In situ subtotal spleen resection combined with selective pericardial devascularization for the treatment of portal hypertension

BACKGROUND Hypersplenism and esophageal varices bleeding are the major complications of portal hypertension(PHT).In recent years,increasing attention has been given to spleen preservation operations.The mode and long-term effects of subtotal splenectomy and selective pericardial devascularization for PHT remain controversial.AIM To investigate the clinical efficacy and safety of subtotal splenectomy combined with selective pericardial devascularization for the treatment of PHT.METHODS This was a retrospective study of 15 patients with PHT who underwent subtotal splenectomy not preserving the splenic artery or vein combined with selective pericardial devascularization in the Department of Hepatobiliary Surgery,Qilu Hospital of Shandong University from February 2011 to April 2022.Fifteen propensity score-matched patients with PHT who underwent total splenectomy at the same time served as the control group.The patients were followed for up to 11 years after surgery.We compared the postoperative platelet levels,perioperative splenic vein thrombosis,and serum immunoglobulin levels between the two groups.Abdominal enhanced computed tomography was used to evaluate the blood supply and function of the residual spleen.The operation time,intraoperative blood loss,evacuation time,and hospital stay were compared between the two groups.RESULTS The postoperative platelet level of patients in the subtotal splenectomy group was significantly lower than that in the total splenectomy group(P<0.05),and the postoperative portal system thrombosis rate in the subtotal splenectomy group was also much lower than that in the total splenectomy group.The levels of serum immunoglobulins(IgG,IgA,and IgM)showed no significant differences after surgery compared with before surgery in the subtotal splenectomy group(P>0.05),but serum immunoglobulin IgG and IgM levels decreased dramatically after total splenectomy(P<0.05).The operation time in the subtotal splenectomy group was longer than that in the total splenectomy group(P<0.05),but there were no significant differences in the amount of intraoperative blood loss,evacuation time,or hospital stay between the two groups.CONCLUSION Subtotal splenectomy not preserving the splenic artery or vein combined with selective pericardial devascularization is a safe and effective surgical treatment for patients with PHT,not only correcting hypersplenism but also preserving splenic function,especially immunological function.

Prognosis after splenectomy plus pericardial devascularization vs transjugular intrahepatic portosystemic shunt for esophagogastric variceal bleeding

BACKGROUND Portal hypertension combined with esophagogastric variceal bleeding(EGVB)is a serious complication in patients with hepatitis B virus(HBV)-related cirrhosis in China.Splenectomy plus pericardial devascularization(SPD)and transjugular intrahepatic portosystemic shunt(TIPS)are effective treatments for EGVB.However,a comparison of the effectiveness and safety of those methods is lacking.AIM To compare the prognosis after SPD vs TIPS for acute EGVB after failure of endoscopic therapy or secondary prophylaxis of variceal rebleeding(VRB)in patients with HBV-related cirrhosis combined with portal hypertension.METHODS This retrospective cohort study included 318 patients with HBV-related cirrhosis and EGVB who underwent SPD or TIPS at West China Hospital of Sichuan University during 2009-2013.Propensity score-matched analysis(PSM),the Kaplan-Meier method,and multivariate Cox regression analysis were used to compare overall survival,VRB rate,liver function abnormality rate,and hepatocellular carcinoma(HCC)incidence between the two patient groups.RESULTS The median age was 45.0 years(n=318;226(71.1%)males).During a median follow-up duration of 43.0 mo,18(11.1%)and 33(21.2%)patients died in the SPD and TIPS groups,respectively.After PSM,SPD was significantly associated with better overall survival(OS)(P=0.01),lower rates of abnormal liver function(P<0.001),and a lower incidence of HCC(P=0.02)than TIPS.The VRB rate did not differ significantly between the two groups(P=0.09).CONCLUSION Compared with TIPS,SPD is associated with higher postoperative OS rates,lower rates of abnormal liver function and HCC,and better quality of survival as acute EGVB treatment after failed endoscopic therapy or as secondary prophylaxis of VRB in patients with HBV-related cirrhosis combined with portal hypertension.There is no significant between-group difference in VRB rates.

Transjugular intrahepatic portosystemic shunt versus open splenectomy and esophagogastric devascularization for portal hypertension with recurrent variceal bleeding

BACKGROUND： Transjugular intrahepatic portosystemic shunt（TIPS） and open splenectomy and esophagogastric devascularization（OSED） are widely used to treat patients with portal hypertension and recurrent variceal bleeding（PHRVB）. This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB.METHODS： The data were retrospectively retrieved from 479 cirrhotic patients（Child-Pugh A or B class） with PHRVB, who had undergone TIPS（TIPS group） or OSED（OSED group） between January 1, 2010 and October 31, 2014.RESULTS： A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively（P=0.122）. Significantly lower incidence of pleural effusion,splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods（29 months）, significantly higher incidences of rebleeding（15.3% vs 4.6%, P=0.001） and hepatic encephalopathy（17.3% vs 3.9%, P=0.001） were observed in the TIPS group than in the OSED group. The incidence of instent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED.CONCLUSION： For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.

Combined Laparoscopic Splenectomy and Esophagogastric Devascularization versus Open Splenectomy and Esophagogastric Devascularization for Portal Hypertension due to Liver Cirrhosis

This study was conducted to compare the feasibility,safety and effectiveness of the combined-laparoscopic splenectomy and esophagogastric devascularization(C-LSED)with open splenectomy and esophagogastric devascularization surgery(OSED)in patients with portal hypertension due to liver cirrhosis.From February 2014 to June 2018,68 patients with portal hypertension were diagnosed as having serious gastroesophageal varices and/or hypersplenism in our center.Thirty patients underwent C-LSED and 38 patients received OSED.Results and outcomes were compared retrospectively.No patients of C-LSED group required an intraoperative conversion to open surgery.Significantly shorter operating time,less blood loss,lower transfusion rates,shorter postoperative hospital stay,lower rates of complications were found in C-LSED group than in C-LSED group(P<0.05).No death and rebleeding were documented in both groups during the follow-up periods of one year Postoperative endoscopy revealed that varices in the patients of both groups were alleviated significantly from severe to mild,and in a part of cases,the varices disappeared.The final results suggest that the C-LSED technique is superior to open procedure,due to slightly invasive,simplified operative procedure,significantly shorter operating time,less intraoperative bleeding and lower post-operative complication rates.And C-LSED offers comparable long-term effects to open surgery.

Laparoscopic versus Open Splenectomy and Devascularization for Massive Splenomegaly Due to Portal Hypertension

Although the clinical benefit of laparoscopic splenectomy and devascularization（LSD） has been elaborated in many studies,its application in massive splenomegaly remains controversial.We conducted a retrospective research to assess the curative efficacy of LSD for massive splenomegaly due to portal hypertension.Forty-seven patients with massive splenomegaly due to portal hypertension were enrolled in this study,and divided into two groups.Twenty-one patients underwent open splenectomy and devascularization（OSD） from June 2010 to October 2012（OSD group）.From March 2013 to February 2015,LSD was performed on 26 patients（LSD group）.Perioperative variables were analyzed.Compared to OSD,LSD was associated with less blood loss（241.9±110.0 m L vs.319.0±139.5 m L,P〈0.05）,more rapid resumption of oral diet（2.46±0.95 days vs.3.76±1.09 days,P〈0.05）,and shorter postoperative hospital stay（5.35±1.65 days vs.7.24±1.55 days,P〈0.05）.It was concluded that for patients with massive splenomegaly due to portal hypertension,LSD is feasible and as safe as OSD.

Prevention and Treatment of Hemorrhage during Laparoscopic Splenectomy and Devascularization for Portal Hypertension

This study was aimed to explore prevention and treatment of hemorrhage during laparoscopic splenectomy plus devascularization（LSD） for portal hypertension by modified and simplified operation. From June 2012 to June 2014, LSD was performed on 138 patients with portal hypertension. The patients were allocated into two groups： earlier stage（ES） group, in which 45 patients received traditional LSD from June 2012 to Sep. 2012; later stage（LS） group, in which 93 patients underwent modified LSD from Jan. 2013 to June 2014. Perioperative variables were compared between the two groups. Laparoscopic operations were successfully performed in all but two patients in ES group who were converted to laparotomy（total conversion rate： 1.4%）. There was no perioperative death or reoperation, and all patients recovered and were discharged from hospital with no serious complications in the six months of postoperative follow-up. The average time in the ES group was longer than that in the LS group（335.1 min vs. 201.3 min, P〈0.05）. LS group outperformed ES group in terms of blood loss（705.4 m L vs. 910.4 mL, P〈0.05）. The average operation time to oral diet intake after surgery（40.5 h vs. 50.3 h, P〈0.05） and postoperative hospital stay（7.4 d vs. 9.0 days, P〈0.05） were much less in the LS group than in the ES group. The overall complication rate（4.3 % vs. 11.1 %, P〈0.05） and conversion rate（0% vs. 4.4%, P〈0.05） were lower in the LS group than in the ES group. It was concluded that prevention and treatment of hemorrhage are the key points of LSD for portal hypertension. By creating a tunnel above the splenic pedicle and a tunnel behind the lower esophagus, the simplified and modified LSD can reduce hemorrhage and improve success of surgery dramatically, and splenomegaly and severe varices are not contraindications.

Esophagogastric devascularization without splenectomy in portal hypertension: safe and effective?

BACKGROUND： Esophagogastric variceal hemorrhage is a life-threatening complication of portal hypertension. In this study, we compared the therapeutic effect of a novel surgi- cal procedure, esophagogastric devascularization without splenectomy （EDWS）, with the widely used modified esopha- gogastric devascularization （MED） with splenectomy for the treatment of portal hypertension.

Combined splenocaval or mesocaval C shunt and portoazygous devascularization in the treatment of portal hypertension: analysis of 150 cases

BACKGROUND: Portal hypertension is a common disease and its major surgical therapeutic approaches include devascularization and shunting. This study was undertaken to investigate the effects of combined splenocaval or mesocaval C shunt and portoazygous devascularization (combined procedures) on portal hypertension. METHODS: The clinical data of 150 patients with portal hypertension who had undergone combined procedures at the First Affiliated Hospital of Zhengzhou University from May1990 to May 2003 were analyzed retrospectively. RESULTS: The mean free portal pressure (FPP) was 25.6±1.83 mmHg, 18.0±2.07 mmHg and 18.4±2.19 mmHg before operation, after splenectomy plus splenocaval or mesocaval C shunt, and combined procedures, respectively. There was no operative death in all patients. The 1-7 year follow-up of 100 patients showed rebleeding in 3 patients, encephalopathy in 4, thrombosis of artificial vascular graft in 3, and dying from liver failure in 2. CONCLUSIONS: The combined procedures can not only decrease portal pressure but also preserve hepatic blood flow to some extent. It may be one of the best choices for treating portal hypertension in China.

A Prospective Randomized Trial of Selective versus Nonselective Esophagogastric Devascularization for Portal Hypertension

Cirrhosis with portal hypertension is a common disease which has a significant impact on the quality of patients＇ life. Esophagogastric devascularization（EGDV） has been demonstrated to be an effective method to treat portal hypertension, however certain complications are associated with it. The purpose of this study was to evaluate the effectiveness and clinical outcome of the selective EGDV（sEGDV） for the treatment of portal hypertension. The study was conducted prospectively from Jan. 1 2011 to Dec. 31, 2012, and 180 patients were randomized to the sEGDV group（n=90） or the non-sEGDV（n-sEGDV） group（n=90）. Patients＇ demographics, preoperative lab test results and operative details were comparable between the two groups. Postoperative and short-term complications were analyzed in two groups. There was statistically significant difference（P〈0.01） in the PVF reduction between the two groups. Post-operative complications showed no statistically significant difference between the two groups in the incidence of bleeding, ascites, acute portal vein thrombosis, fever and hepatic encephalopathy. Mortality between two groups was comparable. The incidence of splenic fossa effusion after the surgery was lower in sEGDV group than in n-sEGDV group. There were no significant differences in the short-term follow-up data such as esophageal varices and portal hypertensive gastropathy（P〉0.05）. It is suggested that sEGDV is a safe, simple and effective surgical procedure. It has both the advantages of the shunt and devascularization because it preserves body＇s voluntary diversion. With the advantage of low incidence of postoperative complications, it is an ideal surgical approach for the treatment of portal hypertension.

Indocyanine green retention is a potential prognostic indicator after splenectomy and pericardial devascularization for cirrhotic patients

BACKGROUND：Splenectomy and pericardial devascularization（SPD）is an effective treatment of upper gastrointestinal bleeding and hypersplenism in cirrhotic patients with portal hypertension.Indocyanine green retention at 15 minutes（ICGR15）was reported to offer better sensitivity and specificity than the Child-Pugh classification in hepatectomy,but few reports describe ICGR15 in SPD.The present study was to evaluate the prognostic value of ICGR15 for cirrhotic patients with portal hypertension who underwent SPD.METHODS：From January 2012 to January 2015,43 patients with portal hypertension and hypersplenism caused by liver cirrhosis were admitted in our center and received SPD.The ICGR15,Child-Pugh classification,model for end-stage liver disease（MELD）score,and perioperative characteristics were analyzed retrospectively.RESULTS：Preoperative liver function assessment revealed that 34 patients were Child-Pugh class A with ICGR15 of13.6%-43.0%and MELD score of 7-20;8 patients were class B with ICGR15 of 22.8%-40.7%and MELD score of 7-17;1patient was class C with ICGR15 of 39.7%and MELD score of 22.The optimal ICGR15 threshold for liver function compensation was 31.2%,which offered a sensitivity of 68.4%and a specificity of 70.8%.Univariate analysis showed preoperative ICGR15,MELD score,surgical procedure,intraoperative blood loss,and autologous blood transfusion were significantly different between postoperative liver function compensated and decompensated groups.Multivariate regression analysis revealed that ICGR15 was an independent risk factor of postoperative liver function recovery（P=0.020）.CONCLUSIONS：ICGR15 has outperformed the Child-Pugh classification for assessing liver function in cirrhotic patients with portal hypertension.ICGR15 may be a suitable prognostic indicator for cirrhotic patients after SPD.

Pericardial devascularization combined with Latarjet’s innervation in the treatment of patients with

Abstract Objective To study the effect of pericardial devascularization combined with Latarjet's innervation on portal hypertension. Methods Forty eight patients undergoing pericardial devascularization combined with Latarjet's innervation were compared with 57 patients with devascularization. Clinical results were evaluated by postoperative portal vein pressure, postoperative rebleeding, operative mortality, abdominal distensison, sudden diarrhea, and gastric retention. Results The incidence of rebleeding, mortality, abdominal distension, sudden diarrhea, and gastric retention was 2%, 6.3%, 6.3%, 4.2% and 0% respectively in pericardial devascularization combined with Latarjet's innervation, and 12.5%, 12.3%, 24.6%, 15.6% and 14% respectively in devascularization. Conclusions Pericardial devascularization combined with Latarjet's innervation preserves the normal function of gastric emptying. This method plays an important role in maintaining nutritional supply and digestive function.

Progress and Prospects of Surgical Treatment of Portal Hypertension

Portal hypertension is a group of syndrome characterized by splenic hyperfunction, esophageal and gastric varices and ascites caused by abnormal portal vein hemodynamics. Among them, upper gastrointestinal bleeding caused by esophageal and gastric varices is the most dangerous complication, which often threatens the lives of patients. After half a century of development, the treatment of portal hypertension is divided into two categories: medical drug therapy, endoscopic therapy and surgical treatment. With the understanding of portal hypertension and the continuous development of medical technology, the surgical operation of portal hypertension has also been greatly improved, reducing postoperative complications and improving the quality of life of patients after operation. However, at present, there is no surgical method that can completely cure portal hypertension. This article reviews the progress of surgical treatment of portal hypertension in recent years, in order to provide reference for the surgical treatment of portal hypertension.

Two surgical procedures for esophagogastric variceal bleeding in patients with portal hypertension

AIM:To determine the clinical value of a splenorenal shunt plus pericardial devascularization(PCVD)in portal hypertension(PHT)patients with variceal bleeding.METHODS:From January 2008 to November 2012,290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding:207 patients received a routine PCVD procedure(PCVD group),and83 patients received a PCVD plus a splenorenal shunt procedure(combined group).Changes in hemodynamic parameters,rebleeding,encephalopathy,portal vein thrombosis,and mortality were analyzed.RESULTS:The free portal pressure decreased to 21.43±4.35 mmHg in the combined group compared with24.61±5.42 mmHg in the PCVD group(P<0.05).The changes in hemodynamic parameters were more significant in the combined group(P<0.05).The long-term rebleeding rate was 7.22%in the combined group,which was lower than that in the PCVD group(14.93%),(P<0.05).CONCLUSION:Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT.It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.

Evaluation of surgical procedure selection based on intraoperative free portal pressure measurement in patients with portal hypertension

BACKGROUND: Various surgical procedures can be used to treat liver cirrhosis and portal hypertension. How to select the most appropriate procedure for patients with portal hypertension has become a difficult problem. This study aimed to analyze the relationship between the value of intraoperative free portal pressure (FPP) and postoperative complications, and to explore the significance of intraoperative FPP measurement with respect to surgical procedure selection. METHODS: The clinical data of 187 patients with portal hypertension who received pericardial devascularization and proximal splenorenal shunt combined with devascularization (combined operation) at the Department of General Surgery in our hospital from January 2001 to September 2008 were retrospectively analyzed. Among the patients who received pericardial devascularization, those with a postoperative FPP >= 22 mmHg were included in a high-pressure group (n=68), and those with FPP <22 mmHg were in a low-pressure group (n=49). Seventy patients who received the combined operation comprised a combined group. The intraoperative FPP measurement changes at different times, and the incidence of postoperative complications in the three groups of patients were compared. RESULTS. The postoperative FPP value in the high-pressure group was 27.5 +/- 2.3 mmHg, which was significantly higher than that of the low-pressure (20.9 +/- 1.8 mmHg) or combined groups (21.7 +/- 2.5 mmHg). The rebleeding rate in the high-pressure group was significantly higher than that in the low-pressure and combined groups. The incidence rates of postoperative hepatic encephalopathy and liver failure were not statistically different among the three groups. The mortality due to rebleeding in the low-pressure and combined groups (0.84%) was significantly lower than that of the high-pressure group. CONCLUSIONS: The study demonstrates that FPP is a critical measurement for surgical procedure selection in patients with portal hypertension. A FPP value >= 22 mmHg after splenectomy and devascularization alone is an important indicator that an additional proximal splenorenal shunt needs to be performed. (Hepatobiliary Pancreat Dis Int 2010; 9: 269-274)

Hand-assisted laparoscopic splenectomy is a useful surgical treatment method for patients with excessive splenomegaly: A metaanalysis

BACKGROUND Hand-assisted laparoscopic splenectomy(HALS) can help overcome the drawbacks of laparoscopic splenectomy(LS) while maintaining its advantages.AIM To evaluate the efficacy and advantages of HALS for splenomegaly.METHODS The relevant literature was reviewed using the PubMed, EMBASE, Cochrane,Ovid Medline, and Wanfang databases to compare the clinical outcomes of HALS and LS. Odds ratios or mean differences were calculated with 95% confidence intervals for fixed-effects and random-effects models. Overall, 754 patients from16 trials who met the inclusion criteria were selected.RESULTS In pure splenectomy, blood loss volume(P < 0.001) and conversion rate(P =0.008) were significantly lower in the HALS group than in the LS group.Conversely, for splenomegaly, the operative time(P = 0.04) was shorter and blood loss volume(P < 0.001) and conversion rate(P = 0.001) were significantly lower in the HALS group than in the LS group. However, no significant difference was observed in hospital stay length, blood transfusion, time to food intake, complications, or mortality rate between the two groups. Moreover, in splenectomy and devascularization of the upper stomach(DUS), the operative time(P = 0.04) was significantly shorter and blood loss volume(P < 0.001) andconversion rate(P = 0.05) were significantly lower in the HALS + DUS group than in the LS + DUS group. However, no significant difference was observed in hospital stay length, timing of diet, and complications between the two groups.CONCLUSION HALS is an ideal surgical treatment method for splenomegaly because it can maximize the benefits for patients while maintaining the advantages of LS.

Transjugular intrahepatic portosystemic shunt and splenectomy are more effective than endoscopic therapy for recurrent variceal bleeding in patients with idiopathic noncirrhotic portal hypertension

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS),splenectomy plus esophagogastric devascularization(SED)and endoscopic therapy+non-selectiveβ-blockers(ET+NSBB)are widely applied in secondary prevention of recurrent gastroesophageal variceal bleeding in patients with liver cirrhosis.These different treatments,however,have not been compared in patients with idiopathic noncirrhotic portal hypertension(INCPH).AIM To compare the outcomes of TIPS,SED and ET+NSBB in the control of variceal rebleeding in patients with INCPH.METHODS This retrospective study recruited patients from six centers across China.Demographic characteristics,baseline profiles and follow-up clinical outcomes were collected.Post-procedural clinical outcomes,including incidence of rebleeding,hepatic encephalopathy(HE),portal vein thrombosis(PVT)and mortality rates,were compared in the different groups.RESULTS In total,81 patients were recruited,with 28 receiving TIPS,26 SED,and 27 ET+NSBB.No significant differences in demographic and baseline characteristics were found among these three groups before the procedures.After treatment,blood ammonia was significantly higher in the TIPS group;hemoglobin level and platelet count were significantly higher in the SED group(P<0.01).Rebleeding rate was significantly higher in the ET+NSBB group(P<0.01).Mortality was 3.6%,3.8%and 14.8%in the TIPS,SED and ET+NSBB groups,respectively,with no significant differences(P=0.082).Logistic regression analysis showed that mortality was significantly correlated with rebleeding,HE,portal thrombosis and superior mesenteric vein thrombosis(P<0.05).CONCLUSION In patients with INCPH,TIPS and SED were more effective in controlling rebleeding than ET+NSBB,but survival rates were not significantly different among the three groups.Mortality was significantly correlated with rebleeding,HE and PVT.

Successful endoscopic treatment of superficial esophageal cancer in a patient with esophageal variceal bleeding:A case report

BACKGROUND The coexistence of esophageal variceal bleeding and superficial esophageal cancer(SEC)is relatively rare in clinical practice.Moreover,there have been few reports of SEC overlying esophageal varices(EVs).Herein,we report our successful use of endoscopic submucosal dissection(ESD),esophageal solitary venous dilatation(ESVD),and endoscopic injection sclerotherapy(EIS)to treat a 75-year-old man who was diagnosed with SEC coexisting with esophageal variceal bleeding.CASE SUMMARY A 75-year-old man was admitted to the hospital due to black stool for 4 days.The patient had a history of liver cancer,cirrhosis,and portal hypertension.Endosco-pic examination revealed esophageal and gastric varicose veins,as well as esoph-ageal carcinoma in situ.We first treated esophageal variceal bleeding by ESVD and EIS.One week later,ESD treatment was done,and the complete rese-ction of early esophageal cancer was successfully completed via endoscopy.There were no postoperative complications,such as bleeding,infection,or perforation.CONCLUSION The sequential treatment of ESVD,EIS,and ESD is an effective method for trea-ting EVs with early esophageal cancer.