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Portal vein thrombosis is a common complication after esophagogastric devascularization and splenectomy (EDS), with concealment and potential risks, which limited the therapeutic effect. The patients undergoing EDS are often accompanied by severe liver cirrhosis, whose abnormal hemostasis poses a dilemma for antithrombotic therapy. This article reviewed on the research progress of hemostasis of these patients, and risk factors, mechanism, prevention, therapy of post-EDS portal vein thrombosis.
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Objective To investigate the change of the hemodynamics of the portal vein and the impact on portal vein thrombosis after esophagogastric devascularization and splenectomy (EDS) with early enteral nutrition.The impact of early enteral nutrition on portal vein thrombosis was studied.Methods 93 patients who underwent EDS in our hospital from January 2017 to January 2015 were randomly assigned to the control group and the study group.In the study group,a nasogastric tube was placed 20 cm into the duodenum-jejunum region.Enteral nutrition was administered via the nasogastric tube 6 hours after the operation.The patients in control group were treated with total parenteral nutriction after the operation.The changes in the diameter of the portal vein,the blood flow velocity and the blood flow of the portal vein were monitored by color Doppler before and after the operation.The relationships of these measurements with formation of portal vein thrombosis were compared with the control group.Results In the enteral nutrition study group,the maximum velocity of the portal vein blood flow decreased from (25.9s-5.6) cm/s before operation to (16.8±5.0) cm/s after operation,and the difference was statistically significant (P＜0.01).The average velocity of portal vein blood flow decreased from (20.6±4.6) cm/s to (14.8±4.2) cm/s after operation,and the difference was also statistically significant (P＜0.01).With the increase in enteral nutrition speed and volume,the average blood flow velocity of the portal vein and the blood flow increased significantly,especially after the third day with the use of Kang Quan Gan,and the difference was statistically significant compared with the control group (P＜0.01).The diameter of the trunk of the portal vein in the study group was wider than that in the control group,and the difference was statistically significant (P＜0.01).The incidences of portal vein thrombosis in two groups were compared.The results showed that the incidence of portal vein thrombosis in the study group (2/48,4.0％) was significantly lower than that in the control group (9/45,20.0％),and the difference was statistically significant (P＜0.05).Conclusion Early enteral nutrition aftcr EDS not only provided enough nutrition,but also reduced portal vein thrombosis rate and promoted liver functional recovery by promoting portal venous blood flow.
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Objective To explore the risk factors of postoperative liver dysfunction in cirrhotic patients with Child-Pugh A liver function after splenorenal shunt and esophagogastric devascularization.Methods 128 Child-Pugh A cirrhotics undergoing splenorenal shunt and portal-azygous disconnection in our hospital from February,2014 to February,2016 were evaluated for risk factors of postoperative liver dysfunction.Results 22 cases (17.2％) developed postoperative liver dysfunction.By single factor analysis,age,history of upper gastrointestinal hemorrhage,ascites,serum prealbumin,serum albumin,mechanical ventilation time after surgery,postoperative serum albumin were associated with postoperative liver dysfunction.Non-conditional Logistic regression showed that age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction.Conclusion Patients' age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction after splenorenal shunt and portal-azygous disconnection.
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Objective To explore the risk factors of postoperative liver dysfunction in cirrhotic patients with Child-Pugh A liver function after splenorenal shunt and esophagogastric devascularization.Methods 128 Child-Pugh A cirrhotics undergoing splenorenal shunt and portal-azygous disconnection in our hospital from February,2014 to February,2016 were evaluated for risk factors of postoperative liver dysfunction.Results 22 cases (17.2％) developed postoperative liver dysfunction.By single factor analysis,age,history of upper gastrointestinal hemorrhage,ascites,serum prealbumin,serum albumin,mechanical ventilation time after surgery,postoperative serum albumin were associated with postoperative liver dysfunction.Non-conditional Logistic regression showed that age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction.Conclusion Patients' age ＞ 60,serum prealbumin ＜ 170 g/L and serum albumin ＜ 30 g/L was independent risk factors for postoperative liver dysfunction after splenorenal shunt and portal-azygous disconnection.
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Objective To compare the safety and feasibility of laparoscopic splenectomy and esophagogastric devascularization (LS + ED) versus open splenectomy and esophagogastric devascularization (OS + ED) in treating portal hypertension using Meta-analysis.Methods Controlled trials comparing LS + ED and OS + ED in treating portal hypertension were electronically searched from Wan Fang Data Knowledge Service Platform,Medalink,CNKI,PubMed,Elsevier,SpringerLink and CBM disc.The most recent search was conducted in April 2015.All the relevant data and references were retrieved and screened.RevMan 5.2 was used for data analysis.Results Eventually,7 randomized controlled trials (RCTs) or high-quality case-controlled studies involving 468 patients were included into this study.Meta-analysis showed LS reduced blood loss [WMD =214.67,95％ CI 198.74-230.60,P ＜ 0.01],shortened flatus time [WMD =17.72,95％ CI 12.39-23.04,P ＜ 0.01] and postoperative hospital stay [WMD =3.75,95％ CI 3.28-4.23,P ＜ 0.01],while the duration of surgery was shorter in OS (P ＞ 0.05).However,OS was comparable with LS in complication rates.Conclusions Comparing with OS,LS had the advantages of reducing intraoperative blood loss and shortening recovery time after operation.In patients with cirrhosis,portal hypertension and esophageal varices,laparoscopic splenectomy was safe and effective.
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ObjectiveTo investigate the effect and safety of laparoscopic splenectomy (LS) combined with esophagogastric devascularization (ED) in the treatment of esophagogastric variceal bleeding and severe hypersplenism. MethodsA retrospective analysis was performed for 68 patients with cirrhotic portal hypertension who visited The Central Hospital of Hanzhong from June 2012 to June 2013. The patients were divided into LS+ED group and open splenectomy (OS)+ED group, with 34 patients in each group. The clinical indices, complications, degree of gastric varices before and after surgery, and changes in Child-Pugh score for liver function were compared between the two groups. The t-test was used for comparison of continuous data between groups, and the chi-square test or the Fisher′s exact test was used for comparison of categorical data between groups. ResultsThe LS+ED group had a significantly lower postoperative drainage volume, significantly less intraoperative blood loss, a significantly shorter length of postoperative hospital stay, and a significantly shorter postoperative ventilation time than the OS+ED group (t=-3.144, -2.536, -4.151, and -2.671, P=0.003, 0.015, 0.001, and 0.002), while the improvements in the degree of gastric varices and Child-Pugh score for liver function showed no significant differences between the two groups (both P＞0.05). ConclusionLS combined with ED can significantly reduce intraoperative blood loss, postoperative drainage volume, time of passage of gas by anus after surgery, and length of postoperative hospital stay, and therefore, it is a safe, feasible, and effective method for the treatment of portal hypertension.
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Objective To investigate the effects and their potential mechanisms of splenectomy plus esophagogastric devascularization on non-invasive indexes of liver fibrosis and the cirrhosis progress in portal hypertensive patients with HBV-related cirrhosis. Methods Twenty consecutive portal hypertensive patients with positive HBsAg,negative HBV-DNA and Child-Pugh A(n=14)or B(n=6)were collected in this study. ELISA method was used to test the level of serum MMP-1 and TIMP-1;electrochemilumines-cence was used to measure hyaluronic acid( HA),N-terminal type Ⅲ procollagen peptide( PC-Ⅲ),lami-nin(LN)and collagen typeⅣ(C-IV). Results The serum TIMP-1,HA,PCⅢ,LN,and C-Ⅳwere signifi-cantly lower than the preoperative levels(p<0. 05),and MMP-1 slowly increased compared with the pre-operative levels(p<0. 05). The changes between TIMP-1 and HA,PC-Ⅲ,LN,or C-Ⅳ were positively correlated(r=0. 458~0. 783,p<0. 01/0. 05). The changes between MMP-1 and HA,PC-Ⅲ,LN,or C-Ⅳ were negatively correlated(r= -0. 545~ -0. 873,p<0. 01/0. 05). Conclusion Splenectomy plus esophagogastric devascularization can decrease non-invasive hepatic fibrosis serum markers and cytokines (TIMP-1),conducive to slowing down the disease progression in patients with cirrhosis.
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Objective To assess the efficacy of extensive esophagogastric devascularization with splenectomy for surgical treatment of portal hypertension complicating cirrhosis of liver, and to explore the pathogenesis of chronic congestive splenomegaly. Methods A retrospective analysis of clinical data of 232 patients of portal hypertension complicating cirrhosis of liver having undergone extensive esophagogastric devascularization with splenectomy was made. Pathological alterations and extracellular matrix productive cells of the congestive splenomegaly were studied both immunohistochemically and histologically. Results The functional markers including the numbers of PLT, WBC, and PTA in the peripheral blood and serum Alb were significantly improved after the operation compared with that of before the operation. Careful pre-operation preparation, replenishment of blood loss during the operation, postoperative drainage of the splenic bed, and prevention of complications were efficiently carried out. The mean volume of CCS spleens was 1 423.67?738.69cm 3. There was an obvious increase in the numbers of vimentin-, ?-SMA-positive cells in the CCS tissues, as well as CD68-positive macrophages. Conclusions The results indicated that extensive esophagogastric devascularization with splenectomy was a reasonably effective alternative therapy for patients with portal hypertension complicated by esophageal varices and congestive splenomegaly. Adequate replacement of blood lost in prevention of operation and postoperative complications were essential for satisfactory recovery of the petient. The activation of macrophagic system, with proliferation of fibroblasts and myofibroblasts, might participate in the pathogenesis of congestive splenomegaly.
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Objective To study a new operative method for treatment of hepatic venous occlasion without (associated) pathologic change of inferior vena cava or long-segment stricture. Methods A total of 44 cases of Budd-chiari syndrome with hepatic venous occlusion without pathologic change or long-segment stricture of (inferior) vena cava underwent combined mesocaval C-shunt, ligation of splenic artery, and esophagogastric (devascularization).Results Pre-shunt portal venous pressure was 36cmH2O(31~45 cmH2O, 1cmH2O=0.0098kPa) and post-shunt pressure fell to 26 cmH2O(21~33 cmH2O),the mean reduction was 10 cmH2O. One patient died of liver failure. A slight degree of hepatic encephalopathy occurred in 2patients who recovered after conservative treatment.Chylorrhea occurred in 4 patients, and it spontaneously disappeared 7d to 3.5months after operation. 39 patients(88.6% follow up) were followed up for 6months to 7years , and there was no case of recurrent bleeding nor hepatic encephalopathy. Ascites disappeared in 31cases,and was markedly reduced in 7 cases .The prosthetic grafts were patent as shown by color Doppler ultra sound in all followed-up patients.Conclusions This operation is simple and effective for B-CS with hepatic venous (occlusion) but not associated with inferior vena caval pathologic change or long-segment stricture.
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Objective Liver function in perioperative periods, postoperative complications, and pathological changes in the liver were studied and compared between patients undergoing emergent and elective surgical intervention (extensive esophagogastric devascularization, EED) for portal hypertension (PTH), with the purpose to elucidate the pathogenesis of PTH. Methods The clinical data and liver biopsies from 150 cases of inpatients with hepatis cirrhosis and PTH who underwent either emergent (28 cases) or elective (100 cases) surgical intervention including extensive esophagogastric devascularization (EED) in 302 th Hospital of PLA were analysed. Liver biopsy was done in 128 patients, and the expression of ?-smooth muscle actin (?-SMA), tubulin?and ?in hepatic stellate cells (HSCs), and endothelin-1 (ET-1) was histochemically studied in the liver tissue. Results It was found that the mean internal diameter of portal veins before surgery was larger and the incidence of pre-operative acute variceal haemorrhage was significantly higher in the emergent EED group than those in the elective EED group (P