Novel classification of non-malignant portal vein thrombosis: A guide to surgical decision-making during liver transplantation

Abstract

Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT as defined here (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. With time, the proposed classifications of non-tumoral chronic PVT have evolved from being anatomy-based, to also incorporating functional parameters. However, none of the currently proposed classifications are directed towards decision-making, regarding the choice of inflow to the graft during transplantation and the outcomes thereof. The present scoping review i) addresses the limits of the currently available classifications in terms of surgical decisiveness, ii) clarifies the concept of physiological or non-physiological portal inflow reconstruction, and subsequently, iii) proposes a new classification of non-tumoral PVT in candidates for liver transplantation; to help tailor the surgical strategy to an individual patient, in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible.

Reply to: “Comment on – A multi-center study of entecavir vs. tenofovir on prognosis of treatment-naïve chronic hepatitis B in the Republic of Korea”

“…First of all, we greatly appreciate the letter from Yu et al, 1 which addressed several concerns regarding our study 2 where we concluded that the risk of hepatocellular carcinoma (HCC) was not statistically different between patients treated with entecavir (ETV) vs. tenofovir disoproxil fumarate (TDF) for chronic hepatitis B virus (HBV) infection. Actually, the controversy concerning which antiviral agent is better in improving prognosis among patients with chronic HBV infection remains, however, the level of evidence favoring the use of any specific antiviral agent has been weak.…”

“…Second, Yu et al 1 commented on variables used in the statistical analyses. However, the addition of serum HBV-DNA and/or alanine aminotransferase levels is not likely to lead to different results, since both ETV and TDF are the recommended antiviral agents, with high genetic barriers.…”

New Insights into the Pathogenesis, Risk Factors, and Treatment of Portal Vein Thrombosis in Patients with Cirrhosis

“…Therefore, a novel classification that better suits the surgical needs has been recently proposed. 35 The age of thrombus may influence the decision of treatment initiation given that a recent thrombus responds better to anticoagulation treatment. PHT can also be aggravated by a thrombosis causing a significant obstruction to flow, and therefore a new classification incorporating the degree of lumen occlusion has been proposed.…”

Comment on – A multi-center study of entecavir vs. tenofovir on prognosis of treatment-naïve chronic hepatitis B in the Republic of Korea

“…In Choi et al's study, 2 decompensated cirrhosis was not excluded, unlike in Kim et al's study. 1 If decompensated cirrhosis was included, we believe that statistical differences between ETV and TDF groups may show up. It is known that, once decompensation occurs, mortality without transplant is as high as 85% over 5 years.…”

“…Propensity score (PS) was computed on the 19 variables and 869 pairs of PS-matched patients. In Kim et al's study, 1 as mentioned in the Statistical Analysis section, PS was computed from 9 variables (age, gender, diabetes, hypertension, compensated cirrhosis, HBeAg status, total bilirubin, albumin, and platelet counts). However, other variables, such as HBV DNA level, alanine aminotransferase, creatinine concentration, ascites, Child-Pugh score, and virologic response, might affect the outcome of the study, [4][5][6] and thus should be taken into consideration.…”