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Darce GFB, Makdissi FF, Ando SDM, Fonseca GM, Kruger JAP, Coelho FF, Rocha MDS, Herman P. HEPATOSPLENIC SCHISTOSOMIASIS-ASSOCIATED CHRONIC PORTAL VEIN THROMBOSIS: RISK FACTOR FOR HEPATOCELLULAR CARCINOMA? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1763. [PMID: 37729278 PMCID: PMC10510374 DOI: 10.1590/0102-672020230045e1763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/20/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Hepatosplenic schistosomiasis is an endemic disease prevalent in tropical countries and is associated with a high incidence of portal vein thrombosis. Inflammatory changes caused by both parasitic infection and portal thrombosis can lead to the development of chronic liver disease with potential carcinogenesis. AIMS To assess the incidence of portal vein thrombosis and hepatocellular carcinoma in patients with schistosomiasis during long-term follow-up. METHODS A retrospective study was conducted involving patients with schistosomiasis followed up at our institution between 1990 and 2021. RESULTS A total of 126 patients with schistosomiasis were evaluated in the study. The mean follow-up time was 16 years (range 5-31). Of the total, 73 (57.9%) patients presented portal vein thrombosis during follow-up. Six (8.1%) of them were diagnosed with hepatocellular carcinoma, all with portal vein thrombosis diagnosed more than ten years before. CONCLUSIONS The incidence of hepatocellular carcinoma in patients with schistosomiasis and chronic portal vein thrombosis highlights the importance of a systematic long-term follow-up in this group of patients.
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Affiliation(s)
| | - Fabio Ferrari Makdissi
- Universidade de São Paulo, Faculty of Medicine, Cancer Institute – São Paulo (SP), Brazil
| | - Sabrina de Mello Ando
- Universidade de São Paulo, Falculty of Medicine, Department of Radiology –São Paulo (SP), Brazil
| | - Gilton Marques Fonseca
- Universidade de São Paulo, Falculty of Medicine, Department of Gastroenterology – São Paulo (SP), Brazil
| | | | - Fabricio Ferreira Coelho
- Universidade de São Paulo, Falculty of Medicine, Department of Gastroenterology – São Paulo (SP), Brazil
| | - Manoel de Souza Rocha
- Universidade de São Paulo, Falculty of Medicine, Department of Radiology –São Paulo (SP), Brazil
| | - Paulo Herman
- Universidade de São Paulo, Falculty of Medicine, Department of Gastroenterology – São Paulo (SP), Brazil
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Rakotomalala JA, Razafindrazoto CI, Randriamifidy NH, Ralaizanaka BM, Maherison S, Hasina Laingonirina DH, Rakotomaharo M, Rasolonjatovo AS, Rakotovao MA, Rakotozafindrabe ALR, Rabenjanahary TH, Fanantenantsoa R, Razafimahefa SH, Ramanampamonjy RM. Splenectomy Combined with Endoscopic Variceal Ligation (EVL) versus EVL Alone for Secondary Prophylaxis of Variceal Bleeding in Hepatosplenic Schistosomiasis: A Retrospective Case-Control Study. Hepat Med 2022; 14:79-85. [PMID: 35611387 PMCID: PMC9124470 DOI: 10.2147/hmer.s367849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/12/2022] [Indexed: 11/23/2022] Open
Abstract
Background Hepatosplenic schistosomiasis (HSS) is one of the most common causes of portal hypertension in developing countries. Variceal bleeding is the most common cause of mortality during HSS. The objective of this study was to evaluate the efficacy of splenectomy associated with endoscopic variceal ligation (EVL) compared with EVL alone in preventing variceal bleeding in patients with HSS. Methods This was a single-center, retrospective, case–control study. Between January 2015 and December 2019, a total of 59 patients with HSS who had at least one variceal bleeding episode and received EVL with or without splenectomy were identified and stratified. In this case–control design, 22 patients had splenectomy + EVL (case group) and 37 patients had EVL alone (control group). The main endpoints were the rate of variceal rebleeding and the mortality rate between the two groups. Results The mean age of our patients was 39.92 ± 13.4 (19–75) years with a sex ratio of 1.8. The recurrence rate of variceal bleeding was significantly lower in the case group (splenectomy + EVL) than in the control group (EVL alone) (4.45% vs 27.2%, p = 0.041). There was no significant difference between the two groups in terms of mortality (4.54 vs 2.7%, p = 1.00). Conclusion Splenectomy combined with EVL was effective than EVL alone in preventing variceal rebleeding in patients with HSS.
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Affiliation(s)
| | | | | | | | - Sonny Maherison
- Gastroenterology Unit, University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar
| | | | - Mialitiana Rakotomaharo
- Gastroenterology Unit, University Hospital Joseph Raseta Befelatanana, Antananarivo, Madagascar
| | | | - Mamisoa Anicet Rakotovao
- General Surgery Unit, University Hospital Andrainjato, Fianarantsoa, Madagascar.,Visceral Surgery Unit, University Hospital Tambohobe, Fianarantsoa, Madagascar
| | | | | | - Rija Fanantenantsoa
- General Surgery Unit, University Hospital Andrainjato, Fianarantsoa, Madagascar.,Visceral Surgery Unit, University Hospital Tambohobe, Fianarantsoa, Madagascar
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Silva-Neto WDB, Quirese C, Moura EGHD, Coelho FF, Herman P. DOES THE DROP IN PORTAL PRESSURE AFTER ESOPHAGOGASTRIC DEVASCULARIZATION AND SPLENECTOMY INFLUENCE THE VARIATION OF VARICEAL CALIBERS AND THE REBLEEDING RATES IN SCHISTOSOMIASIS IN LATE FOLLOW-UP? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2021; 34:e1581. [PMID: 34669877 PMCID: PMC8521859 DOI: 10.1590/0102-672020210002e1581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/14/2020] [Indexed: 11/26/2022]
Abstract
Background: The treatment of choice for patients with schistosomiasis with previous episode of varices is bleeding esophagogastric devascularization and splenectomy (EGDS) in association with postoperative endoscopic therapy. However, studies have shown varices recurrence especially after long-term follow-up. Aim: To assess the impact on behavior of esophageal varices and bleeding recurrence after post-operative endoscopic treatment of patients submitted to EGDS. Methods: Thirty-six patients submitted to EGDS were followed for more than five years. They were divided into two groups, according to the portal pressure drop, more or less than 30%, and compared with the behavior of esophageal varices and the rate of bleeding recurrence. Results: A significant reduction on the early and late post-operative varices caliber when compared the pre-operative data was observed despite an increase in diameter during follow-up that was controlled by endoscopic therapy. Conclusion: The drop in portal pressure did not significantly influence the variation of variceal calibers when comparing pre-operative and early or late post-operative diameters. The comparison between the portal pressure drop and the rebleeding rates was also not significant.
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Affiliation(s)
- Walter de Biase Silva-Neto
- Serviço de Cirurgia Geral e Aparelho Digestivo, Departamento de Clínica Cirúrgica, Faculdade de Medicina, Universidade Federal de Goiás, Goiânia, GO, Brasil
| | - Claudemiro Quirese
- Serviço de Cirurgia Geral e Aparelho Digestivo, Departamento de Clínica Cirúrgica, Faculdade de Medicina, Universidade Federal de Goiás, Goiânia, GO, Brasil
| | - Eduardo Guimarães Horneaux de Moura
- Serviço de Endoscopia, Hospital das Clínicas e Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Fabricio Ferreira Coelho
- Serviço de Cirurgia do Fígado, Hospital das Clínicas e Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Paulo Herman
- Serviço de Cirurgia do Fígado, Hospital das Clínicas e Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Tamarozzi F, Fittipaldo VA, Orth HM, Richter J, Buonfrate D, Riccardi N, Gobbi FG. Diagnosis and clinical management of hepatosplenic schistosomiasis: A scoping review of the literature. PLoS Negl Trop Dis 2021; 15:e0009191. [PMID: 33764979 PMCID: PMC7993612 DOI: 10.1371/journal.pntd.0009191] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hepatosplenic schistosomiasis (HSS) is a disease caused by chronic infection with Schistosma spp. parasites residing in the mesenteric plexus; portal hypertension causing gastrointestinal bleeding is the most dangerous complication of this condition. HSS requires complex clinical management, but no specific guidelines exist. We aimed to provide a comprehensive picture of consolidated findings and knowledge gaps on the diagnosis and treatment of HSS. METHODOLOGY/PRINCIPAL FINDINGS We reviewed relevant original publications including patients with HSS with no coinfections, published in the past 40 years, identified through MEDLINE and EMBASE databases. Treatment with praziquantel and HSS-associated pulmonary hypertension were not investigated. Of the included 60 publications, 13 focused on diagnostic aspects, 45 on therapeutic aspects, and 2 on both aspects. Results were summarized using effect direction plots. The most common diagnostic approaches to stratify patients based on the risk of variceal bleeding included the use of ultrasonography and platelet counts; on the contrary, evaluation and use of noninvasive tools to guide the choice of therapeutic interventions are lacking. Publications on therapeutic aspects included treatment with beta-blockers, local management of esophageal varices, surgical procedures, and transjugular intrahepatic portosystemic shunt. Overall, treatment approaches and measured outcomes were heterogeneous, and data on interventions for primary prevention of gastrointestinal bleeding and on the long-term follow-up after interventions were lacking. CONCLUSIONS Most interventions have been developed on the basis of individual groups' experiences and almost never rigorously compared; furthermore, there is a lack of data regarding which parameters can guide the choice of intervention. These results highlight a dramatic need for the implementation of rigorous prospective studies with long-term follow-up in different settings to fill such fundamental gaps, still present for a disease affecting millions of patients worldwide.
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Affiliation(s)
- Francesca Tamarozzi
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Veronica A. Fittipaldo
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Hans Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, Duesseldorf University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Joachim Richter
- Institute of Tropical Medicine and International Health, Charité Universitätsmedizin, Berlin, Germany
| | - Dora Buonfrate
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Niccolò Riccardi
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - Federico G. Gobbi
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
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5
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Cançado GGL, Nardelli MJ, Barbosa FA, Silva CF, Osório FMF, Ferrari TCA, Couto CA, Faria LC. Portal vein thrombosis in patients with hepatosplenic schistosomiasis who underwent oesophagogastric devascularization combined with splenectomy. Trans R Soc Trop Med Hyg 2021; 115:1004-1009. [PMID: 33537723 DOI: 10.1093/trstmh/trab013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/04/2020] [Accepted: 01/13/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) has been described in nearly 50% of patients who underwent oesophagogastric devascularization combined with splenectomy (EGDS), but no previous study has compared its occurrence in surgical and non-surgical groups. This study aimed to investigate PVT in hepatosplenic schistosomiasis (HSS) and its association with EGDS and upper variceal bleeding (UVB). METHODS Retrospectively, 104 HSS individuals were enrolled. Following EGDS, the occurrence of PVT, mesenteric vein thrombosis (MVT), hospital admissions and UVB were recorded. RESULTS EGDS was performed in 27 (26%) patients. PVT and MVT were detected in 30 (33%) and 8 (9.8%) patients, respectively. Patients who underwent EGDS were at greater risk of PVT (63% vs 19.7%; odds ratio [OR] 6.12 [95% confidence interval {CI} 2.3 to 16.1], p<0.001) when compared with a non-surgical approach. There was no significant difference in UVB occurrence and β-blocker usage. PVT was associated with more hospital admissions (p=0.030) and higher alkaline phosphatase levels (p=0.008). UVB occurrence in patients with and without thrombosis was similar. In multivariate analysis, after adjustment, PVT was associated with the surgical approach (OR 4.56 [95% CI 1.55 to 13.38], p=0.006) and age at HSS diagnosis (OR 0.94 [95% CI 0.90 to 0.99], p=0.021). CONCLUSIONS EGDS was not associated with a decreased frequency of UVB when compared with the non-surgical approach but was an independent risk factor for PVT.
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Affiliation(s)
- Guilherme G L Cançado
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, 30130-100, Belo Horizonte, Brazil.,Department of Gastroenterology and Hepatology, Hospital da Polícia Militar de Minas Gerais, Belo Horizonte, Brazil
| | - Mateus J Nardelli
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Fernanda A Barbosa
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Catherine F Silva
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Fernanda M F Osório
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, 30130-100, Belo Horizonte, Brazil
| | - Teresa C A Ferrari
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Claudia A Couto
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, 30130-100, Belo Horizonte, Brazil.,Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Luciana C Faria
- Instituto Alfa de Gastroenterologia, Hospital das Clínicas, Universidade Federal de Minas Gerais, Av. Professor Alfredo Balena 110, 30130-100, Belo Horizonte, Brazil.,Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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6
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Jiang S, Huang X, Ni L, Xia R, Nakayama K, Chen S. Positive consequences of splenectomy for patients with schistosomiasis-induced variceal bleeding. Surg Endosc 2020; 35:2339-2346. [PMID: 32440930 DOI: 10.1007/s00464-020-07648-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/13/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with hepatic schistosomiasis are at high risk of gastroesophageal variceal bleeding, which is highly torrential and life threatening. This study aimed to assess the effects of splenectomy on patients with schistosomiasis-induced variceal bleeding, especially those influences related to overall survival (OS) rate. METHODS From January 2005 to December 2018, 112 patients with schistosomiasis-induced varices were enrolled. In that period, all the patients with hepatic schistosomiasis who received endoscopic treatment for primary and secondary prophylaxis of gastroesophageal variceal bleeding were found eligible. The patients were divided into splenectomized group (n = 44, 39.3%) and control group (n = 68, 60.7%). RESULTS Multivariate regression analysis of OS showed that splenectomy, hepatic carcinoma, and times of endoscopic treatment were independent prognostic factors for OS. Kaplan-Meier analysis revealed that the 5-year OS rate was 82.7% in splenectomized group versus 53.2% in control group (P = 0.037). The rate of no recurrence of variceal bleeding during 5-year (56.8% vs. 47.7%, P = 0.449) indicated that there was no significant difference between the two groups. Patients who received splenectomy had increased risk of portal vein thrombosis (52.3% vs. 29.4%, P = 0.012) and decreased proportion of severe ascites (20.5% vs 50.0%, P = 0.002). CONCLUSION Splenectomy prior to endoscopic treatment provides a superior long-term survival for patients with schistosomiasis-induced variceal bleeding.
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Affiliation(s)
- Siyu Jiang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Xiaoquan Huang
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Liyuan Ni
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Ruiqi Xia
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Kiyoko Nakayama
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China
| | - Shiyao Chen
- Department of Gastroenterology and Hepatology, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital of Fudan University, 180 Fenglin Road, Shanghai, 200032, People's Republic of China.
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Miura K, Sato Y, Yabuuchi T, Kaneko N, Ishizuka K, Chikamoto H, Akioka Y, Nawashiro Y, Hisano M, Imamura H, Miyai T, Sakamoto S, Kasahara M, Fuchinoue S, Okumi M, Ishida H, Tanabe K, Hattori M. Individualized concept for the treatment of autosomal recessive polycystic kidney disease with end-stage renal disease. Pediatr Transplant 2020; 24:e13690. [PMID: 32128974 DOI: 10.1111/petr.13690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/01/2020] [Accepted: 02/17/2020] [Indexed: 12/19/2022]
Abstract
Management of children with autosomal recessive polycystic kidney disease (ARPKD) who develop end-stage renal disease (ESRD) remains challenging because of concomitant liver disease. Patients with recurrent cholangitis are candidates for liver-kidney transplantation, while the treatment for patients with splenomegaly and pancytopenia due to portal hypertension is controversial. Herein, we report 7 children who were treated using an individualized treatment strategy stratified by liver disease. Two patients with recurrent cholangitis underwent sequential liver-kidney transplantation, while 4 patients with splenomegaly and pancytopenia but without recurrent cholangitis underwent splenectomy followed by isolated kidney transplantation. The remaining patient, who did not have cholangitis and pancytopenia, underwent isolated kidney transplantation. Blood cell counts were normalized after splenectomy was performed at the median age of 8.7 (range, 7.4-11.7) years. Kidney transplantation was performed at the median age of 8.8 (range, 1.9-14.7) years in all patients. Overwhelming post-splenectomy infections and cholangitis did not occur during the median follow-up period of 6.3 (range, 1.0-13.2) years. The estimated glomerular filtration rate at the last follow-up was 53 (range, 35-107) mL/min/1.73 m2 . No graft loss occurred. Our individualized treatment strategy stratified by recurrent cholangitis and pancytopenia can be a feasible strategy for children with ARPKD who develop ESRD and warrants further evaluation.
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Affiliation(s)
- Kenichiro Miura
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yasuyuki Sato
- Department of Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Tomoo Yabuuchi
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Naoto Kaneko
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kiyonobu Ishizuka
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hiroko Chikamoto
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuko Akioka
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Pediatrics, Saitama Medical University, Saitama, Japan
| | - Yuri Nawashiro
- Department of Nephrology, Chiba Children's Hospital, Chiba, Japan
| | - Masataka Hisano
- Department of Nephrology, Chiba Children's Hospital, Chiba, Japan
| | - Hideaki Imamura
- Division of Pediatrics, Department of Reproductive and Developmental Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Takayuki Miyai
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Shohei Fuchinoue
- Department of Surgery, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Hideki Ishida
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Motoshi Hattori
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
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Can Early Diagnosis of Varices, Regular Praziquantel, and Reduction of Hepatitis Coinfection Reduce Mortality among Patients Attended for Periportal Fibrosis in Northwestern Tanzania? A Case-Control Study. J Parasitol Res 2020; 2020:5484315. [PMID: 32231794 PMCID: PMC7094192 DOI: 10.1155/2020/5484315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/28/2020] [Indexed: 11/17/2022] Open
Abstract
Background Schistosoma mansoni is highly endemic in the Lake Zone part of Tanzania and most people are chronically infected. Periportal fibrosis (PPF) is the commonest complication of chronic S. mansoni infection documented in up to 42% of studied participants in the community-based studies. These patients are at high risk of mortality since most of them are diagnosed late with bleeding varices. At Bugando, Schistosoma-related varices contributed to 70% of patients admitted due to vomiting blood with a two months' mortality of over 10%. Earlier studies had reported higher mortality of up to 29% among patients with PPF even with the best in-hospital care. Understanding factors that increased the risk of mortality is important clinically in devising ways that can improve the outcome of this subgroup of patients. Methods A retrospective analysis of patients with PPF from 2015 through 2018 was done. Their sociodemographic, clinical, laboratory, ultrasonographic, endoscopic, and survival status data were collected for analysis. STATA 13 was used for analysis, the prevalence of varices, active schistosomiasis, and hepatitis B coinfection was determined. Cumulative mortality as a major outcome was also determined, and factors associated with increased risk of mortality were assessed by a logistic regression model. Results In total, 250 participants were included in this analysis. Majority, 222 (88.8%; 95% CI: 84.2-92.4) had active S. mansoni infection, and 40 (16.0%; 95% CI: 11.6-21.1) had S. mansoni-HBV coinfection. Cumulatively, 39 (15.6%; 95% CI: 11.3-20.7) patients died, with most deaths, 31 (79.5%; 95% CI: 63.5-90.7) occurring within two years following the diagnosis of PPF (chi2 = 6.3; p = 0.012). The odds of mortality were independently associated with fishing (OR: 10.8; 95% CI: 2.2-52; p = 0.003), upper gastro intestinal bleeding (OR: 2.4; 95% CI: 1.1-5.4; p = 0.037), HBV coinfection (OR: 3.3; 95% CI: 1.2-91; p = 0.019), and ascites (OR: 3.3; 95% CI: 1.3-8.2; p = 0.010). Conclusions In this, S. mansoni endemic area, varices, actives schistosomiasis, hepatitis B coinfection, and mortality are highly common. Screening for varices and initiation of prophylaxis, administration of praziquantel, and screening for hepatitis B should be part and parcel of care of these patients. The first two years of diagnosis, patients are at high risk of mortality; risk factors in this study should assist planning a closer follow-up of patients at risk of mortality to improve their long-term outcome.
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9
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SILVA NETO WDBD, TREDICCI TM, COELHO FF, MAKDISSI FF, HERMAN P. PORTAL PRESSURE DECREASE AFTER ESOPHAGOGASTRIC DEVASCULARIZATION AND SPLENECTOMY IN SCHISTOSOMIASIS: LONG-TERM VARICES BEHAVIOR, REBLEEDING RATE, AND ROLE OF ENDOSCOPIC TREATMENT. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55:170-174. [DOI: 10.1590/s0004-2803.201800000-30] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 03/23/2018] [Indexed: 11/22/2022]
Abstract
ABSTRACT BACKGROUND: Schistosomiasis is an endemic health problem affecting about four million people. The hepatosplenic form of the disease is characterized by periportal hepatic fibrosis, pre-sinusoidal portal hypertension and splenomegaly. Liver function is preserved, being varices bleeding the main complication of the disease. The surgical treatment used in the majority of centers for the prevention of rebleeding is esophagogastric devascularization and splenectomy. Most authors reported better results with the association of surgical and postoperative endoscopic treatment. OBJECTIVE: The aim of this study was to compare the intra operative portal pressure decrease and esophageal varices behavior and rebleeding rates in patients submitted to surgical and postoperative endoscopic treatment after long-term follow-up. METHODS: A retrospective study of 36 patients with schistosomiasis with, at least, one previous bleeding from esophageal varices rupture submitted to esophagogastric devascularization and splenectomy, added to endoscopic varices postoperative treatment was performed. Patients were stratified according to the intra operative portal pressure decrease in two groups: reduction below and above 30%. Long-term varices presence, size and bleeding recurrence were evaluated. RESULTS: Regarding varices behavior, no significant influence was observed in both groups of portal pressure fall. Regarding bleeding recurrence, despite three times more frequent in the group with lower portal pressure fall, no significant difference was observed. All patients were submitted to postoperative endoscopic treatment. CONCLUSION: Esophageal varices banding, rather than portal pressure decrease, seems to be the main responsible factor for good results after combination of two therapies (surgery and endoscopy) for patients with portal hypertension due to schistosomiasis; further studies are necessary to confirm this hypothesis.
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Colaneri RP, Coelho FF, de Cleva R, Herman P. Laparoscopic Treatment of Presinusoidal Schistosomal Portal Hypertension Associated With Postoperative Endoscopic Treatment: Results of a New Approach. Surg Laparosc Endosc Percutan Tech 2017; 27:90-93. [PMID: 27661203 DOI: 10.1097/sle.0000000000000302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM To propose a laparoscopic treatment for schistosomal portal hypertension. METHODS Ten patients with schistosomiasis and portal hypertension, with previous gastrointestinal hemorrhage from esophageal varices rupture, were evaluated. Patients were subjected to a laparoscopic procedure, with ligature of splenic artery and left gastric vein. Upper gastrointestinal endoscopy was performed on the 30th postoperative day, when esophageal varices diameter was measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings. RESULTS There was no operative mortality. One patient had a postoperative splenic infarction that was conservatively treated. Mean hospitalization time was 5 days. During endoscopy 30 days after surgery, a decrease in variceal diameters was observed in 6 patients. During follow-up (mean 84 mo), after endoscopic therapy 8 patients had eradicated varices, but 4 presented with recurrence. Considering the late postoperative evaluation, all patients had a decrease in variceal diameters. A mean of 3.8 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence; one had a minor bleeding episode and the other had 2 episodes of bleeding varices requiring blood transfusion. In both patients, bleeding was controlled with endoscopic therapy. No late mortality was observed. CONCLUSIONS Laparoscopic ligature of the splenic artery and the left gastric vein is a promising and less-invasive method for the treatment of schistosomal portal hypertension.
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Affiliation(s)
- Renata P Colaneri
- Department of Gastroenterology, University of São Paulo Medical School, São Paulo, Brazil
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Asztely MS, Eriksson B, Gabone RM, Nilsson LÅ. Is ultrasonography useful for population studies on schistosomiasis mansoni? An evaluation based on a survey on a population from Kome Island, Tanzania. Acta Radiol Open 2016; 5:2058460116686392. [PMID: 28286672 PMCID: PMC5330413 DOI: 10.1177/2058460116686392] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 12/03/2016] [Indexed: 11/15/2022] Open
Abstract
Background Observation of characteristic alterations at liver ultrasonography in clinical schistosomiasis mansoni cases has initiated utilization of this examination method in population surveys in areas where this disease is endemic. Purpose To present results of liver ultrasonography and their relation to epidemiological data of a population in an area endemic for S. mansoni, to estimate the precision of classification of periportal anatomy changes known as periportal fibrosis (PPF), and to evaluate the relevance of ultrasonography in epidemiological studies on S. mansoni. Material and Methods A total of 459 inhabitants on Kome Island, Lake Victoria, Tanzania were examined by ultrasound with image documentation by locally trained personnel. A subsample of this population, 116 individuals, was subject to ultrasonography by two examiners independently. Separately, the images were classified for PPF according to the Managil protocol, twice for the subsample. Results PPF could be classified for 458 individuals; 64% and 36% were classified as I or II, respectively; none was classified as 0; only one as III. Results were similar for the subsample examined twice. Comparing the two separate classifications of all 232 sets of images of the subsample gave a Kappa (K) value of 0.50. When comparing the classifications of each of the two different examinations of the same individuals of the subsample, K values of 0.29 and 0.34 for the first and second classification, respectively, were obtained. Conclusion Ultrasonography does not appear to correlate well with disease stage. Presently, it should not be utilized for staging of schistosoma mansoni-related liver damage in population surveys.
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Affiliation(s)
- Mats Sl Asztely
- Department of Radiology, The Sahlgrenska Academy, University of Göteborg, Sweden
| | - Bo Eriksson
- Centre for Health Metrics, The Sahlgrenska Academy, University of Göteborg, Sweden
| | | | - Lars-Åke Nilsson
- Department of Medical Microbiology and Immunology, The Sahlgrenska Academy, University of Göteborg, Sweden
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Left Ventricular Dilation and Pulmonary Vasodilatation after Surgical Shunt for Treatment of Pre-Sinusoidal Portal Hypertension. PLoS One 2016; 11:e0154011. [PMID: 27119143 PMCID: PMC4847763 DOI: 10.1371/journal.pone.0154011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 04/07/2016] [Indexed: 02/07/2023] Open
Abstract
Objective The aim of this study was to prospectively investigate the long-term cardiovascular and pulmonary hemodynamic effects of surgical shunt for treatment of portal hypertension (PH) due to Schistosomiasis mansoni. Location The University of São Paulo Medical School, Brazil; Public Practice. Methods Hemodynamic evaluation was performed with transesophageal Doppler and contrast-enhanced echocardiography (ECHO) on twenty-eight participants with schistosomal portal hypertension. Participants were divided into two groups according to the surgical procedure used to treat their schistosomal portal hypertension within the last two years: group 1—distal splenorenal shunt (DSRS, n = 13) and group 2—esophagogastric devascularization and splenectomy (EGDS, n = 15). Results The cardiac output (5.08 ± 0.91 L/min) and systolic volume (60.1 ± 5.6 ml) were increased (p = 0.001) in the DSRS group. DSRS participants had a significant increase (p < 0.0001) in their left ventricular end-systolic and end-diastolic diameters as well as in their left ventricular end-diastolic and end-systolic volumes (p < 0.001) compared with the preoperative period. No statistically significant difference was found in the patients who underwent EGDS. ECHO revealed intrapulmonary vasodilatation (IPV) in 18 participants (64%), 9 DSRS and 9 EGDS (p > 0.05). Conclusions The late increase in the cardiac output, stroke volume and left ventricular diameters demonstrated left ventricular dilatation after a distal splenorenal shunt. ECHO revealed a greater prevalence for IPV in patients with schistosomiasis than has previously been described in patients with PH from liver cirrhosis.
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Yu H, Guo S, Wang L, Dong Y, Tian G, Mu S, Zhang H, Li D, Zhao S. Laparoscopic Splenectomy and Esophagogastric Devascularization for Liver Cirrhosis and Portal Hypertension Is a Safe, Effective, and Minimally Invasive Operation. J Laparoendosc Adv Surg Tech A 2016; 26:524-30. [PMID: 27064936 DOI: 10.1089/lap.2016.0032] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the recent years, laparoscopic splenectomy and esophagogastric devascularization (LSD) for liver cirrhosis and portal hypertension rapidly gained the interest of hepatobiliary surgeons due to its minimal invasion. This study aimed to gather and analyze available data from the observational studies that have compared LSD and open splenectomy and esophagogastric devascularization (OSD) for liver cirrhosis and portal hypertension. MATERIALS AND METHODS All the studies comparing LSD and OSD for liver cirrhosis and portal hypertension were searched on the available databases, including the Cochrane Central Register of Controlled Trials, Medline, Science Citation Index, EMBASE, China National Knowledge Infrastructure, Wanfang Database, and China Biomedical Database. Data were analyzed using Review Manager software version 5.0. RESULTS After the literature search, a total of 17 studies were included in the meta-analysis, which involved 1093 patients: 552 in the laparoscopic group and 541 in the open group. The laparoscopic group was shown to have a lower overall postoperative complication rate (0.43; 95% confidence interval [CI; 0.29-0.64]) than the open group (P < .0001), which was not associated with heterogeneity between the studies. The laparoscopic group was shown to have a lower intraoperative blood loss (-320.62; 95% CI [-552.35 to -88.9]), shorter time of oral intake (-29.08 hours; 95% CI [-35.28 to -22.88]), and shorter hospital stay (95% CI [-6.19 to -2.19]) than those of the open group (P < .00001). The operative time of the laparoscopic group was 42.16 minutes longer (95% CI [32.20-52.11]) compared with the open group (P < .00001). There was no significant difference of hospitalization costs between the studies. CONCLUSION This meta-analysis demonstrated that laparoscopic left lateral resection is a safe and feasible option associated with a reduced overall complication rate. The current evidence suggested that it could be performed routinely in liver centers.
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Affiliation(s)
- Haibo Yu
- 1 Department of Hepatobiliary Surgery, Henan Provincial People's Hospital , Zhengzhou, China .,2 People's Hospital of Zhengzhou University , Zhengzhou, China
| | - Si Guo
- 2 People's Hospital of Zhengzhou University , Zhengzhou, China .,3 Clinical Laboratory, Henan Provincial People's Hospital , Zhengzhou, China
| | - Liancai Wang
- 1 Department of Hepatobiliary Surgery, Henan Provincial People's Hospital , Zhengzhou, China .,2 People's Hospital of Zhengzhou University , Zhengzhou, China
| | - Yadong Dong
- 1 Department of Hepatobiliary Surgery, Henan Provincial People's Hospital , Zhengzhou, China .,2 People's Hospital of Zhengzhou University , Zhengzhou, China
| | - Guanjin Tian
- 1 Department of Hepatobiliary Surgery, Henan Provincial People's Hospital , Zhengzhou, China .,2 People's Hospital of Zhengzhou University , Zhengzhou, China
| | - Senmao Mu
- 1 Department of Hepatobiliary Surgery, Henan Provincial People's Hospital , Zhengzhou, China .,2 People's Hospital of Zhengzhou University , Zhengzhou, China
| | - Huifeng Zhang
- 2 People's Hospital of Zhengzhou University , Zhengzhou, China .,4 Intensive Care and Treatment Unit, Henan Provincial People's Hospital , Zhengzhou, China
| | - Deyu Li
- 1 Department of Hepatobiliary Surgery, Henan Provincial People's Hospital , Zhengzhou, China .,2 People's Hospital of Zhengzhou University , Zhengzhou, China
| | - Sihai Zhao
- 5 Key Laboratory of Environment and Genes Related to Diseases, Education Ministry, Xi'an Jiaotong University School of Medicine , Shaanxi, China
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da Silva-Neto WDB, Quireze-Júnior C, Tredicci TM. Late results of esophagogastric devascularization and splenectomy associated with endoscopic treatment in patients with schistosomiasis. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2015; 28:197-9. [PMID: 26537146 PMCID: PMC4737362 DOI: 10.1590/s0102-67202015000300013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/11/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Schistosomiasis is endemic problem in Brazil affecting about three to four million people, and digestive hemorrhage caused by esophageal varices rupture is the main complication of the disease. Surgical treatment has become a therapeutic option, especially for secondary prophylaxis after at least one episode of bleeding. The surgical technique used by the vast majority of surgeons for the prevention of rebleeding is esophagogastric devascularization and splenectomy. Although with good postoperative results, rebleeding rate is significant, showing the need to follow-up endoscopy in all patients. AIM To evaluate long-term results of patients submitted to esophagogastric devascularization and splenectomy and postoperative endoscopic treatment regarding esophageal varices caliber and rebleeding rates. METHODS A retrospective study of 12 patients underwent esophagogastric devascularization and splenectomy followed for more than five years. RESULTS All patients showed varices size reduction, and no patient had postoperative bleeding recurrence. CONCLUSION Esophagogastric devascularization and splenectomy decreased significantly the esophageal variceal size when associated with endoscopic follow-up, being effective for bleeding recurrence prophylaxis.
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Affiliation(s)
| | - Claudemiro Quireze-Júnior
- Departamento de Clínica Cirúrgica, Faculdade de Medicina, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | - Thiago Miranda Tredicci
- Departamento de Clínica Cirúrgica, Faculdade de Medicina, Universidade Federal de Goiás, Goiânia, GO, Brazil
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Martins GLP, Bernardes JPG, Rovella MS, Andrade RG, Viana PCC, Herman P, Cerri GG, Menezes MR. Radiofrequency ablation for treatment of hypersplenism: A feasible therapeutic option. World J Gastroenterol 2015; 21:6391-6397. [PMID: 26034376 PMCID: PMC4445118 DOI: 10.3748/wjg.v21.i20.6391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 12/06/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
We present a case of a patient with hypersplenism secondary to portal hypertension due to hepato-splenic schistosomiasis, which was accompanied by severe and refractory thrombocytopenia. We performed spleen ablation and measured the total spleen and ablated volumes with contrast-enhanced computed tomography and volumetry. No major complications occurred, thrombocytopenia was resolved, and platelet levels remained stable, which allowed for early treatment of the patient’s underlying disease. Previous work has shown that splenic radiofrequency ablation is an attractive alternative treatment for hypersplenism induced by liver cirrhosis. We aimed to contribute to the currently sparse literature evaluating the role of radiofrequency ablation (RFA) in the management of hypersplenism. We conclude that splenic RFA appears to be a viable and promising option for the treatment of hypersplenism.
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Richter J, Bode JG, Blondin D, Kircheis G, Kubitz R, Holtfreter MC, Müller-Stöver I, Breuer M, Hüttig F, Antoch G, Häussinger D. Severe liver fibrosis caused by Schistosoma mansoni: management and treatment with a transjugular intrahepatic portosystemic shunt. THE LANCET. INFECTIOUS DISEASES 2015; 15:731-7. [PMID: 25769268 DOI: 10.1016/s1473-3099(15)70009-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Liver diseases are common in inhabitants and migrants of tropical countries, where the liver can be exposed not only to toxins but also to many viral, bacterial, fungal, and parasitic infections. Schistosomiasis--a common parasitic infection that affects at least 240 million people worldwide, mostly in Africa--is regarded as the most frequent cause of liver fibrosis worldwide. We present a case of a 19-year-old male refugee from Guinea with recurrent oesophageal variceal bleeding due to schistosomal liver fibrosis refractory to endoscopic therapy. This case was an indication for portosystemic surgery, which is a highly invasive non-reversible intervention. An alternative, less invasive, reversible radiological procedure, used in liver cirrhosis, is the placement of a transjugular intrahepatic portosystemic shunt (TIPS). After thorough considerations of all therapeutic options we placed a TIPS in our patient. In more than 3 years of observation, he is clinically well apart from one episode of hepatic encephalopathy related to an acute episode of viral gastroenteritis. Bleeding from oesophageal varices has not recurred. In this Grand Round, we review the diagnostic approaches and treatment options for portal hypertension due to schistosomal liver fibrosis.
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Affiliation(s)
- Joachim Richter
- Tropical Medicine Unit, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
| | - Johannes G Bode
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Dirk Blondin
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Gerald Kircheis
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Ralf Kubitz
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Martha C Holtfreter
- Tropical Medicine Unit, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Irmela Müller-Stöver
- Tropical Medicine Unit, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Matthias Breuer
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Falk Hüttig
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
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Colaneri RP, Coelho FF, Cleva RD, Perini MV, Herman P. Splenic artery ligature associated with endoscopic banding for schistosomal portal hypertension. World J Gastroenterol 2014; 20:16734-16738. [PMID: 25469045 PMCID: PMC4248220 DOI: 10.3748/wjg.v20.i44.16734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/14/2014] [Accepted: 07/16/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To propose a less invasive surgical treatment for schistosomal portal hypertension.
METHODS: Ten consecutive patients with hepatosplenic schistosomiasis and portal hypertension with a history of upper gastrointestinal hemorrhage from esophageal varices rupture were evaluated in this study. Patients were subjected to a small supraumbilical laparotomy with the ligature of the splenic artery and left gastric vein. During the procedure, direct portal vein pressure before and after the ligatures was measured. Upper gastrointestinal endoscopy was performed at the 30th postoperative day, when esophageal varices diameter were measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings.
RESULTS: There was no intra-operative mortality and all patients had confirmed histologic diagnoses of schistosomal portal hypertension. During the immediate postoperative period, two of the ten patients had complications, one characterized by a splenic infarction, and the other by an incision hematoma. Mean hospitalization time was 4.1 d (range: 2-7 d). Pre- and post-operative liver function tests did not show any significant changes. During endoscopy thirty days after surgery, a decrease in variceal diameters was observed in seven patients. During the follow-up period (57-72 mo), endoscopic therapy was performed and seven patients had their varices eradicated. Considering the late postoperative evaluation, nine patients had a decrease in variceal diameters. A mean of 3.9 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence at the late postoperative period, which was controlled with endoscopic banding in one patient due to variceal rupture and presented as secondary to congestive gastropathy in the other patient. Both bleeding episodes were of minor degree with no hemodynamic consequences or need for blood transfusion.
CONCLUSION: Ligature of the splenic artery and left gastric vein with supraumbilical laparotomy is a promising and less invasive method for treating presinusoidal schistosomiasis portal hypertension.
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Pereira FMF, Evangelista-Neto J, Brito N, Amaral F, da Fonseca-Neto OCL, Lacerda CM. Angiografic and pressoric changes determined by splenectomy with left gastric vein ligature in mansoni schistosomiasis. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2014; 26:302-8. [PMID: 24510039 DOI: 10.1590/s0102-67202013000400010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 08/08/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND In hepatosplenic schistosomiasis occurs diffuse hepatic fibrosis associated with venous congestion of the portal system resulting in hepatosplenomegaly. It can produce digestive hemorrhage caused by rupture of esophageal and stomach varices or peptic gastroduodenal mucosal lesions. AIM To study the effects of splenectomy and ligature of the left gastric vein on portohepatic hemodynamics. METHOD Twenty-three patients with hepatosplenic schistosomiasis mansoni were studied before and about two weeks after operation through angiographic diameter of the common and proper hepatic artery, splenic artery, superior mesenteric artery, portal vein, superior mesenteric vein and left gastric vein. The pressures of the inferior vena cava and central venous pressure, free hepatic vein, the hepatic sinusoidal and occluded vein were measured. RESULTS The splenectomy and ligature of the left gastric vein determined low morbidity and null mortality. It determined significant addition to the following variables: diameters of the common and proper hepatic artery; diameter of the superior mesenteric vein. It determined non significant increase on the following measurements: right atrial pressure and diameter of the superior mesenteric artery. It determined non significant decrease to the following variables: inferior vena cava pressure; free hepatic vein pressure; occluded hepatic vein pressure; sinusoidal pressure, diameter of the portal vein. CONCLUSION Splenectomy and ligature of the left gastric vein do not determine portal hemodynamic changes capable of breaking the functional hemodinamic balance that characterizes the hepatosplenic mansoni schistosomiasis.
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COELHO FF, PERINI MV, KRUGER JAP, FONSECA GM, de ARAÚJO RLC, MAKDISSI FF, LUPINACCI RM, HERMAN P. Management of variceal hemorrhage: current concepts. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2014; 27:138-44. [PMID: 25004293 PMCID: PMC4678684 DOI: 10.1590/s0102-67202014000200011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 03/11/2014] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The treatment of portal hypertension is complex and the the best strategy depends on the underlying disease (cirrhosis vs. schistosomiasis), patient's clinical condition and time on it is performed (during an acute episode of variceal bleeding or electively, as pre-primary, primary or secondary prophylaxis). With the advent of new pharmacological options and technical development of endoscopy and interventional radiology treatment of portal hypertension has changed in recent decades. AIM To review the strategies employed in elective and emergency treatment of variceal bleeding in cirrhotic and schistosomotic patients. METHODS Survey of publications in PubMed, Embase, Lilacs, SciELO and Cochrane databases through June 2013, using the headings: portal hypertension, esophageal and gastric varices, variceal bleeding, liver cirrhosis, schistosomiasis mansoni, surgical treatment, pharmacological treatment, secondary prophylaxis, primary prophylaxis, pre-primary prophylaxis. CONCLUSION Pre-primary prophylaxis doesn't have specific treatment strategies; the best recommendation is treatment of the underlying disease. Primary prophylaxis should be performed in cirrhotic patients with beta-blockers or endoscopic variceal ligation. There is controversy regarding the effectiveness of primary prophylaxis in patients with schistosomiasis; when indicated, it is done with beta-blockers or endoscopic therapy in high-risk varices. Treatment of acute variceal bleeding is systematized in the literature, combination of vasoconstrictor drugs and endoscopic therapy, provided significant decline in mortality over the last decades. TIPS and surgical treatment are options as rescue therapy. Secondary prophylaxis plays a fundamental role in the reduction of recurrent bleeding, the best option in cirrhotic patients is the combination of pharmacological therapy with beta-blockers and endoscopic band ligation. TIPS or surgical treatment, are options for controlling rebleeding on failure of secondary prophylaxis. Despite the increasing evidence of the effectiveness of pharmacological and endoscopic treatment in schistosomotic patients, surgical therapy still plays an important role in secondary prophylaxis.
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Affiliation(s)
- Fabricio Ferreira COELHO
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
- Serviço de Transplantes, Departamento de Cirurgia,
Santa Casa de Misericórdia (2Transplant Service, Department of Surgery, Santa
Casa de Misericórdia de São Paulo)
| | - Marcos Vinícius PERINI
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
- Instituto do Câncer do Estado de São Paulo in
São Paulo, SP, Brazil; (3Instituto do Câncer do Estado de São Paulo
in São Paulo, Brazil)
| | - Jaime Arthur Pirola KRUGER
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
- Instituto do Câncer do Estado de São Paulo in
São Paulo, SP, Brazil; (3Instituto do Câncer do Estado de São Paulo
in São Paulo, Brazil)
| | - Gilton Marques FONSECA
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
| | - Raphael Leonardo Cunha de ARAÚJO
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
| | - Fábio Ferrari MAKDISSI
- Instituto do Câncer do Estado de São Paulo in
São Paulo, SP, Brazil; (3Instituto do Câncer do Estado de São Paulo
in São Paulo, Brazil)
| | - Renato Micelli LUPINACCI
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
- Service de Chirurgie Générale,
Viscérale et Endocrinienne, Hôpital Pitié Salpetrière in
Paris, França (4Service de Chirurgie Générale, Viscérale et
Endocrinienne, Hôpital Pitié Salpetrière in Paris, France)
| | - Paulo HERMAN
- Serviço de Cirurgia do Fígado e
Hipertensão Portal, Departamento de Gastroenterologia, Hospital das
Clínicas da Faculdade de Medicina da Universidade de São Paulo (1Liver
Surgery Unit, Department of Gastroenterology, University of São Paulo Medical
School
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Batista-Neto J, Tognetti LB, Ribeiro LT, Balwani MDC, Muritiba T, Alves EEC. Evolutional profile of the esophageal varices after splenectomy associated with ligation of the left gastric vein and sclerotherapy in schistosomal portal hypertension. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2014; 26:49-53. [PMID: 23702871 DOI: 10.1590/s0102-67202013000100011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 12/06/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND The schistosomiasis affects 200 million people in 70 countries worldwide. It is estimated that 10% of those infected will develop hepatosplenic status and of these, 30% will progress to portal hypertension and esophagogastric varices, whose expression is through gastrointestinal bleeding with significant mortality in the first bleeding episode. Multiple surgical techniques have been developed to prevent re-bleeding. AIM To evaluate the evolutional profile of esophageal varices after splenectomy + ligation of the left gastric vein associated with endoscopic sclerotherapy in schistosomal portal hypertension. METHODS Prospective and observational study including schistosomiasis patients with previous history of upper digestive hemorrhage and underwent to splenectomy + ligation of the left gastric vein and sclerotherapy. The variables were: evolutional profile of esophageal varices before and after surgery and re-bleeding rate. RESULTS The sample included 30 patients, 15 patients for each gender. The age ranged from 19 to 74 years (median = 43 years). There was a reduction in the degree, caliber and red spots in all patients (p< 0.05). The eradication of varices with sclerotherapy was achieved in 86.7% and with surgery alone in 15.4%. The mean follow-up was 28 months, ranging from two to 76 months. Were carried from one to seven sessions of sclerotherapy and the average was three per patient to eradicate varices. Four (13.3%) did not complete the follow-up. The re-bleeding rate was 16.7%. CONCLUSION There was a reduction of the degree, caliber and red spots of esophageal varices in all patients.
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Affiliation(s)
- João Batista-Neto
- Group of Liver, Bile Ducts, Pancreas and Portal Hypertension Surgery, General Surgery and Specialties Service, University Hospital Prof. Alberto Antunes, Faculty of Medicine, Federal University of Alagoas, Maceio, Brazil.
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Ferreira FG. [The indexing of ABCD in PubMed and surgery of schistosomal portal hypertension in Brazil]. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 26:248-50. [PMID: 24190389 DOI: 10.1590/s0102-67202013000300020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Ferraz AAB, Campos JM, de Araújo JGC, de Carvalho MRC, Ribeiro Neto JP, Ferraz EM. Influence of the inversion of the portal/splenic vein diameter in the results of the surgical treatment of schistossomotic portal hypertension. Rev Col Bras Cir 2011; 38:35-40. [PMID: 21537741 DOI: 10.1590/s0100-69912011000100007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 02/15/2010] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the morbidity and mortality in surgical treatment of schistosomal portal hypertension in patients with inversion of the Portal/Splenic Vein diameter ratio. METHODS We conducted a retrospective cross-sectional study of patients undergoing surgical treatment of portal hypertension in the period between September 1993 and January 2004. The study population was divided into two groups: a) Inversion--splenic vein diameter greater than or equal to portal vein's--and b) control group (portal vein diameter greater than the splenic vein's). Statistical comparisons used the Student t test for averages difference, chi-square test for proportions difference and Fisher's exact test for small samples. RESULTS 169 patients were analyzed, with follow-up averaging 23.6 months. Twenty-one patients (12.4%) had splenic vein caliber greater of equal than the portal vein's (Inversion--study group). The mean preoperative diameter of the portal and splenic veins were respectively 1.49 and 1.14 cm in the control group, and 0.98 versus 1.07 cm in the inversion group. The portal vein diameter was significantly higher in the control group when compared to the inversion group (p <0.05). Varices in the gastric fundus were found in 33.3% of the inversion group and in 38.5% of patients in the control group. Postoperative rebleeding occurred in 23.1% of patients in the inversion group and in 13.4% of the control group ones (p > 0.05). In the postoperative evaluation with Doppler ultrasonography of portal vessels, no cases of portal vein thrombosis were observed in the inversion group, whilst in the control group portal thrombosis was identified in 16.9% of the patients (p <0.05). Death occurred in one (4.8%) individual from the inversion group; mortality was 4.1% in the control group (p>0.05). The mean serum level of platelets was significantly lower (65,950/mm²) in the inversion group than in the controls (106,647/mm²) (p<0.05). CONCLUSION The results suggest that the reversal of portal/splenic vein caliber ratio does not represent a contraindication to surgical treatment of schistosomal portal hypertension.
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Affiliation(s)
- Alvaro Antônio Bandeira Ferraz
- Department of General Surgery, Hospital das Clinicas, Federal University of Pernambuco (HC-UFPE SCG), Recife, Pernambuco, Brazil.
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Andraus W, Pinheiro RS, Haddad LB, Herman P, D'Albuquerque LAC. The best approach for splenectomy in portal hypertension. Surgery 2011; 149:853. [PMID: 21497875 DOI: 10.1016/j.surg.2011.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 02/15/2011] [Indexed: 11/18/2022]
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