Pericardial Devascularization Research Articles

Modified laparoscopic splenectomy and pericardial devascularization for the aged patients with portal hypertension

Objective To investigate and compare the safety and efficacy of pericardial devascularization combined with either modified laparoscopic or open splenectomy for cirrhotic and aged patients with bleeding varices due to portal hypertension and secondary hypersplenism.Methods 139 cirrhotic patients with bleeding varices due to portal hypertension and secondary hypersplenism were treated at the Chnical Medical College of Yangzhou University.A retrospective study was conducted on the patients (n =42) who received pericardial devascularization combined with either modified laparoscopic or open splenectomy between January 2011 and October 2013.These patients were divided into the laparoscopic group (LAP,n =20) and the open group (OPEN,n =22).The peri-operative clinical parameters were analyzed and were compared.Results When compared to the OPEN group,the operative time in the LAP group was longer (P ＜ 0.05).However,the amount of intraoperative bleeding,pain score on the first day after operation,time to the first meal after operation,time to first passage of flatus,time to first off-bed activity,postoperative hospital stay and complications in the LAP group were all less than the OPEN group (all P ＜ 0.05).Furthermore,the postoperative body temperature,white blood cell counts (days 1 and 3),AST (days 3 and 7) and ALT (days 7) concentrations in the LAP group were significantly better than the OPEN group.Conclusions Modified laparoscopic splenectomy and pericardial devascularization for the aged was safe,feasible and with good therapeutic effect.It had better short-term clinical effect than that of open surgery. Key words: The aged ; Hypertension, portal; Laparoscopy ; Splenectomy ; Devascularization

Expert consensus on technical specifications of pericardial devascularization (2013 edition)

There are many operation methods in the surgical treatment of portal hypertension with esophageal gastric varices bleeding,and the technical levels vary significantly in different areas.Therefore,the consensus on technical specifications of pericardial devascularization (2013 edition) is made by experts group from the Ministry of Health Special Fund for Research in the Public Interest Reasonable choice and application of treatment of portal hypertension.The surgical indications of pericardial devascularization is portal hypertension with esophageal and gastric varices bleeding.Laboratory and imaging examinations,surgical risk assessment and preoperative preparation should be done before operation.The decision of choosing selective or non-selective paraesophagogastric devascularization depends on the patient's actual situation.Controversial still exits on simultaneous splenectomy.The idea of in situ splenectomy and possible side effects of devascularization on subsequent liver transplantation are specially emphasized in the experts consensus. Key words: Liver cirrhosis ; Portal hypertension ; Esophageal and gastric varices; Devascularization

Comparison of modified laparoscopic and open splenectomy and pericardial devascularization for the treatment of cirrhotic portal hypertension

Objective To investigate the safety and short-term efficacy of modified laparoscopic and open splenectomy and pericardial devascularization for the treatment of cirrhotic portal hypertension.Methods The clinical data of 107 patients with cirrhotic portal hypertension who were admitted to the Clinical Medical College of Yangzhou University from January 2010 to February 2013 were retrospectively analyzed.Patients were divided into the modified laparoscopic group (37 patients) and the open group (70 patients).The intra-and postoperative condition of the patients of the 2 groups were compared.The measurement data were analyzed using the t test or Mann-Whitney U test,and the enumeration data were analyzed using the chi-square test.Results The median operation time of the modified laparoscopic group was 210 minutes (range,185-245 minutes),which was longer than 175 minutes of the open group (range,150-190 minutes),with significant difference between the 2 groups (Z =-4.624,P ＜ 0.05).The median volume of intra-operative blood loss,pain rating index of the first day after operation,first appetite time after operation,initial passage of flatus time,postoperative off-bed activity time and duration of postoperative hospital stay were 150 ml (range,100-200 ml),2.5 ± 0.9,(1.5 ± 0.7) days,(2.4 ± 1.0) days,(2.7 ± 0.7) days,(10.5 ± 2.2) days in the modified laparoscopic group,and 300 ml (range,188-400 ml),5.1 ± 1.1,(2.8 ± 0.6) days,(3.2 ± 1.0) days,(5.9 ± 0.9) days and (15.7 ± 4.3) days in the open group,with significant difference between the 2 groups (Z =-3.570,t =-12.546,-9.834,-3.635,-18.780,-8.350,P ＜ 0.05).The number of patients who had postoperative complications in the modified laparoscopic group was 5,which was significantly smaller than 25 in the open group (x2 =5.913,P ＜ 0.05).Conclusions The procedure of modified laparoscopic splenectomy and pericardial devascularization for cirrhotic portal hypertension is safe,feasible and with good therapeutic effect.It has better short-term clinical effect than open surgery. Key words: Portal hypertension; Laparoscopy; Splenectomy; Pericardial devascularization

Laparoscopic splenectomy plus preoperative endoscopic variceal ligation versus splenectomy with pericardial devascularization (Hassab’s operation) for control of severe varices due to portal hypertension

Our research was conducted to introduce a new, compound surgical method for laparoscopic splenectomy (LS) with preoperative endoscopic variceal ligation (EVL) and compare the new method's efficiency with that of Hassab's operation in patients with severe esophageal varices due to portal hypertension. Between March 2009 and March 2012, 47 patients with liver cirrhosis, portal hypertension, and severe esophageal varices were retrospectively analyzed. Of these patients, 19 received the combined preoperative EVL and LS (minimally invasive surgery, MIS group), and 28 patients received splenectomy with pericardial devascularization (Hassab's operation, H group). Before surgery, there were no differences in the patient characteristics of the two groups. There were no significant differences in operating time, but significantly less intraoperative blood loss and shorter postoperative hospital stay were found in the MIS group compared with the H group. The mean follow-up periods of the MIS and H groups were 12.1 and 13.6 months, respectively. No deaths were documented during the follow-up period. Generally, hematological parameters and liver function variables eventually revealed considerable improvement in both groups. In the MIS group, the patients with varices improved significantly from severe to mild, and in some cases, the varices disappeared after treatment. Three patients in the H group suffered rebleeding and were treated with repeated EVL. No bleeding or rebleeding occurred in the MIS group. The final results suggest that LS with preoperative EVL provides a restorative efficacy equivalent to that of Hassab's operation. Based on the recurrence rate and the rebleeding rate of severe esophageal varices, our surgical strategy (EVL and LS) is a safe and minimally invasive technique that appears satisfactory in comparison to other open procedures.

Treatment selection for gastric cancer with portal hypertension: clinical management

Treatment for gastric cancer with portal hypertension must consider the eradication of the tumor and the change of hemodynamics in portal hypertension (PHT). Few reports have described the surgical procedures and postoperative complications of surgery for gastric cancer associated with PHT. The clinical data of 22 patients with PHT undergoing curative surgery for gastric cancer during 5 years were retrospectively analyzed. For 12 patients classified in Child's class A, D2 lymph node (LN) dissection was performed, and 10 patients classified into Child's class B were treated with D1 LN dissection. Surgical treatment included total gastrectomy combined with pericardial devascularization, distal subtotal gastrectomy, distal subtotal gastrectomy combined with splenectomy, and distal subtotal gastrectomy combined with pericardial devascularization with posterior gastric artery and left inferior phrenic artery preserved. A liver biopsy was analyzed in all patients. Postoperative complications developed in 50 % (11/22 patients) and the mortality rate was 9 % (2/22). The rate of postoperative ascites in patients with Child's class A was much lower than in those with Child's class B (P < 0.05). "Operation time," "volume of hemorrhage," "platelet count," and "treatment of PHT" are all risk factors of liver function deterioration. However, there was no significant difference in liver function deterioration rate between patients with Child's class A and Child's class B (P > 0.05). The occurrence rate of complications in patients with PHT was much higher compared to those without with PHT (P < 0.05). Individualized selection of surgical approaches is crucial for treatment of gastric carcinoma accompanied by PHT. Surgical treatment should be based on preoperative TNM stage, liver function, and degree of PHT.

Noninvasive Assessment of Portal Hypertension by Ultrasonography

To explore the feasibility of noninvasive assessment of portal hypertension (PHT) by ultrasonography. A total of 18 PHT patients who were planning to undergo splenectomy combiend with pericardial devascularization received ultrasonography one week before surgery (PHT group). In addition, 20 healthy volunteers were enrolled as the controls (control group). The conventional two-dimentional (2D) ultrasound, Doppler ultrasound and contrast-enhanced ultrasound (CEUS) parameters were compared between these two groups. For patients in the PHT group, the portal vein pressure was measured using portal vein puncture, and its relationship with the above parameters were further analyzed. The 2D ultrasound, Doppler ultrasound and CEUS parameters showed significant differences between the PHT group and control group (p < 0.01). Three ultrasonographic features including area under the time-intensity curve (TIC) of portal venous phase/hepatic arterial phase (Qp/Qa), intensity of portal venous phase/hepatic arterial phase (Ip/Ia), and base-to-peak ascending slope (βp/βa) were negatively correlated with the portal vein pressure (correlation coefficient: -0.701, -0.625, and -0.494, respectively). In this study, Qp/Qa and Ip/Ia have reduced significantly in PHT group compared with that in the control group (p <0.01), suggesting that in PHT patients, intensity and proportion of portal vein perfusion declined; while intensity and proportion of hepatic artery perfusion gradually rise due to buffering effect, thus gradually reversed the proportion of blood supplying through portal vein and hepatic arteries. Meanwhile, the decline of βp/βa, TTP, and RT confirmed that the increased flow velocity of the hepatic artery and decreased flow velocity of portal vein led to increased slope of TIC curve of the ascending branch of hepatic artery segment and decreased slope in portal vein segment, moreover; meanwhile, the increased overall slope of curve caused an advanced time to peak. In PHT group, Qp/Qa, Ip / Ia, and βp/βa were negatively correlated with the portal vein pressure, with correlation coefficients of -0.701, -0.625 and -0.494, respectively, indicating that these three ultrasound contrast parameters not only objectively reflected the pathophysiological process and the hemodynamic characteristics of chronic liver diseases but also showed a good correlation with portal pressure, therefore it was expected for clinical use as a new method for noninvasive assessment of portal vein pressure in PTH patients.

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

To determine the clinical value of a splenorenal shunt plus pericardial devascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding. 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), and 83 patients received a PCVD plus a splenorenal shunt procedure (combined group). Changes in hemodynamic parameters, rebleeding, encephalopathy, portal vein thrombosis, and mortality were analyzed. The free portal pressure decreased to 21.43 ± 4.35 mmHg in the combined group compared with 24.61 ± 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). 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.

Outcome of Laparoscopic Splenectomy with Sandwich Treatment Including Pericardial Devascularization and Limited Portacaval Shunt for Portal Hypertension Due to Liver Cirrhosis

To investigate the feasibility, effectiveness, and safety of a combination therapy of laparoscopic splenectomy (LS) with pericardial devascularization (PD) (laparoscopic Hassab's procedure) with or without limited portacaval shunt (LPS) for patients with portal hypertension due to liver cirrhosis. During September 2008 to April 2012, 42 patients underwent a combined treatment of LS with PD in our hospital. Of these subjects, 16 patients had an assessment of free portal vein pressure of more than 3.92-4.4 kPa and underwent a further limited LPS. Information on patients' demographics, diagnosis, and indication of splenectomy and perioperative variables was collected and analyzed. All patients successfully survived the operation, and 2 patients required an intraoperative conversion to open splenectomy because of intraoperative bleeding. For patients with LS plus PD, the mean operating time was 145 minutes, and the estimated blood loss was 146.2 mL. For patients who received an additional LPS, the total operating time was 232 minutes, and the established blood loss was 338.1 mL. The mean postoperative hospital stay was 11.7 and 12.3 days, respectively. Postoperative complications occurred in 1 patient who suffered gastric leakage, who received a re-operation and recovered later, and in 5 patients who experienced ascites, who received conserved medical treatment. During the follow-up, 2 patients had esophageal variceal bleeding 3 months and 1 year, respectively, after surgery. One patient had an encephalopathy 1 year after surgery, and 2 patients suffered a portal vein thrombosis without any clinical symptom. All of them were treated with conservation therapy. Two patients died 24-36 months and more than 36 months after surgery, because of liver failure. The other patients recovered well. We concluded that being only slightly invasive, the sandwich strategy treatment of LS with PD and LPS is feasible, effective, and safe for patients with portal hypertension due to liver cirrhosis.

Transumbilical Single-Incision Laparoscopic Splenectomy Plus Pericardial Devascularization Using Conventional Instruments: Initial Experience of 5 Cases

Laparoendoscopic single-site surgery (LESS) has been proposed for several intra-abdominal surgical interventions. However, application of the LESS technique in portal hypertension is still in its infancy. We report in this article a new technique of LESS splenectomy plus pericardial devascularization with conventional laparoscopic instruments in patients with portal hypertension. From January 2010 to April 2012, LESS splenectomy plus pericardial devascularization was performed on 5 patients with portal hypertension. Surgical techniques and short-term outcomes were summarized and analyzed retrospectively. All the operations were successful with a mean operative duration of 252 minutes (range, 220-270 minutes), intraoperative blood loss of 290 mL (range, 250-350 mL), and hospital stay of 8.2 days (range, 7-9 days). No intraoperative or postoperative complications were recorded. The umbilical incision healed well with a satisfactory cosmetic effect. LESS splenectomy plus pericardial devascularization is feasible when performed by experienced laparoscopic surgeons and may offer safety comparable to that of the conventional laparoscopic operation.

Quantitative evaluation of portal pressure by contrast enhanced ultrasonography

Objective To investigate the feasibility of non-invasive quantitative evaluation of portal pressure (Pp) by contrast enhanced ultrasonography (CEUS).Methods 18 portal hypertension patients (PTH group) were performed with CEUS within one week before splenectomy and pericardial devascularization,and 20 healthy volunteers as controls were recruited in this study (control group).Hepatic-right kidney sectionwas chosen to calculate the area under curve of portal vein/hepatic artery (Qp/Qa) and the perfusion intensity of portal vein/hepatic artery (Ip/Ia) through time intensity curves (TIC) of liver parenchyma generated from CEUS images.Pp was measured by intra-operative mesenteric vein catheter,and the correlation betweenPp and Qp/Qa,Ip/Ia were analyzed by Pearson correlation test.Results The levels of Qp/Qa and Ip/Ia in the PTH group were 2.28 ± 0.66 and 0.35 ± 0.14 respectively,which were both significantly declined than that in the controlgroup (5.72 ± 3.69 and 1.97 ± 0.17).In the PTH group,the correlation coefficient were-0.747 and-0.617,and the linear regression equations were Y =-83 X + 5.013 andY =-15X + 0.837,which indicated that Qp/Qa and Ip/Ia had significant correlation with Pp.Conclusions CEUS parameters,including Qp/Qa and Ip/Ia,are significantly correlated to Pp in portal hypertension patients,which indicate that CEUS could be a new non-invasive clinical method for evaluating Pp. Key words: Ultrasonography; Microbubbles; Hypertension, portal

The research of hemodynamic changes in portal hypertension combining with subtotal gastrectomy

Objective To build up a pig model of portal hypertension combined with subtotal gastrectomy,and study the hemodynamic changes of portal vein system.Methods 26 Susscrota domesticas are divided into three groups randomly.The experimental group ( EG,n =10) will receive the subtotal gastrectomy in the onestage operation,and will be subtotally coarctated the vena portae after one month.The portal hypertension group (PG,n =10) will receive the sham subtotal gastrectomy at first and followed by subtotally coarctated the vena portae.And the shamoperated group ( SG,n =6) will receive the sham subtotal gastrectomy at first and the sham subtotally coarctated the vena portae one month later.The portal pressure will be measured,and the hemodynamic changes in all groups will be detected by computer tomography and cast form.Results ( 1 ) The portal pressure in the EG and PG are statistically significance higher than the SG.And no difference was found between the EG and PG after the operation.(2) After subtotal gastrectomy,there are no new blood vessel appear in the gastric stump and the anastomosis between the stomach and the intestines.The blood supply of the gastric stump are mainly supported by the left gastric arteria and arteriae gastro-omentalis sinistra.The venous return of the gastric are mainly through the left gastric vein and left gastroepiploic vein.Conclusion ( 1 ) The method of subtotally coarctating the vena portae can build up a model of portal hypertension combined with subtotal gastrectomy.(2) The patients of portal hypertension who alreadly underwent subtotal gastrectomy is not suitable for the pericardial devascularization and the modified Sugiura procedure. Key words: Subtotal gastrectomy; Portal hypertension; Hemodynamic; Therapy

A comparative study between hand-assisted laparoscopic splenectomy and open splenectomy in combination with pericardial devascularization to treat portal hypertension

Objective To investigate the changes in liver function and the efficacy of either hand-assisted laparoscopic surgery (HALS) or open splenectomy (OS) in combination with pericardial devascularization in the treatment of portal hypertension. Methods The clinical data of 94 patients who received splenectomy combined with pericardial devascularization to treat portal hypertension due to cirrhosis from Jan 2002 to May 2008 were analyzed retrospectively. 56 patients received OS and 38patients HALS. The operating time, intraoperative blood loss, postoperative complications, liver dysfunction and mortality were analyzed according to the Child's grading. Results There was no difference in the operating time between HALS and OS (P＞0. 05). The intraoperative blood loss and postoperative complications were 5.6% and 10.8%, respectively (P＜0. 05). There was no significant difference in the serum ALT between HALS and OS, but there was a significant difference in the ALB (P＜0. 05). The AST also had a significant difference on postoperative day 5 (P＜0. 05). The serum ALT and AST were elevated after HALS, but there was a significant difference only for AST (P＜0.05). The serum ALT and AST in OS were significantly higher after than before operation (P＜0. 05). The serum ALB in OS was significantly lower after operation (P＜0.05), but it was significantly lower only on postoperative days 1 and 3 (P＜0.05) in HALS. Conclusions Compared with OS, HALS combined with pericardial devascularization caused less damage to the intestinal tract and the liver function. It is a feasible and safe operation and it had fewer postoperative complications. Key words: Hand-assisted laparoscopy; Portal hypertension; Cirrhosis; Splenectomy; Pericardial devascularization

Efficacy of endoscopic variceal ligation and its correlation with liver function

To analyze the efficacy of endoscopic variceal ligation and its correlation with liver function. 322 patients received EVL (endoscopic variceal ligation) and 34 patients with PDP (pericardial devascularization procedure) were retrospectively analyzed and divided into groups A, B and C. These patients were then subdivided into bleeding and non-bleeding subgroups according to Child-Pugh scores of liver function and history of upper gastrointestinal bleeding. The bleeding rate and mortality were contrasted between EVL and PDP. Liver function, Platelet count, leucocyte count and spleen thickness of before and after ligation were contrasted in EVL. The bleeding rate and mortality were 1.7%, 3.4%, 7.0%; 0%, 5.1%, 8.1% in EVL group and 9.1%, 14.3%, 100.0%; 0%, 9.5%, 50.0% in PDP group, respectively. Variceal obliteration needed means of 2.1+/-0.7, 3.1+/-0.8 and 4.2+/-1.2 sessions in A, B and C ligation groups, respectively (F = 41.2, P is less than 0.01). On subgroup analysis, the numbers of ligation session were 2.6+/-0.7, 3.2+/-0.9 and 4.3+/-1.1 in A, B and C bleeding subgroup (F = 39.3, P value is less than 0.01) and 2.0+/-0.6, 2.7+/-0.6, and 2.9+/-0.4 in A, B and C non-bleeding subgroup, respectively (F = 17.0, P value is less than 0.01). ALT, AST, Platelet count and leucocyte count reduced significantly, spleen thickness increased remarkably in bleeding subgroup after ligation. The efficacy of EVL was significantly negatively correlated with liver function and prior to pericardial devascularization procedure. EVL had no effect on liver function but might increase spleen thickness and aggravate hypersplenism. EVL was recommended especially for the bleeding liver cirrhosis patients with Child B and C scores.

Comparison of pericardial devascularization with modified Sugiura procedure in management of portal hypertension

Objective To compare the effect of pericardial devascularization with that of the modified Sugiura procedure in management of portal hypertension. Methods From 1990 to 2008, 236patients with portal hypertension underwent operations including pericardial devascularization in 147and modified Sugiura in 89 in our hospital. Results There were 12 perioperative deaths (8.2 % ), and 2 rebleedings (2 % ) in the pericardial devascularization group, and 7 perioperative deaths (7.9 % ) and 2 rebleedings(3.4 % ) in the modified Sugiura group. The follow-up rate was 91.9 % in the pericardial devascularization group and 87.8% in the modified Sugiura group respectively, in a period from 6 months to 19 years. The 1-, 3-and 5-year rebleeding rates were 5.7%,15.2% and 25.5% in the pericardial devascularization group and 6.9%, 16.3%, 29.5 % in the modified Sugiura group, respectively. The 1-, 3- and 5-year survival rates were 87.8% ,79.1% and 69.7% in the pericardial devascularization group and 95.8 %,85.0%, 76.9 % in the modified Sugiura group, respectively. Conclusion Modified Sugiura procedure and pericardial devascularization have differences in perioperative mortality as well as rebleeding and survival rates. Key words: Hypertension, portal; Pericardial devascularization; Modified Sugiura procedure

Clinical analysis of portal vein thrombosis after splenocaval shunt plus devascularization in treatment of portal hypertension

Objective To explore the clinical characteristics of portal vein thrombosis(PVT) after splenocaval shunt plus devascularization in treatment of portal hypertension and find Out ways for its prevention.Methods The formation,diagnosis,treatment of PVT and variceal rehemorrhage in 110 patients with portal hypertension who received splenocaval shunt plus devascularization procedures (Combined Group)and 92 patients subjected to pericardial devascularization operation(PCDV Group) were retrospectively analyzed.Meanwhile,the effect of two procedures on PVT was compared.Results The incidence of PVT was 10.0%in combined group and 22.8%in PCDV group (P<0.05).The rebleeding rate from esophagogastric varices because of PVT in combined group was 3.6%,which was significantly lower than that of 10.8%in PCDV group(P<0.05).Conclusion Splenoeaval shunt plus devascularization is a better choice to decrease the incidence of PVT.The postoperative anti-coagulation therapy in the early stage is important for the prevention of PVT. Key words: Hypertension,portal; Shunt; Thrombosis; Devascularization

Effects of modified splenocaval shunt plus devascularization on esophagogastric variceal bleeding: a comparative study of this treatment and devascularization only in cirrhotic portal hypertension

Pericardial devascularization (PCDV) and portosystemic shunt were reported to have favorable results for the management of portal hypertension in cirrhotic patients in China and the West, respectively. This study was undertaken to investigate the effects of a modified proximal splenocaval shunt plus PCDV on variceal bleeding in patients with portal hypertension. From January 1997 to December 2007, 168 patients with portal hypertension of cirrhotic origin received an operation for gastroesophageal variceal bleeding. Of these, 90 patients received a splenocaval shunt plus a PCDV procedure (Combined Group) and the other 78 patients received a PCDV procedure only (PCDV Group). The procedure-related morbidity and mortality, rebleeding, encephalopathy, and survival rates were analyzed. Postoperative mortality was 3.3% in the combined group and 5.1% in the PCDV group (P > 0.05). Overall morbidity was 13.3% in the combined group and 15.4% in the PCDV group (P > 0.05). The rate for rebleeding, including variceal bleeding and gastropathy, was 5.1% in the combined group, which was significantly lower than that in the PCDV group, at 16.7% (P < 0.05). The incidence of encephalopathy was 6.63% in the combined group and 6.67% in the PCDV group (P > 0.05). The 1-, 3-, 5- and 10-year survival rates were 97.4, 91.7, 80.0, and 60.0% in the combined group and 96.7, 83.3, 73.3, and 53.3% in the PCDV group (P > 0.05). The modified splenocaval shunt plus PCDV is a safe and effective procedure for the long-term control of variceal bleeding; the procedure may not only maintain the portal flow to the liver, but may also protect the liver function in cirrhotic patients. The better clinical outcome means that the procedure may be one of the best choices for treating portal hypertension of cirrhotic origin.

Laparoscopic Splenectomy and Periesophagogastric Devascularization with Endoligature for Portal Hypertension in Children

Bleeding from esophagogastric varices is an importment complication of portal hypertension. Recently, significant progress in laparoscopic technology has enabled the devascularization of the lower esophagus and upper stomach in a less invasive way. In this article, we report our preliminary experience with laparoscopic splenectomy and periesophagogastric devascularization by endoligature and its effectiveness for bleeding varices with hypersplenism in children. Six children with bleeding portal hypertension and developed severe thrombocytopenia and/or leukopenia underwent laparoscopic splenectomy and selective pericardial devascularization by using silk endoligature combined with a Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, OH). The patients included 5 males and 1 female, who ranged in age from 8 to 17 years. After a massive splenectomy was performed, we devascularized the periesophagogastric collateral vessels and perforating veins of the upper stomach to the level of the incisura angularis and the lower esophagus 5 or 6 cm away from the esophagocardia junction. The stem of the gastric coronary vein and paraesophageal collateral veins were not dissected in order to reserve portal blood flow toward the azygous shunt. All the procedures were completed successfully under a whole laparoscope. The operative time ranged from 180 to 270 minutes. Intraoperative blood loss was estimated to be from 80 to 200 mL. None of the patients required a blood transfusion. There were no significant complications either intra- operatively or postoperatively, and all patients had returned to usual activity by 5 days. Postoperative platelet count and white blood cell count increased in individual patients. The data were statistically significant (p = 0.006 and 0.002, respectively). During a postoperative follow-up period of 8-40 months, all children were asymptomatic, with improved growth and hematology and no rebleeding, sepsis, or encephalopathy. Laparoscopic massive splenectomy with selective periesophagogastric devascularization is a feasible, effective, and safe surgical procedure and has all the benefits of minimally invasive surgery. It offers a new alternative modality for children with bleeding portal hypertension and hypersplenism.

Application of anastomat in the surgery of portal hypertension

Objective To investigate the therapeutice effect of the partial resection of lower part of the esophagus pins pericardial pevaseularization by using transabdominal anastomat in the treatment of portal hyportension.Methods In 84 portal hypertensive patients, 42 were that were treated with partial resection of lower part of the esophagus with transabdominal anastomat plus pericarlial devascularization (as experimental group) and 42 were that were treated with only pericardial derivascularization (as control group). The therapeutic effect and security were evaluated. Results In the experimental group, no patients had rebleeding, the varicose veins of lower part of the esophagus disappeared after 3 months, the cure rate of varicose veins was 100%, the stenosis rate of anastomotic stoma was zero; In the control group, the rebleeding rate was 26.2% (11/42), the cure rate of varicose veins was 50%after 3 months, 25 patients were checked to have moderate or severe varicose veins after 12 months. Conclusion Partial resection of lower part of the esophagus in the treatment of portal hyportension is safe. It could improve the effect of pericardial devascularization and lower the recrudescence rate. Key words: Anastomat; Pericardial devascularization; Portal hyportension

Effects of combined procedure and devascularization alone on hyperdynamics of the portal venous system in patients with portal hypertension

Shunts and devascularizations have totally different effects on the hemodynamics of the portal venous system. The actual results of pericardial devascularization (PCDV) alone and conventional splenorenal shunt combined with pericardial devascularization (combined procedure, CP) should be determined by more clinical observations. This study aimed to evaluate effects on hemodynamics in the portal venous system after CP and PCDV only. In 20 patients who received CP and 18 who received PCDV, hemodynamic parameters of the portal venous system were studied by magnetic resonance angiography 1 week before and 2 weeks after operation. Free portal pressure (FPP) was continuously detected by a transducer during the operations. Compared to the preoperative data, a decreased flow in the portal vein (PVF) [(563.12 ± 206.42) mL/min vs (1080.63 ± 352.85) mL/min, P 0.05] had no significant decrease, while FPP [(21.50 ± 2.67) mmHg vs (24.40 ± 3.78) mmHg, P < 0.01] had a significant decrease as compared with that in the PCDV group. PVF and FPP could be decreased by both surgical procedures, but the effect of decreasing FPP was much better in the combined procedure than in PCDV alone. Further, there was no significant difference in PVF between the two groups. It is suggested that the combined surgical procedure could integrate the advantages of shunting with those of devascularization, as well as maintaining the normal anatomic structure of hepatic portal system, thus it should be one of the best choices for patients with portal hypertension when surgical interventions are considered.

Value of prophylactic pericardial devascularization for treatment of portal hypertension

目的 探讨断流术在预防门静脉高压症引起的食管下端胃底曲张静脉破裂出血中的安全性和有效性.方法 将1995年5月至2005年5月收治的128例无上消化道出血史的门静脉高压症病人分为非手术组和手术组,非手术组主要采取保肝、利尿、减慢心率等治疗,定期随访.手术组行断流术(Hassab术或改良Sugiura术).比较分析两组的临床资料、治疗方法以及长期随访结果.结果 手术组总并发症发生率25.0%,总手术死亡率3.6%,远期出血率2.0%,无肝性脑病,死亡率2.0%.非手术组远期出血率24.2%,肝性脑病发生率4.8%,死亡率9.7%.结论 断流术在门静脉高压症病人中施行是安全的,预防食管下端胃底曲张静脉破裂出血也是有效的,使外科医生在治疗时多了一种选择.Hassab术比改良Sugiura术更加适合应用在预防性治疗中。