Periesophagogastric Devascularization Research Articles

Comparison of long-term outcomes of splenectomy with periesophagogastric devascularization and transjugular intrahepatic portosystemic shunt in treating cirrhotic portal hypertension patients with recurrent variceal bleeding

PurposeTransjugular intrahepatic portosystemic shunt (TIPS) and splenectomy with periesophagogastric devascularization (SPD) are widely used to treat cirrhotic portal hypertension (PH) and prevent variceal rebleeding. However, direct comparisons between these two approaches are rare. This study was designed to compare the long-term outcomes of TIPS and SPD in patients with cirrhotic PH and variceal rebleeding.MethodsThe study included cirrhotic PH patients with a history of gastroesophageal variceal bleeding between 18 and 80 years of age who were admitted to the Third Affiliated Hospital of Sun Yat-sen University from January 2012 to January 2022. Patients were enrolled into two groups according to TIPS or SPD was performed. Baseline characteristics were matched using propensity score matching (PSM).ResultsA total of 230 patients underwent TIPS, while 184 underwent SPD. PSM was carried out to balance available covariates, resulting in a total of 83 patients in the TIPS group and 83 patients in the SPD group. Patients in SPD group had better liver function during 60 months follow-up. Five-year overall survival rates in SPD group and TIPS group were 72 and 27%, respectively, at 2 years were 88 and 86%, respectively. The 2- and 5-year freedom from variceal rebleeding rates were 95 and 80% in SPD group and 80 and 54% in TIPS group.ConclusionsSPD is clearly superior to TIPS in terms of OS and freedom from variceal rebleeding in patients with cirrhotic PH. In addition, SPD improved liver function in patients with cirrhotic PH.

Splanchnic Vein Thrombosis in Liver Cirrhosis After Splenectomy or Splenic Artery Embolization: A Systematic Review and Meta-Analysis.

Splenectomy and splenic artery embolization are major treatment options for hypersplenism and portal hypertension in liver cirrhosis, but may lead to splanchnic vein thrombosis (SVT), which is potentially lethal. We conducted a systematic review and meta-analysis to explore the incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization and the risk factors for SVT. All relevant studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization was pooled. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Sixty-six studies with 5632 patients with cirrhosis were included. The pooled incidence of SVT after splenectomy and splenic artery embolization was 24.6% (95% CI 20.2-29.3%) and 11.7% (95% CI 7.1-17.3%), respectively. A meta-analysis of three comparative studies demonstrated that the incidence of SVT after splenectomy was statistically similar to that after splenic artery embolization (OR 3.15, P = 0.290). Platelet count, mean platelet volume, preoperative splenic or portal vein diameter, preoperative or postoperative portal blood velocity, splenic volume and weight, and periesophagogastric devascularization were significant risk factors for SVT after splenectomy. Postoperative use of preventive antithrombotic therapy was a significant protective factor against SVT after splenectomy. SVT is common in liver cirrhosis after splenectomy and splenic artery embolization. Coagulation and hemostasis factors, anatomical factors, and surgery-related factors have been widely identified for the assessment of high risk of SVT after splenectomy. Prophylactic strategy after splenectomy, such as antithrombotic therapy, might be considered in such high-risk patients. This study was registered in PROSPERO with a registration number of CRD42019129673.

Association Between Changes in Splanchnic Hemodynamics and Risk Factors of Portal Venous System Thrombosis After Splenectomy with Periesophagogastric Devascularization.

BackgroundThe purpose of this study was to investigate splanchnic hemodynamic changes and determine an optimal cutoff value for risk factors of portal venous system thrombosis (PVST) after splenectomy with periesophagogastric devascularization (SPD) in cirrhotic patients with esophageal and gastric variceal bleeding (EGVB) and portal hypertension (PH).Material/MethodsData on patients who underwent SPD were collected retrospectively from January 2013 to December 2017. Color Doppler ultrasound was performed to detect hemodynamic changes of the hepatic artery, splenic artery, splenic vein, and portal vein in included patients (n=60) and healthy volunteers (n=30). Outcomes were compared between preoperative and postoperative biochemical indicators. The cutoff values for hemodynamics were identified using receiver operating characteristic (ROC) curve analysis, and univariate and multivariate analyses of risk factors of PVST were performed.ResultsIn our series, hemodynamic indexes of splenic artery, spleen vein, and portal vein in the study group were significantly higher than that of the control group (P<0.05). Multivariate analysis revealed that the portal vein flow and the internal diameter of the portal vein were significantly correlated with PVST. The ROC analysis revealed that the cutoff points for portal vein flow and internal diameter of the splenic vein and portal vein were ≥1822.32 ml/min, ≥1.37 cm, and ≥1.56 cm, respectively.ConclusionsSPD is an effective treatment in cirrhotic patients with concomitant EGVB and PH by increasing hepatic artery flow and decreasing portal vein flow. High portal vein flow and wider diameters of the portal vein and splenic vein are important markers of PVST.

Splenectomy plus periesophagogastric devascularization in the treatment of cirrhotic patients with portal hypertention and splentic artery steal syndrome

Objective To study the hemodynamic changes before and after splenectomy plus periesophagogastric devascularization in patients with splenic artery steal syndrome (SASS) so as to provide a theoretical basis for the treatment of portal hypertension concomitant with hypersplenism. Methods The database of 30 patients who underwent splenectomy plus devascularization from January 2015 to January 2017 was studied retrospectively. Color Doppler ultrasound was performed to detect hemodynamic changes in the hepatic artery, splenic artery, splenic vein and portal vein in patients with portal hypertension and in healthy controls. The outcomes between preoperative and postoperative biochemical indicators were compared. Results The hemodynamic indexes of splenic artery, splenic vein and portal vein in the study group were significantly higher than those in the control group (P<0.05). The peak systolic velocity [(35.3±5.1) cm/s vs. (53.1±7.0) cm/s] and blood flow [(175.9±30.5) ml/min vs. (297.0±48.3) ml/min)] of the hepatic artery were significantly lower than those of the control group (P<0.05). The peak systolic velocity [(60.7±11.9) cm/s vs. (35.3±5.1) cm/s] and blood flow [(388.8±79.6) ml/min vs. (175.86±30.46) ml/min] of the hepatic artery increased significantly after operation (P<0.05). After splenectomy, the levels of the leucocyte [(7.9±3.8)×109/L vs. (2.8±1.4)×109/L)], thrombocyte [(491.3±194.9)×109/L vs. (47.4±16.0)×109/L)], bilirubin [(15.0±10.6) μmol/L vs. (24.4±13.8) μmol/L)] and transaminase [(32.94±8.57) U/L vs. (43.37±16.59) U/L)] reco-vered when compared with the preoperative data (P<0.05). Conclusions SASS was detected in cirrhotic patients who had portal hypertension concomitant with hypersplenism. Splenectomy plus periesophagogastric devascularization were effective and safe for cirrhotic patients with hypersplenism and concomitant esophageal and gastric variceal bleeding. Key words: Cirrhosis; Portal hypertension; Hypersplenism; Hemodynamics; Devascula-rization

The Efficacy and Safety of Endoscopically Guided Stapled Fundal Mini-Gastrectomy for the Treatment of Bleeding Fundal Varices: A Single Tertiary Care Center Experience

Introduction: Gastric varices develop in 5–33% of patients with portal hypertension. Gastric variceal bleeding is a major problem accused for a lot of deaths in cirrhotic sufferers, so its management and early prophylaxis is a must. Surgery turns into the only hope for patients with huge varices or resistant cases to repeated endoscopic management. Fundectomy and devascularization may be a good option in this class of patients. The aim of this study is to evaluate endoscopically guided stapled fundal minigasterectomy with periesophagogastric devascularization and splenectomy in treatment of gastric fundal varices. Patients and methods: This study included twenty two selected patients with gastric varices admitted to Gastroenterology, Liver and Laparoscopic unit, General surgery department, Tanta University Hospitals, during the period from January 2014 to January 2016. All cases were operated by endoscopically guided stapled fundal minigasterectomy with periesophagogastric devascularization and splenectomy. The evaluation included operative characteristics, operative findings and morbidity and postoperative complications. Results: The operative time ranged from 75 minutes to 180 minutes, with a mean of 106 + 15 minutes. Intraoperative bleeding occurred in one patient (4.55%) due to injury of one of the retroperitoneal veins treated by underrunning sutures and blood transfusion. There was no operative or postoperative mortality and only one patient developed recurrent fundal varices (4.55%) without bleeding attacks during the follow up period. Follow up ranged from 1 to 2 years with a mean of 1.5 years. Conclusion: Endoscopically guided stapled fundal minigasterectomy with peri-esophagogastric devascularization is a safe and effective method in the treatment and prophylaxis of fundal varices, and should be a used in treating bleeding fundal varices and in prophylaxis of huge ones.

Periesophagogastric devascularization without splenectomy in the treatment of portal hypertension

Gastroesophageal variceal bleeding is one of the major causes of death for patients with portal hypertension.The treatment of portal hypertension has evolved from surgery being the only option to the wide range of options currently available,including endoscopic sclerotherapy of varietals ligation,interventional radiology and surgery.Given the shortage of liver transplantation donors,devascularization would be one of the major treatments for portal hypertension for a considerable time.Based on the clinical experience of the People's Hospital of Peking University,we think that peraesophagogastric devascularization without splenectomy is a better option for the treatment of portal hypertension,with less operation time,less intraoperative blood loss and fewer postoperative complications,and better short-and long-term hemostatic effect. Key words: Portal hypertension ; Devascularization without splenectomy; Upper gastroesophageal bleeding

Risk factors and clinical characteristics of portal vein thrombosis after splenectomy in patients with liver cirrhosis

Portal vein thrombosis (PVT) is a potential lethal complication and may have negative influence on the prognosis after splenectomy in patients with liver cirrhosis. Prevention and timely detection of PVT are quite significant. There is a lack of knowledge about the clinical features and risk factors of PVT. Our study aimed to investigate the risk factors and clinical characteristics of PVT in order to figure out the high-risk individuals. We collected the clinical data of 472 consecutive patients with non-neoplastic liver cirrhosis who had undergone splenectomy from January 2008 to December 2010 in our institution. Clinical and surgical characteristics of patients who developed PVT postoperatively and those who did not develop PVT were compared. Univariate and multivariate analyses of risk factors of PVT were performed. The mortality and rebleeding rate of the patients were also evaluated. Of the 472 patients, 52 were excluded from the study. PVT developed in 71 (71/420, 16.9%) patients. Multivariate analysis revealed that wider preoperative portal vein diameter, postoperative thrombocytosis, prolonged prothrombin time and periesophagogastric devascularization were significantly correlated with PVT development [odds ratio (OR): 5.701, 2.807, 1.850 and 2.090, respectively]. The incidence of PVT in patients who took antiplatelet drugs was not lower than that in those who did not. Follow-up showed that patients in the PVT group had a tendency towards reduced overall survival but it was not statistically significant. Gastrointestinal bleeding occurred more often in the PVT group than that in the non-PVT group (P=0.044). Wider preoperative portal vein diameter, postoperative thrombocytosis, prolonged prothrombin time and periesophagogastric devascularization are independent risk factors of PVT. PVT is related with higher risk of postoperative gastrointestinal hemorrhage but has no significant impact on the overall survival.

Therapeutic effect of autologous bone marrow-derived liver stem cells transplantation in hepatitis B virus-induced liver cirrhosis.

To determine the safety, feasibility and therapeutic effect of in vitro-expanded autologous bone marrow-derived liver stem cells (BMDLSC) transplantation in cirrhotic patients following chronic hepatitis B virus infection. Twelve patients with post-hepatitic cirrhosis and portal hypertension who required splenectomy with periesophagogastric devascularization were included and were divided into two groups. Group I included six patients who received autologous BMDLSC infusion via the hepatic artery after in vitro expansion for 7 days. Group II (control group) included six patients who received normal saline infusion via the same route during splenectomy with periesophagogastric devascularization. The therapeutic effects were compared 3 months later. Patients in Group I were followed-up for 24 months after transplantation. There were no adverse effects during short- and long-term follow-ups. Three months after the operation, patients who received BMDLSC infusion showed better hepatic function than those who received saline infusion (p<0.05). Patients in Group I showed stable liver function parameters with no complications during the 24-month follow-up period. Transplantation of in vitro-expanded autologous BMDLSC via the hepatic artery is a safe and effective treatment for decompensated liver cirrhosis.

Reconsideration of liver transplantation for portal hypertension due to hepatitis B cirrhosis: a single center experience.

Some patients with portal hypertension due to hepatitis B cirrhosis who were suitable for periesophagogastric devascularization with splenectomy (PDS) also met the indications of liver transplantation (LT), the study compared the effect of PDS and LT, and of PDS followed by LT when required. Patients with portal hypertension due to hepatitis B cirrhosis were analyzed. Patients were organized into PDS or LT groups, and PDS followed by LT. The PDS group suffered from lower incidence of severe postoperative complications (p=0.007) and perioperative death (p=0.015) than group LT. The 1-, 3- and 5-year survival rates of the PDS and LT groups were 99.3%, 98.1% and 89.0%, and 91.1%, 85.4% and 79.0%, respectively (p=0.04). There were no significant differences in severe postoperative complications (p=1.000) or perioperative mortality (p=1.000) between the PDS followed by LT and the LT groups, and their 1-, 3- and 5-year survival rates were 91.2%, 82.1% and 82.1%, and 91.1%, 85.4% and 79.0%, respectively (p=0.694). For patients with portal hypertension due to hepatitis B cirrhosis, when they satisfy the indications for both PDS and LT, we appeal to perform PDS as bridging therapy for final liver transplantation.

Preoperative predictors of portal vein thrombosis after splenectomy with periesophagogastric devascularization

To evaluate the predictive value of preoperative predictors for portal vein thrombosis (PVT) after splenectomy with periesophagogastric devascularization. In this prospective study, 69 continuous patients with portal hypertension caused by hepatitis B cirrhosis underwent splenectomy with periesophagogastric devascularization in West China Hospital of Sichuan University from January 2007 to August 2010. The portal vein flow velocity and the diameter of portal vein were measured by Doppler sonography. The hepatic congestion index and the ratio of velocity and diameter were calculated before operation. The prothrombin time (PT) and platelet (PLT) levels were measured before and after operation. The patients' spleens were weighed postoperatively. The diameter of portal vein was negatively correlated with the portal vein flow velocity (P < 0.05). Thirty-three cases (47.83%) suffered from postoperative PVT. There was no statistically significant difference in the Child-Pugh score, the spleen weights, the PT, or PLT levels between patients with PVT and without PVT. Receiver operating characteristic curves showed four variables (portal vein flow velocity, the ratio of velocity and diameter, hepatic congestion index and diameter of portal vein) could be used as preoperative predictors of postoperative portal vein thrombosis. The respective values of the area under the curve were 0.865, 0.893, 0.884 and 0.742, and the respective cut-off values (24.45 cm/s, 19.4333/s, 0.1138 cm/s(-1) and 13.5 mm) were of diagnostically efficient, generating sensitivity values of 87.9%, 93.9%, 87.9% and 81.8%, respectively, specificities of 75%, 77.8%, 86.1% and 63.9%, respectively. The ratio of velocity and diameter was the most accurate preoperative predictor of portal vein thrombosis after splenectomy with periesophagogastric devascularization in hepatitis B cirrhosis-related portal hypertension.

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.

Long‐Term Results of Fundectomy and Periesophagogastric Devascularization in Patients with Gastric Fundal Variceal Bleeding

Gastric variceal bleeding is life-threatening, and occasionally it requires operative intervention, but its treatment is controversial. Based on our experience, we considered that fundectomy and periesophagogastric devascularization (FPD) offers an effective treatment method. Accordingly, this study was undertaken to document postoperative and long-term follow-up results, such as, gastric variceal bleeding recurrence and patient survival. A retrospective analysis was conducted on 41 patients with gastric fundal variceal bleeding who underwent FPD between August 1994 and May 2005. The evaluation included clinical characteristics, operative morbidity, mortality, and long-term follow up results. Operative morbidity and mortality rates were 26.8% and 17.1%, respectively. Child-Pugh classification, number of previous variceal bleeding episodes, success of preoperative intervention, and ongoing active bleeding during surgery were all factors found to have significant effects on postoperative mortality. No recurrent bleeding from gastric varices was encountered over a median follow-up period of 52.1 months. The cumulative 5-year survival rate was 62.0%, and the major causes of death were hepatocellular carcinoma (HCC) and hepatic failure. The operative procedure used in this study resulted in a low rate of recurrent bleeding and good long-term survival. This analysis of results suggests that fundectomy and periesophagogastric devascularization is an effective therapeutic intervention in patients with fundal variceal bleeding.

Portal vein flow rate used as a early predictor of portal vein thrombosis after periesophagastric devascularization

To evaluate the predictive value of portal vein flow rate preoperative for portal vein thrombosis (PVT) after periesophagastric devascularization in hepatitis B cirrhosis-related portal hypertension. From January 2007 to July 2008, 45 patients with portal hypertension caused by hepatitis B cirrhosis were performed splenectomy with peri-esophagogastric devascularization in the same medical group in West China Hospital of Sichuan University. The portal vein flow rate and the diameter of portal vein were measured with doppler sonography respectively before and after the operation. At the same time, the level of PT and PLT were detected. The weight of spleens were measured after operation. Thirteen cases suffered from PVT postoperatively. Portal vein flow rate was significantly lower in patients with PVT postoperation than that in patients without PVT (P < 0.01). In patients with PVT (n = 13) postoperation, the preoperative portal vein flow rate was (19.5 +/- 5.3) cm/s. Among the 13 cases, there were 12 cases whose flow rate were lower than 25 cm/s, and 1 case whose flow rate was 32. 3 cm/s; In patients without PVT (n = 32), the preoperative portal vein flow rate was (9.6 +/- 8.0) cm/s. In patients with lower rate (n = 17), the incidence rate of PVT was 70.6%; in patients with higher rate (n = 28), the incidence rate of PVT was 3.6%. The incidence rate of PVT in patients with lower rate was significantly lower than patients with higher rate (P < 0.01). The diameter of portal vein in patients with PVT was significantly wider than patients without PVT. The diameter of portal vein was negative correlative with the portal vein flow rate. The value 25 cm/s was of diagnostic efficiency, the sensitivity was 92.3%, and specificity was 70.6%. The portal vein flow rate preoperative can be used as an early predictor of portal vein thrombosis after periesophagastric devascularization in hepatitis B cirrhosis-related portal hypertension to give a guide to clinical work.

New operative method for fundal variceal bleeding: fundectomy with periesophagogastric devascularization.

Cirrhotic patients with gastric fundal bleeding occasionally require operative intervention. Fundal variceal bleeding may be controlled by performing a fundectomy in addition to periesophagogastric devascularization. For 23 patients with cirrhosis, preoperative nonsurgical intervention alone could not achieve definitive control of variceal bleeding from the gastric fundus, and periesophagogastric devascularization with the fundectomy--specifically resection of the varix-bearing lesion in the fundus--was performed. Direct inspection and palpation determined the area for the fundectomy, and resection was limited to the engorged varix-bearing area. The overall mortality rate was 26.1%. There were two postoperative deaths (18.2%) among 11 patients in the elective operation group and four deaths (33.3%) among 12 patients in the emergency operation group ( p > 0.05). The mortality rates among class A, B, and C patients, following the Child-Pugh classification for hepatic functional reserve, were 0% (0/4), 23.1% (3/13), and 50.0% (3/6), respectively ( p > 0.05). The patients who died had been transfused preoperatively with a mean of 13.0 +/- 10.5 units, and those who survived received a mean of 6.00 +/- 5.96 units ( p > 0.05). Patients who were successfully stabilized by preoperative endoscopic intervention had significantly lower mortality ( p < 0.001). During follow-up there was no recurrent bleeding from gastric varices, and there was only one case (4.35%) of hemorrhage from esophageal varices. Hence, periesophagogastric devascularization and fundectomy offers an alternative operative method for cirrhotic patients with variceal hemorrhaging from the gastric fundus.

Management of upper gastrointestinal bleeding from portal hypertension: Elective or emergency operation?

Objective: To evaluate the clinical outcome of emergency and elective operation of splenectomy with periesophagogastric devascularization in treating upper gastrointestinal hemorrhage resulted from portal hypertension. Methods: We retrospectively reviewed 219 patients of upper gastrointestinal hemorrhage resulted from portal hypertension treated using emergency or elective operation between Jul 2002 and Aug 2010. The clinical data were collected and analyzed. Results: In the group of elective operation, four patients with grade B and three with grade C died, and in the group of emergency operation, two patients with Grade B and four with Grade C died. The Grade C patients treated using emergency operation presented with a higher mortality than those treated using elective operation, but no significant difference was found (p>0.05). In the two groups, no patients with Grade A died. 17 cases (11.1%) suffered from complications in the group of elective operation and 11 cases (16.7 %) in emergency operation (p>0.05). The complication rate in patients with Grade C is significantly higher than that in patients with Grade A or B in each group (p<0.05). The hospital stay and cost in group of elective operation are significantly higher than those in group of emergency operation (p<0.05). Conclusion: The patients with Grade A or B treated using emergency operation have similar clinical outcomes as those treated using elective operation, but emergency operation may result in higher rate of death and complication in patients with Grade C.