Reply to Senzolo et al.

We appreciate the interest of Senzolo et al. in commenting on our study [11]. Unfortunately, we cannot agree with their comments, starting with the never-ending dilemma about sedation by assessing the portal pressure gradient (PPG). The authors argue that propofol allegedly decreases the accuracy of PPG assessment, based on the paper of Reverter et al. [22]. The term deep sedation utilized in our protocol is not the same as the Ramsay 4 sedation in the study of Reverter et al. The disparity in sedation levels, combined with the fact that the Reverter et al. study assessed the impact of propofol and remifentanil, compared with our study, which was performed strictly with propofol, could have generated significant fluctuations in the authors’ observed pressures, which we did not record in our study.

The determination of the gradient by the two techniques in separate sessions is a factor that may certainly increase the variability of the results in our study. Nevertheless, this increase was unbiased, as indicated in the Bland–Altman plot, which showed a similar distribution of variability above and below the level of no difference between the techniques. Another specific component of variability would be certain patient subgroups, such as metabolic dysfunction-associated steatotic liver disease (MASLD), in which hepatic venous portal gradient (HVPG) measurement may not be fully reliable [33]. In our study, seven patients were included with MASLD etiology. Unfortunately, the small sample size did not allow for independent analysis of the data. We agree that the concordance of the technique in these patients would warrant specific analysis.

Regarding the safety of the technique, in our study two patients out of 33 (6%) experienced procedure-related bleeding, which was resolved during the procedure. Owing to the small number of events and patients in the study, it was not possible to accurately establish the adverse event rate for the technique. Nevertheless, a recent study performed endoscopic ultrasound (EUS)-guided PPG on 385 patients and estimated this rate to be 1.8% [44], which is similar to the percentage described for HVPG [55].

While the current trend favors noninvasive techniques, EUS-PPG is expected to be recognized as a minimally invasive test that is no more invasive than an EUS-guided puncture for fine-needle aspiration. This approach could enable the use of the gold standard (measurement of PPG) to be utilized safely and with global availability in cases where noninvasive tests yield uncertain results or in the presence of specific etiologies.

In summary, it may be time to reconsider our reluctance to adopt new approaches, particularly in light of the widespread use of EUS. This technique has allowed the use of PPG measurement in clinical practice, rather than being available only in limited centers. And with a pleasant deep sedation that can allow several diagnostic tests to be performed during a single procedure, who would resist change?

Publication History

Article published online:
28 May 2025

• References

• 1 Martinez-Moreno B, Martínez Martínez J, Herrera I. et al. Correlation of endoscopic ultrasound-guided portal pressure gradient measurements with hepatic venous pressure gradient: a prospective study. Endoscopy 2025; 57: 62-67
• 2 Reverter E, Blasi A, Abraldes JG. et al. Impact of deep sedation on the accuracy of hepatic and portal venous pressure measurements in patients with cirrhosis. Liver Int 2014; 34: 16-25
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