Laparoscopic Splenectomy And Azygoportal Disconnection Research Articles

Can laparoscopic splenectomy and azygoportal disconnection be safely performed in patients presenting with cirrhosis, hypersplenism and gastroesophageal variceal bleeding? How to do it, tips and tricks (with videos)

BackgroundThe minimally invasive splenectomy and azygoportal disconnection procedure has evolved into an established treatment option for patients with cirrhosis, hypersplenism and gastroesophageal variceal bleeding. However, it remains technically challenging, particularly in patients presenting with splenomegaly. This study provides a comprehensive description of the laparoscopic splenectomy and azygoportal disconnection (LSD) technique for managing hypersplenism and gastroesophageal variceal bleeding, emphasising crucial strategies to overcome technical challenges and optimise surgical outcomes. MethodsThis retrospective observational study includes consecutive patients undergoing LSD by a single surgeon. The attachment includes video showcasing the surgical techniques. ResultsIn this study, 30 patients undergo LSD successfully. The mean operative time is 150.75 ± 25.81 min, and the mean blood loss is 119.62 ± 70.94 mL. The average length of postoperative hospital stay is 10.43 ± 1.97 days. Allogeneic blood transfusion was administered to two patients only. No conversions occurred. Haemoglobin, white blood cell and platelet counts on the seventh postoperative day are significantly higher than those on the day of admission. ConclusionThis study provides the results of the LSD technique performed in patients with hypersplenism and gastroesophageal variceal bleeding by a highly experienced surgeon. It offers tips and tricks for successfully performing the LSD technique, which can contribute to quick patient rehabilitation and optimal postoperative results.

Novel Preoperative Type IV Collagen to Predict the Risk of Hepatocellular Carcinoma in Patients with Hepatitis B Virus-Related Cirrhotic Portal Hypertension After Laparoscopic Splenectomy and Azygoportal Disconnection.

Although laparoscopic splenectomy and azygoportal disconnection (LSD) can significantly decrease portal vein pressure and even the incidence of hepatocellular carcinoma (HCC) in patients with cirrhotic portal hypertension (CPH), postoperative HCC inevitably occurs in certain patients. The purpose of this study was to seek a novel preoperative non-invasive predictive indicator to predict the occurrence of postoperative HCC. From April 2012 to April 2022, we collected clinical data of 178 hepatitis B virus (HBV)-related CPH patients. Based on inverse treatment probability weighting, candidate variables for predicting postoperative HCC were determined by means analysis. Then, a novel preoperative non-invasive prediction indicator (ie, type IV collagen-alpha fetoprotein-fibrosis-4 score [IVAF-FIB-4]) was established based on candidate variables, and its predictive ability was explored. Postoperative HCC occurred in 9 (5.1%) patients. Correlation analyses showed that the IVAF-FIB-4 had a significant positive correlation with HCC (r = 0.835, P < 0.001). IVAF-FIB-4 showed a high accuracy (the area under the receiver operating characteristic curve: 0.939, 95% confidence interval [CI]: 0.818-1.000; sensitivity: 88.9%; specificity: 93.5%). At the end of follow-up, the incidence density of HCC in patients with IVAF-FIB-4 (1) was significant higher than that in patients with IVAF-FIB-4 (0) (138.1/1000 vs 1.1/1000 person-years; rate ratio: 130.475, 95% CI: 16.318-1043.227). In logistic regression, IVAF-FIB-4 was an independent risk factor for HCC (odds ratio: 668.000, 95% CI: 53.895-8279.541; P < 0.001). IVAF-FIB-4 is a novel preoperative noninvasive predictive indicator for predicting postoperative HCC in HBV-related CPH patients after LSD, with satisfactory predictive ability.

The decreased risk of hepatocellular carcinoma in hepatitis B virus-related cirrhotic portal hypertension patients after laparoscopic splenectomy and azygoportal disconnection.

Posthepatitic cirrhosis is one of the leading risk factors for hepatocellular carcinoma (HCC) worldwide, among which hepatitis B cirrhosis is the dominant one. This study explored whether laparoscopic splenectomy and azygoportal disconnection (LSD) can reduce the risk of HCC among patients with hepatitis B virus (HBV)-related cirrhotic portal hypertension (CPH). A total of 383 patients with HBV-related CPH diagnosed as gastroesophageal variceal bleeding and secondary hypersplenism were identified in our hepatobiliary pancreatic center between April 2012 and April 2022, and conducted an 11-year retrospective follow-up. We used inverse probability of treatment weighting (IPTW) to correct for potential confounders, weighted Kaplan-Meier curves, and logistic regression to estimate survival and risk differences. Patients were divided into two groups based on treatment method: LSD (n = 230) and endoscopic therapy (ET; n = 153) groups. Whether it was processed through IPTW or not, LSD group showed a higher survival benefit than ET group according to Kaplan-Meier analysis (P < 0.001). The incidence density of HCC was higher in the ET group compared to LSD group at the end of follow-up [32.1/1000 vs 8.0/1000 person-years; Rate ratio: 3.998, 95% confidence intervals (CI) 1.928-8.293]. Additionally, in logistic regression analyses weighted by IPTW, LSD was an independent protective predictor of HCC incidence compared to ET (odds ratio 0.516, 95% CI 0.343-0.776; P = 0.002). Considering the ability of LSD to improve postoperative survival and prevent HCC in HBV-related CPH patients with gastroesophageal variceal bleeding and secondary hypersplenism, it is worth promoting in the context of the shortage of liver donors.

Splenectomy and azygoportal disconnection decreases the risk of hepatocellular carcinoma for cirrhosis patients with portal hypertension bleeding: a 10-year retrospective follow-up study based on the inverse probability of treatment weighting method.

Liver cirrhosis is the highest risk factor for hepatocellular carcinoma (HCC) worldwide. However, etiological therapy is the only option in cirrhosis patients to decrease the HCC risk. The aim of this study was to explore whether laparoscopic splenectomy and azygoportal disconnection (LSD) decreases the risk of HCC for patients with cirrhotic portal hypertension (CPH). Between April 2012 and April 2021, we identified 595 CPH patients in our hepatobiliary pancreatic center who were diagnosed with gastroesophageal variceal bleeding and secondaryhypersplenism, and performed a 10-year retrospective follow-up. Inverse probability of treatment weighting (IPTW) was used to adjust for potential confounders, weighted Kaplan-Meier curves and logistic regression to estimate survival and risk differences. According to the method of therapy, patients were divided into LSD (n = 345) and endoscopic therapy (ET; n = 250) groups. Kaplan-Meier analysis revealed that patients who underwent LSD had higher survival benefit with those who underwent ET (P < 0.001). At the end of the follow-up, ET group was associated with a higher HCC incidence density compared with LSD group (28.1/1000 vs 9.6/1000 person-years; Rate ratio [RR] 2.922, 95% confidence intervals [CI] 1.599-5.338). In addition, logistic regression analyses weighted by IPTW revealed that, compared with ET, LSD was an independent protective predictor of HCC incidence (odds ratio [OR] 0.440, 95% CI 0.316-0.612; P < 0.001). Considering the better postoperative survival and the ability to prevent HCC in CPH patients with gastroesophageal variceal bleeding and secondary hypersplenism, LSD is worth popularization in situations where liver donors are scarce.

Vagus Nerve–Preserving Laparoscopic Splenectomy and Azygoportal Disconnection with Versus Without Intraoperative Endoscopic Variceal Ligation: a Randomized Clinical Trial

BackgroundEsophagogastric variceal bleeding is the most common lethal factor for patients with cirrhotic portal hypertension. We firstly developed a laparoscopic splenectomy and azygoportal disconnection (LSD) with intraoperative endoscopic variceal ligation (LSDL) technique. In this study, we aimed to evaluate whether LSDL is feasible and safe and whether LSDL can effectively prevent esophagogastric variceal re-bleeding (EVR), as compared with single LSD. MethodsIn this randomized controlled single-center study, 88 patients with cirrhosis who had esophagogastric variceal bleeding and hypersplenism were randomly assigned to receive either LSD (n = 44) or LSDL (n = 44) between January 2020 and December 2021. The primary outcome was EVR. ResultsNo patients withdrew from the study. There were no significant differences in estimated blood loss, incidence of blood transfusion, time to first flatus and off-bed activity, or postoperative hospital stay between the two groups. Compared with that in the LSD group, operation time was significantly longer in the LSDL group (138.5±19.4 min vs. 150.3±19.0 min, P < 0.05); however, LSDL was associated with a significantly decreased EVR rate at 1-year follow-up (8/44 vs. 1/44, P < 0.05). Univariate analysis and multivariate logistic regression revealed that LSDL was a significant independent protective factor against EVR in comparison with LSD (relative risk: 0.105, 95% confidence interval 0.012–0.877; P = 0.037). ConclusionsOur newly developed LSDL procedure is not only technically feasible and safe; it also contributed to lowering the EVR risk more so than single LSD. Trial RegistrationWe registered our research at https://www.clinicaltrials.gov/. The name of research registered is “Laparoscopic Splenectomy and Azygoportal Disconnection with Intraoperative Endoscopic Variceal Ligation.” The trial registration identifier at clinicaltrials.gov is NCT04244487.

Clinical effects of cluster technology optimization and innovations on laparoscopic splenectomy and azygoportal disconnection: a single-center retrospective study with 500 consecutive cases.

In Asia, laparoscopic splenectomy and azygoportal disconnection (LSD) has been widely regarded as a preferential treatment modality for cirrhotic portal hypertension (PH). However, LSD involves high surgical risk, technical challenges, and many potential postoperative complications. Technology optimization and innovation in LSD aiming to solve to these difficulties has scarcely been reported. In this retrospective study, we aimed to evaluate the clinical therapeutic effect of our cluster technology optimization and innovation on LSD for PH. From February 2012 to January 2020, 500 patients with cirrhosis who had esophagogastric variceal bleeding and hypersplenism underwent LSD in our department. According to different operation periods, patients were divided into the early-, intermediate-, and late-period groups. We collected information regarding clinical characteristics of all patients as well as their preoperative and postoperative follow-up data. Compared with the early-period group, operation time and postoperative hospital stay were all significantly different and gradually declined from the intermediate- and late-period groups, respectively (all P &lt; 0.05). Intraoperative blood loss of these three groups was gradually decreased, with significant differences (P &lt; 0.05). The incidences of delayed gastric emptying and diarrhea in the late-period group were all significantly lower than those in the early- and intermediate-period groups, respectively (all P &lt; 0.05). Compared with the early-period group, the incidence of variceal re-bleeding was significantly lower in the intermediate- and late-period groups (all P &lt; 0.05). Our cluster technology optimization and innovation of LSD not only contributed to faster recovery and fewer complications but also enhanced surgical safety for patients. It is worth promoting this approach among patients with EVB and hypersplenism secondary to cirrhotic PH.

Robotic-assisted versus laparoscopic approach of Bai-Jiang-style vagus nerve-preserving splenectomy and azygoportal disconnection.

Robotic surgery has been widely accepted in many kinds of surgical procedures. Little is known about clinical effects of robotic-assisted splenectomy and azygoportal disconnection (RSD) for gastroesophageal variceal bleeding and secondary hypersplenism owing to cirrhotic portal hypertension. The aim of this study was to evaluate whether RSD is feasible and safe for patients with cirrhotic portal hypertension and whether RSD is superior to laparoscopic splenectomy and azygoportal disconnection (LSD). We retrospectively investigated the clinical effects of 50 patients with cirrhosis who underwent vagus nerve-preserving RSD (n = 20) and LSD (n = 30) between September 2020 and October 2021. We compared patients' demographic, intraoperative, and perioperative variables. RSD and LSD were successful in all patients. Operative time did not differ significantly between the RSD group and LSD group (151.15 ± 21.78min vs. 144.50 ± 24.30min, P > 0.05), but intraoperative blood loss were significantly reduced in the RSD group (61.00 ± 34.93mL vs. 105.00 ± 68.77mL, P < 0.05). No statistically significant differences were found regarding intraoperative allogeneic transfusion rate, visual analog scale pain score on the postoperative first day, time to first oral intake, initial passage of flatus, initial off-bed activity, postoperative hospital stay, and overall perioperative complication rate (all P > 0.05). In conclusion, RSD is not only a technically feasible and safe procedure but it was associated with less blood loss than LSD for cirrhotic portal hypertension with gastroesophageal variceal bleeding and secondary hypersplenism. Registered at researchregistery.com: trial registration number is researchregistry7244, date of registration October 10, 2021, registered retrospectively.

Predictors of portal vein thrombosis after laparoscopic splenectomy and azygoportal disconnection in hepatitis B cirrhosis: a prospective study.

The thrombosis of the main and intrahepatic branches of the portal vein (TMIP) is potentially lethal and deemed a common complication following laparoscopic splenectomy and azygoportal disconnection (LSD) in patients with cirrhosis and portalhypertension (PH). The predictors of TMIP after LSD remain unclear. The aim of this prospective study was to explore the predictive and risk factors for TMIP after LSD in cirrhotic patients with PH caused only by hepatitis B virus. From September 2014 to March 2017, we enrolled 115 patients with hepatitis B cirrhosis and PH who successfully underwent LSD. Patients were subdivided into a TMIP group and a non-TMIP group. Univariate and multivariate logistic regression analysiswasconductedon 24 items of demographic and preoperative data, to explore the risk factors of TMIP. Twenty-nine (25.22%) patients developed TMIP on postoperative day (POD) 7 and 26 (22.81%) patients developed TMIP on POD 30. From POD 7 toPOD 30, 12 patients who did not have TMIP at POD 7 were newly diagnosed with TMIP, with portal vein diameter 15.05 ± 2.58mm. Another 14 patients in whom TMIP had resolved had portal vein diameter 14.02 ± 1.76mm. Univariate analysis and multivariate logistic regression revealed that portal vein diameter ≥ 13mm [relative risk (RR) 5.533, 95% confidence interval (CI) 1.222-25.042; P = 0.026] and portal vein diameter ≥ 15mm (RR 3.636, 95% CI 1.466-9.021; P = 0.005) were significant independent risk factors for TMIP on POD 7 and 30, respectively. Portal vein diameter ≥ 13mm and ≥ 15mm were significant independent predictors for TMIP after LSD in patients with hepatitis B cirrhosis and PH on POD 7 and POD 30, respectively. We registered our research at https://www. gov/ . The name of research registered is "Warfarin Prevents Portal Vein Thrombosis in Patients After Laparoscopic Splenectomy and Azygoportal Disconnection." The trial registration identifier at clinicaltrials.gov is NCT02247414.

Novel noninvasive liver fibrotic markers to predict postoperative re-bleeding after laparoscopic splenectomy and azygoportal disconnection: a 1-year prospective study.

Esophagogastric variceal re-bleeding (EGVR) is a common and potentially lethal complication after open or laparoscopic splenectomy and azygoportal disconnection (LSD) in patients with cirrhosis andportalhypertension. Currently, noninvasive biomarkers for predictingEGVR are lacking. This prospective study focused on developing a noninvasive and convenient clinical model for predicting postoperative EGVR. Between September 2014 and March 2017, we enrolled 164 patients with cirrhosis who successfully underwent LSD. Based on the absence or presence of EGVR, patients were divided into EGVR and non-EGVR groups. We used correlation analysis to determine significant candidate variables among the liver fibrotic markers procollagen type III (PC-III), hyaluronidase (HA), laminin (LN), and type IV collagen (C-IV). Postoperative EGVR occurred in 22 (13.41%) patients. Correlation analyses showed that LN (r = 0.375; p < 0.001) and C-IV (r = 0.349; p < 0.001) were significantly positively associated with EGVR. The area under the receiver operating characteristic curve (AUC) of LN was 0.817 (95% confidence interval [CI] 0.722-0.913); that of C-IV was 0.795 (95% CI 0.710-0.881). In logistic multivariate regression, cutoff values LN ≥ 64µg/L and of C-IV ≥ 65µg/L were independent risk factors for EGVR. LN ≥ 64µg/L combined with C-IV ≥ 65µg/L was the best performing model, with AUC 0.867 (95% CI 0.768-0.967). LN and C-IV are potential markers to predict EGVR. Combining the two markers showed satisfactory ability to predict EGVR in patients with cirrhosis and portal hypertension after LSD.

Effects of laparoscopic splenectomy and azygoportal disconnection on liver synthesis function and cirrhosis: a 2-year prospective study.

Laparoscopic splenectomy and azygoportal disconnection (LSD) is widely used for the treatment of esophagogastric variceal haemorrhage and hypersplenism owing to cirrhotic portal hypertension. However, whether LSD improves liver synthesis function and cirrhosis remains unclear. The aim of this study is to investigate the effect of LSD on liver synthesis function and cirrhosis based on a prospective 2-year follow-up study. A total of 118 patients with cirrhotic portal hypertension who underwent LSD were included in this study. We analysed clinical data including routine blood parameters, liver function, liver-synthesised proteins (antithrombin III, protein S, and protein C), liver fibrotic markers (type IV collagen (IV-C), procollagen type III (PC-III), laminin, and hyaluronidase), portal vein diameter, and portal blood flow velocity. Postoperative portal vein diameter and portal blood flow velocity all showed gradual declines during the 2-year follow-up; compared with preoperative values, these were all significantly decreased from postoperative week (POW) 1 (all P < 0.001). Postoperative Child-Pugh scores and total bilirubin, albumin, international normalised ratio, antithrombin III, protein S, protein C, IV-C, PC-III, laminin, and hyaluronidase levels also all showed gradual improvements during the 2-year follow-up; compared with preoperative levels, these were all significantly improved from postoperative month (POM) 6, POW 1, POM 3, POM 3, POM 3, POM 6, POM 18, POW 1, POM 3, POM 24, and POM 18, respectively (all P < 0.05). LSD not only decreases portal hypertension and improves liver function, it also enhances liver synthesis function and reduces liver fibrosis.

Laparoscopic splenectomy and azygoportal disconnection combining with pre- and postoperative endoscopic intervention - A sandwich-style sequential therapy for portal hypertensive bleeding: A retrospective cohort study

In patients who survive the first esophageal variceal bleeding (EVB) resulting from portal hypertension, the probability of fatal esophageal variceal re-bleeding (EVR) is high. We have developed a sandwich-style sequential therapy combining laparoscopic splenectomy and azygoportal disconnection (LSD) with preoperative and postoperative endoscopic intervention (LSDE). The aim of the present study was to investigate whether LSDE is safe and effective and to evaluate whether the postoperative EVR rate for LSDE was lower than that for LSD without periodical postoperative endoscopic intervention (NLSDE). We retrospectively investigated the outcomes of 226 patients with cirrhosis with EVB and secondary hypersplenism who all received preoperative endoscopic variceal ligation (EVL) to manage emergency EVB then underwent NLSDE (n=106) or LSDE (n=120) between February 2012 and April 2016. The perioperative and follow-up variables of the two groups were evaluated. Between the two groups, there were no differences in number of blood transfusions, intraoperative blood loss, postoperative complications, and hospital stay. LSDE showed shorter operation time (p=0.001) and lower EVR rates during the periods ranging from 1 to 12 months, 4 to 6 months, 4 to 12 months, and 7 to 12 months (all p<0.05) than NLSDE. Dynamic changes in the diameter of the esophageal varices and the rates of EVL in the LSDE group both decreased gradually and significantly over the 12-month follow-up period (all p<0.0001). Laparoscopic splenectomy and azygoportal disconnection with periodical postoperative endoscopy is safe and effective for reducing the EVR rate in cirrhotic portal hypertension.

Warfarin versus aspirin prevents portal vein thrombosis after laparoscopic splenectomy and azygoportal disconnection: A randomized clinical trial

IntroductionPortal vein system thrombosis (PVST) is a common, potentially life-threatening complication after splenectomy. The optimal recognized anticoagulation drugs for preventing PVST in cirrhotic patients after splenectomy remain unclear. The aim of this study is to evaluate the safety and efficacy of warfarin in preventing PVST after laparoscopic splenectomy and azygoportal disconnection (LSD). MethodsIn this randomized controlled single-center study, 80 cirrhotic patients who underwent LSD were randomly assigned to 2 years of treatment with either warfarin (n = 40) or aspirin (n = 40). The primary outcome was prevention of PVST. Sonographers and radiologists who assessed outcomes were blinded to group assignments. Intention-to-treat analysis was performed. ResultsDuring the first year, excluding two patients withdrawing from the study, 15 of the 39 warfarin-treated patients (38.5%) and five of the 39 aspirin-treated patients (12.8%) did not develop PVST (P = 0.010). The incidence of PVST in the first 2 postoperative years was significantly lower in the warfarin group than in the aspirin group (F = 7.360, P = 0.008). The warfarin group in paired within-group comparisons had significantly greater improvements in total bilirubin and albumin levels at baseline versus at 6 months postoperatively and in creatinine levels at baseline versus at 12, 18, and 24 months postoperatively respectively (all P < 0.05). In contrast, those paired comparisons of the aspirin group showed no significant differences (all P > 0.05). ConclusionsWarfarin therapy was safe and effective and significantly reduced the risk of PVST after LSD, compared with aspirin treatment. Warfarin treatment was associated with better liver function protection and renal function improvement than aspirin treatment.

Liver Retraction Using n-Butyl-2-Cyanoacrylate (NBCA) Glue during Laparoscopic Splenectomy and Azygoportal Disconnection in Cirrhotic Patients.

Background Although liver retraction using n-butyl-2-cyanoacrylate (NBCA) glue has been applied to laparoscopic upper abdominal surgery in noncirrhotic patients, there is still no consensus on its safety and feasibility for cirrhotic patients. In this study, we aimed to investigate the safety and effectiveness of liver retraction using NBCA glue during laparoscopic splenectomy and azygoportal disconnection (LSD) for gastroesophageal varices and hypersplenism secondary to liver cirrhosis and portal hypertension. Methods Thirty-nine gastroesophageal varices and hypersplenism secondary to liver cirrhosis and portal hypertension patients were included in our study. We performed LSD in the presence of NBCA glue (n = 22, NBCA group) and absence of NBCA glue (n = 17, n-NBCA group), respectively. The operation time, blood loss, postoperative hospitalization, and liver function were compared between the two groups. Results There was no mortality during the operation. One patient in non-NBCA group received open surgery due to parenchyma hemorrhage. Postoperative pleural effusion occurred in 2 cases of the NBCA group and 1 of the non-NBCA group. One showed left subphrenic abscess in the non-NBCA group. No postoperative bleeding occurred after 9-30 months of follow-up. The time of operation in NBCA group was significantly shorter than those in n-NBCA group (198.86±17.86 versus 217.81±20.25min, P<0.01). Blood loss in NBCA group was significantly lower than non-NBCA group (159.09±56.98 versus 212.50±88.51 ml, P<0.05). The levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were increased on day 1 after LSD and decreased to normal level on day 7 after LSD in both groups. There was no significant difference in postoperative hospitalization and liver function between the two groups. Conclusion Liver retraction using NBCA glue during LSD for gastroesophageal varices and hypersplenism secondary to liver cirrhosis and portal hypertension is safe, effective, and feasible.

A meta-analysis on the short-term outcomes between laparoscopic versus open splenectomy and azygoportal disconnection in the prevention and treatment of portal hypertension hemorrhage

Objective To systematically evaluate the short-term outcomes of laparoscopic splenectomy and azygoportal disconnection (LSD) with open splenectomy and azygoportal disconnection (OSD) in the prevention and treatment of portal hypertension (PHT) hemorrhage. Methods A meta-analysis was conducted to evaluate the short-term outcomes published in randomized controlled studies and high quality case-controlled studies on patients who underwent LSD or OSD from January 2006 to January 2016. Results 1 359 patients from 18 Chinese and English articles which met the inclusion criteria were included into this study. LSD and OSD were performed in 685 patients (the LSD group) and 674 patients (the OSD group), respectively. Meta-analysis showed that there was no significant difference in operation time between the LSD and OSD groups [MD=17.66, 95%CI=(-2.46~37.78), P>0.05]. When compared with the OSD group, the LSD group had a shorter postoperative hospitalization stay [MD=-3.99, 95%CI=(-4.82~-3.16), P<0.05], earlier postoperatively first passing of flatus [MD=-1.09, 95%CI=(-1.41~-0.78), P<0.05], less intraoperative bleeding [MD=-272.66, 95%CI=(-345.11~-200.21), P<0.05], a lower complication rate [OR=0.34, 95%CI=(0.25~0.47), P<0.05], less postoperative pain [MD=-2.54, 95%CI=(-2.79~-2.29), P<0.05], shorter postoperative ambulation time [MD=-3.16, 95% CI=(-3.53~-2.79), P<0.05], less amount of peritoneal drainage [MD=-180.28, 95%CI=(-293.06~-67.49), P<0.05] and earlier recovery from postoperative loss in appetite [MD=-1.42, 95%CI=(-1.70~-1.13), P<0.05]. Conclusion Compared with the traditional OSD, LSD had the advantages of less invasiveness, quicker recovery and higher quality of life in the perioperative period. LSD is the preferred operation for the prevention and treatment of PHT massive hemorrhage. Key words: Laparoscopy; Portal hypertension; Splenectomy; Azygoportal disconnection; Meta-analysis

Modified Laparoscopic Pyloroplasty During Laparoscopic Splenectomy and Azygoportal Disconnection for the Prevention of Postoperative Gastroparesis.

Gastroparesis is a common complication after splenectomy and azygoportal disconnection, remaining a chronic debilitating disorder with considerable treatment challenges. To minimize postoperative gastroparesis, we have developed a new modified laparoscopic pyloroplasty (LP) technique for use during laparoscopic splenectomy and azygoportal disconnection (LSD). We retrospectively evaluated the outcomes of 31 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism who underwent synchronous LSD with modified LP (n = 14) or LSD without modified LP (n = 17) between January 2015 and August 2015. Perioperative variables were compared. LSD with and without modified LP were successful in all patients. Operation time was significantly longer for LSD with modified LP than LSD without modified LP ( P = .001). However, the LSD with modified LP group had significantly reduced incidences of bloating 1 month postoperatively ( P < .05), nausea ( P < .05), and bloating ( P < .05) 3 months postoperatively, gastric retention 3 months postoperatively ( P < .0001), and prokinetic use at 1 month ( P = .009) and 3 months postoperatively ( P < .05) compared with the LSD without modified LP group. Gastric emptying scintigraphy showed that the mean time required to empty 50% of the ingested meal was significantly shorter in the LSD with modified LP group than in the LSD without modified LP group at 3 months postoperatively (74.3 ± 19.1 vs 261.7 ± 61.0 minutes, P < .0001). Modified LP during LSD was feasible, effective, and safe, and significantly reduced short-term symptoms of postoperative gastroparesis.

Predictors of portal vein system thrombosis after laparoscopic splenectomy and azygoportal disconnection: A Retrospective Cohort Study of 75 Consecutive Patients with 3-months follow-up

IntroductionPortal vein system thrombosis (PVST) is an alarming and potentially life-threatening complication of laparoscopic splenectomy and azygoportal disconnection (LSD). The objective of this study was to investigate negative and positive predictors of PVST after LSD in patients receiving anticoagulant regimens with aspirin or warfarin. MethodsSeventy-five consecutive patients who underwent LSD from 2013 to 2014 were retrospectively reviewed. Patients received anticoagulant regimen with warfarin (n = 35) or aspirin (n = 40) according to individual preference. International normalized ratio (INR) and the incidence of PSVT were compared in patients received anticoagulant regimen with warfarin or aspirin on postoperative days (POD) 7, 30, and 90, and factors associated with PVST at these time points were determined by univariate and logistic multivariable regression analyses. ResultsPortal vein diameter was an independent negative predictor of PVST on PODs 7, 30, and 90. Anticoagulation with warfarin was an independent positive predictor of PVST on PODs 30 and 90, and INR was an independent positive predictor of PVST on POD 90. Dynamic changes in the incidence of PVST on the day of admission and on PODs 7, 30, and 90 differed significantly between the warfarin and aspirin groups (P = 0.002). No patient experienced perioperative bleeding. ConclusionsPortal vein diameter was an independent negative predictor, while anticoagulation therapy with warfarin and INR were independent positive predictors, of PVST after LSD. Early anticoagulation with warfarin is safe and effective for the prevention of PVST after LSD.

Anticoagulation Therapy with Warfarin Versus Low-Dose Aspirin Prevents Portal Vein Thrombosis After Laparoscopic Splenectomy and Azygoportal Disconnection.

Portal vein system thrombosis (PVST) is a frequent and potentially life-threatening complication after laparoscopic splenectomy and azygoportal disconnection (LSD) in patients with cirrhotic portal hypertension. The objective of this study was to investigate the safety and effectiveness of warfarin with a target international normalized ratio (INR) of 2.0-2.5 for the prevention of PVST after LSD. Hitherto, this is the first study to assess the use of warfarin in this field. We retrospectively analyzed a database of 73 consecutive patients who underwent LSD from January 2013 to September 2014. Patients were categorized into the warfarin group (34 patients) and the aspirin group (39 patients). The INR and incidence of PSVT were monitored for 90 days. Compared with the aspirin group, the warfarin group had a lower incidence of PVST on postoperative day (POD) 30 [17/34 (50.0%) versus 29/39 (74.4%); P = .032] and POD 90 [8/34 (23.5%) versus 30/39 (76.9%); P < .0001] and main portal vein thrombosis (MPVT) on POD 90 [3 (8.8%) versus 13 (33.3%); P = .012]. From POD 30 to 90, the warfarin group achieved more complete recanalization of PVST [9/17 (52.9%) versus 3/29 (10.3%), P = .005] and MPVT [9/12 (75.0%) versus 3/12 (25.0%), P = .039]. Multiple logistic regression analysis revealed that warfarin was an independent protective factor for PVST at POD 90 (relative risk, 0.027; 95% confidence interval, 0.004-0.168; P < .001). No patients developed bleeding complications. Anticoagulation therapy with warfarin is safe and effective for the prevention of PVST in cirrhotic patients with portal hypertension after LSD.

Laparoscopic Splenectomy and Azygoportal Disconnection: a Systematic Review.

Background and Objectives:Given the technical difficulty of laparoscopic splenectomy and azygoportal disconnection (LSD), data are limited that compare the laparoscopic to the open procedure. As the technique becomes more widespread, questions regarding its safety, feasibility, and reproducibility must be addressed. This review assesses the current status of LSD.Methods:We conducted our literature review with a search of the PubMed database. All published series of 5 or more laparoscopic splenectomy and azygoportal disconnection procedures were examined. The demographic, intraoperative, and postoperative data analyzed included number of ports, conversion rate, operative duration, estimated intraoperative blood loss, postoperative hospital stay, and complications.Results:Fifteen articles met the review criteria. Of 412 laparoscopic procedures, traditional laparoscopic splenectomy and azygoportal disconnection (TLSD) was used in 322 patients (78.2%), a modified laparoscopic procedure (MLSD) in 79 (19.2%), and a single-incision laparoscopic procedure (SLSD) in 11 (2.7%). Compared with the traditional and single-incision laparoscopic procedures, the MLSD procedure was associated with shorter operative duration and less blood loss. Furthermore, although the incidence of postoperative portal vein system thrombosis was higher in the laparoscopic than in the open splenectomy with azygoportal disconnection (OSD) procedure, the LSD procedure was associated with less pulmonary infection and pleural effusion and fewer incisional and overall complications than the open procedure. The rate of conversion to an open procedure was 5.4%.Conclusions:LSD is feasible and safe for selected patients when performed by an expert laparoscopic surgeon. It has perioperative advantages over OSD, but studies with longer follow-up periods and larger samples of patients are needed.

A New Technique for Laparoscopic Splenectomy and Azygoportal Disconnection

Laparoscopic splenectomy and azygoportal disconnection (LSD) using many different surgical techniques has become increasingly popular for treatment of cirrhotic patients with bleeding portal hypertension and secondary hypersplenism. Surgical procedures with the least possible impairment are consistently expected by both surgeons and patients. Here, we report a clinical cohort of 10 patients who underwent LSD with a new technique and present the advantages of less impairment during performance of this new technique. A cohort of 10 cirrhotic patients with bleeding portal hypertension and secondary hypersplenism treated with LSD were studied. During the procedure, an electromechanical morcellator allowed for easy extraction of the entire massive splenic tissue without a cumbersome intracorporeal bag, enlarged incision, or hand-assisted incision. Various perioperative data were recorded. LSD was successful in all patients. There was no conversion to open operations or significant perioperative complications. The operative time was 288.0 ± 53.9 minutes, the spleen removal time was 39.3 ± 15.1 minutes, and blood loss was 240.0 ± 217.1 mL. This new technique involving the use of an electromechanical morcellator provides expedient recovery and minimal postoperative pain and scarring. LSD with this technique is a feasible, effective, and safe surgical procedure, and embodies all the benefits of minimally invasive surgery for cirrhotic patients with bleeding portal hypertension and hypersplenism.

Laparoscopic and open splenectomy and azygoportal disconnection for portal hypertension

To compare the outcomes of laparoscopic and open splenectomy and azygoportal devascularization for portal hypertension. From June 2006 to March 2009, laparoscopic splenectomy and azygoportal disconnection (LSD) were performed on 28 patients with cirrhosis, bleeding due to portal hypertension, and secondary hypersplenism. Success was achieved in 26 patients. Demographic, intraoperative, and postoperative variables of the patients were compared. Success of laparoscopic splenectomy and azygoportal disconnection was achieved in all but two patients (7.14%) who required open splenectomy and azygoportal devascularization (OSD). The operation time was significantly longer in patients undergoing LSD than in those undergoing OSD (235 +/- 36 min vs 178 +/- 47 min, P < 0.05). The estimated intraoperative blood loss was much more in patients receiving OSD than in those receiving LSD (420 +/- 50 mL vs 200 +/- 30 mL, P < 0.01). The proportion of patients undergoing laparoscopic and open splenectomy and azygoportal disconnection who received transfusion of packed red blood cells during or after the operation was 23.08% and 38.46%, respectively (P < 0.05). The time of first oral intake was faster in patients after LSD than in those after OSD (1.5 +/- 0.7 d vs 3.5 +/- 1.6 d, P < 0.05). The hospital stay of patients after LSD was shorter than that of patients after OSD (6.5 +/- 2.3 d vs 11.7 +/- 4.5 d, P < 0.05). The pain requiring medication was less severe in patients after LSD than in those after OSD (7.69% vs 73.08%, P < 0.001). The overall complication rate was lower in patients after LSD than in those after OSD (19.23% vs 42.31%, P < 0.05). Laparoscopic splenectomy and azygoportal disconnection are the feasible, effective, and safe surgical procedure, and are advantageous over minimally invasive surgery for bleeding portal hypertension and hypersplenism.