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The portal vein system is the main blood supply system of the liver, and damage to the portal vein system caused by cirrhotic portal hypertension may be the second hit to the liver. Protection of the portal vein will ensure sufficient blood supply of the liver and maintain its structure and function. Starting from the physiological structure and pathological changes of the portal vein, this article elaborates on the adverse effect of portal hypertension on the liver from the three new perspectives of thrombosis of the portal system, abnormal angiogenesis, and disturbance of hepatic sinusoidal homeostasis. It is suggested to change the current status of passive treatment of portal hypertension complications and encourage scientific exploration to reduce portal hypertension from multiple angles as early as possible to avoid repeated endoscopic devascularization of collateral circulation and splenectomy, so as to reduce various factors for the damage of the portal system, maintain the homeostasis of the portal system, and protect the liver.
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Objective To evaluate the feasibility and clinical outcomes of interventional treatment of Budd-Chiari syndrome (BCS) associated with simultaneous upper gastrointestinal hemorrhage.Methods The clinical data of 32 patients of BCS with upper gastrointestinal hemorrhage from October 2015 to April 2008 in First Affiliated Hospital of Zhengzhou University were analyzed retrospectively.Variceal embolization and inferior vena cave (IVC) and/or hepatic veins (HV) angioplasty were performed simultaneously.Perioperative complications were observed.Portal vein pressures were measured through catheterization preand post-operation.Restenosis of IVC and HV,upper gastrointestinal hemorrhage were observed on followup.Results Percutaneous transluminal balloon angioplasty were successfully carried out in all patients:16 patients with IVC and 17 patients with HV stenosis underwent angioplasty without stent placement.Portography indicated one esophageal and gastric varices in 17 patients and two in 15 patients.All the varices were embolized successfully.The portal vein pressure reduced from (35.7±2.9) cmH2O to (31.2±2.5) cmH2O (P ＜ 0.05,1 cmH2O =0.098 kPa).Portal vein pressure reduced from (35.8± 3.0) cmH2O to (30.7±2.3) cmH2O in HV type BCS post-operation,and reduce from (35.6±3.0) cmH2O to (31.8±2.6) cmH2O in HV and IVC involved type,which indicated that portal vein pressure decreased more obviously after HV recanalization.On follow-up for 3 to 32 months (mean 11.7 ±7.8 months),7 patients with IVC and 5 patients with HV stenosis developed restenosis.Transluminal balloon angioplasty was performed.No upper gastrointestinal hemorrhage occurred during the follow-up period.Conclusion One-stage interventional treatment of BCS with upper gastrointestinal hemorrhage was safe and effective,and had satisfactory mediumlong term outcomes.
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Objective To investigate the clinical outcomes of radical surgery for pancreatic body and tail tumors accompanied with sinistral portal hypertension (SPH).Method The clinicopathological data of 35 patients with pancreatic body and tail tumors accompanied with SPH operated from January 2004 to December 2014 were retrospectively analyzed.Results Of 35 patients,22 patients had body and tail pancreatic carcinomas,10 patients had malignant solid pesudopaillary tumors and 1 patients had a neuroendocrine tumor.All these patients developed splenomegaly and varices in the gastric fundus with normal hepatic function.The splenic vein pressure was (27.3 ±3.8)cmH2O (1 cmH2O =0.098 kPa),its average diameter was (1.3 ± 0.3) cm,and the speed of splenic vein blood flow was (8.9 ± 0.8) cm/s.Of the 35 patients with pancreatic body and tail tumors who underwent radical resectional operations,22 patients in addition underwent devascularization.There were 13 of these 22 patients who underwent pericardical devascularization and the remaining 9 underwent total or proximal gastrectomy.The main complications were pancreatic fistula (n =5,14.2％),intra-abdominal infection (n =4,11.5％),delayed gastric emptying (n =1,2.8％),lymphatic fistula (n =1,2.8％) and gastric perforation (n =1,2.8％).The post-complication morbidity rate was 34％.All these patients were followed-up for 6 to 60 months after operations.There was no upper gastrointestinal bleeding which occurred within 6 months of operation.Conclusion Multi-disciplinary treatment,complete preoperative evaluation,correct perioperative and individualized management enhanced efficacy in the surgical treatment of patients with pancreatic body and tail tumors with SPH.
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Objective To investigate the causes and prevention measures for patients with portal hypertension hypersplenism undergone splenectomy plus pericardial devascularization and post-operative portal vein thrombosis (portal vein thrombogenesis,PVT).Methods 178 cases of splenectomy plus devascularization from July 2013 to May 1994 in Cangzhou Central Hospital of Hebei Province,including 102 cases of early postoperative application of low molecular heparin anticoagulant for the prevention group,76 cases without anticoagulant medicine as control group.33 cases with PVT found by B ultrasound or CT scan,were treated with urokinase body intravenous thrombolysis,hepatic artery catheterization thrombolysis,intestinal resection of + Fogarty catheter embolectomy vein stump treatment respectively.Results The total incidence of thrombosis was 18.5％ (33/178),prevention group was 8.8％ (9/102),including 7 cases in grade Ⅰ,Ⅲ,Ⅳ thrombus,in 1 cases,no intestine necrosis.The control group thrombosis rate was 31.6％ (24/76),including 7 cases in grade Ⅰ,Ⅲ,Ⅳ,thrombosis in 17 cases,5 cases of intestine necrosis,two groups of thrombosis rate were significantly differences (x2 =14.932,P =0.000).Thrombus disappeared completely in 7 cases,the thrombus grading decreased in 2 cases in the preventive group after thrombolysis,and thrombus disappeared completely in 6 cases,11 cases of thrombosis degraded in the control group after treatment of thrombolysis,1 case cured by TIPS with thrombolysis and thrombectomy,1 case died of sudden digestive tract bleeding,Among 5 cases of intestinal necrosis,4 cases died and 1 case undergone abdominal exploration being found with intestine & colon necrosis.Conclusions There are a variety of factors causing PVT after splenectomy and devascularization.Early anticoagulation can significantly reduce the incidence of PVT,early discovery and treatment can prevent severe outcome.
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ObjectiveTo evaluate the effect of early anticoagulation therapy in the prevention of portal venous system thrombosis (PVT) in portal hypertensive patients undergoing splenectomy plus portaazygous devascularization. MethodsAt our hospital from August 1994 to July 2011,157 patients underwent splenectomy plus devascularization. Among them 89 cases (beginning 2000 )receiving intravenous low molecular dextran 500 ml daily for 7 days starting immediately postoperatively,and after 48 h subcutaneously low molecular weight heparin calcium 4250 U every 12 hours for 7 - 14 d were in group A.Before 2000,the 68 cases receiving no postoperative anticoagulation therapy were in the control group (B).After 3 - 12 months follow-up,PVT was evaluated and compared between the two groups. ResultsIn group A thrombosis incidence was 8％ (7/89),of which class Ⅰ, Ⅱ thrombosis accounted for 71％(5/7),class Ⅲ and up thrombosis accounted for 29％ (2/7),there was no bowel necrosis case; In group B thrombosis incidence was 29％ (20/68),class Ⅰ,Ⅱ thrombosis accounted for 20％ (4/20),class Ⅲand above thrombosis accounted for 80％ (16/20),3 cases suffered from intestinal necrosis,the difference was statistically significant (P ＜ 0.01 ). ConclusionsMultifactors lead to postoperative PVT formation,early postoperative,anticoagulation therapy is safe,and effective in the prevention of postoperative PVT.
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Objective To evaluate the efficacy of Fluency stent-graft (Bard Corp) in transjugular intrahcpatic portosystemic shunt (TIPS).Methods The clinical data of 21 consecutive patients treated by TIPS using Fluency stent-grafts were retrospectively reviewed.All of them were recurrent variceal bleeding secondary to portal vein hypertension,1 was bleeding secondary to primary hepatic carcinoma with port vein thrombns,and 1 was Budd-Chiari syndrome.They were followed-up after (10.1 ± 4.6) months (2.0 to 24.0 months).Stent-grafts patancy,portal vein pressure and liver function were recorded and compared.Results Twenty-five stent-grafts were successfully implanted in 21 patients,23 stent grafts were 8 mm 2 were 10 mm in diameter.The covered length of the stents varied from 6 to 8 cm.The bleeding was stopped and the portal vein pressure decreased significantly from (25.4 ± 3.5) mm Hg to (15.4 ± 2.8) mm Hg (t = 12.495,P < 0.01).During the follow-up period,The patient with primary HCC and portal vein thrombosis died 4 months after the procedure. One case had a new primary HCC during the follow-up and died 24 months after the procedure.One ease with variceal bleeding secondary to portal vein hypertension died of muhisystem organ failure.One case occluded in the hepatic vein and had another stcnt graft implanation.The other 17 cases had no stenosis after 7 to 17 months follow-up.Ultrasound showed that the stents were patent 1 week before the patients died.Three cases had transient symptoms of hepatic encephalopathy and recovered after treatment.The Child scores of the 19 patients survived more than 6 months were 6.3 ±1.4 before and 6.4 ± 1.9 after the procedure without significant difference (t = 0.645,P > 0.05).Conclusion The Fluency stent-grafts could increase the patency of the TIPS,but its efficacy on the long-term effect and hepatic encephalopathy need further investigation.
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Objective To investigate the effect on free portal pressure (FPP), postoperative complications and rebleeding of devascularization procedure with intact portasystemic collateral shunts. Methods The clinical data of 121 patients with portal hypertension undergoing devascularization in our hospital from 1994 to 2004 were retrospectively analyzed. Patients were divided into two groups(96 cases and 25 cases) , respectively according to whether or not the portasystemic collateral shunts were reserved during operation. Results (1) Free portal pressure (FPP) decreased significantly after devascularization in both two groups [(47?8) cmH2O vs. (37?5) cmH2O, (41?7) cmH2O vs. (37?6) cmH2O; P
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Objective To review the experience on the surgical management for advanced gastric carcinoma with portal hypertension. Methods In this study, 14 advanced gastric carcinoma with portal hypertension patients were analyzed retrospectively, liver cirrhosis was found in 13 cases. In 10 esophageal variceal patients, 5 had upper gastrointestinal bleeding history. All of those cases were associated with different degree of hypersplenism. The tumours situated at the upper third of the stomach in 2 patients, middle and upper third in 2 and lower third in 10. Five patients underwent curative distal subtotal gastrectomy and splenectomy, 2 cases did radical distal subtotal gatrectomy and pericardial devascularizaion, 2 curative distal subtotal gastrectomy combined with splenic artery ligation,2 did total gastrectomy and pericardial devascularizaion,2 cases did radical proximal gastrectomy and pericardial devascularization and 1 patient did distal subtotal gastrectomy only. Results Three died from extensive wound bleeding, jejunal fistula and liver failure respectively. 3 patients were complicated by left subdiaphragmatic abscess, hepatic dysfunction and massive ascites individually. The morbidity and mortality rate were 42.86% and 21.43% respectively. Conclusion The surgical procedures for patients of advanced gastric carcinoma with portal hypertension caused a considerably high postoperative mortality and morbidity rate.
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Objective To investigate the changes of CD cells in splenic tissue in patients with portal hypertension(PHT) accompanied by hypersplenism to explore the features of immunological function in patients with PHT.Methods The resected splenic tissue was made into paraffin sections for the detection of number and distribution of CD_3~+,CD_8~+,CD_(20)~+ and CD_(68)~+ cells,with the control of those in healthy individuals.Results The numbers of CD_3~+,CD_8~+,CD_(20)~+ and CD_(68)~+ cells remarkably decreased in patients with PHT accompanied by hypersplenism compared with those in normal controls.In normal controls,the CD_(68)~+ cells mainly existed in splenic lymphocyte nodules and red pulp(RP),and in patients with PHT,they existed in splenic lymphocyte nodules and periarterial lymphatic sheath(PALS).Compared with the normal controls,the numbers of CD_(68)~+ in splenic lymphocyte nodules,red pulp and marginal zone(MZ) decreased in patients with PHT.Conclusion The number and distribution of CD cells are changed in patients with PHT accompanied by hypersplenism.With splenectomy,the immunological function may be improved and the abnormalities in routine blood parameters and liver function be corrected.However,the immunological indexes detected in the study can not completely show the systematic immunological function of the patients with PHT accompanied by hypersplenism.Thus we should conduct a long-term follow-up study on immunological function in these patients.
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Objective To evaluate pericardial devascularization with splenectomy (PCDV) for the treatment of cirrhotic portal hypertension. Methods From January 1994 to December 2004, 177 patients were treated by PCDS, among them posthepatitic cirrhosis was identified in 170 cases, and alcoholic cirrhosis in 7. One hundred and thirty two patients were operated on electively, 25 prophylactically, and 20 emergently. Results The bleeding control rate was 95% , the overall operative mortality rate was 4. 5%. The main causes of death were upper gastrointestinal bleeding, hepatic failure and intra-abdomimal hemorrhage. The mean follow-up time was 3. 6 years. The 5-year survival rate was 90%. The 5-year recurrent bleeding rate was 5. 1% , The rate of postoperative hepatic encephalopathy was 5. 1%. Conclusions This procedure has the advantage of high successful rate of bleeding control, low complication rate, and long term survival.
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Objective To investigate the pathogenesis of portal hypertensive gastropathy(PHG). Methods Two rat models with portal hypertension(PHT) and a sham operation group were established to detect the pathological changes in histology and ultrastructure of the gastric mucosa as well as quantitative changes in histological morphology by graphic analysis computer system. Results Prominent edema, scattered red dots/ecchymosis were found in gastric mucosa in rats with PHT. Light and scan electron microscopy showed swelling or exfoliating of the epithelium cell, reduction of gastric gland number, thin of gastric mucosa, while infiltration of inflammatory cells, epithelium metaplasia were not found. The most characteristic findings were the changes of the mucosal capillaries and venules in both mucosal basal lamina and submucosa layer light microscopically, as well as the transmutation, stenosis and loose intercellular joining of the capillaries on electron microscopy. Ultrastructure observation revealed numerous pinocytes in epithelial cells as well as proliferation and hyperplasia of smooth muscle, collagenous fiber and extracellular matrix in venules. Quantitative analysis showed that the ratios of the cross sectional area and the vascular wall area between the gastric wall area(CSA/GWA & VWA/GWA) was higher in liver cirrhosis(LC) and portal vein stenosis(PVS) groups than that in sham operation(SO) group. There was a positive correlation between portal vein pressure and the ratio of the length of damaged mucosa and the length of mucosa(LDM/LM that was higher in LC group than in PVS group). Conclusions In rats with cirrhotic portal hypertension, distinct gastric microvascular morphological changes are the major etiological factor of PHG as a part of pathological changes in portal hypertension.