LAUSR

BACKGROUND Spontaneous portosystemic shunts (SPSS) frequently develop in liver cirrhosis. Recent data suggested that presence of a single large SPSS is associated with complications, especially overt hepatic encephalopathy (oHE). However, presence of >1 SPSS is common. This study evaluates the impact of total cross-sectional SPSS area (TSA) on outcome of patients with liver cirrhosis. METHODS In this retrospective international multicentric study, computed tomography (CT) scans of 908 cirrhotic patients with SPSS were evaluated for TSA. Clinical and laboratory data were recorded. Each detected SPSS radius was measured and TSA calculated. 1-year survival was primary and acute decompensation (oHE, variceal bleeding, ascites) secondary endpoint. RESULTS 301 patients (169 male) were included in the training cohort. 30% of all patients presented >1 SPSS. TSA cut-off of 83 mm2 was determined to classify patients with small or large TSA (S-/L-TSA). L-TSA patients presented higher MELD (11 vs. 14) and more commonly history of oHE (12% vs. 21%, p<0.05). During follow up L-TSA patients developed more oHE episodes (33% vs. 47%, p<0.05) and showed lower 1-year survival than S-TSA (84% vs. 69%, p<0.001). Multivariate analysis identified L-TSA (HR 1.66, 1.02-2.70, p<0.05) as independent predictor of mortality. An independent multicentric validation cohort of 607 patients confirmed L-TSA patients with lower 1-year survival (77% vs. 64%, p<0.001) and more oHE development (35% vs. 49%, p<0.001) than S-TSA. CONCLUSION This study suggests that TSA >83mm2 increases the risk for oHE and mortality in liver cirrhosis. Our results may have impact on clinical use of TSA/SPSS for risk stratification and clinical decision-making considering management of SPSS.