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• W4249447623 abstract "We are thankful to Dr Mancuso for showing interest in our recently published commentary entitled “Toward a Comprehensive New Classification of Portal Vein Thrombosis in Patients With Cirrhosis.”1Sarin S.K. et al.Gastroenterology. 2016; 151: 574-577Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar We appreciate the author’s concern that there is a lack of long-term data regarding the impact of portal vein thrombosis (PVT) on the natural history of cirrhosis, specifically whether PVT is a cause or a consequence of hepatic decompensation. Moreover, the impact of underlying prothrombotic state and the management of PVT are still a matter of debate. In fact, our commentary1Sarin S.K. et al.Gastroenterology. 2016; 151: 574-577Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar was an attempt to highlight these issues and was meant to encourage prospective observational and interventional studies to prevent and treat PVT in different cohorts of patients. The anatomicofunctional classification we proposed is likely to provide homogeneity in assessment and monitoring therapeutic endpoints with clarity. The classification not only improves upon the prevalent anatomic classifications of PVT, but impresses on symptomatology to inform interventional strategies. The meta-analysis cited by the author includes only 3 studies. The studies are quite heterogeneous; 1 study included 148 patients with only main trunk PVT, and the other 2 studies, included 70 and 42 patients irrespective of main/branch or partial/complete thrombosis.2Stine J.G. et al.World J Hepatol. 2015; 7: 2774-2780Crossref PubMed Scopus (77) Google Scholar Despite being heterogeneous, all studies showed that PVT had a poor outcome on transplant waiting as well as posttransplant outcomes. We do need more studies segregating branch versus main trunk or partial versus complete thrombosis to derive firm conclusions. The impact of PVT on natural history of cirrhosis is like opening Pandora’s box. Despite differences in patient population, the evidence weighs in favor of PVT influencing progression of liver disease, decompensation of cirrhosis, transplant scenario; surgical technique, perioperative complications and long-term graft survival. In fact, the Baveno-VI3deFranchis R. J Hepatol. 2015; 63: 743-752Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar and other guidelines4EASL Clinical Practice GuidelinesJ Hepatol. 2016; 64: 179-202Abstract Full Text Full Text PDF PubMed Scopus (421) Google Scholar consider treating patients with PVT in the presence of main trunk involvement, mesenteric vein involvement, on transplant waiting lists, and those having a progressive course with or without involvement of main trunk and suggest 3-month surveillance. In the study referred to by the author involving 1243 patients, 118 patients (10.7%) had PVT over 47 months and PVT had no impact on either mortality or hepatic decompensation.5Nery F. et al.Hepatology. 2015; 61: 660-667Crossref PubMed Scopus (281) Google Scholar This study, however, showed that patients with PVT had higher disease severity score and proposed that PVT may not be a direct cause of liver disease progression or decompensation, but it is the progressive liver disease that leads to reduced portal flow and predisposition to PVT. The study did not show any difference in the outcome of branch or main PV occlusion. There is a need to identify cirrhotic patients who are at high risk to develop PVT over time.1Sarin S.K. et al.Gastroenterology. 2016; 151: 574-577Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar, 6Zocco M.A. et al.J Hepatol. 2009; 51: 682-689Abstract Full Text Full Text PDF PubMed Scopus (344) Google Scholar Villa et al7Villa E. et al.Gastroenterology. 2012; 143 (e1-e4): 1253-1260Abstract Full Text Full Text PDF PubMed Scopus (501) Google Scholar have in fact shown that anticoagulation could prevent development of PVT and decompensation. Anticoagulation in advanced cirrhosis is safe and resolution of thrombus can be achieved in nearly 50% cases, justifying pretransplant anticoagulation protocols.8Qi X. et al.Eur J Intern Med. 2015; 26: 23-29Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar, 9Hibi T. et al.Ann Surg. 2014; 259: 760-766Crossref PubMed Scopus (98) Google Scholar We agree with the author that multicenter, large cohort trials are required to evaluate the natural history, need for anticoagulation, and likely outcome in patients with asymptomatic and symptomatic incomplete or complete thrombosis of the PVT. In light of all these facts, the proposed anatamicofunctional classification becomes a relevant yardstick for assessment, enrolment into clinical protocols, and monitoring of patients of cirrhosis with a high probability of developing PVT or those presenting with protean manifestations of portal vein thrombosis. Classification of Portal Vein Thrombosis in CirrhosisGastroenterologyVol. 152Issue 5PreviewI believe that further comments are appropriate about the need of a new classification of portal vein thrombosis (PVT) in patients with cirrhosis, as discussed in the interesting paper recently published in Gastroenterology.1 Full-Text PDF" @default.
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• W4249447623 doi "https://doi.org/10.1053/j.gastro.2017.03.003" @default.
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