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Objective:To evaluate whether vagus nerve-guided robotic splenectomy and azygoportal disconnection (VNRSD) is feasible and safe and to determine whether VNRSD can be competent for well protecting vagus nerve.Methods:In this prospective clinical study, 12 cirrhotic patients with portal hypertension, hypersplenism and esophagogastric variceal bleeding (EVB) who accepted VNRSD at the Clinical School of Medicine of Yangzhou University between January 2022 and March 2022 were included, including 5 females and 7 males, aged (56.6±11.6) years old. Clinical data such as visual analog scale (VAS) pain score, conversion to laparotomy, esophagogastric variceal bleeding, and death were collected. The patients were asked to reexamine in the outpatient department 1 month after the operation, and the diarrhea, delayed gastric emptying and epigastric fullness were followed up.Results:VNRSD was successfully performed in all patients. There was no conversion to open or laparoscopic operations. The operation time was (170.0±16.8) min, blood loss was (60.8±11.3) ml, VAS pain score on the first day was (2.2±0.9) scores, and the postoperative hospital stay was (7.7±0.7) d, the four patients had main portal vein system thrombosis on the 7th day after operation. At the first day after operation, all patients were mange to take semi-fluid and off-bed activity. There were no incisional complications, pneumonia, gastric fistula, pancreatic fistula, and abdominal infection. No patients suffered from diarrhea, delayed gastric emptying, and epigastric fullness. None of the patients suffered from esophagogastric variceal bleeding, hepatic encephalopathy or death after operation and one month after operation, and the esophagogastric variceal were significantly improved. And no patient complained of abdominal distension or diarrhea.Conclusion:VNRSD procedure is not only technically feasible and safe, but also effectively protects anterior and posterior vagal trunks and all their branches, completely eradicating digestive system complications.
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Objective:To evaluate the clinical efficacy of laparoscopic splenectomy and azygoportal disconnection (LSD) with intraoperative endoscopic variceal ligation (LSDL) in the treatment of esophagogastric variceal bleeding (EVR).Method:In this study,90 cirrhotic patients with esophagogastric variceal bleeding (EVB) were divided to receive either LSD ( n=45) or LSDL ( n=45) from Jan 2020 and Dec 2021. Results:There were no significant differences in estimated blood loss, incidence of blood transfusion, time to first flatus, off-bed activity and postoperative hospital stay between the two groups (all P>0.05). Compared with LSD group, operation time was longer in LSDL group[ (140±21) min vs. (150±19) min, t=2.420, P=0.018]. LSDL was associated with significantly decreased EVR rate in one year follow-up (2% vs. 18%, P=0.030). Univariate analysis and multivariate logistic regression revealed that LSDL was a significant independent protective factor for EVR as compared with LSD ( P<0.05). Conclusion:LSDL procedure is not only technically feasible and safe, it also contributed to lower postoperative EVR risk than single LSD.
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Objective:To investigate the value of liver fibrosis serum markers in predicting esophagogastric variceal re-bleeding (EGVR) after laparoscopic splenectomy and azygoportal discon-nection (LSD).Methods:The prospective study was conducted. The clinical data of 155 cirrhotic portal hypertension patients with EGVR after LSD in the Clinical Medical College of Yangzhou University from September 2014 to January 2017 were selected. Observation indicators: (1) grouping situations of the enrolled patients; (2) risk factors analysis for postoperative EGVR; (3) prediction of postoperative EGVR; (4) follow-up. Follow-up was conducted using telephone interview, outpatient examination and hospitalization. Patients were followed up once every 3 months after operation to detect occurrence of EGVR and survival of patient up to January 2018. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data wite skewed distribution were represented as M(range), and comparison between groups was conducted using the non-parameter test. Count data were described as absolute numbers, and comparison between groups were conducted using the chi-square test or Fisher exact probability. Logistic regression model was used for multivariate analysis. The area under curve (AUC) of receiver operating characteristic (ROC) curve was used to estimate the diagnostic efficiency. The Youden index was used to determine the optimal cut-off point. Results:(1) Grouping situations of the enrolled patients. A total of 155 patients were selected for eligibility. There were 106 males and 49 females, aged (53±11)years. Of the 155 patients, there were 21 cases with EGVR in the postoperative 1 year and 134 cases without EGVR in the postoperative 1 year. The protein expression of laminin and collagen Ⅳ were 100.3(range, 16.1?712.2)μg/L and 68.4(range, 35.0?198.8)μg/L in patients with EGVR, vs 35.5(range, 2.0?521.2)μg/L and 43.5(range, 4.3?150.4)μg/L in patients without EGVR, showing significant differences between them ( Z=?4.55, ?4.52, P<0.05). (2) Risk factors analysis for postoperative EGVR. According to the Youden index, the optimal cut-off point of protein expression of laminin and collagen Ⅳ were 64.0 μg/L and 65.0 μg/L, respec-tively. Results of multivariate analysis showed that the protein expression of laminin ≥64.0 μg/L and the protein expression of collagen Ⅳ ≥65.0 μg/L were independent risk factors for postoperative EGVR ( odds ratio=9.69, 8.16, 95 confidence intervals as 3.05?30.82, 2.65?25.15, P<0.05). (3) Prediction of postoperative EGVR. Results of ROC curve showed that the AUC of laminin and collagen Ⅳ in predicting postoperative EGVR was 0.79 (95% confidence interval as 0.66?0.92), with sensi-tivity as 0.62 and specificity as 0.96. (4) Follow-up. All the 155 patients were followed up for 12(range, 1?12)months. During the follow-up, there were 21 of the 155 patients (13.55%) with post-operative EGVR, including 3 cases died of EGVR. Of the 21 patients with postoperative EGVR, there were 6 cases with postoperative EGVR during the first month after operation including 2 cases died, 5 cases with postoperative EGVR at postoperative 1?3 month, 6 cases with postoperative EGVR more than 3 month and less than 6 month after operation and 4 cases with postoperative EGVR at postoperative 6?12 months including 1 case died at postoperative 12 month. Conclusions:Laminin and collagen Ⅳ show satisfactory ability to predict EGVR after LSD.
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Objective:To investigate the clinical efficacy of Da Vinci robotic assisted vagus nerve-preserving splenectomy and azygoportal disconnection.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 10 cirrhotic portal hypertension patients with esophagogastric variceal bleeding and hypersplenism who were admitted to Clinical Medical College of Yangzhou University from February to May 2021 were collected. There were 4 males and 6 females, aged from 43 to 64 years, with a median age of 55 years. All 10 patients underwent Da Vinci robotic assisted vagus nerve-preserving splenectomy and azygoportal discon-nection. Observation indicators: surgical situations, intraoperative autologous blood transfusion, conversion to open laparotomy, allogeneic blood transfusion, the operation time, volume of intra-operative blood loss, time to initial diet intake, time for out-of-bed activity, postoperative complica-tion, duration of postoperative hospital stay and follow-up. Follow-up was conducted using out-patient examination and telephone interview to detect recurrent gastrointestinal hemorrhage and gastric retention up to July 2021. Measurement data with normal distribution were represented as Mean± SD and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers. Results:All 10 patients underwent Da Vinci robotic assisted nerve-preserving splenectomy and azygoportal disconnection successfully, with intraopera-tive autologous blood transfusion and without conversion to open laparotomy or allogeneic blood transfusion. The operation time, volume of intraoperative blood loss, time to initial diet intake and time for out-of-bed activity of 10 patients were (180±14)minutes, (111±28)mL, (1.5±0.5)days and (2.5±0.7)days, respectively. Of the 10 patients, 1 case underwent mild pancreatic leakage, 1 case underwent pneumonia, 2 cases underwent portal vein thrombosis and 3 cases underwent splenic vein thrombosis. Patients with postoperative complications was cured after conservative treatment. The duration of postoperative hospital stay of 10 patients was (8.9±0.9)days. All 10 patients were discharged without perioperative death and followed up for 1 to 4 months, with a median follow-up time of 3 months. There was no patient undergoing gastrointestinal hemorrhage and gastric reten-tion.Conclusion:Da Vinci robotic assisted vagus nerve-preserving splenectomy and azygoportal disconnection is safe and feasible for the treatment of cirrhotic portal hypertension patients with esophagogastric variceal bleeding and hypersplenism.
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Intrahepatic cholangiocarcinoma(ICC) is a malignant tumor that originates in the epithelium of the proximal proximal to the second-degree bile ducts and has a high degree of malignancy. The causes of ICC are widely geographically diverse. Pathogenesis of ICC involves multiple molecular alterations at the level of genome, epigenome and stromal environment resulting in several deregulated signal transduction pathways. There are three types of pathological classification: mass-forming, periductal infiltrating, and intraductal growth. The mixed type of mass-forming + periductal infiltrating has the highest degree of malignancy. Early diagnosis of ICC is not easy, and tumor biomarkers such as CA19-9, CEA and so on, have some reference values, and multiple imaging examinations are needed to confirm each other. The effect of surgery mainly depends on the characteristics of the tumor, the vascular invasion of the tumor, the resection margin of the tumor and lymphatic metastasis. Lymph node dissection is controversial. If local lymphatic metastasis is identified, standardized lymph node dissection can improve ICC prognosis. Some ICC patients benefit from laparoscopic staging. In experienced centers, minimally invasive treatment can provide oncological outcomes similar to open resection for specific ICC patients. Liver transplantation is feasible in early ICC patients, but further clinical validation is needed.
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Objective@#To investigate the clinical efficacy of laparoscopic splenectomy combined with pericardial devascularization in the treatment of cirrhotic patients with cirrhotic portal hypertension.@*Methods@#The retrospective and descriptive study was conducted. The clinicopathological data of 425 patients with cirrhotic portal hypertension who were admitted to Northern Jiangsu People′s Hospital Affiliated to Yangzhou University were collected. There were 289 males and 136 females, aged (53±11)years, with a range from 21 to 79 years. All the patients were allocated into 3 periods according to the operation time, including 100 patients of early period from February 2012 to March 2014, 156 patients of mature technology period from April 2014 to August 2016, and 169 patients of technology innovation period from september 2016 to December 2018. The patients of early period and mature technology period underwent laparoscopic splenectomy combined with pericardial devascularization, and the patients of technology innovation period underwent vagus nerve-preserving laparoscopic splenectomy combined with pericardial devascularization. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Patients were followed up by outpatient examination to detect the upper digestive rebleeding, gastric retention, and diarrhea up to March 2019. Sequential therapy of endoscopic variceal ligation (EVL) was slectively performed on patients based on results of gastroscopy. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using ANOVA, and paired comparison was analyzed using the t test. Measurement data with skewed distribution were represented as M (range), and comparison between groups was anlyzed using the Kruskal-Wallis rank sum test, and paired comparison was analyzed using the rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test and Fisher exact probability.@*Results@#(1) Surgical situations: the operation time, volume of intraoperative blood loss, cases with intraoperative blood transfusion, cases with conversion to open surgery, and cases with emergency operation for bleeding were (187±46)minutes, 150 mL (range, 50-1 300 mL), 2, 2 , 1 for patients of early period, (164±22)minutes, 50 mL (range, 30-100 mL), 1, 1, 1 for patients of mature technology period, and (150±18)minutes, 50 mL (range, 10-300 mL), 0 , 0 , 0 for patients of technology innovation period, respectively. There were significant differences in the operation time and volume of intraoperative blood loss between the three groups (F=55.482, χ2=94.620, P<0.05). There was no significant difference in the cases with intraoperative blood transfusion, cases with conversion to open surgery, or cases with emergency operation between the three groups (P>0.05). (2) Postoperative situations: 425 patients had oral aspirin enteric-coated tablets for prevention of thrombus, with no perioperative death. Duration of postoperative hospital stay, cases with portal vein thrombosis at postoperative 7 days, cases with pancreatic fistula, cases with pulmonary infection, and cases with abdominal infection were (11.0±2.9)days, 46, 2, 1, 0 for patients of early period, (9.9±1.7)days, 81, 3, 0, 0 for patients of mature technology period, and (8.8±1.3)days, 83, 2, 1, 1 for patients of technology innovation period, respectively. There was a significant difference in the duration of postoperative hospital stay between the three groups (F=39.836, P<0.05), between patients of mature technology and patients of early period (t=3.329, P<0.05), between patients of mature technology period and patients of technology innovation (t=6.502, P<0.05). There was no significant difference in the cases with portal vein thrombosis at postoperative 7 days between the three groups (χ2=0.865, P>0.05) and no significant difference in the cases with pancreatic fistula, cases with pulmonary infection, or cases with abdominal infection between the three groups (P>0.05). Patients with portal vein thrombosis at postoperative 7 days had oral aspirin enteric-coated tablets or warfarin for treatment. Patients with pancreatic fistula, pulmonary infection, and abdominal infection were cured and discharged after conservative treatment. (3) Follow-up: all the 425 patients were followed up for 1-72 months, with a median follow-up of 36 months. Of the 425 patients, 261 underwent postoperative sequential therapy of EVL, including 133 patients of mature technology period and 128 patients of technology innovation period. The incidence rate of upper digestive rebleeding was 3.83%(10/261) of the 261 patients undergoing postoperative sequential therapy of EVL and 17.68%(29/164) of 164 patients without postoperative sequential therapy of EVL, showing a significant difference between them (χ2=23.185, P<0.05). The incidence rates of gastric retention and diarrhea were 96.24%(128/133) and 61.65%(82/133) for 133 patients undergoing sequential therapy of EVL in mature technology period, and 1.56%(2/128) and 3.91%(5/128) for 128 patients undergoing sequential therapy of EVL in technology innovation period, showing significant differences between them (χ2=233.876, 97.883, P<0.05).@*Conclusions@#It is safe and feasible of laparoscopic splenectomy combined with pericardial devascularization for patients with cirrhotic portal hypertension, and intraoperative vagus nerve-preserving can reduce volume of intraoperative blood loss and incidence of postoperative complications.
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Objective To investigate the clinical efficacy of laparoscopic splenectomy combined with pericardial devascularization in the treatment of cirrhotic patients with cirrhotic portal hypertension.Methods The retrospective and descriptive study was conducted.The clinicopathological data of 425 patients with cirrhotic portal hypertension who were admitted to Northern Jiangsu People's Hospital Affiliated to Yangzhou University were collected.There were 289 males and 136 females,aged (53±11)years,with a range from 21 to 79 years.All the patients were allocated into 3 periods according to the operation time,including 100 patients of early period from February 2012 to March 2014,156 patients of mature technology period from April 2014 to August 2016,and 169 patients of technology innovation period from september 2016 to December 2018.The patients of early period and mature technology period underwent laparoscopic splenectomy combined with pericardial devascularization,and the patients of technology innovation period underwent vagus nerve-preserving laparoscopic splenectomy combined with pericardial devascularization.Observation indicators:(1) surgical situations;(2) postoperative situations;(3) follow-up.Patients were followed up by outpatient examination to detect the upper digestive rebleeding,gastric retention,and diarrhea up to March 2019.Sequential therapy of endoscopic variceal ligation (EVL) was slectively performed on patients based on results of gastroscopy.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using ANOVA,and paired comparison was analyzed using the t test.Measurement data with skewed distribution were represented as M (range),and comparison between groups was anlyzed using the Kruskal-Wallis rank sum test,and paired comparison was analyzed using the rank sum test.Count data were described as absolute numbers or percentages,and comparison between groups was analyzed using the chi-square test and Fisher exact probability.Results (1) Surgical situations:the operation time,volume of intraoperative blood loss,cases with intraoperative blood transfusion,cases with conversion to open surgery,and cases with emergency operation for bleeding were (187±46) minutes,150 mL (range,50-1 300 mL),2,2,1 for patients of early period,(164±22)minutes,50 mL (range,30-100 mL),1,1,1 for patients of mature technology period,and (150± 18)minutes,50 mL (range,10-300 mL),0,0,0 for patients of technology innovation period,respectively.There were significant differences in the operation time and volume of intraoperative blood loss between the three groups (F=55.482,x2 =94.620,P＜0.05).There was no significant difference in the cases with intraoperative blood transfusion,cases with conversion to open surgery,or cases with emergency operation between the three groups (P＞0.05).(2) Postoperative situations:425 patients had oral aspirin enteric-coated tablets for prevention of thrombus,with no perioperative death.Duration of postoperative hospital stay,cases with portal vein thrombosis at postoperative 7 days,cases with pancreatic fistula,cases with pulmonary infection,and cases with abdominal infection were (11.0±2.9) days,46,2,1,0 for patients of early period,(9.9±.1.7)days,81,3,0,0 for patients of mature technology period,and (8.8±1.3)days,83,2,1,1 for patients of technology innovation period,respectively.There was a significant difference in the duration of postoperative hospital stay between the three groups (F =39.836,P ＜ 0.05),between patients of mature technology and patients of early period (t =3.329,P＜0.05),between patients of mature technology period and patients of technology innovation (t =6.502,P＜0.05).There was no significant difference in the cases with portal vein thrombosis at postoperative 7 days between the three groups (x2 =0.865,P ＞ 0.05) and no significant difference in the cases with pancreatic fistula,cases with pulmonary infection,or cases with abdominal infection between the three groups (P＞0.05).Patients with portal vein thrombosis at postoperative 7 days had oral aspirin enteric-coated tablets or warfarin for treatment.Patients with pancreatic fistula,pulmonary infection,and abdominal infection were cured and discharged after conservative treatment.(3) Follow-up:all the 425 patients were followed up for 1-72 months,with a median follow-up of 36 months.Of the 425 patients,261 underwent postoperative sequential therapy of EVL,including 133 patients of mature technology period and 128 patients of technology innovation period.The incidence rate of upper digestive rebleeding was 3.83％ (10/261) of the 261 patients undergoing postoperative sequential therapy of EVL and 17.68％ (29/164) of 164 patients without postoperative sequential therapy of EVL,showing a significant difference between them (x2 =23.185,P＜0.05).The incidence rates of gastric retention and diarrhea were 96.24％ (128/133) and 61.65％ (82/133) for 133 patients undergoing sequential therapy of EVL in mature technology period,and 1.56％ (2/128) and 3.91％(5/128) for 128 patients undergoing sequential therapy of EVL in technology innovation period,showing significant differences between them (x2 =233.876,97.883,P＜0.05).Conclusions It is safe and feasible of laparoscopic splenectomy combined with pericardial devascularization for patients with cirrhotic portal hypertension,and intraoperative vagus nerve-preserving can reduce volume of intraoperative blood loss and incidence of postoperative complications.
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Portal vein system thrombosis (PVST) is a common complication in patients after open or laparoscopic splenectomy or combined with devascularization.It may endanger the health of the patients after surgery and even potentially endanger the patient's life in severe cases.The formation and development of PVST is affected by many factors,and the correct use of anticoagulant drugs play a vital role in the prevention and treatment of PVST in postoperative patients with cirrhotic portal hypertension.This article discusses the advances in research on the prevention and treatment of PVST after open or laparoscopic splenectomy or combined with devascularization with anticoagulant drugs,and reviews the current anticoagulant properties and recommends of anticoagulant therapy,further guides the use of clinical anticoagulant drugs to reduce the incidence of PVST and improve the quality of life in patients with such surgery.