08634476

August 30, 2025, 08:45

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Dear Editor, We read with great interest the article “Changes in liver and spleen stiffness after transjugular intrahepatic portosystemic shunt and their relationship with prognosis” by Liu et al. This study provides valuable insights into the dynamic changes of liver and spleen stiffness post-transjugular intrahepatic portosystemic shunt (TIPS) and their prognostic value, filling an important gap in non-invasive monitoring of TIPS outcomes. However, three aspects could be further refined to enhance the study’s clinical relevance and evidence robustness. First, the study lacks analysis of the impact of TIPS shunt patency on changes in liver and spleen stiffness. The authors report that spleen stiffness decreases significantly post-TIPS and correlates with portal pressure gradient (PPG), but they do not clarify whether these stiffness changes are influenced by shunt function (e.g., stenosis or occlusion). Clinically, TIPS shunt dysfunction (a common complication) can lead to re-elevated portal pressure, which may reverse the initial reduction in spleen stiffness. Without documenting shunt patency status (e.g., via Doppler ultrasound or venography) at each follow-up time point and stratifying stiffness trends by patency, it is difficult to determine whether the observed stiffness changes are purely due to TIPS-induced hemodynamic improvement or confounded by shunt dysfunction. This gap limits the ability to interpret stiffness trends as reliable indicators of long-term TIPS efficacy. Second, the study does not explore the relationship between changes in liver/spleen stiffness and the severity of overt hepatic encephalopathy (OHE). Although logistic regression shows no correlation between baseline stiffness and post-TIPS OHE, the dynamic changes in stiffness (e.g., the magnitude of spleen stiffness reduction) may still be associated with OHE risk. For example, a more pronounced decrease in spleen stiffness might reflect better portal decompression, potentially reducing the risk of OHE by altering gut-liver axis function or ammonia metabolism. Additionally, the study only includes OHE of grade ≥2, excluding milder grades (grade 1), which are clinically relevant for early intervention. Analyzing stiffness changes in relation to OHE severity and including all OHE grades would provide a more comprehensive understanding of how stiffness correlates with this key TIPS complication. Third, the study’s subgroup analysis of liver cirrhosis etiology is insufficient to inform the etiology-specific prognostic value of stiffness. The cohort includes patients with viral, alcoholic, and immunological cirrhosis, but the authors do not stratify survival outcomes or stiffness trends by etiology. Previous studies have shown that cirrhosis etiology affects liver stiffness progression and TIPS prognosis—for instance, alcoholic cirrhosis may be associated with more rapid stiffness changes due to ongoing inflammation, compared to viral cirrhosis. Without etiology-specific subgroup analyses, it is unclear whether the identified liver stiffness cutoff (35.15 kPa) or the prognostic role of stiffness applies uniformly across different etiologies. This limits the study’s ability to guide personalized TIPS assessment for patients with distinct cirrhosis causes. In conclusion, Liu et al.’s work makes a meaningful contribution to non-invasive monitoring of TIPS outcomes. Addressing the above issues—by integrating shunt patency data, analyzing stiffness changes with OHE severity, and exploring etiology-specific effects—would further strengthen the study’s scientific rigor and clinical utility. We look forward to seeing supplementary analyses or follow-up studies to address these points. Sincerely, Xiong Yuezhihong Yichang Central People's Hospital

First, thank you very much for your professional comments on the article published in World Journal of Gastrointestinal Surgery. Second, we read your comments with great interest. You are welcome to format your valuable comments into a Letter to the Editor and submit it online to World Journal of Gastrointestinal Surgery at https://www.f6publishing.com. There are no restrictions on the number of words, figures (color, B/W) or authors for a Letter to the Editor. In addition, the article processing charge will be exempted for this Letter to the Editor. As with all articles published by the Baishideng Publishing Group, the Letter to the Editor will be published online after completing peer review. The guidelines for a Letter to the Editor can be found at: https://www.wjgnet.com/bpg/GerInfo/219. Finally, we look forward to receiving your high-quality Letter to the Editor, which will promote academic communication and lead the development of this discipline.