Devascularization Surgery Research Articles

Is re-Rex shunt a better choice for patients with failed Rex shunt?

To review our single-center surgical outcomes of redo operations after failed Rex shunt procedures. From September 2017 to October 2021, a total of 20 patients (11 males, 9 females; median age: 8.6 years) with Rex shunt occlusions were admitted to our hospital. Two of these patients were previously operated on in our hospital, and the remaining 18 were from other centers. All patients underwent repeat operations after detailed preoperative evaluations. Preoperative wedged hepatic vein portography (WHVP) was conducted for 18 patients. Thirteen patients exhibited well-developed Rex recessus and intrahepatic portal vein during WHPV examination, consistent with the intraoperative exploration results. Fifteen patients (75%, 15/20) underwent redo-Rex shunt, four underwent Warren shunt and one underwent devascularization surgery. During the redo-Rex shunt operations, the left internal jugular veins (IJV) were used as bypass grafts in 11 patients; the intra-abdominal veins were used in 4 patients. The patients were followed up for 12-59 months (mean, 24.8 months). After redo Rex shunts, the grafts were patent in 14 patients (93.3%, 14/15), but 1 graft had thrombosis (6.7%, 1/15). Three patients suffered from postoperative anastomotic stenosis, and all of the stenosis was relieved with balloon dilatations. After re-Rex shunts, esophageal varices and spleen size were substantially reduced, and the platelet count significantly increased. Postoperative graft thrombosis was found in 1 patient after Warren shunt (1/4, 25%), and there was no graft stenosis. Compared with Warren surgery, patients who underwent re-Rex shunt had a significantly higher rate of platelet increase. Redo-rex shunts can be finished in most patients with failed Rex shunts. Re-Rex shunt is a preferred surgical choice after a failed Rex shunt when a good bypass graft is available, and the surgical success rate can reach more than 90%. A suitable bypass graft is essential for a successful redo Rex shunt. Preoperative WHVP is recommended for the design of a redo surgical plan preoperatively.

Splenic Artery Steal Syndrome in Patients with Liver Cirrhosis: A Retrospective Clinical Study.

BACKGROUND Splenic artery steal syndrome (SASS) can aggravate liver damage in patients with cirrhosis. This study explored whether SASS could be an effective therapeutic target for improving hepatic artery perfusion and liver function in patients with decompensated cirrhosis. MATERIAL AND METHODS Based on inclusion and exclusion criteria, 87 patients with hepatitis B cirrhosis and portal hypertension hypersplenism admitted to our General Surgery Department for splenectomy and pericardial devascularization surgery were selected. A total of 35 cases met the diagnostic criteria of SASS and were assigned to the SASS group; the remaining 52 cases were assigned to the control group. The indicators before, during, and after surgery were compared between the 2 groups. RESULTS There were no significant differences in preoperative and intraoperative indicators between SASS group and control group (P>0.05). The MELD score 7 days after surgery and the hepatic artery diameter and hepatic artery velocity 14 days after surgery in both groups were significantly better than before surgery. The MELD score 7 days after surgery in the SASS group was significantly better than that in the control group, and the hepatic artery diameter and hepatic artery velocity 14 days after surgery in the SASS group were significantly better than those in the control group (P<0.05). CONCLUSIONS Splenectomy and pericardial devascularization surgery was an effective treatment to redirect blood flow to the hepatic artery for cirrhotic patients diagnosed with SASS. The introduction of cirrhotic SASS into clinical practice may benefit more patients with cirrhotic portal hypertension and hypersplenism.

Obstetric hemorrhage and surgical emergencies training workshops on fresh cadavers and simulators result in high application in daily practices and decreased patient referral.

Objective:In this study, we aimed to evaluate the effects of obstetric emergencies workshops combining theoretical lectures, simulation trainers and fresh cadaver models on daily practices and referrals of obstetrics and gynecology specialists.Materials and Methods:This is a prospective observational study involving obstetrics and gynecology specialists attending the Turkish Society of Obstetrics and Gynecology endorsed obstetrics hemorrhage management courses held in 2018 and 2019. The training course is an annually organized two-day course, one day allotted to theoretical lectures and the other day to practical training on both simulators and fresh cadavers. Trainees participating in the course was surveyed with an anonymous questionnaire on their motivation to attend the course and their juridical history of obstetric patient management. Attendees were asked to disclose whether they had ever independently performed the procedures stated in the questionnaire or not, before commencing the course and 1 year after attending the course.Results:Among the attendees 22% (n=32) had at least one obstetrical malpractice lawsuit and 36.1% (n=52) were accused of Health Care Complaints Comission. The main motivation of the attendees for taking this course was Professional development followed by reducing maternal mortality and morbidity and avoiding malpractice. One year after the course, attendees applying uterine devascularization surgery increased by 36.1% (52/144), uterine compression sutures increased by 52.7% (76/144), and ability to apply uterine balloon tamponade increased by 59.7% (86/144). Besides improvement in other obstetric surgical skills an indirect effect seen that the attandees operated on high-risk cases increased in placenta previa (15.3%), placenta acreata spectrum (30.5%), operative deliveries (27.7%), peripartum hysterectomy (24.9%) and relaparotomy for postpartum hemorrhage (34.7%).Conclusion:Opportunities of attending well organized fresh cadaveric workshops on managing postpartum hemorrhage and other obstetric surgeries, can quickly adapt to daily practice, restore the professional confidence of obstetric and gynecology specialists, and eventually decrease patient referral.

Impact of Portal Vein Thrombosis on Endoscopic Variceal Band Ligation in Liver Cirrhosis

Background. Portal vein (PV) thrombosis (PVT) is a common complication of liver cirrhosis and can refer to thrombosis within the PV that can extend to its left or right branches and in some cases to the superior mesenteric vein or the splenic vein (Chawla and Bodh, 2015). For severe PVT patients, there are possibilities of increasing PV resistance and reduction of the blood flow though PV towards liver, which exacerbate liver function damage meanwhile elevating the gastrointestinal variceal bleeding risk. Endoscopic Variceal band ligation (EVL) is often used to prevent esophageal variceal bleeding; postoperative complications such as severe gastrointestinal bleeding and bleeding-related death, fever, retrosternal pain, and esophageal stenosis may appear. There was absence of the research which evaluated the impact of PVT in liver cirrhosis on the complication of endoscopic Variceal band ligation for now. We herein aimed to compare cirrhosis patients with and without PVT of recent complications after EVL. Method. We established the retrospective investigation on 144 consecutive cirrhosis patients (excluding patients with hepatocellular carcinoma and who received portal vein-systemic circulation devascularization or shunt surgery, splenectomy, hepatectomy, liver transplantation, transjugular intrahepatic portal vein stent shunt (TIPS), endoscopic varices Variceal ligation, or sclerotherapy before) who have received first endoscopic esophageal varices band ligation in Gastrointestinal Endoscopy Center of the First Affiliated Hospital, College of Medicine, ZheJiang University, between January 2014 and December 2017. Portal vein Doppler ultrasonography, liver computerized tomography (CT), and angiography or liver-enhanced magnetic resonance imaging (MRI) were applied to evaluate the portal vein thrombosis of each patient before EVL. There were 18 patients confirmed with portal vein thrombosis while the other 126 patients without PVT. The primary end point for this research is the upper gastrointestinal hemorrhage and related death occurred from the date of ligation until leaving hospital, and the secondary end point is the appearance of postoperative fever and retrosternal pain. Results. There are no significant differences of gastrointestinal bleeding, bleeding-related death, fever, or retrosternal pain after EVL and the length of hospital stays between cirrhotic patients with or without PVT ( P = 0.34 , 0.51 , 0.58 , 0.61 , 0.88 ). Conclusion. Liver cirrhosis with portal vein thrombosis did not increase incidence of recent complications of the endoscopic Variceal band ligation.

Surgical Treatment for Serious Complications of Portal Biliopathy

Introduction: Surgical treatment for complication of portal biliopathy is an exception. It implies a high risk of bleeding given the prominent collaterals present in the hepatoduodenal pedicle secondary to portal cavernomatosis. Methods: Descriptive study of 4 patients who presented serious complications linked to portal biliopathy that required surgical management within the Clinical Hospital of Universidad Católica. Results: Woman 59 years, with necrohemorrhagic pancreatitis (1996), biliodigestive bypass (2001) and portal cavernomatosis (2004) was presenting repeated episodes of hemobilia, one with hypovolemic shock. A Warren's shunt was tried (2005), but it failed. Then, a choledochal devascularization and hepatic-jejunal re-anastomosis intervention was made. Man 57 years, with HIV positive and serious pancreatitis (2007), developed portal thrombosis post inflammatory and cavernomatosis and presented repeated cholangitis. Roux-en-Y reconstruction was made (2012). Woman 47 years, with V Leiden factor deficit and portal cavernomatosis (2012), presented repeated cholangitis. After multiple endoscopic stent treatments, given recurrence of cholangitis and jaundice, a Roux-en-Y biliary reconstruction was performed (2015). Man 47 years, with neonatal trombosis and cavernomatosis for omphalitis, had portal devascularization surgery made at 7 and 14 years old, he had repeated cholangitis despite multiple endoscopic attempts. Roux-en-Y was performed. All anastomosis was made in biliary conducts with multiple collateral veins that were handled with bipolar coagulation, ligatures and stiches. On the long term, none repeated episodes of hemobilia or cholangitis. Conclusion: The surgery could be a definite solution for portal biliopathy complications. However, it has only been made for selective cases because it implies high complexity and risk.

Prognosis of endotherapy versus splenectomy and devascularization for variceal bleeding in patients with hepatitis B-related cirrhosis.

This study aimed to compare the long-term outcome of endotherapy versus a combination of splenectomy and devascularization for variceal bleeding in patients with hepatitis B-related cirrhosis (HBRC). A total of 1074 patients with HBRC and acute variceal bleeding (AVB) treated with endotherapy and 248 patients with HBRC treated with a combination of splenectomy and devascularization surgery were included in the analysis. After one-to-one propensity score matching, 151 paired patients were selected. The primary end-point was death. The secondary outcomes were 3-year survival, 5-year survival, and rebleeding. Complications were recorded. The median follow-up time was 1165days in the endoscopic group and 1709days in the surgical group. Before matching, the 1-year, 3-year, and 5-year survival rates were significantly lower in the endoscopic group than in the surgical group (91.1 vs 96.3%, P = 0.017; 79.6 vs 91.6%, P = 0.001; 65.2 vs 81.3%, P = 0.001). After matching, no significant differences were found between groups (94.5 vs 95.2%, P = 0.767; 87.0 vs 88.9%, P = 0.635; 77.9 vs 77.9%, P = 0.905). The rebleeding rate was lower in the surgical group than in the endoscopic group; the rebleeding-free survival rate was similar in the two groups. No patient died of complications. No statistically significant difference was observed in complications between groups. Both endotherapy and a combination of splenectomy and devascularization are good choices for patients with AVB. The rebleeding rate was lower after the surgical procedure, but the long-term prognosis was similar.

The role of a multidisciplinary team in the management of portal hypertension

BackgroundGastroesophageal variceal hemorrhage is the most severe complication of portal hypertension, with a high mortality rate. The current recommendations for gastroesophageal varices include pharmacological treatment, endoscopic treatment, transjugular intrahepatic portosystemic shunt (TIPS) placement, and splenectomy with devascularization surgery. Multidisciplinary team (MDT) comprises of a group of medical experts and specialists across a range of disciplines, providing personalized and targeted patient care tailored to each individual’s condition, circumstances, and expectations.MethodsPatients referred to the MDT clinic since its establishment in September 2014 were prospectively enrolled and followed-up for at least 12 months. Patient baseline characteristics, treatment methods, outcome and survival were compared to non-MDT patients retrieved from a prospectively maintained database with propensity score matching.ResultsPropensity-score matching (PSM) was carried out to balance available covariates, resulting in 58 MDT patients vs. 111 non-MDT patients. Overall survival and variceal rebleed was compared between the two groups. The rate of variceal rebleed was significantly higher in the non-MDT group, while no difference in overall survival was observed.ConclusionsThis study is the first to investigate the role of a multidisciplinary team in the management of gastroesophageal varices secondary to portal hypertension. Patients treated based on MDT clinic recommendations had a significantly lower risk for variceal rebleed.

The Application of Proximal Splenic Vein Ligation to Prevent Portal Vein Thrombosis in Laparoscopic Splenectomy Plus Pericardial Devascularization Surgery

Objective: To investigate the application of proximal splenic vein (SV) ligation in laparoscopic splenectomy plus pericardial devascularization (LSPD) surgery. Methods: From January 2017 to December 2018, 31 patients with portal hypertension of liver cirrhosis in Zhejiang Provincial people’s Hospital were treated with LSPD surgery with the ligation of proximal SV. Results: All the 31 patients were performed without any transfer to open operation. The operation time were 139.35 ± 19.48 min, blood loss were 138.06 ± 54.49 ml. Postoperative hospital stay (PHS) was 8.26 ± 1.59 days. There were 4 patients with postoperative portal vein thrombosis (PVT), among them 2 patients were degree I and 2 patients were degree II. There are no severe postoperative PVT cases. There were no abdominal infection, no pancreatic leakage, no abdominal hemorrhage, no liver failure or no upper gastrointestinal bleeding cases. Conclusion: LSPD combined with ligation of proximal SV is safe and feasible, and short-term follow-up can effectively prevent the formation of PVT after operation.

Intra-abdominal hypertension triggered by portal vein thrombosis postoperatively: an ignored, but potential, cause of acute kidney failure in patients with cirrhosis

Intra-abdominal hypertension (IAH), even abdominal compartment syndrome, resulting from major stem portal venous thrombosis (MSPVT) postoperatively can lead to acute kidney failure (AKF). However, few physicians consider this clinical presentation, which is rarely reported in the literature. IAH often induces a few obvious clinical presentations, such as oliguria, anuria, and abdominal distension, etc., even in cases with normal liver function. Many doctors consider that AKF is due to hepatorenal syndrome (HRS), while postoperative development of portal vein thrombosis (PVT) may be another important factor inducing AKF, which appears to have been ignored in recent years. In fact, devascularization surgery and/or shunt placement for treatment of portal hypertension are known to easily induce PVT, especially during devascularization procedures because of the rapid accumulation of platelets. In addition, the risk of hypercoagulability increases because of the use of hemostatic agents. Also, PVT may lead to gastro-intestinal congestion and tissue edema, which can contribute to the development of IAH. Abdominal distension became very obvious because collateral circulation could not be restored in time due to MSPVT after ligamentectomy surrounding the liver. Thus, it was difficult to arrive at a diagnosis of PVT at an earlier stage by B-type ultrasound and/or measurement of D-dimer levels. To achieve an early diagnosis, it is very important to actively incorporate the methods mentioned above. However, these methods are not recommended unless the diagnosis of HRS is definitive. The effective treatment is to administer anticoagulants, such as low-molecular-weight heparin, and to discontinue hemostatic agents in time. AKF will not benefit from Terlipressin if HRS was not considered as the major cause of AKF, especially in cases of IAH. It is well known that peritoneal dialysis and/or hemodialysis should be adopted to sustain kidney function postoperatively .

Laparoscopic splenectomy and azygoportal disconnection with intraoperative splenic blood salvage

Intraoperative blood salvage can reduce or avoid perioperative allogeneic blood transfusion. Salvaging the blood in the portal hypertension-induced enlarged spleen becomes an issue of concern during devascularization surgery because an enlarged spleen accommodates a large red cell pool. We report 20 cases of laparoscopic splenectomy and azygoportal disconnection and present the advantages of the use of intraoperative splenic blood salvage during the procedure. A total of 20 cirrhotic patients with esophagogastric variceal bleeding refractory to treatment with β-blockers and endoscopic therapy were studied. Laparoscopic splenectomy with azygoportal disconnection was performed. During the procedure, an intraoperative autologous blood salvage device recovered the splenic blood. The perioperative data were recorded from various viewpoints. The operative time was 3.1 ± 0.3 h and the blood loss was 70.5 ± 32.5 ml. The weight of the excised and morcellated spleen was 826.0 ± 155.1 g. The volume of autotransfused blood was 541.0 ± 150.4 ml. No patient received a perioperative allogeneic blood transfusion. There were no significant complications either intraoperatively or postoperatively. The hemoglobin value increased from 9.3 ± 0.8 to 11.5 ± 1.1 g/dl at postoperative day 1 (p < 0.01). During a postoperative follow-up period of 18.0 ± 9.0 months for 18 patients, neither esophageal variceal bleeding nor encephalopathy recurred. Laparoscopic splenectomy with azygoportal disconnection is a feasible, effective, and safe surgical method for the treatment of bleeding portal hypertension. Intraoperative splenic blood salvage can avoid the risk associated with allogeneic transfusion during the procedure, with an advantage of significantly increased postoperative hemoglobin levels.

Preoperative Evaluation of Endoscopic Ultrasonography and Portography in Selecting Devascularization Surgery for Esophagogastric Varices

This study assesses the role of endoscopic ultrasonography (EUS) and portography in selection of mode of devascularization surgery for esophagogastric varices (EGV) in patients with portal hypertension and reports our experience in the treatment of EGV with modified devascularization surgery. Forty-two cirrhotic patients with EGV were treated with devascularization surgery for variceal hemorrhage. Preoperatively, percutaneous transhepatic portography (PTP) and EUS were used as the guiding mode for therapy of EGV. In addition to devascularization and splenectomy, esophageal transection (ET) was performed in 26 patients with upward-flow varices (UFV), whereas 16 patients with downward-flow varices (DFV) underwent proximal gastrectomy instead of ET. In both UFV and DFV groups, grade II of intramural varices and extramural collaterals were most commonly observed on EUS imaging. There was no significant difference of EUS grading between these two groups (P > 0.05). The incidence of postoperative complications, mortality, and recurrent varices were not significantly different between these two groups. The overall 5-year survival rate for UFV group was 69.2 per cent, whereas that for the DFV group was 68.7 per cent (P > 0.05). Our study shows that devascularization surgery is highly effective for the prevention of recurrent bleeding from EGV, and it provides an alternative treatment modality. Combined PTP and EUS are very helpful in determining adequate modalities of devascularization surgery.

Effect of spontaneous portosystemic shunts on hemorrhage from esophagogastric varices.

The role of a massive spontaneous portosystemic shunt (MSPSS) in cirrhotic patients with portal hypertension remains unclear. The aim of this study was to investigate clinical outcomes and portal hemodynamic changes following ligation of the MSPSS during devascularization surgery. Portography and gastroendoscopy were performed before and after surgery for hemodynamic and follow-up studies. Three types of MSPSS were demonstrated portographically: 22 portoumbilical shunts, 18 splenorenal shunts, and 2 inferior mesenteric-caval shunts. A total of 40 MSPSS patients with esophagogastric variceal (EGV) bleeding underwent surgery: 26 had ligation of the MSPSS, and the remaining 14 served as the nonligation group. Neither the preoperative mean portal pressure (MPP) nor the postoperative MPP were significantly different between the ligation and nonligation groups (p>0.1), and there was no significant difference regarding surgical mortality, recurrent varices, or cumulative survival rate for the two groups in the follow-up study. However, postoperative portography demonstrated persistent drainage of portal flow and decreased intrahepatic portal perfusion in the nonligation patients. Clinical signs of hepatic encephalopathy subsided after ligation of the MSPSS in three patients. Therefore ligation of the MSPSS, which may be responsible for the development of encephalopathy, is recommended during devascularization surgery for EGV in cirrhotic patients.

Portographic evaluation for recurrent esophagogastric varices following devascularization surgery.

To investigate, by transhepatic portography, the changes in portosystemic collaterals and recurrent esophagogastric varices after devascularization surgery. Thirty-five patients, who had undergone devascularization surgery 2-8 years previously, underwent follow-up portography and the collaterals and drainage routes were compared with preoperative portography results. Newly formed collaterals were present in 30 of 35 patients and the origins and drainage routes differed from preoperative ones. Most common were new collaterals arising from the junction of the portal and superior mesenteric veins; the next most frequent arose from a main portal branch, the portal trunk, or the superior mesenteric vein. New collaterals with recurrent varices were seen in 20 patients and without varices in 10; 5 patients had no collaterals or varices. Since the development of new collaterals is common in portal hypertensive patients following devascularization surgery, regular follow-up for recurrent varices is necessary.

Portographic Evaluation for Recurrent Esophagogastric Varices Following Devascularization Surgery

Portographic Evaluation for Recurrent Esophagogastric Varices Following Devascularization Surgery