Reply to Letter Re: Management of Gastric Varices

Excerpt

We thank Dr. Matsumoto for his comments about our article [1], and we agree that some degree of splenic congestion was present before the BRTO procedure, related not only to the underlying portal hypertension but also to the superimposed splenoportal thrombus. However, splenic congestion was latent in this patient (symptomatically and by imaging) and became overt only after the BRTO procedure. As discussed in the article, we also agree that closing a large gastrorenal shunt may partially increase portal pressure, which may increase blood flow and pressure into other collaterals, thereby worsening esophageal varices and/or ascites. Our discussion advocated the combination of several techniques, including BRTO, transjugular intrahepatic portosystemic shunt (TIPS), and partial splenic embolization (PSE), because each therapy alone often may be insufficient. …