Introduction: The recently developed Freiburg Index of Post‐TIPS Survival (FIPS) allows improved risk classification of patients with decompensated cirrhosis allocated to transjugular intrahepatic portosystemic shunt (TIPS) implantation. This study investigated the prognostic value of the FIPS in patients hospitalized with acute decompensation of cirrhosis (AD), outside the setting of TIPS implantation.Methods: A total of 1133 patients with AD were included in a retrospective, multi‐centre study. Ninety‐day, 180‐day and 1‐year mortality were recorded and the FIPS' performance in predicting mortality at these time points was analysed using ROC analyses.Results: Ninety‐day, 180‐day and 1‐year mortality were 17.7%, 24.4% and 30.8%. Uni‐ and multivariable Cox regression models showed that the FIPS independently predicted 1‐year mortality in the study cohort (HR 1.806, 95% CI 1.632–1.998, p < .0001). In ROC analyses, the FIPS offered consistently high performance in the prediction of mortality within 1 year after AD (area under the receiver operator characteristic [AUROC]: 1‐year mortality .712 [.679–.746], 180‐day mortality .740 [.705–.775] and 90‐day mortality .761 [.721–.801]). In fact, in the subgroup of patients presenting with variceal bleeding, the FIPS even showed significantly improved discriminatory performance in the prediction of long‐term mortality (AUROC 1‐year mortality: .782 [.724–.839]) in comparison with established prognostic scores, such as the CLIF‐C AD score (.724 [.660–.788], p = .0071) or MELD 3.0 (.726 [.662–.790], p = .0042).Conclusions: The FIPS accurately predicts mortality in patients with AD and seems to offer superior prognostication of long‐term mortality in patients with variceal bleeding.

Introduction Colorectal strictures related to endoscopic resection (ER) of large nonpedunculated colorectal polyps (LNPCPs) may be problematic. Data on prevalence, risk factors, and management are limited. We report a prospective study of colorectal strictures following ER and describe our approach to management. Methods We analyzed prospectively collected data over 150 months, until June 2021, for patients who underwent ER for LNPCPs ≥ 40 mm. The ER defect size was graded as < 60 %, 60 %–89 %, or ≥ 90 % of the luminal circumference. Strictures were considered “severe” if patients experienced obstructive symptoms, “moderate” if an adult colonoscope could not pass the stenosis, or “mild” if there was resistance on successful passage. Primary outcomes included stricture prevalence, risk factors, and management. Results 916 LNPCPs ≥ 40 mm in 916 patients were included (median age 69 years, interquartile range 61–76 years, male sex 484 [52.8 %]). The primary resection modality was endoscopic mucosal resection in 859 (93.8 %). Risk of stricture formation with an ER defect ≥ 90 %, 60 %–89 %, and < 60 % was 74.2 % (23/31), 25.0 % (22/88), and 0.8 % (6 /797), respectively. Severe strictures only occurred with ER defects ≥ 90 % (22.6 %, 7/31). Defects < 60 % conferred low risk of only mild strictures (0.8 %, 6/797). Severe strictures required earlier (median 0.9 vs. 4.9 months; P = 0.01) and more frequent (median 3 vs. 2; P = 0.02) balloon dilations than moderate strictures. Conclusion Most patients with ER defects ≥ 90 % of luminal circumference developed strictures, many of which were severe and required early balloon dilation. There was minimal risk with ER defects < 60 %.

Acute variceal bleeding (AVB) is a life-threatening complication of cirrhosis that can precipitate acute-on-chronic liver failure (ACLF), leading to poor outcomes. This multicenter retrospective study evaluated the impact of ACLF on the long-term outcomes of patients admitted with AVB and compared the performance of prognostic scores in predicting 1-year mortality. A total of 168 patients with cirrhosis admitted with AVB between January 2013 and December 2022 were included. ACLF was diagnosed using the Chronic Liver Failure-Consortium Organ Failure (CLIF-C OF) score at admission and reassessed at 48 hours. Prognostic scores including the Child-Pugh, AIMS65, and CLIF-C model scores were evaluated. Multivariable logistic regression analysis was performed to identify predictors of 6-week rebleeding, and Kaplan-Meier analysis was conducted to assess survival outcomes. ACLF was present at admission in 21 patients (12.5%) and developed within 48 hours in two (1.2%). Although ACLF at admission was associated with a higher unadjusted 1-year mortality rate, it was not independently predictive after adjusting for hepatic reserve (Child-Pugh score) and age (hazard ratio, 0.97; 95% confidence interval, 0.32 to 2.94; p=0.951). The Child-Pugh score was the strongest predictor of the 1-year mortality rate (area under the receiver operating characteristic curve=0.718). The absence of hepatic encephalopathy independently predicted 6-week rebleeding (p=0.015). Endoscopy timing (<12 hours vs ≥12 hours) did not influence the 6-week mortality rate, rebleeding, or the 1-year survival rate in either the ACLF or non-ACLF group. Although ACLF identifies patients with AVB at high risk, it primarily reflects the severity of the underlying liver dysfunction rather than serving as an independent predictor. Management should prioritize stabilization and optimization prior to endoscopy and individualized follow-up to evaluate transplant candidacy.

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Background and study aims Because of concerns about peri-procedural adverse events (AEs), guidelines recommend anesthetist-managed sedation (AMS) for long and complex endoscopic procedures. The safety and efficacy of physician-administered balanced sedation (PA-BS) for endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) ≥20 mm is unknown. Patients and methods We compared PA-BS with AMS in a retrospective study of prospectively collected data from consecutive patients referred for management of LNPCPs (NCT01368289; NCT02000141). A per-patient propensity analysis was performed following a 1:2 nearest-neighbor (Greedy-type) match, based on age, gender, Charlson comorbidity index, and lesion size. The primary outcome was any peri-procedural AE, which included hypotension, hypertension, tachycardia, bradycardia, hypoxia, and new arrhythmia. Secondary outcomes were unplanned admissions, 28-day re-presentation, technical success, and recurrence. Results Between January 2016 and June 2020, 700 patients underwent EMR for LNPCPs, of whom 638 received PA-BS. Among them, the median age was 70 years (interquartile range [IQR] 62–76 years), size 35 mm (IQR 25–45 mm), and duration 35 minutes (IQR 25–60 minutes). Peri-procedural AEs occurred in 149 (23.4%), most commonly bradycardia (116; 18.2%). Only five (0.8%) required an unplanned sedation-related admission due to AEs (2 hypotension, 1 arrhythmia, 1 bradycardia, 1 hypoxia), with a median inpatient stay of 1 day (IQR 1–3 days). After propensity-score matching, there were no differences between PA-BS and AMS in peri-procedural AEs, unplanned admissions, 28-day re-presentation rates, technical success or recurrence. Conclusions Physician-administered balanced sedation for the EMR of LNPCPs is safe. Peri-procedural AEs are infrequent, transient, rarely require admission (<1%), and are experienced in similar frequencies to those receiving anesthetist-managed sedation.

Rajiv Kurup, Scott Read, Golo Ahlenstiel. Gut and Liver -0001;0:. https://doi.org/10.5009/gnl260329