6,10–12 In our study, B-RTO was shown to inhibit the lowering of hepatic functional reserve in the long term. The hepatic functional reserve gradually decreased at an earlier stage in patients with SRS compared to those without SRS. In addition, the vital prognosis was significantly decreased in patients with SRS, and SRS was considered to be one of the factors that affect

the prognosis. We had Ku0059436 previously examined pre- and post-BRTO clinical examination data and parameters of liver function expressed at a hepatic cellular level. These parameters were examined using intrinsic clearance of indocyanine green (ICGCli)22,23 by continuous infusion in combination with catheterization. The results showed increased portal venous blood flow and a significant improvement of ICGCli, which expresses metabolic activity

of hepatocytes. Liver function was demonstrated to improve at the hepatic cellular level by B-RTO.24 Cardoso et al.25 reported similar results. Namely, ICGCli was shown to improve significantly when portal blood flow was increased two-fold in mandatory perfusion in the isolated recipient’s cirrhotic liver, which became unnecessary GSI-IX at the human liver transplantation. These results were supported by the intact hepatocyte theory,26,27 and they are consistent with the improvement of hepatic functional reserve by increased portal blood flow click here after B-RTO. In other words, in patients with SRS of major portosystemic shunt, the decrease in the hepatic functional reserve was reversible. B-RTO obliterates a shunt. A transjugular intrahepatic portosystemic shunt (TIPS)28 is a diametrically opposite treatment and establishes a shunt. There has not been a consensus on the effects of TIPS on hepatic function from decreasing the portal blood pressure and the

portal blood flow. There are reports that TIPS does not change29–32 or that it worsens33,34 the liver function, but there is no report stating that TIPS improves the liver function. In studies on a hepatic cellular level, TIPS was reported to decrease ICGCli.35,36 In contrast, there is no report indicating that B-RTO lowers the liver function. In comprehensively considering the reports until now and the results of our study, a portosystemic shunt is a pathological anatomy that should be obliterated. Then at what stage should SRS be obliterated by B-RTO? There are also patients in whom liver function was unchanged after B-RTO. Advancement of hepatic parenchymal disorder occurs and a shunt is formed due to portal hypertension. Portal pressure begins to decrease with the development of a large shunt (high shunt rate). In such patients with spontaneously reduced pressure, hepatopetal portal flow is decreased and the hepatofugal steal to a shunt becomes excessive (overshunting). Thus, it is thought that the decline of liver function is promoted.