeding (EGVB) treated with transjugular intrahepatic portosystemic shunt (TIPS).
UNASSIGNED: A total of 293 patients treated with TIPS were included. The receiver operator characteristic curve (ROC) was used to calculate the optimal cut-off values of parameters such as NLR. The Kaplan-Meier curve and Cox proportional risk model were used to evaluate the effects of NLR and other variables on 2-year all-cause mortality.
UNASSIGNED: The area under the ROC for NLR was 0.634, with an optimal cutoff value of 4.9. Two-year mortality rates for patients with high (≥4.9) and low (<4.9) NLR were 22.1% and 9.3%, respectively (Log rank test: P = 0.002). After correcting for confounders, multivariate analysis demonstrated that NLR ≥ 4.9 (HR = 2.741, 95% CI 1.467-5.121, P = 0.002), age ≥ 63 (HR = 3.403, 95% CI 1.835-6.310, P < 0.001), and gender (male) (HR = 2.842, 95% CI 1.366-5.912, P = 0.001) were independent risk factors for the mortality outcome. Considering the stratification of early and selective TIPS treatment, high NLR still significantly increased the risk of mortality for patients (Log rank test: P = 0.007, HR = 2.317, 95% CI 1.232-4.356).
UNASSIGNED: NLR can help to predict survival in EGVB patients after TIPS, and the type of TIPS should also be considered in practical applications.

BACKGROUND: Portal shunt and immune status related to the spleen are related to the occurrence of hepatic encephalopathy (HE). It is unknown whether spleen volume before transjugular intrahepatic portosystemic shunt (TIPS) is related to postoperative HE.
OBJECTIVE: To investigate the relationship between spleen volume and the occurrence of HE.
METHODS: This study included 135 patients with liver cirrhosis who underwent TIPS, and liver and spleen volumes were elevated upon computed tomography imaging. The Kaplan-Meier curve was used to compare the difference in the incidence rate of HE among patients with different spleen volumes. Univariate and multivariate Cox regression analyses were performed to identify the factors affecting overt HE (OHE). Restricted cubic spline was used to examine the shapes of the dose-response association between spleen volumes and OHE risk.
RESULTS: The results showed that 37 (27.2%) of 135 patients experienced OHE during a 1-year follow-up period. Compared with preoperative spleen volume (901.30 ± 471.90 cm3), there was a significant decrease in spleen volume after TIPS (697.60 ± 281.0 cm3) in OHE patients. As the severity of OHE increased, the spleen volume significantly decreased (P < 0.05). Compared with patients with a spleen volume ≥ 782.4 cm3, those with a spleen volume < 782.4 cm3 had a higher incidence of HE (P < 0.05). Cox regression analysis showed that spleen volume was an independent risk factor for post-TIPS OHE (hazard ratio = 0.494, P < 0.05). Restricted cubic spline model showed that with an increasing spleen volume, OHE risk showed an initial increase and then decrease (P < 0.05).
CONCLUSIONS: Spleen volume is related to the occurrence of OHE after TIPS. Preoperative spleen volume is an independent risk factor for post-TIPS OHE.

Transjugular intrahepatic portosystemic shunt (TIPS) is an essential procedure for the treatment of portal hypertension but can result in hepatic encephalopathy (HE), a serious complication that worsens patient outcomes. Investigating predictors of HE after TIPS is essential to improve prognosis. This review analyzes risk factors and compares predictive models, weighing traditional scores such as Child-Pugh, Model for End-Stage Liver Disease (MELD), and albumin-bilirubin (ALBI) against emerging artificial intelligence (AI) techniques. While traditional scores provide initial insights into HE risk, they have limitations in dealing with clinical complexity. Advances in machine learning (ML), particularly when integrated with imaging and clinical data, offer refined assessments. These innovations suggest the potential for AI to significantly improve the prediction of post-TIPS HE. The study provides clinicians with a comprehensive overview of current prediction methods, while advocating for the integration of AI to increase the accuracy of post-TIPS HE assessments. By harnessing the power of AI, clinicians can better manage the risks associated with TIPS and tailor interventions to individual patient needs. Future research should therefore prioritize the development of advanced AI frameworks that can assimilate diverse data streams to support clinical decision-making. The goal is not only to more accurately predict HE, but also to improve overall patient care and quality of life.

UNASSIGNED: Colorectal surgery in patients with inflammatory bowel disease (IBD) and cirrhosis has increased morbidity, which may preclude surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) is postulated to reduce surgical risk. In this retrospective single-center study, we characterized perioperative outcomes in patients with IBD and cirrhosis who underwent preoperative TIPS.
UNASSIGNED: We identified patients with IBD and cirrhosis who had undergone preoperative TIPS for portal decompression between 2010 and 2023. All other indications for TIPS led to patient exclusion. Demographic and medical data were collected, including portal pressure measurements. Primary outcome of interest was perioperative outcomes.
UNASSIGNED: Ten patients met the inclusion criteria. The most common surgical indications were dysplasia (50%) and refractory IBD (50%). TIPS was performed at a median of 47 days (IQR 34-80) before surgery, with reduction in portal pressures (22.5 vs. 18.5 mmHg, P < .01) and portosystemic gradient (12.5 vs. 5.5 mmHg, P < .01). Perioperative complications occurred in 80% of patients, including surgical site bleeding (30%), wound dehiscence (10%), systemic infection (30%), liver function elevation (50%), and coagulopathy (50%). No patients required re-operation, with median length of stay being 7 days (IQR 5.5-9.3). The 30-day readmission rate was 40%, most commonly for infection (75%), with 2 patients having intra-abdominal abscesses and 1 patient with concern for bowel ischemia. Ninety-day and one-year survival was 100% and 90%, respectively. Patients with primary sclerosing cholangitis (PSC)-cirrhosis were noted to have higher perioperative morbidity and a 30-day readmission rate.
UNASSIGNED: In patients with IBD and cirrhosis, preoperative TIPS facilitated successful surgical intervention despite heightened risk. Nevertheless, significant complications were noted, in particular for patients with PSC-cirrhosis.