ObjectivesEarly placement of transjugular intrahepatic portosystemic shunt (TIPS) has been shown to improve survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10–13) with cirrhosis and acute variceal bleeding (AVB). However, early TIPS criteria may overestimate the mortality risk in a significant proportion of patients, and the survival benefit conferred by early TIPS in such patients has been questioned. Alternative criteria have been proposed to refine the criteria used to identify candidates for early TIPS. Nevertheless, the true survival benefit provided (or not) by early TIPS compared with standard treatment in the different risk categories has not been investigated in specifically designed comparative studies.DesignWe collected data on 1425 consecutive patients with cirrhosis and AVB who were admitted to 12 university hospitals in China between December 2010 and June 2016. Of these, 206 patients received early TIPS, and 1219 patients received standard treatment. The Fine and Gray competing risk regression model was used to compare the outcomes between the two groups that were stratified based on the currently available risk stratification systems after adjusting for liver disease severity and other potential confounders.ResultsOverall, early TIPS was associated with an 80% relative risk reduction (RRR) in mortality at 6 weeks (adjusted HR=0.20; 95% CI: 0.10 to 044; p<0.001) and 51% RRR at 1 year (adjusted HR=0.49, 95% CI: 0.32 to 0.73; p<0.001) compared with standard treatment. In stratification analyses, the RRRs in mortality did not significantly differ among the risk categories. However, the absolute risk reductions (ARRs) of mortality were more pronounced in high-risk patients. The ARRs at 6 weeks were −2.1%, −10.2% and −32.4% in Model for End-stage Liver Disease (MELD) ≤11, 12–18 and ≥19 patients and were −1.5%, −9.1% and −23.2% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). The ARRs for mortality at 1 year were −1.7%, −5.4% and −32.7% in MELD ≤11, 12–18 and ≥19 patients, respectively, and −3.6%, −5.2% and −20.3% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). After adjusting for liver disease severity and other potential confounders, a survival benefit was observed in MELD ≥19 or Child-Pugh C patients but not in MELD ≤11 or Child-Pugh A patients. In MELD 12–18 patients, a survival benefit was observed within 6 weeks but not at 1 year. In Child-Pugh B patients, a survival benefit was observed in those with active bleeding but not those without active bleeding. However, the evaluation of active bleeding was associated with a high interobserver variability. Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding or rebleeding and new or worsening ascites, without increasing the risk of overt hepatic encephalopathy.ConclusionsEarly TIPS was associated with improved survival in patients with MELD ≥19 or Child-Pugh C ...

See Covering the Cover synopsis on page 379.BACKGROUND AND AIMS: Current guidelines recommend surveillance for patients with nondysplastic Barrett's esophagus (NDBE) but do not include a recommended age for discontinuing surveillance. This study aimed to determine the optimal age for last surveillance of NDBE patients stratified by sex and level of comorbidity. METHODS: We used 3 independently developed models to simulate patients diagnosed with NDBE, varying in age, sex, and comorbidity level (no, mild, moderate, and severe). All patients had received regular surveillance until their current age. We calculated incremental costs and quality-adjusted life-years (QALYs) gained from 1 additional endoscopic surveillance at the current age versus not performing surveillance at that age. We determined the optimal age to end surveillance as the age at which incremental costeffectiveness ratio of 1 more surveillance was just less than

Background and Aims Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child‐Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF‐C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child‐Pugh B cirrhosis and AVB. Approach and Results We analyzed the pooled individual data from two previous studies of 608 patients with Child‐Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF‐C ADs for 6‐week and 1‐year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P < 0.001] and 0.556 [P < 0.001]) and other prognostic models. With X‐tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF‐C ADs <48), intermediate risk (CLIF‐C ADs 48‐56), and high risk (CLIF‐C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6‐week death, respectively. Nevertheless, the performance of CLIF‐C ADs for predicting a composite endpoint of 6‐week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF‐C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). Conclusions In patients with Child‐Pugh B cirrhosis and AVB, risk stratification using CLIF‐C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6‐week death or further bleeding, the data‐driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.

ObjectiveTo explore the diagnostic value of digital subtraction angiography (DSA) and the effectiveness of endovascular treatment for a post-pancreaticoduodenectomy hemorrhage (PPH).ResultsDuring the DSA examination, positive results were found in 29 patients, yielding a positive rate of 69.0%. The manifestations of the DSA examination included contrast medium extravasation, pseudoaneurysm, and artery walls coarse. All 29 patients with positive results underwent endovascular treatment, including transartery embolization (TAE) in 28 patients and covered stents placement in one patient. The technical success and clinical success rates were 100% and 72.4%, respectively. Re-bleeding occurred in 8 of the 29 patients after the first treatment (27.6%). The mortality of PPH was 17.2% (5 of 29). Two of the five PPH patients died following severe infections, and three died from multiple organ failure.Materials and MethodsA DSA examination was conducted using clinical and imaging data of 42 patients, and endovascular treatment for delayed PPH was retrospectively analyzed.ConclusionsDSA examination is a minimally invasive and rapid method for the diagnosis of delayed PPH. For patients with positive DSA results, endovascular treatment can be performed rapidly, safely, and effectively. Therefore, the DSA examination and endovascular treatment could be considered a preferred treatment approach for delayed PPH.

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