Laparoscopic Splenectomy and Esophagogastric Devascularization Versus Endoscopic Varices Ligation Plus Laparoscopic Splenectomy in the Treatment of Portal Hypertension.

Background/Aims: To compare laparoscopic splenectomy and esophagogastric devascularization (LSED) with endoscopic variceal ligation (EVL) plus laparoscopic splenectomy (LS) in treating esophagogastric variceal bleeding (EGVB) caused by portal hypertension (PH). Methods: Between January 2015 and May 2022, 87 patients with PH caused by hepatitis B cirrhosis were included in the retrospective study (34 in LSED versus 53 in EVL + LS). Results: The clinical features of both groups were well-matched (P > .05). The EVL+LS group was associated with shorter operation time, lower operative blood loss, faster gastrointestinal (GI) recovery, lower C-reactive protein levels, and shorter hospital stays after operation (P < .05). Operative morbidity was more significant in the LSED group (19 55.9% versus 18 33.9%) (P < .05). On postoperative days 1 and 3, albumin levels were remarkably lower (P < .05) in the LSED group. The mean follow-up was 24.3 months for LSED and 26.5 for EVL+LS. Hematological parameters, hepatic functional status, hepatic hemodynamics, and endoscopy indicated a substantial improvement in both groups (P < .05), but no significant difference was identified (P > .05). There was no discernible difference in the incidence of GI bleeding between the two groups (P > .05). Conclusion: EVL+LS is a safer, simpler, and more minimally invasive treatment of EGVB secondary to PH.

Efficacy, feasibility and safety of TIPS in the treatment of recurrent portal hypertension with variceal bleeding after open splenectomy and esophagogastric devascularization.

PURPOSE: To investigate the efficacy, feasibility, and safety of transjugular intrahepatic portosystemic shunt (TIPS) as a treatment for patients with recurrent portal hypertension with variceal bleeding (RPHVB) who have previously undergone open splenectomy and esophagogastric devascularization (OSED). METHODS: The data were retrospectively retrieved from 39 cirrhotic RPHVB patients who had undergone OSED from August 2015 to December 2020. All patients were treated with TIPS using the Viabahn stent. RESULTS: Out of the 39 patients included in the study, TIPS was successfully performed in 38 patients with a success rate of 97.44%. One patient had a failed attempt due to cavernous transformation of the portal vein (CTPV). Among the 38 patients who underwent TIPS, 33 patients also underwent varicose vein embolization, while the remaining 5 patients only underwent TIPS procedure. A total of 39 Viabahn stents were implanted, with 5 patients receiving stents expanded to their nominal diameter of 8 mm and the remaining 33 patients having their shunt maintained at a diameter of 6 mm. The postoperative hemostasis rate was 97.37% (37/38). The portal vein pressure (PVP) and portal pressure gradient (PPG) decreased significantly from (31.28 ± 6.24) and (20.61 ± 5.14) mmHg to (19.58 ± 4.69) and (9.24 ± 3.07) mmHg, respectively (P < 0.001). During the follow-up period, the rebleeding rate was 6.09% (2/29), while the incidence of hepatic encephalopathy (HE) and shunt dysfunction was 13.79% (4/29) for each. CONCLUSION: Transjugular intrahepatic portosystemic shunt is an effective, feasible and safe treatment for RPHVB patients who have previously undergone OSED. A satisfactory clinical outcome could be achieved with a 6 mm-diameter shunt in most patients.

Impact of concurrent splenectomy and esophagogastric devascularization on surgical outcomes of partial hepatectomy for hepatocellular carcinoma in patients with clinically significant portal hypertension: A multicenter propensity score matching analysis.

PURPOSE: Portal hypertension due to cirrhosis is common among patients with hepatocellular carcinoma (HCC). This study aimed to compare the outcomes of partial hepatectomy in patients with HCC and clinically significant portal hypertension (CSPH) with or without concurrent splenectomy and esophagogastric devascularization (CSED). PATIENTS AND METHODS: From a multicenter database, patients with HCC and CSPH who underwent curative-intent hepatectomy were identified. Postoperative morbidity and mortality, and long-term overall survival (OS) were compared in patients with and without CSED before and after propensity score matching (PSM). RESULTS: Of the 358 enrolled patients, 86 patients underwent CSED. Before PSM, the postoperative 30-day morbidity and mortality rates were comparable between the CSED and non-CSED group (both P > 0.05). Using PSM, 81 pairs of patients were created. In the PSM cohort, the 5-year OS rate of the CSED group were significantly better than the non-CSED group (52.9% vs. 36.5%, P= 0.046). The former group had a significantly lower rate of variceal bleeding on follow-up (7.4% vs. 21.7%, P= 0.014). On multivariate analysis, CSED was associated with significantly better OS (HR: 0.39, P < 0.001). CONCLUSION: Hepatectomy and CSED can safely be performed in selected patients with HCC and CSPH, which could improve postoperative prognosis by preventing variceal bleeding, and prolonging long-term survival.

Research progress on the portal vein thrombosis after esophagogastric devascularization and splenectomy / 中华肝胆外科杂志

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.

Laparoscopic splenectomy via the spleen bed in combination with selective esophagogastric devascularization for patients with cirrhotic portal hypertension: a single-institution experience.

INTRODUCTION: The safety and feasibility of laparoscopic splenectomy plus selective esophagogastric devascularization (LSSD) via the spleen bed for cirrhotic portal hypertension have not been well studied. AIM: To assess the safety and feasibility of LSSD via the spleen bed for patients with cirrhotic portal hypertension. MATERIAL AND METHODS: From June 2012 to December 2017, 423 patients suffering from portal hypertension and hypersplenism with liver cirrhosis underwent surgery in our department. One hundred and sixty-seven of these patients received totally LSSD, and the others received open splenectomy and esophagogastric devascularization (OSD). The characteristics, intraoperative and postoperative details and complications of the two groups were compared. RESULTS: The operations were successfully performed in all patients. Intraoperative blood loss volume and blood transfusion were similar between the two groups (all p-values > 0.05). Postoperative length of hospital stay and time to oral intake were significantly shorter, but operation time was longer in the LSSD group compared with the OSD group (all p < 0.05). However, postoperative portal vein diameter was significantly smaller in the LSSD group (p < 0.001). The postoperative grade of varices was significantly lower in the LSSD group (p = 0.030). No significant differences were detected between the two groups regarding postoperative liver function, but the incidences of pancreatic leakage, pleural effusion, and wound infections were higher in the OSD group (all p < 0.05). CONCLUSIONS: LSSD via the spleen bed is safe and feasible for liver cirrhosis and portal hypertension.

Transjugular intrahepatic portosystemic shunt and splenectomy are more effective than endoscopic therapy for recurrent variceal bleeding in patients with idiopathic noncirrhotic portal hypertension.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS), splenectomy plus esophagogastric devascularization (SED) and endoscopic therapy + non-selective ß-blockers (ET + NSBB) are widely applied in secondary prevention of recurrent gastroesophageal variceal bleeding in patients with liver cirrhosis. These different treatments, however, have not been compared in patients with idiopathic non-cirrhotic portal hypertension (INCPH). AIM: To compare the outcomes of TIPS, SED and ET + NSBB in the control of variceal rebleeding in patients with INCPH. METHODS: This retrospective study recruited patients from six centers across China. Demographic characteristics, baseline profiles and follow-up clinical outcomes were collected. Post-procedural clinical outcomes, including incidence of rebleeding, hepatic encephalopathy (HE), portal vein thrombosis (PVT) and mortality rates, were compared in the different groups. RESULTS: In total, 81 patients were recruited, with 28 receiving TIPS, 26 SED, and 27 ET + NSBB. No significant differences in demographic and baseline characteristics were found among these three groups before the procedures. After treatment, blood ammonia was significantly higher in the TIPS group; hemoglobin level and platelet count were significantly higher in the SED group (P < 0.01). Rebleeding rate was significantly higher in the ET + NSBB group (P < 0.01). Mortality was 3.6%, 3.8% and 14.8% in the TIPS, SED and ET + NSBB groups, respectively, with no significant differences (P = 0.082). Logistic regression analysis showed that mortality was significantly correlated with rebleeding, HE, portal thrombosis and superior mesenteric vein thrombosis (P < 0.05). CONCLUSION: In patients with INCPH, TIPS and SED were more effective in controlling rebleeding than ET + NSBB, but survival rates were not significantly different among the three groups. Mortality was significantly correlated with rebleeding, HE and PVT.

Combined Laparoscopic Splenectomy and Esophagogastric Devascularization versus Open Splenectomy and Esophagogastric Devascularization for Portal Hypertension due to Liver Cirrhosis.

This study was conducted to compare the feasibility, safety and effectiveness of the combined-laparoscopic splenectomy and esophagogastric devascularization (C-LSED) with open splenectomy and esophagogastric devascularization surgery (OSED) in patients with portal hypertension due to liver cirrhosis. From February 2014 to June 2018, 68 patients with portal hypertension were diagnosed as having serious gastroesophageal varices and/or hypersplenism in our center. Thirty patients underwent C-LSED and 38 patients received OSED. Results and outcomes were compared retrospectively. No patients of C-LSED group required an intraoperative conversion to open surgery. Significantly shorter operating time, less blood loss, lower transfusion rates, shorter postoperative hospital stay, lower rates of complications were found in C-LSED group than in C-LSED group (P<0.05). No death and rebleeding were documented in both groups during the follow-up periods of one year. Postoperative endoscopy revealed that varices in the patients of both groups were alleviated significantly from severe to mild, and in a part of cases, the varices disappeared. The final results suggest that the C-LSED technique is superior to open procedure, due to slightly invasive, simplified operative procedure, significantly shorter operating time, less intraoperative bleeding and lower post-operative complication rates. And C-LSED offers comparable long-term effects to open surgery.

The therapeutic effect of splenectomy plus selective pericardial devascularization versus conventional pericardial devascularization on portal hypertension in China: a meta-analysis.

BACKGROUND: To systematically review perioperative outcomes and postoperative complications between splenectomy plus s-EGDV and n-sEGDV for portal hypertension complicated with thoracic esophageal varices and bleeding by a meta-analysis. METHOD: We searched the databases of PubMed, the Cochrane Library, Web of Science, EMBASE, TCGA, Chinese Biomedicine Database from January 2000 to June 2017, and included studies that compared perioperative outcomes and postoperative complications between s-EGDV and n-sEGDV. These included studies were assessed by two independent investigators. RESULTS: Seven randomized controlled trials (RCTs) and seven non-randomized observational clinical studies (OCS) were included. The s-EGDV was more beneficial than n-sEGDV in reducing the PVF (OR = 4.26; 95% CI, 2.81-5.71; P < 0.00001; I2 = 97% for heterogeneity), portal vein flow (OR = -111.75; 95% CI, -197.13-26.38; P = 0.01; I2 = 90% for heterogeneity), portal hypertensive gastropathy(OR = 0.38; 95% CI, 0.28-0.51; P < 0.00001; I2 = 0% for heterogeneity), hepatic encephalopathy (OR = 0.40; 95% CI, 0.23-0.71; P = 0.002; I2 = 22% for heterogeneity), postoperative re-bleeding (OR = 0.43; 95% CI, 0.29-0.63; P < 0.0001; I2 = 9% for heterogeneity), postoperative mortality (OR = 0.52; 95% CI, 0.32-0.85; P = 0.009; I2 = 0% for heterogeneity) and in increasing hepatic artery flow (OR = 92.53; 95% CI, 9.60-175.46; P = 0.03; I2 = 95% for heterogeneity). CONCLUSION: sEGDV offers a more effective surgical approach with fewer complications to treat portal hypertension than n-sEGDV. Upon further detailed analysis of the surgical indications and hemodynamic and postoperative major complications of selective devascularization, sEGDV likely will provide us with a new direction in the choice of surgical approach for portal hypertension.

The impact of enteral nutrition on the development of portal vein thrombosis after esophagogastric devascularization and splenectomy / 中华肝胆外科杂志

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.

Risk factors of postoperative liver dysfunction in cirrhotics after splenorenal shunt and esophagogastric devascularization / 中华普通外科杂志

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.

Risk factors of postoperative liver dysfunction in cirrhotics after splenorenal shunt and esophagogastric devascularization / 中华普通外科杂志

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.

Laparoscopic versus open splenectomy with esophagogastric devascularization for portal hypertension: a Meta-analysis / 中华肝胆外科杂志

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.

Clinical effect of laparoscopic splenectomy combined with esophagogastric devascularization in treatment of liver cirrhosis with portal hypertension / 临床肝胆病杂志

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.

The effects of splenectomy plus esophagogastric devascularization on serum MMP-1,TIMP-1 and cirrhotic serum markers of liver cirrhosis patients / 临床外科杂志

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.

A clinical and pathological study of surgical therapy for the patients with portal hypertension complicating cirrhosis of liver / 解放军医学杂志

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.

Mesocaval C-shunt plus ligation of splenic artery and esophagogastric (devascularization) in the treatment of type II Budd- Chiari syndrome / 中国普通外科杂志

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 36cmH2O(31~45 cmH2O, 1cmH2O=0.0098kPa) and post-shunt pressure fell to 26 cmH2O(21~33 cmH2O),the mean reduction was 10 cmH2O. 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.

An inquiry into mechanism of portal hypertension through comparative analysis of 150 cases of cirrhosis and portal hypertension undergoing emergent or elective surgical intervention / 解放军医学杂志

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