Alimentary Pharmacology & Therapeutics最新文献

{"title":"Letter: Re-Examining Seton Efficacy in Perianal Crohn's Disease—Critical Considerations for Outcome Measurement and Clinical Interpretation. Authors' Reply","authors":"Jeffrey D. McCurdy, Blair Macdonald, Greg Rosenfeld, Talat Bessissow, Vipul Jairath, David H. Bruining, Siddharth Singh","doi":"10.1111/apt.70153","DOIUrl":"https://doi.org/10.1111/apt.70153","url":null,"abstract":"<p>We thank Dr. Liu and colleagues for their interest in our study [<span>1, 2</span>]. Three important considerations were raised in their letter that require further explanation.</p>\u0000<p>We did not capture seton duration prior to initiating anti-TNF therapy. Our study reflected real-world practice. Therefore, it is likely that there was variability in the duration of setons prior to initiating anti-TNF therapy. Contrary to Dr. Liu and colleagues' recommendation to delay anti-TNF for greater than 8 weeks after seton placement, we recommend against this practice for a number of reasons. First, delays in initiating anti-TNF therapy are associated with worsening luminal Crohn's disease [<span>3</span>] and persistent perianal fistula Crohn's disease (PFCD) activity (OR, 2.98; 95% CI, 1.30–6.80) [<span>4</span>]. Second, animal models have demonstrated that setons promote fistula tract epithelialization, a phenomenon believed to prevent fistula closure [<span>5, 6</span>]. Finally, surgical guidelines recommend initiating biologic therapy soon after the control of sepsis to avoid unnecessary delays in healing [<span>7</span>]. Therefore, we believe that anti-TNF therapy should be initiated as soon as possible for PFCD, after source control has been achieved.</p>\u0000<p>We did not omit the key aspects of seton technical variables influencing seton efficacy. Indeed, our propensity score-weighted analysis adjusted for supra/transsphincteric anatomy. This was chosen based on previous work where we demonstrated a trend towards anti-TNF treatment failure in patients with supra/transsphincteric anatomy (OR, 2.28; 95% CI, 0.97–5.35) [<span>4</span>]. In contrast, we did not adjust for transsphincteric anatomy (versus intersphincteric anatomy) since this was not associated with anti-TNF treatment failure (OR,1.04; 95% CI, 0.57–1.90) [<span>4</span>]. Importantly, cutting setons were not used in our study. This is in accordance with guidelines that recommend against their use for complex PFCD due to the risk of anal sphincter injury [<span>7, 8</span>]. Similar to our practice, 90% of surgeons from the United Kingdom reported they would never use cutting setons [<span>9</span>].</p>\u0000<p>We agree with Dr. Liu and colleagues that, when assessed clinically, fistula remission lacks objectivity. This is why we chose major adverse fistula outcomes, a composite of exams under anaesthesia, hospitalisation for PFCD and faecal diversion for PFCD, as our primary outcome. It was our perception that these elements represented the most objective measures to capture major adverse outcomes related to PFCD that could be reasonably obtained retrospectively. We also agree with Dr. Liu and colleagues that patient-centric outcome measures such as patient-reported outcomes and quality-of-life measures would have added valuable information to our study. These will be important to assess in prospective studies since it has yet to be established in a clinical trial whether setons truly imp","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"74 1","pages":""},"PeriodicalIF":7.6,"publicationDate":"2025-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143872603","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter: Re-Examining Seton Efficacy in Perianal Crohn's Disease—Considerations for Outcome Measurement and Clinical Interpretation","authors":"Dingsheng Liu, Banghua Zhong, Lili Guo","doi":"10.1111/apt.70131","DOIUrl":"https://doi.org/10.1111/apt.70131","url":null,"abstract":"<p>We read with great interest the multicentre study by McCurdy et al. investigating the impact of setons on perianal fistula outcomes in patients with Crohn's disease (CD) receiving anti-TNF therapy [<span>1</span>]. This retrospective analysis provided valuable insights into current clinical practice. However, we wish to highlight methodological considerations that may influence the interpretation of these null findings.</p>\u0000<p>First, the study defined “seton exposure” as the presence of ≥ 1 seton at anti-TNF initiation but did not address seton retention duration, a factor directly affecting fistula tract maturation. Prolonged seton drainage (≥ 8 weeks pre-biologic initiation) may improve fistula response rates by optimising local sepsis control [<span>2</span>]. In the absence of data on seton dwell time, the reported HR for major adverse fistula outcomes (1.23; 95% CI 0.68–2.21) may have underestimated therapeutic benefits in patients receiving adequate drainage periods.</p>\u0000<p>Second, the propensity score model accounted for fistula complexity via MRI-based classifications but omitted key technical variables influencing seton efficacy. Consensus guidelines emphasise that seton positioning relative to fistula tracts (inter-sphincteric vs trans-sphincteric) and material type (cutting vs draining) significantly affect outcomes [<span>3</span>]. The lack of stratification by these parameters introduced unmeasured heterogeneity, particularly given the 17-year study span during which seton techniques evolved substantially.</p>\u0000<p>Third, the definition of fistula remission (“clinical assessment”) lacks objective imaging confirmation. A considerable proportion of clinically quiescent fistulas exhibit persistent inflammation on MRI predictive of relapse. Incorporating radiographic endpoints (e.g., MAGNIFI-CD criteria) in future studies could enhance outcome validity [<span>4</span>].</p>\u0000<p>Additionally, the study's exclusive focus on objective clinical endpoints overlooked the multidimensional nature of perianal fistula management. In clinical practice, sustained seton drainage frequently correlates with meaningful symptom alleviation, particularly reduced pain and improved daily function, even when complete anatomical closure remains elusive. By omitting patient-reported outcomes tracking pain severity, drainage frequency, or quality of life metrics, the analysis failed to capture critical dimensions of therapeutic success that directly influence treatment decisions and patient satisfaction. Therefore, future investigations should prioritise integrating both anatomical and patient-centric metrics such as the Fistula Quality of Life Index and visual analogue scale for pain to bridge this evidence gap. This would better align research outcomes with the complex goals of fistula care, where symptom control and functional restoration often outweigh idealised anatomical benchmarks.</p>\u0000<p>In conclusion, while the authors provided important observational","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"91 1","pages":""},"PeriodicalIF":7.6,"publicationDate":"2025-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143872602","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association Between Volume, Intensity and Rhythm of Physical Activity Measured by Accelerometer and Risk of All-Cause and Cause-Specific Mortality in Individuals With MASLD","authors":"Yu Peng, Fubin Liu, Peng Wang, Jianxiao Gong, Huijun Zhou, Jiale Gu, Ailing Qin, Liangkai Chen, Fangfang Song","doi":"10.1111/apt.70169","DOIUrl":"https://doi.org/10.1111/apt.70169","url":null,"abstract":"Individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) have a higher mortality risk, and physical activity is important to MASLD management. However, a comprehensive exploration of associations of volume and intensity of physical activity and rest-activity rhythm (RAR) based on an accelerometer with all-cause and cause-specific mortality in MASLD individuals was scarce.","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"8 1","pages":""},"PeriodicalIF":7.6,"publicationDate":"2025-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143872601","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter: Association Between Viral Replication Activity and Postoperative Recurrence of HBV-Related Hepatocellular Carcinoma—Authors' Reply","authors":"Jiwon Yang, Won-Mook Choi","doi":"10.1111/apt.70146","DOIUrl":"https://doi.org/10.1111/apt.70146","url":null,"abstract":"<p>We appreciate the interest of Yang in our study [<span>1, 2</span>] on the association between viral replication activity and postoperative recurrence of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC), and we welcome the opportunity to clarify certain aspects of our study and address the points raised.</p>\u0000<p>First and foremost, we would like to clarify that patients who initiated antiviral therapy (AVT) more than 3 months after surgery were excluded in order to avoid immortal time bias. We agree that HBV viral activity is dynamic and that postoperative monitoring may provide additional prognostic information. However, our study specifically focused on the prognostic significance of preoperative baseline viral replication activity, which remains clinically relevant in many real-world settings where preoperative decisions must be made based on limited dynamic data. Furthermore, we consider that the ‘field effect’—potentially partially reflected by HBV DNA levels—may persist for a prolonged period even under AVT, thereby influencing hepatocarcinogenesis or recurrence [<span>3, 4</span>].</p>\u0000<p>Second, the primary purpose of our competing risk analysis was to account for death or liver transplantation as events that may preclude HCC recurrence and thereby influence outcomes. In this context, the occurrence of such competing events is what matters, rather than the evaluation of their specific causes [<span>5</span>].</p>\u0000<p>Third, we used imaging criteria in accordance with internationally accepted guidelines [<span>6, 7</span>], which have demonstrated high diagnostic accuracy, particularly in experienced centres. Given that the diagnosis of HCC is predominantly based on imaging rather than pathological confirmation, we find it difficult to agree that the absence of pathological confirmation for recurrence significantly compromises the reliability of our study results.</p>\u0000<p>Finally, to our knowledge, few studies have followed a large cohort of 2384 patients with very early- or early-stage HBV-related HCC for a median of 4.9 years. Considering the decreased risk of recurrence beyond 5 years post-surgery [<span>8</span>] and the gradual attenuation of the ‘field effect’ over time, we believe that both the sample size and follow-up duration are sufficient to support the validity of our study outcomes.</p>\u0000<p>We acknowledge the limitations inherent in a retrospective, non-confirmatory study, including the possibility of unmeasured confounding and residual bias, and agree that further research is warranted.</p>","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"14 1","pages":""},"PeriodicalIF":7.6,"publicationDate":"2025-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143872604","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter: Addressing the Growing Disparities in Alcohol-Associated Liver Disease—A Call for Equitable Healthcare Strategies: Authors' Reply","authors":"Elias D. Rady, Ahmad Anouti, Courtney N. Roberts, Thomas G. Cotter","doi":"10.1111/apt.70158","DOIUrl":"https://doi.org/10.1111/apt.70158","url":null,"abstract":"&lt;p&gt;On behalf of our coauthors, we appreciate the insightful commentary by El-Kassas et al. on our study examining disparities among a diverse Texas-based alcohol-associated liver disease (ALD) inpatient cohort [&lt;span&gt;1&lt;/span&gt;]. Their letter highlights important social and biological contributors to these disparities, which merit further exploration [&lt;span&gt;2&lt;/span&gt;].&lt;/p&gt;\u0000&lt;p&gt;El-Kassas et al. emphasised the potential role of genetic predisposition, particularly due to polymorphisms in PNPLA3 and TM6SF2, in modulating ALD severity across racial and ethnic groups. These variants not only contribute to ALD disease progression, as El-Kassas et al. noted, but are also associated with an increased risk of hepatocellular carcinoma [&lt;span&gt;3, 4&lt;/span&gt;]. Moreover, alcohol use patterns, obesity and type 2 diabetes can amplify this known genetic effect [&lt;span&gt;5&lt;/span&gt;]. The extent to which these environmental and metabolic risk factors modulate genetic risk across different racial and ethnic groups remains poorly understood. To this end, our research team is prospectively studying how these factors interact and influence prognosis in the racially, ethnically and socioeconomically diverse ‘Dallas Dionysus Study’ early-stage ALD cohort.&lt;/p&gt;\u0000&lt;p&gt;Most ALD patients are diagnosed late (i.e., decompensated cirrhosis), often with no efficacious treatments beyond liver transplantation [&lt;span&gt;6&lt;/span&gt;]. Importantly, El-Kassas et al. highlight important systemic barriers to timely ALD diagnosis, such as health literacy, implicit biases and fragmented healthcare systems. Our findings support these concerns, revealing disproportionate increases in ALD hospital encounters among racial and ethnic minorities, which may suggest these populations tend to present later in the disease's progression. Schneider et al. (2024) further emphasise the role of ethnic disparities in liver disease, showing significant variations in the prevalence of liver disease phenotypes across different ethnic groups and sexes [&lt;span&gt;7&lt;/span&gt;]. Guided by a comprehensive conceptual framework, our ‘Dallas Dionysus Study’ cohort undergoes baseline assessments of health literacy, barriers to care and medical mistrust (focusing on perceived disparities in treatment based on ethnicity or race). Understanding how these social determinants of health disproportionately affect outcomes may help guide interventions to address diagnostic delays in disadvantaged populations.&lt;/p&gt;\u0000&lt;p&gt;El-Kassas et al. propose several multi-level interventions to address disparities in ALD diagnosis and treatment, including Medicaid expansion, enhanced provider education on implicit biases, and targeted early alcohol use disorder (AUD) and ALD screening for high-risk groups. We strongly support these initiatives and advocate for comprehensive policy efforts that address both upstream social determinants and downstream clinical interventions to mitigate ALD disparities [&lt;span&gt;8&lt;/span&gt;]. In alignment with these recommendations, our ongoing","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"29 1","pages":""},"PeriodicalIF":7.6,"publicationDate":"2025-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143857763","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Featured Cover","authors":"Prateek Sharma,&nbsp;Michael Vaezi,&nbsp;Peter Unge,&nbsp;Kjell Andersson,&nbsp;Kajsa Larsson,&nbsp;Ivan Popadiyn,&nbsp;Maria Rosenholm,&nbsp;Andras Rosztóczy,&nbsp;Elham Yektaei,&nbsp;David Armstrong","doi":"10.1111/apt.70165","DOIUrl":"10.1111/apt.70165","url":null,"abstract":"<p>The cover image is based on the article <i>Clinical Trial: Dose-Finding Study of Linaprazan Glurate, A Novel Potassium-Competitive Acid Blocker, Versus Lansoprazole for the Treatment of Erosive Oesophagitis</i> by Prateek Sharma et al., https://doi.org/10.1111/apt.70109\u0000 \u0000 <figure>\u0000 <div><picture>\u0000 <source></source></picture><p></p>\u0000 </div>\u0000 </figure></p>","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"61 10","pages":"i"},"PeriodicalIF":6.6,"publicationDate":"2025-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/apt.70165","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143857777","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter: Addressing the Growing Disparities in Alcohol‐Associated Liver Disease—A Call for Equitable Healthcare Strategies","authors":"Mohamed El‐Kassas, Abdel‐Naser Elzouki, Khalid M. AlNaamani","doi":"10.1111/apt.70101","DOIUrl":"https://doi.org/10.1111/apt.70101","url":null,"abstract":"","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"43 1","pages":""},"PeriodicalIF":7.6,"publicationDate":"2025-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143857548","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Editorial: Carvedilol Remains the First‐Line Treatment of Portal Hypertension After the CALIBRE Trial","authors":"Thomas Reiberger, Benedikt Simbrunner","doi":"10.1111/apt.70098","DOIUrl":"https://doi.org/10.1111/apt.70098","url":null,"abstract":"&lt;p&gt;Portal hypertension (PH) is a major consequence of cirrhosis, driving severe complications such as variceal bleeding or ascites. For the prevention of variceal haemorrhage in cirrhosis patients, primary prophylaxis can be performed by non-selective beta-blockers (NSBB) or endoscopic variceal ligation (EVL); however, the Baveno-VII consensus strongly recommends the Carvedilol as the first-line approach [&lt;span&gt;1&lt;/span&gt;]. Recent results of the prematurely terminated and thus, underpowered CALIBRE trial [&lt;span&gt;2&lt;/span&gt;] showed no significant difference of bleeding rates in the carvedilol versus EVL arm. Next to being cost-sparing, no major safety concerns about Carvedilol emerged, while numerically more bleedings in the EVL arm occurred [&lt;span&gt;2&lt;/span&gt;]. Already more than 20 years ago, Tripathi et al. demonstrated that carvedilol ameliorates PH by its additional α1-adrenergic activity on top of combined beta-1/2-adrenergic blockade [&lt;span&gt;3&lt;/span&gt;]. Later their randomised controlled trial established that carvedilol was more effective than EVL for primary prophylaxis: bleeding rates were 10% versus 23% after a median of 20 months (relative hazard 0.41) [&lt;span&gt;4&lt;/span&gt;]. Long-term follow-up of this trial confirmed that patients treated with carvedilol had improved survival compared to EVL [&lt;span&gt;5&lt;/span&gt;].&lt;/p&gt;\u0000&lt;p&gt;In other studies, carvedilol consistently exerted superior efficacy as compared to propranolol in reducing hepatic venous pressure gradient (HVPG) and preventing variceal (re)-bleeding in primary and secondary prophylaxis [&lt;span&gt;6, 7&lt;/span&gt;]. Moreover, a dose–response study identified 12.5 mg/day as an optimal dose, balancing portal pressure reduction with acceptable systemic side effects on arterial blood pressure [&lt;span&gt;8&lt;/span&gt;].&lt;/p&gt;\u0000&lt;p&gt;The superior ability of Carvedilol to improve PH-related outcomes over traditional NSBB via more potent HVPG reduction was underscored by recent multicenter studies: Carvedilol significantly reduced the risk of any type of decompensation (39% risk reduction) in patients with compensated cirrhosis and prevented further decompensation and mortality (43% risk reduction) in patients with decompensated cirrhosis [&lt;span&gt;9&lt;/span&gt;]. An individual patient data meta-analysis of randomised controlled trials (comparing Carvedilol vs. no treatment or EVL) confirmed a significantly lowered risk of both first decompensation (by 49%) and deaths (by 58%) with carvedilol—indicating an overall survival benefit of Carvedilol-treated cirrhosis patients that goes beyond prevention of variceal haemorrhage [&lt;span&gt;10&lt;/span&gt;].&lt;/p&gt;\u0000&lt;p&gt;Considering the previous evidence, the surprising ‘negative’ CALIBRE trial results [&lt;span&gt;2&lt;/span&gt;] of similar first bleeding rates with Carvedilol (5 patients, 3.8%) versus EVL (10 patients, 7.6%) should be critically reviewed, even if the early trial termination and lack of power (only 265 patients were recruited representing 10% of the initially planned sample size) prevent meaningful conclusions.","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"26 1","pages":""},"PeriodicalIF":7.6,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143841351","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Trial: A Multicentre Randomised Controlled Trial of Carvedilol Versus Variceal Band Ligation in Primary Prevention of Variceal Bleeding in Liver Cirrhosis (CALIBRE Trial)","authors":"Dhiraj Tripathi, Kelly Handley, Lisa Holden, Zainab Abdali, Sue Jowett, Jonathan Mathers, Christopher Poyner, Paul Richardson, James Ferguson, Ian Rowe","doi":"10.1111/apt.70080","DOIUrl":"https://doi.org/10.1111/apt.70080","url":null,"abstract":"The superior efficacy of non-selective beta-blockers (NSBB) compared with variceal band ligation (VBL) in the primary prevention of variceal bleeding is uncertain.","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"30 1","pages":""},"PeriodicalIF":7.6,"publicationDate":"2025-04-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143841104","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter: Post-TIPS Hepatic Encephalopathy—The Long-Term Mortality Conundrum in Cirrhotic Patients With Portal Hypertension","authors":"Wenting Wei, Caiyun Lu, Jialin Wu, Junwei Chen","doi":"10.1111/apt.70079","DOIUrl":"https://doi.org/10.1111/apt.70079","url":null,"abstract":"&lt;p&gt;We read with interest the recently published article by Xiang et al., entitled ‘Post-TIPS Overt Hepatic Encephalopathy Increases Long-Term but Not Short-Term Mortality in Cirrhotic Patients With Variceal Bleeding: A Large-Scale, Multicenter Real-World Study’ [&lt;span&gt;1&lt;/span&gt;]. The authors highlighted that post-TIPS overt hepatic encephalopathy (OHE) is associated with an increased risk of long-term, but not short-term, mortality in cirrhotic patients with portal hypertension. Their study provides valuable insights into the long-term implications of OHE and its significance for the management of portal hypertension in this patient population. However, there are a few considerations remaining.&lt;/p&gt;\u0000&lt;p&gt;First, the author did not emphasise whether the stent access was through the right or middle hepatic vein, nor did they specify if the stent was positioned in the left or right portal vein, which may influence the incidence of OHE.&lt;/p&gt;\u0000&lt;p&gt;A meta-analysis comparing the clinical efficacy of stents placed in different portal vein branches manifested that the rate of postoperative HE was significantly lower in the left portal vein group compared to the right portal vein group (5.7% vs. 18.1%, OR 0.19; &lt;i&gt;p&lt;/i&gt; &lt; 0.00001) [&lt;span&gt;2&lt;/span&gt;]. Hence, more details about the TIPS procedure and subgroup analysis are needed to draw a robust conclusion.&lt;/p&gt;\u0000&lt;p&gt;Second, the study did not investigate the impact of TIPS stent diameter, which had a notable influence on mortality according to Table 3 [&lt;span&gt;1&lt;/span&gt;]. Specifically, a previous study conducted by Yan et al. showed that, compared to a conventional 8-mm shunt, the 6-mm TIPS stent significantly reduced the incidence of OHE after TIPS (27.6% vs. 12.1%, &lt;i&gt;p&lt;/i&gt; = 0.040, 1-year; 36.2% vs. 19.0%, &lt;i&gt;p&lt;/i&gt; = 0.038, 2-year) and protected perioperative liver function for patients with small liver volume [&lt;span&gt;3&lt;/span&gt;]. Therefore, we assume that a lower stent diameter can reduce the risk of post-TIPS OHE and thus decrease long-term mortality.&lt;/p&gt;\u0000&lt;p&gt;Third, the presence of spontaneous portosystemic shunts (SPSS) is an often-overlooked risk factor that may reduce hepatic perfusion and contribute to the development of OHE [&lt;span&gt;4, 5&lt;/span&gt;]. However, the potential role of SPSS embolisation was not addressed in the article. The association between SPSS and OHE or mortality needs further discussion. Since there is evidence showing that the 2-year cumulative incidence of OHE was significantly lower in the TIPS plus simultaneous SPSS embolisation (TIPS + E) group compared with the TIPS group (21.2% vs. 48.3%; HR: 0.38, 95% CI, 0.15–0.97; &lt;i&gt;p&lt;/i&gt; = 0.043), so did the death rate (15.0% vs. 6.9%, &lt;i&gt;p&lt;/i&gt; = 0.352) [&lt;span&gt;6&lt;/span&gt;].&lt;/p&gt;\u0000&lt;p&gt;Fourth, the author conducted propensity score matching with a caliper width set at 0.2, which may lack statistical rigor. Additionally, while the authors stated that standardised mean differences (SMD) were calculated before and after matching to assess intergroup balance, these resu","PeriodicalId":121,"journal":{"name":"Alimentary Pharmacology & Therapeutics","volume":"74 1","pages":""},"PeriodicalIF":7.6,"publicationDate":"2025-04-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143837019","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}