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Resumen Una de las consecuencias más graves de la trombosis de la vena porta extrahepática es la hipertensión portal con sangrado variceal recurrente. Una vez falla la ligadura endoscópica de las várices y el eje esplenoportal no se encuentra permeable, la devascularización tipo Sugiura modificado puede ser la única alternativa. Se ha documentado su uso en pacientes con cirrosis, pero hay poca información en personas no cirróticas. En este artículo se describe una serie de 4 casos de pacientes no cirróticos, en los cuales se realizó dicho procedimiento. Los pacientes fueron seguidos durante 12 meses y ninguno presentó episodios de resangrado de las várices esofágicas, ni tampoco se requirió la ligadura de las várices residuales. Esta cirugía se perfila como una alternativa terapéutica para este tipo de pacientes.
Abstract One of the most serious consequences of extrahepatic portal vein thrombosis is portal hypertension with recurrent variceal bleeding. Once endoscopic variceal ligation fails and the spleno-portal axis is not permeable, modified Sugiura devascularization may be the only alternative. Its use in patients with cirrhosis has been reported, but there is little information on non-cirrhotic patients. This article presents a series of four cases of non-cirrhotic patients that underwent this procedure. Patients were followed for twelve months; none presented episodes of esophageal varices re-bleeding nor required ligation of residual varices. This surgery is outlined as a therapeutic alternative for this type of patients.
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Anciano , Vena Porta , Trombosis de la Vena , Hemorragia , Métodos , Terapéutica , Várices Esofágicas y Gástricas , Hipertensión PortalRESUMEN
Objective To evaluate the impact of the re-modified Sugiura procedure on portal hemodynamics and liver function in cirrhotic patients with portal hypertension.Methods Forty patients with cirrhosis and portal hypertension who underwent the re-modified Sugiura procedure in the Yichang Second People's Hospital from June 2006 to October 2014 were studied.Changes in the free portal pressure (FPP),portal venous flow (PVF) and liver functions before and after operation were analyzed.Results (1) The FPP at different phases of the operation (after opening the abdomen,after splenectomy,and after devascularization) were (43.2 ± 1.8) cmH2O,(34.8 ± 1.6) cmH2O and (35.2 ± 1.7) cmH2O,respectively.There were significant differences in FPP between the phases of after splenectomy and after opening the abdomen,as well as after devascularization and after opening the abdomen (P ＜ 0.05).There was no significant difference in FPP between after devascularization and after splenectomy (P ＞ O.05).(2) The PVF,which were measured with Doppler sonography at 4 time points (preoperative 1 day,postoperative 10 days,postoperative 6 months,postoperative 18 months),were (1 420.4 ± 137.7) ml/min,(1 205.2 ± 126.7) ml/min,(875.8 ± 118.0) ml/min and (893.8 ± 114.7) n1/min,respectively.There were significant differences in PVF between postoperative 10 days and preoperative 1 day,between postoperative 6 months and postoperative 10 days,as well as between postoperative 18 months and preoperative 1 day (P ＜0.05).There was no significant difference in PVF between postoperative 18 months and postoperative 6 months (P ＞0.05).(3)The liver functions were evaluated using the Child-Pugh score at 4 time points (preoperative 1 day,postoperative 10 days,postoperative 6 months,postoperative 18 months).There were no significant differences among the time points,(P ＞ 0.05).Conclusion The re-modified Sugiura's procedure durably,appropriately and effectively reduced the PVF and FPP,but it did not have any negative effects on the liver functions of patients with cirrhosis.
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Objective To discuss the effect of pericardial devascularization plus gastric fundus transaction in advance schis?tosomiasis patients with portal hypertension. Methods Thirty?six advanced schistosomiasis patients with portal hypertension treated with devascularization plus gastric fundus transaction(a portal hypertension group),as well as 10 patients treated with modified Sugiura operation(a modified Sugiura operation group)in the Third People’s Hospital of Yangxin County since 2006 were chosen as the observation objects,and the clinical effects of the two groups were observed and compared. Results The op?eration time,indwelling time of stomach tube,time to taking food after operation,drainage tube removal time of the portal hy?pertension group were all shorten than those of the modified Sugiura operation group(all P0.05). In addition,1 case with delayed gastric emptying and 1 case with stomal leak of esopha?gus happened in the modified Sugiura operation group,while no corresponding complications happened in the portal hyperten?sion group. Conclusions Pericardial devascularization plus gastric fundus is a relatively easy procedure which has a good short?term clinical effect,and therefore it is suitable for application in primary hospitals. However,its long?term effect still needs fur?ther observation.
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Objective To investigate the clinical efficacy of re-modified Sugiura procedure for the treatment of portal hypertension.Methods The retrospective cohort study was adopted.The clinical data of 119 patients with portal hypertension who were admitted to Second People's Hospital of Yichang from June 2006 to October 2014 were collected.Seventy-two patients who underwent pericardial devascularization were allocated into the Hassab group,and the other 47 patients who underwent the re-modified Sugiura procedure were allocated into the R-M Sugiura group.All the patients firstly underwent splenectomy.The patients of the Hassab group received the classical surgery of pericardial devascularization,and the operation in the R-M Sugiura group was improved on the modified Sugiura procedure in several aspects:(1) the cardia was transected obliquely.(2) Paraesophageal vessels were preserved by selective pericardial devascularization.(3) The pedicled omentum covered the anterior anastomosis and was sutured to the posterior abdominal wall.Observed indices included (1) intraoperative and postoperative situations:operation time,volume of intraoperative blood loss,postoperative anal exhaust time and duration of postoperative hospital stay.(2) Postoperative complications:postoperative pleural effusion,perioperative digestive tract re-bleeding,difficult swallowing,portal vein thrombosis and gastric dynamic dysfunction.(3) Situation of follow-up.The follow-up was performed by telephone interview and outpatient examination to observe the grading of the esophageal varices at postoperative month 6 and 18 using gastroscope till February 2016.Measurement data with normal distribution were presented as x ± s,and comparison between groups was done by the t test.Count data were analyzed by the chi-square test.Ranked data were analyzed by Wilcoxon rank test.Results (1) Intraoperative and postoperative situations:operation time of the Hassab group and the R-M Sugiura group was (201 ± 27) minutes and (255 ± 32) minutes,respectively,with a statistically significant difference between the 2 groups (t =9.67,P ＜ 0.05).The volume of intraoperative blood loss,postoperative anal exhaust time and duration of postoperative hospital stay were (380 ± 86) mL,(2.7 ± 0.7) days,(14.2 ± 2.4) days in the Hassab group and (401 ± 72) mL,(3.0 ± 1.7) days,(15.1 ± 2.7) days in the R-M Sugiura group,respectively,showing no statistically significant difference (t =1.35,1.26,1.86,P ＞ 0.05).(2) Postoperative complications:dysphagia was detected in 3 patients of the Hassab group and in 10 patients of the R-M Sugiura group at the postoperative day 10,with a statistically significant difference between the 2 groups (x2 =0.86,P ＜ 0.05).However,dysphagia was detected in 1 patient of the Hassab group and in 4 patients of the R-M Sugiura group at the postoperative day 20,showing no statistically significant difference between the 2 groups (x2 =2.03,P ＞ 0.05).The number of postoperative pleural effusion,perioperative digestive tract rebleeding,portal vein thrombosis and gastric dynamic dysfunction of the Hassab group and the R-M Sugiura group were 23,6,10,8 cases and 20,1,6,6 cases,respectively,showing no statistically significant difference (x2=1.39,1.02,0.03,0.08,P ＞ 0.05).(3) Situation of follow-up:all the patients were reexamined using gastroscope to observe the grading of esophageal varices.There were 0,7,56,9 patients of G0,G Ⅰ,G Ⅱ,G Ⅲ grading of varices in the Hassab group and 35,12,0,0 patients in the R-M Sugiura group at postoperative month 6,showing a statistically significant difference between the 2 groups (Z =-9.64,P ＜ 0.05).There were 0,0,48,24 patients of G0,G Ⅰ,G Ⅱ,G Ⅲ grading of varices in the Hassab group and 24,20,3,0 patients in the R-M Sugiura group at postoperative month 18,showing a statistically significant difference between the 2 groups (Z =-9.28,P ＜ 0.05).Conclusion The re-modified Sugiura procedure is more effective than the Hassab operation in curing portal hypertension,and it could also reduce the rate of rehemorrhage and improve the short-term and long-term prognosis.
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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.