Spontaneous Portosystemic Shunts Research Articles

Clinical Implications and Management of Spontaneous Portosystemic Shunts in Liver Cirrhosis.

Portal hypertension from chronic liver disease leads to the formation of collateral blood vessels called spontaneous portosystemic shunts (SPSS). These shunts may form from existing vessels or through neo-angiogenesis. Their location affects clinical outcomes due to varying risks and complications. This review summarizes current knowledge on SPSS, covering their clinical impact and management strategies. Recent data suggest that SPSS increases the risk of variceal bleeding, regardless of shunt size. The size of the shunt is crucial in the rising incidence of hepatic encephalopathy (HE) linked to SPSS. It also increases the risk of portopulmonary hypertension and portal vein thrombosis. Detecting and assessing SPSS rely on computed tomography (CT) and magnetic resonance imaging. CT enables precise measurements and the prediction of cirrhosis progression. Management focuses on liver disease progression and SPSS-related complications, like HE, variceal bleeding, and portopulmonary hypertension. Interventional radiology techniques such as balloon-occluded, plug-assisted, and coil-assisted retrograde transvenous obliteration play a pivotal role. Surgical options are rare but are considered when other methods fail. Liver transplantation (LT) often resolves SPSS. Intraoperative SPSS ligation is still recommended in patients at high risk for developing HE or graft hypoperfusion.

Interventional embolisation for patients with cirrhosis and recurrent or persistent hepatic encephalopathy related to spontaneous portosystemic shunts: protocol for a prospective, non-randomised controlled study

IntroductionThe presence of spontaneous portosystemic shunts (SPSS) has been identified to be associated with hepatic encephalopathy (HE) in patients with cirrhosis. Nevertheless, the role of interventional embolisation in managing such...

Efficacy of TIPS plus extrahepatic collateral embolisation in real-world data: a validation study

ObjectivesThe efficacy of transjugular intrahepatic portosystemic shunt (TIPS) plus extrahepatic collateral embolisation (TIPS+E) in reducing rebleeding and hepatic encephalopathy (HE) post-TIPS was recently reported in a meta-analysis, but further validation...

Pre-operative evaluation of spontaneous portosystemic shunts as a predictor of post-hepatectomy liver failure in patients undergoing liver resection for hepatocellular carcinoma

Pre-operative evaluation of spontaneous portosystemic shunts as a predictor of post-hepatectomy liver failure in patients undergoing liver resection for hepatocellular carcinoma

Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade's Literature Focusing on Incidence, Risk Factors, and Prophylaxis.

Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension and its' complications in liver cirrhosis, yet the development of hepatic encephalopathy (HE) remains a significant concern. This review covers the reported incidence, risk factors, and management strategies for post-TIPS HE over the past decade. Incidence varies widely (7-61%), with factors like age, liver function, hyponatremia, and spontaneous portosystemic shunts influencing risk. Procedural aspects, including TIPS timing, indication, and stent characteristics, also contribute. Pharmacological prophylaxis with lactulose and rifaximin shows promise, but current evidence is inconclusive. Procedural preventive measures, such as shunt embolization and monitoring portal pressure gradients, are explored. Treatment involves pharmacological options like lactulose and rifaximin, and procedural interventions like stent diameter reduction. Ongoing studies on novel predictive markers and emerging treatments, such as faecal microbiota transplant, reflect the evolving landscape in post-TIPS HE management. This concise review provides clinicians with insights into the multifaceted nature of post-TIPS HE, aiding in improved risk assessment, prophylaxis, and management for patients undergoing TIPS procedures.

Evolution of spontaneous portosystemic shunts over time and following aetiological intervention in patients with cirrhosis

Spontaneous portosystemic shunts (SPSS) develop frequently in cirrhosis. Changes over time and the effect of aetiological interventions on SPSS are unknown, so we aimed to explore the effect of these variables on SPSS evolution. Patients with cirrhosis from the Baveno VI-SPSS cohort were selected provided a follow-up abdominal CT or MRI scan was available. Clinical and laboratory data were collected at baseline and follow-up. Imaging tests were reviewed to evaluate changes in the presence and size of SPSS (large (L)-SPSS was ≥8mm) over time. Regarding alcohol- or HCV-related cirrhosis, two populations were defined: cured patients (abstinent from alcohol or successful HCV therapy), and non-cured patients. A total of 617 patients were included. At baseline SPSS distribution was 22% L-SPSS, 30% small (S)-SPSS, and 48% without (W)-SPSS. During follow-up (median follow-up of 63 months), SPSS distribution worsened: L-SPSS 26%, S-SPSS 32%, and W-SPSS 42% (p <0.001). Patients with worse liver function during follow-up showed a simultaneous aggravation in SPSS distribution. Non-cured patients (n= 191) experienced a significant worsening in liver function, more episodes of liver decompensation and lower transplant-free survival compared to cured patients (n= 191). However, no differences were observed regarding SPSS distribution at inclusion and at follow-up, with both groups showing a trend to worsening. Total shunt diameter increased more in non-cured (52%) than in cured patients (28%). However, total shunt area (TSA) significantly increased only in non-cured patients (74 to 122mm2, p <0.001). The presence of SPSS in cirrhosis increases over time and parallels liver function deterioration. Aetiological intervention in these patients reduces liver-related complications, but SPSS persist although progression is decreased. There is no information regarding the evolution of spontaneous portosystemic shunts (SPSS) during the course of cirrhosis, and especially after disease regression with aetiological interventions, such as HCV treatment with direct-acting antivirals or alcohol abstinence. These results are relevant for clinicians dealing with patients with cirrhosis and portal hypertension because they have important implications for the management of cirrhosis with SPSS after disease regression. From a practical point of view, physicians should be aware that in advanced cirrhosis with portal hypertension, after aetiological intervention, SPSS mostly persist despite liver function improvement, and complications related to SPSS may still develop.

Endoscopic Ultrasound-Guided Transgastric Shunt Obliteration for Recurrent Hepatic Encephalopathy.

Occlusion of spontaneous portosystemic shunts (SPSSs) in patients with cirrhosis may be required in recurrent or refractory hepatic encephalopathy. We describe a novel method for occlusion of SPSS using endoscopic ultrasound (EUS). EUS-guided transgastric shunt obliteration was performed by injecting glue and coils directly into SPSS. EUS-guided transgastric shunt obliteration was performed for 7 patients in 9 sessions. Complete cessation of Doppler flow was achieved in 6/7 cases. Adequate clinical response was observed in 6/7 patients. No procedure-related severe adverse events were seen. This novel technique is a potentially effective and efficient method for shunt obliteration.

Massive spontaneous portosystemic shunt is a solid, easily identifiable prognostic factor in patients with cirrhosis.

Spontaneous portosystemic shunts (SPSSs) are associated with complications and death in cirrhosis. We evaluated chronic portosystemic encephalopathy (CPSE) and survival in cirrhotic patients with massive (>10 mm diameter) SPSS (MSPSS). We have retrospectively compared 77 cirrhotic patients with MSPSS and 77 paired-matched patients without SPSS. More patients with MSPSS presented with CPSE (40.3% vs. 20.8%, P = 0.010) or died (33.8% vs. 18.2%, P = 0.039). Model for Endstage Liver Disease (MELD) score [hazard ratio (HR) 1.146, 95% confidence interval (CI) 1.099-1.195], follow-up (FU) ascites (HR 5.128, 95% CI 2.396-10.973) and age (HR 1.048, 95% CI 1.017-1.080) were associated with CPSE; and MELD score (HR 1.082, 95% CI 1.035-1.131), FU renal failure (HR 9.319, 95% CI 3.595-24.158), and FU ascites (HR 4.320, 95% CI 1.615-11.555) were associated with death. Liver function worsened faster in the MSPSS group. Among patients with better liver function (MELD < 11.5), MSPSS patients presented worse survival (P = 0.048, Breslow test). Comparing patients by the Child-Pugh group, we did not find differences in survival; in patients from Child-Pugh group B + C, the MSPSS group presented less time free of CPSE (P < 0.05, log-rank test). Patients with splenorenal MSPSS presented better survival (P = 0.04, log-rank test), and patients with umbilical MSPSS had shorter time free of CPSE (P < 0.016, log-rank test). MSPSS increased CPSE and death risks during long FU. Even with better liver function (MELD < 11.5), MSPSS was associated with lower survival. Splenorenal MSPSS presented better survival and the umbilical type was associated with shorter time free of CPSE.

Prediction and prevention of the first episode of overt hepatic encephalopathy in patients with cirrhosis.

Hepatic encephalopathy (HE) is one of the most important complications of patients with liver cirrhosis. In addition, HE is associated with a dismal prognosis and has detrimental effects on patients' quality of life. Thus, it is of pivotal importance to identify patients at high risk for overt HE (OHE) in whom primary prophylaxis may be justified. In this narrative review, we aim to provide insight into predictors and prediction tools for a first-time episode of OHE and to scrutinize the current level of evidence of primary prophylaxis. In recent decades, several cognitive tests, composite scores, and blood-based biomarkers have been demonstrated to be predictive of a first-time episode of OHE. Among the best validated are the established tests for minimal HE, such as the Psychometric Hepatic Encephalopathy Score, determination of the critical flicker frequency, Stroop EncephalApp, or the Animal Naming Test. Individualized risk stratification using blood-based biomarkers and cross-sectional imaging (sarcopenia and spontaneous portosystemic shunts) is coming to the fore, but validation in larger multicenter cohorts is often lacking. On the basis of current evidence, a recommendation for primary prophylaxis of a first episode of OHE cannot be made in general. Only 2 studies have investigated the prevention of a first-time OHE episode as the primary endpoint. In this narrative review, we provide a concise overview of the current evidence levels on prediction tools and pharmacological prevention of a first episode of OHE. In addition, we give an outlook on future research targets to improve knowledge on this important topic.

Clinical Impact of Spontaneous Portosystemic Shunts in Liver Transplantation: A Comprehensive Assessment Through Total Shunt Area Measurement.

The impact of spontaneous portosystemic shunts (SPSSs) on natural history of cirrhotic patients was recently evaluated through the measurement of total shunt area (TSA), a novel tool that allows a comprehensive assessment of SPSSs extension, identifying a direct correlation of higher TSA with lower patient survival. The role of SPSSs in liver transplant (LT) is still debated: we sought to investigate the clinical impact of TSA on the development of early allograft dysfunction (EAD), acute kidney injury (AKI), postoperative complications, and graft and patient survival following LT. Preoperative imaging of 346 cirrhotic patients undergoing primary LT between 2015 and 2020 were retrospectively revised, recording the size and anatomy of each SPSS to calculate TSA. The impact of TSA and selected patient and donor characteristics on the development of EAD, AKI, and clinically relevant complications was evaluated through univariate and multivariate logistic regression, whereas their effect on graft and patient survival was investigated through Cox regression analysis. A TSA exceeding 78.54 mm 2 resulted as an independent risk factor for the development of EAD (odds ratio [OR]: 2.327; P = 0.003), grade 3 AKI (OR: 2.093; P = 0.041), and clinically relevant complications (OR: 1.962; P = 0.015). Moreover, higher TSA was significantly related to early graft and patient survivals, emerging as an independent risk factor for 12-mo graft loss (hazard ratio: 3.877; P = 0.007) and patient death (hazard ratio: 2.682; P = 0.018). Higher TSA emerged as a significant risk factor for worse postoperative outcomes following LT, supporting the need for careful hemodynamic assessment and management of patients presenting multiple/larger shunts.

Spontaneous portosystemic shunts outside the esophago-gastric region: Prevalence, clinical characteristics, and impact on mortality in cirrhotic patients: A systematic review and meta-analysis

BackgroundSpontaneous portosystemic shunt (SPSS) other than esophago-gastric varices is one of the consequences of cirrhosis-induced portal hypertension (PHT), but its role is not fully understood. Therefore, we conducted a systematic review and meta-analysis to determine the prevalence and clinical characteristics of SPSS (excluding esophago-gastric varices) and its impact on mortality in patients with cirrhosis. MethodsEligible studies were identified from MedLine, PubMed, Embase, Web of Science, and Cochrane Library between Jan 1, 1980 and Sep 30, 2022. Outcome indicators were SPSS prevalence, liver function, decompensated events, and overall survival (OS). ResultsTotally, 2015 studies were reviewed, of which 19 studies recruiting 6884 patients were included. On pooled analysis, the prevalence of SPSS was 34.2% (26.6%∼42.1%). SPSS patients had significantly higher Child-Pugh scores and grades and Model for End-stage Liver Disease scores (all P<0.05). Moreover, SPSS patients experienced a higher incidence of decompensated events, including hepatic encephalopathy, portal vein thrombosis, and hepatorenal syndrome (all P<0.05). Additionally, SPSS patients had significantly shorter OS than the non-SPSS group (P<0.05). ConclusionsIn patients with cirrhosis, SPSS outside the esophago-gastric region is common, characterized by severe impairment of liver function, high rates of decompensated events, including HE, PVT, and hepatorenal syndrome, as well as a high mortality rate.

Endovascular therapy accompanied by spontaneous portosystemic shunts for overt hepatic encephalopathy

Objective: To preliminarily evaluate the safety and efficacy of shunt-related interventional therapy accompanied with spontaneous portosystemic shunts (SPSS) in patients with hepatic encephalopathy (HE). Methods: Case data on six patients who underwent interventional therapy accompanied by SPSS for HE from January 2017 to March 2021 were collected to evaluate the efficacy and postoperative complications. Results: All six patients underwent SPSS. Four patients had hepatitis B cirrhosis; one had alcoholic cirrhosis; and one had hepatic arterioportal fistula-induced portal hypertension. Child-Pugh liver function scores were C and B in three and three cases, respectively. The SPSS type was gastrorenal shunt in two cases; portal-thoracic-azygos venous in two cases; portal-umbilical-iliac venous in one case; and portal-splenic venous - inferior vena cava in one case. Two of them had previously had a transjugular intrahepatic portosystemic shunt (TIPS), and there were SPSS prior to TIPS. Five cases (5/6) successfully underwent shunt embolization, and one case (1/6) underwent stent implantation for flow restriction (portal-umbilical-iliac vein). The technical success rate was 100%. HE did not recur during hospitalization or the three-month follow-up period. However, one case had a recurrence of HE within a year after surgery and was treated symptomatically, while another experienced gastrointestinal bleeding a year after surgery.. Conclusion: SPSS embolization or flow restriction is effective and safe for improving HE patients' symptoms.

Hepatic Encephalopathy after Transjugular Intrahepatic Portosystemic Shunt Creation.

Transjugular intrahepatic portosystemic shunt (TIPS) creation is effective in treating the sequelae of decompensated liver cirrhosis-including medically refractory ascites and variceal bleeding-by decompressing the portal venous system through a manmade portosystemic conduit within the liver. However, the altered physiology in which splenomesenteric blood bypasses intrahepatic portal venous perfusion can precipitate varying degrees of hepatic encephalopathy (HE). While the majority of post-TIPS HE cases can be treated medically, some require escalated management strategies, including endovascular interventions to modify the indwelling TIPS and/or occlude competitive physiologic spontaneous portosystemic shunts. This review article details the epidemiology, risk factors, diagnosis, classification, and treatment of post-TIPS HE.

EUS-guided coil placement and cyanoacrylate glue injection for gastric variceal bleeding with obvious spontaneous portosystemic shunts.

Ectopic embolism caused by cyanoacrylate glue for the treatment of gastric varices with obvious spontaneous portosystemic shunts is a serious complication of endoscopic therapy. This study was performed to investigate the safety and therapeutic effect of EUS-guided coil placement and cyanoacrylate glue injection for gastric varices with obvious spontaneous portosystemic shunts. Six patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts were included in this study. We evaluated the success rate of variceal occlusion after intraoperative embolization, the postoperative rebleeding rate at 48 h and 2 weeks posttreatment, and the incidence of ectopic embolism and other adverse events. Gastroscopy and computed tomography portal venography (CTPV) were performed 7 months later. All patients underwent successful coil placement and cyanoacrylate glue injection under EUS guidance. The blood flow was confirmed by Doppler examination, the target vessels were successfully blocked, and no rebleeding had occurred at 48 h or 2 weeks after endoscopic treatment. Gastroscopy was repeated 7 months after endoscopic treatment, revealing local ulcer formation. CTPV was also repeated 7 months after endoscopic treatment, showing that the coils were present in the target vessels with no displacement, the portosystemic shunt vessels were occluded, and no ectopic embolization had occurred. The coil placement combined with cyanoacrylate glue embolism is a safe and effective method for patients with gastric variceal bleeding and obvious spontaneous portosystemic shunts.

Closing spontaneous portosystemic shunts in cirrhosis: Does it make sense? Does it work? What does it take?

Spontaneous portosystemic shunts (SPSS) are an often neglected cause of hepatic encephalopathy associated with cirrhosis. Nowadays, SPSS are considered as radiological biomarkers of clinically significant portal hypertension rather than the previous dogmatic perceived decompressive vessels. SPSS are not rare as they can be diagnosed in over 60% of the patients with cirrhosis by mere contrast-enhanced CT. Moreover, they are clinically relevant since they impact on all portal hypertensive related complications, in particular medically refractory HE, and represent an independent predictor of decompensation and mortality in cirrhosis, irrespective of the type of SPSS. Taken together, these elements warrant strategies to target these shunts directly which is currently is achieved via interventional radiology embolization. In this review, we discuss why it makes sense to tackle SPSS, how to do it and what it takes to do it right based on aggregated literature.

Nonsplenorenal Spontaneous Portosystemic Shunts in Liver Transplant Attitude and Outcomes: A Single-Center Series

Management of nonsplenorenal spontaneous portosystemic shunts (NSRSPSS) in liver transplant (LT) is controversial. Reports on the influence of its ligation suggest improvements in morbidity and survival. Retrospective study of a single-center series. The objective was to analyze the outcomes and post-LT survival after the closure of NSRSPSS. Between January 2005 and April 2021 a total of 23 patients with NSRSPSS underwent LT. The shunt was superior mesenteric vein-vena cava in 12 (52.2%), inferior mesenteric vein-vena cava in 6 (26.1%), through the left gastric vein in 4 (17.4%), and portocava in 1 (4.3%). Seven patients presented portal vein thrombosis, with thrombectomy being performed in 5. Moreover, 21 patients had portoportal anastomosis, 1 patient required portal reconstruction at the splenomesenteric confluence, and 1 had a coronary-portal anastomosis. The NSRSPSS was closed in 22 cases (95.7%). The mean (SD) portal flow before and after the closure of NSRSPSS was 1395 (572) mL/min and 1773 (583) mL/min (104.4 [47.9] mL/min/100 g and 127.9 [4.9] mL/min/100 g, respectively). Six patients (26.1%) presented primary graft dysfunction, 13 (56.5%) acute kidney injury, and 9 (39%) ascites. Three arterial stenoses (13%), 2 biliary stenoses (8.6%), and 1 intrahepatic portal thrombosis (4.3%) occurred. Median intensive care unit and hospital stay was 5 days (range, 3-8 days) and 15 days (range, 13-21 days). After a mean follow-up of 5.18 (3.2) years, all patients except 1 are alive. The closure of the NSRSPSS during LT can optimize portal flow, with potential influence in morbidity and survival rates.

Functional recovery from refractory hepatic encephalopathy following angiographic obliteration of a large, spontaneous portal-umbilical portosystemic shunt: a case report

BackgroundHepatic encephalopathy (HE) as a consequence of cirrhosis with portal hypertension has a profound impact on quality of life for both patients and caregivers, has no gold-standard diagnostic test, and is a risk factor for mortality. Spontaneous portosystemic shunts (SPSS) are common in patients with cirrhosis, can be challenging to identify, and in some cases, can drive refractory HE. Cross-sectional shunt size greater than 83mm2 is associated with liver disease severity, overt HE, and mortality.Case presentationWe report a patient with refractory HE and frequent hospitalization in the context of an occult spontaneous portal-umbilical portosystemic shunt with an estimated cross-sectional area of 809mm2. Following identification and angiographic retrograde transvenous obliteration of the SPSS using plugs, coils and sclerosant, there was improvement in neurocognitive testing and no further hospitalization for HE.ConclusionSPSS in the context of cirrhosis with portal hypertension can contribute to the debilitating effects of refractory HE. This case highlights the opportunity to search for SPSS in patients with HE unresponsive to therapy as angiographic obliteration is usually safe, well-tolerated, and clinically effective.

Management of spontaneous portosystemic shunts at the time of liver transplantation: treatment or observation? Results of a systematic review.

Optimal treatment of spontaneous portosystemic shunts (SPSS) during liver transplantation (LT) remains debated. We systematically reviewed the literature on definitions, treatment and outcomes of patients presenting SPSS undergoing LT. According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we used PubMed to retrieve all studies dealing with SPSS and LT between January 1987 and January 2020. The primary endpoints were definitions and outcomes according to the management of SPSS (treatment vs observation). Thirteen studies detailing the management of 962 SPSS were retrieved. Hemodynamically significant SPSS were defined as those having diameter ≥ 10mm in 41% (n = 395) of patients. SPSS were splenorenal (42%), cavo-gastric (15.2%), umbilical (7.4%), mesenterico-caval (n = 31; 3.2%), mesenterico-renal (0.1%) and unreported (31.9%), respectively. At the time of LT 372 shunts (38.7%) were treated while 590 were observed (61.3%). During a follow-up time ranging from 4months to 5years, the reported overall survival (OS) at 1year was not significantly different except for one study. Portal vein anastomosis complications (i.e. reduced flow, stenosis or thrombosis) were similarly reported in observed [n = 26 (4%)] and ligated SPSS [n = 10 (2%)] (p = 0.22) but the rate of relaparotomy was significantly higher in observed SPPS (16 vs 2; p = 0.01) to rescue post LT portal vein thrombosis (n = 6) and reduced portal flow and graft dysfunction (n = 10). There was a heterogeneous management of SPSS during LT in the literature. Ligation of SPPS did not reduce vascular complications neither improved survival. A randomized prospective study might contribute to identify best management of SPSS at time of LT.

Management of Spontaneous Portosystemic Shunts in 231 Patients Who Underwent Living Donor Liver Transplantation: A Retrospective Study from a Single Center in Nagasaki, Japan.

BackgroundWe have ligated spontaneous portosystemic shunts (SPSS) in living donor liver transplantation (LDLT) when a postoperative interventional radiology (IVR) approach was impossible or the intraoperative hepatopetal flow was insufficient. This retrospective study from a single center in Nagasaki, Japan aimed to investigate the management of SPSS in 231 patients who underwent LDLT between January 2006 and December 2019.Material/MethodsSPSS were identified in 63 patients (27.3%). Perioperative factors and survival rates were compared in the study population with SPSS divided into 2 groups: the ligation group and the non-ligation group. The post-transplant course was examined in greater detail in the non-ligation group.ResultsSPSS were ligated in 20 patients (31.7%). The indication for shunt ligation was an impossible postoperative approach (10 patients; 50%) or poor intraoperative hepatopetal flow (10 patients; 50%). There was no significant difference in the 1- and 5-year overall survival rates between the ligation and non-ligation group (80%, 80% vs 76%, 55%, respectively, P=0.17). Of the 34 patients in the non-ligation group who could be observed for 6 months, 14 patients (48.3%) had a spontaneous regression of SSPS. Additionally, 5 patients who required postoperative IVR had a good clinical course. There was no graft failure or adverse events in the non-ligation group.ConclusionsUnnecessary ligation could be avoided by using our criteria. When postoperative IVR is possible with sufficient intraoperative hepatopetal flow, SPSS do not always need to be ligated in LDLT.

Embolization of spontaneous portosystemic shunts as treatment for refractory hepatic encephalopathy

Hepatic encephalopathy (HE) is a common complication of cirrhosis associated with a reduced survival. The presence of high-flux spontaneous porto-systemic shunts can induce HE even in patients with preserved liver function. To evaluate the effect of spontaneous porto-systemic shunt embolization (SPSE) over HE and its long-term evolution. Retrospective analysis of 11 patients (91% males) with severe HE non-responsive to medical treatment in whom a SPSE was performed. The grade of HE (employing West Haven score), survival, MELD and Child-Pugh score, ammonia levels, degree of disability (employing the modified Rankin scale (mRs)) were evaluated before and at thirty days after procedure. The most common etiology found was non-alcoholic steatohepatitis (63.6%). A reduction of at least two score points of HE was observed in all patients after thirty days. There was a significant reduction on median (IQR) West Haven score from 3 (2-3) at baseline to 1 (0-1) after the procedure (p < 0.01). Twelve months survival was 63.6%. There was a decrease in median ammonia level from 106.5 (79-165) (ug/dL) to 56 (43-61) after SPSE (p = 0.006). The median mRS score before and after the procedure was 3 (3-5) and 1 (1-2.5), respectively (p < 0.01). According to our experience, SPSE is a feasible and effective alternative to improve HE and functionality of patients with refractory EH.