Gastric Devascularization Research Articles

Hand-assisted laparoscopic splenectomy and gastropancreatic fold division: a less-invasive simplified technique of Hassab's procedure for refractory esophagogastric varices.

Some patients with refractory esophagogastric varices require surgery, such as gastric devascularization and splenectomy (Hassab's procedure). However, these patients are at risk of perioperative morbidities when undergoing devascularization to develop collateral vessels. We performed a more simplified procedure, splenectomy, and en bloc gastropancreatic fold division (GPFD) with hand-assisted laparoscopic surgery. Four patients with refractory esophagogastric varices and portal hypertension underwent splenectomy and GPFD. We reviewed patients' perioperative laboratory and morphological data, operative variables, and postoperative outcomes. Esophagogastric varices improved in 3 (75%) of the 4 patients. In one patient, esophageal varices (F1RC0) were observed 3years after surgery, but they required no treatment and only received follow-up. Treatment with splenectomy and GPFD is not only less invasive than Hassab's procedure but also provides effective outcomes for refractory esophagogastric varices.

Two Cases of Gastric Varices with Left-sided Portal Hypertension due to Essential Thrombocythemia Treated with Gastric Devascularization or Partial Splenic Embolization.

Left-sided portal hypertension (LSPH) is a condition of extrahepatic portal hypertension that often results in bleeding from isolated gastric varices (GVs). LSPH is sometimes caused by myeloproliferative diseases, such as essential thrombocythemia (ET). We herein report two cases of GVs with LSPH due to ET that were successfully controlled by gastric devascularization (GDS) or partial splenic embolization (PSE). Since each patient with LSPH due to ET has a different pathology, optimal treatment should be performed depending on the patient's condition, such as platelet counts, hemodynamics, or the prognosis. We believe that these cases will serve as a reference for future cases.

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy induces gastric neo-angiogenesis

BackgroundThe risk of an anastomotic leakage (AL) following Ivor-Lewis esophagectomy is increased in patients with calcifications of the aorta or a stenosis of the celiac trunc. Ischemic conditioning (ISCON) of the gastric conduit prior to esophagectomy is supposed to improve gastric vascularization at the anastomotic site. The prospective ISCON trial was conducted to proof the safety and feasibility of this strategy with partial gastric devascularization 14 days before esophagectomy in esophageal cancer patients with a compromised vascular status. This work reports the results from a translational project of the ISCON trial aimed to investigate variables of neo-angiogenesis. MethodsTwenty esophageal cancer patients scheduled for esophagectomy were included in the ISCON trial. Serum samples (n = 11) were collected for measurement of biomarkers and biopsies (n = 12) of the gastric fundus were taken before and after ISCON of the gastric conduit. Serum samples were analyzed including 62 different cytokines. Vascularization of the gastric mucosa was assessed on paraffin-embedded sections stained against CD34 to detect the degree of microvascular density and vessel size. ResultsBetween November 2019 and January 2022 patients were included in the ISCON Trial. While serum samples showed no differences regarding cytokine levels before and after ISCON biopsies of the gastric mucosa demonstrated a significant increase in microvascular density after ISCON as compared to the corresponding gastric sample before the intervention. ConclusionThe data prove that ISCON of the gastric conduit as esophageal substitute induces significant neo-angiogenesis in the gastric fundus which is considered as surrogate of an improved vascularization at the anastomotic site.

Long-term results of laparoscopic Hassab's procedure for esophagogastric varices with portal hypertension.

Recent reports have shown laparoscopic gastric devascularization and splenectomy (Hassab's procedure) to be a safe and effective treatment for esophagogastric varices with portal hypertension. However, the long-term postoperative results remain unclear. Between 2009 and 2015, 17 patients with portal hypertension and esophagogastric varices underwent laparoscopic Hassab's procedure at our institution. Two patients were lost to long-term follow-up (at least 2 years) and excluded. The remaining 15 patients' data and endoscopic findings were retrospectively reviewed. The median postoperative follow-up period was 56 months. The median spleen volume, operation time, blood loss, and length of postoperative hospital stay were 651 (320-1,265) mL, 305 (275-547) minutes, 347 (24-1,131) mL, and 20 (8-41) days, respectively. According to the endoscopic findings 1 year after surgery, the esophagogastric varices disappeared in three patients and improved in 12 patients. The median platelet count was significantly higher 1 year after surgery (19.7 × 104 /dL) than before surgery (5.5 × 104 /dL) (P < .001) and remained stable 2 years after surgery. Two patients died of liver disease. The remaining 13 patients, with a median postoperative follow-up of 57 months, were alive without bleeding from esophagogastric varices. Laparoscopic Hassab's procedure is a feasible treatment for esophagogastric varices with portal hypertension in terms of both short- and long-term results.

Laparoscopic ischaemic conditioning of the gastric conduit prior to a hybrid mckeown oesophagectomy may not decrease the risk of anastomotic leak.

IntroductionMorbidity associated with anastomotic leak after oesophagectomy is significant. Techniques to reduce this risk include ischaemic conditioning of the gastric conduit prior to oesophagectomy.AimTo quantify the rate of anastomotic leak after a hybrid minimally invasive McKeown oesophagectomy preceded by laparoscopic gastric devascularization (LGD).Material and methodsWe identified patients who had undergone neoadjuvant chemoradiotherapy followed by LGD and McKeown oesophagectomy and conducted a retrospective case series. The primary outcome was anastomotic leak, and secondary outcomes included common post-operative complications within 30 days.ResultsEleven patients were identified. Seventy-three per cent were male, and 7 of 11 patients were age 70+ years. 91% of tumours were located in the lower oesophagus or gastroesophageal junction (GEJ), and 72% of the series had clinical stage of II–III. The median ischaemic conditioning time was 15 days. Eighteen per cent of patients developed an anastomotic leak, and all were managed non-operatively. One patient developed an anastomotic stricture. Three patients developed pneumonia. Three patients suffered wound infection at the site of the neck incision. One had respiratory failure requiring ventilator support. None required reoperation or readmission. There were no mortalities following either operation.ConclusionsLaparoscopic ischaemic conditioning via LGD prior to a hybrid McKeown oesophagectomy for malignancy was associated with a leak rate similar to previously published data for a McKeown oesophagectomy without prior LGD.

Treatment outcomes after splenectomy with gastric devascularization or balloon-occluded retrograde transvenous obliteration for gastric varices: a propensity score-weighted analysis from a single institution.

BackgroundAlthough balloon-occluded retrograde transvenous obliteration (BRTO) is often selected to treat gastric varices caused by portal hypertension, data comparing BRTO and splenectomy with gastric devascularization (Sp + Dev) are limited.MethodsFrom January 2009 to February 2018, 100 patients with gastric varices caused by portal hypertension who underwent Sp + Dev (n = 45) or BRTO (n = 55) were included. Overall survival (OS) and the rebleeding rate were calculated using the inverse probability of a treatment weighting-adjusted log-rank test. Independent risk factors were identified by Cox regression analysis. Changes in liver function and adverse events after the procedures were analyzed.ResultsPatients in the Sp + Dev group tended to have lower platelet counts than those in the BRTO group, but liver function did not differ between these groups. The 5-year OS rates for the Sp + Dev and BRTO groups were 73.4 and 50.0% (p = 0.005), respectively. There were no significant differences in rebleeding rates between the two groups. Multivariate analysis showed that serum albumin level ≤3.6 g/dL, prothrombin time% activity (PT%) ≤80%, and serum creatinine level ≥0.84 mg/dL were poor prognostic factors. Although the Sp + Dev group had more short-term complications after procedures, Sp + Dev tended to be more effective in improving liver function than BRTO.ConclusionsSp + Dev showed better OS and improvement of liver function compared with BRTO for the treatment of gastric varices caused by portal hypertension.Electronic supplementary materialThe online version of this article (10.1007/s00535-020-01693-9) contains supplementary material, which is available to authorized users.

Prevention of recurrent bleeding from varicose veins of the esophagus and stomach among patients with decompensated liver cirrhosis

Aim. To evaluate the efficiency of laparoscopic devascularization of the esophagus and stomach with endoscopic ligation of varicose esophageal veins in the prevention of esophageal-gastric bleeding among patients with decompensated liver cirrhosis. Methods. The results of treatment of 73 patients with decompensated liver cirrhosis and high risk of bleeding were analyzed. To prevent recurrent bleeding from esophageal and gastric veins, all patients underwent endoscopic ligation at the first step of treatment. In case of inefficiency of ligation and recurrence of varicose veins of esophagus, laparoscopic devascularization of esophagus and stomach was performed. The efficiency of laparoscopic devascularization with intraoperative endoscopic ligation of varicose esophageal veins and ligation as an independent method of treatment for the prevention of upper gastrointestinal bleeding was estimated by comparison of the frequency of recurrence of esophageal and gastric bleeding and recurrence of esophageal varices according to upper endoscopy in comparison groups. Results. In 6 months, 1 and 2 years after laparoscopic devascularization of the esophagus and stomach in combination with endoscopic ligation, the risk of bleeding is less compared to endoscopic ligation as an isolated treatment method (p=0.05; p=0.052; p=0.06). Laparoscopic devascularization with ligation reduces the risk of recurrence of esophageal varices during the first year after surgery by 20% (χ2=2.61; p=0.106), in 2 years by 23% (χ2=1.75; p=0.091) compared to endoscopic ligation only. Conclusion. Patients with liver cirrhosis with decompensated hepatic failure satisfactorily postpone endovideosurgical interventions; laparoscopic gastric devascularization with the intersection of the main inflows to the esophageal varicose veins is an effective method to prevent esophageal-gastric hemorrhage among patients with decompensated liver cirrhosis after ineffective endoscopic ligation.

A successful clinical pathway protocol for minimally invasive esophagectomy.

Minimally invasive esophagectomy is associated with significant morbidity, which can substantially influence the hospital length of stay for patients. Anastomotic leak is the most devastating complication. Minimizing major postoperative complications can facilitate adherence to a clinical pathway protocol and can decrease hospital length of stay. This is a retrospective study of 130 patients who underwent an elective laparoscopic and thoracoscopic Ivor Lewis esophagectomy for esophageal carcinoma between August 2014 and June 2018. A total of 112 patients (86%) underwent neoadjuvant chemoradiation. All of the 130 patients underwent a laparoscopic gastric devascularization procedure a median of 15days prior to the esophagectomy. The target discharge date was postoperative day number 8. Thirty patients (23.08%) had postoperative complications. Atrial fibrillation (20 patients) [15.38%] was the most frequent complication. Four patients (3.1%) developed an anastomotic leak. There was one postoperative death (0.77%) in the cohort of patients. The median length of stay was 8days. The mean length of stay for patients without complications was 8days ± 1.2days and 12.4days ± 7.1days for patients with one or more complications (p = 0.002). The development of postoperative complications after minimally invasive Ivor Lewis esophagectomy significantly increases hospital length of stay. Performing the operation with a specialized tandem surgical team and including preoperative ischemic preconditioning of the stomach minimizes overall and anastomotic complications and facilitates on time hospital discharge as defined by a perioperative clinical pathway protocol.

P3.50: Portal hypertensive surgery for management of diffuse portomesenteric venous thrombosis - Surgical technique and long-term outcome

Introduction: Patients with diffuse portomesenteric venous thrombosis (PMVT) are often referred to the abdominal organ transplant centers particularly those with experience in gut transplantation. Despite the proven therapeutic efficacy of multivisceral transplantation (MVTx) for these complex patients, the forgotten different modalities of portal hypertensive surgery could be a better alternative particularly for those with compensated liver disease and gut varices in the milieu of a thrombophilic state. Methods: Between Aug2012 and Jan2019, a total of 28 patients referred to our center with diffuse PMVT underwent surgical intervention. Indication was history of variceal bleeding and occult varices in the setting of thrombophilia. All except 1 were adults with a mean age of 42±15 yrs. Precipitating causes of PMVT were thrombophilia (78%) and pancreatitis (18%). All patients had clinical, endoscopic and radiologic evidence of PMVT with stigmata of extra-hepatic portal hypertension. Variceal bleeding was reported in 36% patients. Type of shunt was determined intra-operative suitable visceral vascular anatomy and transplantation dictated by co-existence of advanced liver disease. Results: Portal hypertensive surgery was performed in 27 patients (96%) while MVTx was performed in one. The surgical modality was atypical non-selective portosystemic shunt in 14 patients (52%) and gastro-esophageal devascularization in the remaining 13 (48%). Partial gastric devascularization was commonly performed in patients with atypical shunt that may not completely decompress the left portal hypertensive compartment. Splenectomy was unavoidable in 4 patients. The utilization of autologous and synthetic vascular grafts are shown in Table 1. With a mean follow up of 40±26 months, overall shunt patency was radiologically documented in 78% patients. Recurrence of bleed occurred in only 1 patient (7%) despite shunt patency. Throughout the follow up period, surgical complications were minor (grade I & II) in 64% patients and major (grade III & IV) in 21% [Clavien grade]. With one mortality due to acute leukemia, all patients are currently alive with an overall survival rate of 96%. Conclusion: Portal hypertensive surgery is a viable alternative to MVTx for the management of diffuse PMVT and preserved hepatic function. Portal decompressive surgery should always be considered for thrombophilic patients with silent gut varices who are in need of life-long anticoagulation therapy.

Esophageal Replacement after Gastric Devascularization Is Safe but May Not Decrease Anastomotic Complications of a Cervical Anastomosis

Esophageal Replacement after Gastric Devascularization Is Safe but May Not Decrease Anastomotic Complications of a Cervical Anastomosis

Laparoscopic Gastric Devascularization Reduces Anastomotic Complications after Minimally Invasive Esophagectomy

Laparoscopic Gastric Devascularization Reduces Anastomotic Complications after Minimally Invasive Esophagectomy

Correction of complications portal hypertension syndrome

The results a new approach of simultaneous correction of complications of portal hypertension with endovideosurgical method are considered. Surgeries of 4 patients, suffering from portal hypertension, were performed by laparoscopic access and included gastric devascularization with ligation and the transection of the left gastric and short gastric veins; ligation of the splenic artery; resection of the parietal peritoneum, retroperitoneal tissue, and lumbar muscles in the lumbar triangle. Average duration of one surgery was 120±22 minutes. The highest volume of blood loss was 150±35 ml. There were no intraoperative complications. The average time spent in the IC unit was 14±4,2 hours. On the day following the surgery, all patients were able to get out of the bed, walked on their own and were allowed to have liquid food. Each patient had one session of endoscopic ligation with an overlay of 5 to 8 Cook ligatures to eradicate varicose veins of the esophagus. The postoperative period of hospital treatment was 10±2,3 days, treatment responses were favorable in all patients. The total time of inpatient stay was 22±3 days. All patients underwent two sessions of reinfusion of externally modified ascitic fluid. The postoperative spiral computer tomographies and subtraction digital angiographies showed effectiveness of disconnection of vessels in the gastroesophageal system. Blood flow in the splenic artery is not detected, ultrasound shows shrinkage of spleen. The maximum follow-up after the operation was 10 months. There were no episodes of bleeding recurrence and no signs of ascites. All patients are socially adapted and able to work, and do not present any complaints during follow-up examinations.

ЕФЕКТИВНІСТЬ ОПЕРАЦІЙ АЗИГОПОРТАЛЬНОГО РОЗ’ЄДНАННЯ У ХВОРИХ ПРИ ЦИРОЗІ ПЕЧІНКИ ТА ВАРИКОЗНИХ ЗМІНАХ ВЕН СТРАВОХОДУ І ШЛУНКА

Визначено ефективність хірургічної тактики у 67 хворих на цироз печінки (ЦП) з варикозними змінами вен стравоходу та шлунка з використанням операцій азигопортального роз’єднання (АПР). З приводу ЦП та варикозного ураження вен стравоходу і шлунка у пацієнтів 1–ї групи виконано стандартну операцію АПР Паціори з додатковою повною деваскуляризацією вен шлунка; у хворих 2–ї групи – операцію Паціори з частковою деваскуляризацією вен шлунка; у пацієнтів 3–ї – групи прошивання вен стравоходу і шлунка. Тривалість виконання операцій, об’єм інтраопераційної крововтрати вірогідно не різнилися в усіх групах. За частотою ускладнень та летальністю у безпосередньому та віддаленому післяопераційному періоді виражені переваги відзначені у 1–й групі. Доведено ефективність операцій АПР з приводу ЦП та варикозного ураження вен стравоходу і шлунка. За умови максимально повної деваскуляризації шлунка можливо суттєво зменшити частоту ускладнень, післяопераційної кровотечі та летальність.

Customization of laparoscopic gastric devascularization and splenectomy for gastric varices based on CT vascular anatomy.

Laparoscopic gastric devascularization(Lap GDS) and splenectomy (SPL) for gastric varices is technically challenging because of highly developed collateral vessels and bleeding tendency. We investigated the feasibility of customization of Lap GDS and SPL based on CT vascular anatomy. We analyzed 61 cirrhotic patients with gastric varices who underwent Lap GDS and SPL between 2006 and 2014. Lap GDS was customized according to the afferent feeding veins (left gastric vein (LGV) and/or posterior gastric vein (PGV)/short gastric vein (SGV)) and efferent drainage veins (gastrorenal shunt and/or gastrophrenic shunt, or numerous retroperitoneal veins) based on CT imaging. Thirty-four patients with efferent drainage veins suitable for balloon-occluded retrograde transvenous obliteration (B-RTO) underwent B-RTO instead of surgical GDS, with subsequent Lap SPL. Among 27 patients with gastric varices unsuitable for B-RTO, 15 patients with PGV/SGV underwent Lap GDS of the greater curvature and SPL, and 12 patients with LGV or LGV/PGV/SGV underwent Lap GDS of the greater and lesser curvature and SPL. The mean operation time was 294min and mean blood loss was 198g. There was no mortality or severe morbidity. Gastric varices were eradicated in all 61 patients, with no bleeding or recurrence during a mean follow-up of 55.9months. The cumulative 3-, 5-, and 7-year survival rates were 92, 82, and 64%, respectively. Lap GDS and SPL customized based on CT vascular anatomy is a safe and effective procedure for treating gastric varices.

食道離断および胃上部血行郭清を施行した Caroli 病の1例

食道離断および胃上部血行郭清を施行した Caroli 病の1例

Hassab手術（脾臓摘出術および胃上部血行郭清術）が奏効した進行性の汎血球減少症と食道胃静脈瘤を有する非アルコール性脂肪肝炎（NASH）の1例

Hassab手術（脾臓摘出術および胃上部血行郭清術）が奏効した進行性の汎血球減少症と食道胃静脈瘤を有する非アルコール性脂肪肝炎（NASH）の1例

Preventing anastomotic complications: early results of laparoscopic gastric devascularization two weeks prior to minimally invasive esophagectomy.

Laparoscopic gastric devascularization (LGD) is an innovative method to improve gastric conduit perfusion and improve anastomotic healing following esophagectomy. This study reports our early experience with LGD performed two weeks prior to minimally invasive esophagectomy (MIE) with intrathoracic anastomosis. We performed a retrospective review of all patients who underwent LGD prior to minimally invasive Ivor Lewis esophagectomy between August 2014 and July 2015 at a large academic medical center. LGD included staging laparoscopy with division of the short gastric vessels, left gastric artery and coronary vein, and posterior gastric attachments. Patient demographics, comorbid conditions, clinical stage, use of neoadjuvant chemoradiation, perioperative events, length of hospital stay, 60-day readmission, and complications were collected and analyzed. Thirty patients underwent LGD prior to minimally invasive Ivor Lewis esophagectomy, and 21 (70%) received neoadjuvant chemoradiation. LGD was performed a median of 14.5 (9-42) days prior to esophagectomy. Median operative time was 39 (18-56) minutes, and median length of stay was 0 (0-1) days. There were no complications or readmissions following LGD. MIE was completed laparoscopically in 93% of patients; two patients required conversion to an open procedure due to mediastinal inflammation following neoadjuvant chemoradiation. Five patients (17%) were readmitted within 60days of surgery: one (3%) patient with an anastomotic leak, two (7%) with pneumonia, and two (7%) with post-operative nausea and vomiting. One patient (3%) expired following an anastomotic leak that required reoperation, and no patients developed an anastomotic stricture during the study period. LGD with delayed esophageal resection and reconstruction can be safely performed two weeks prior to MIE with minimal morbidity. The low rate of anastomotic leak (3%) and absence of anastomotic strictures in this series suggest that this approach may successfully improve gastroesophageal anastomotic healing and reduce the rate of anastomotic complications reported with single-stage approaches.

Feasibility of laparoscopic gastric devascularization and splenectomy for gastric varices

Feasibility of laparoscopic gastric devascularization and splenectomy for gastric varices

Epiploic gonadal vein as a new bypass route for extrahepatic portal venous obstruction: report of a case.

A 61-year-old man was referred to our hospital to treat extrahepatic portal venous obstruction. Endoscopic injection sclerotherapy (EIS) was performed for the esophageal varices; however, the patient returned with massive hematemesis from gastric varices 6 months after treatment. Although the varices were treated with EIS, gastric devascularization and splenectomy concomitant with shunt surgery were required to treat uncontrollable, frequent diarrhea and abdominal distension. Because the splenic vein, left gastric vein, left portal vein, and inferior vena cava were inadequate for anastomosis, an epiploic gonadal vein bypass was performed. The bypass graft remains patent 7 months after surgery, and the patient is in good health without any clinical symptoms. We describe a new bypass route for extrahepatic portal venous obstruction.

64Cu-ATSM Hypoxia Positron Emission Tomography for Detection of Conduit Ischemia in an Experimental Rat Esophagectomy Model.

BackgroundWe designed a hypoxia-imaging modality to detect ischemia of the gastric conduit after esophagectomy.Materials and MethodsA rat esophagectomy model was created using 12-16-week-old, 300-350 g male Sprague-Dawley rats. In the operation group (n=6), partial gastric devascularization was performed by ligating the left gastric artery and the short gastric arteries and an esophagogastric anastomosis was performed. In the control group (n=6), the esophageal-gastric junction was incised and suturing was performed without gastric devascularization. Positron emission tomography (PET) images were taken using a microPET rodent model scanner, 24 h after the initial operation, after injection of 200 μCi 64Cu-diacetyl-bis (N4-methylsemicarbazone) (64Cu-ATSM) and pimonidazole 120 mg/kg. After microPET imaging, autoradiography and immunohistochemistry were performed.ResultsThe PET image revealed 64Cu-ATSM uptake at the fundus in the operation group 3 h after 64Cu-ATSM injection. The maximum percentage of the injected dose per gram of tissue was higher in the operation group (0.047±0.015 vs. 0.026±0.006, p=0.021). The fundus/liver ratio was also higher in the operation group (0.541±0.126 vs. 0.278±0.049, p=0.002). Upon autoradiography, 64Cu-ATSM uptake was observed in the fundus in the operation group, and was well-correlated to that observed on the PET image. Upon immunohistochemistry, expression of hypoxia-inducible factor 1a and pimonidazole were significantly increased at the fundus and lesser curvature compared to the greater curvature in the operation group.ConclusionHypoxia PET imaging with 64Cu-ATSM can detect ischemia in a rat esophagectomy model. Further clinical studies are needed to verify whether hypoxia imaging may be useful in humans.