Long-term results with the modified Sugiura procedure for the management of variceal bleeding: standing the test of time in the treatment of bleeding esophageal varices

Long-term outcomes of oesophagogastric devascularization and splenectomy in patients with portal hypertension and liver cirrhosis

BACKGROUND

Research about the long-term outcomes of oesophagogastric devascularization and splenectomy (OGDS) to treat portal hypertension (PH) is scarce. This study aimed to evaluate the safety and long-term treatment efficacy of OGDS, especially in elderly patients.

METHODS

During 2010-2016, open splenectomy and oesophagogastric devascularization (OSOD) and laparoscopic splenectomy and oesophagogastric devascularization were performed in 124 (group A) and 29 (group C) patients diagnosed with PH and liver cirrhosis, respectively. All patients aged less than 65 years. Besides, 39 patients aged 65 years or older undergoing open splenectomy and oesophagogastric devascularization were classified into group B. All clinical data were retrospectively analysed.

RESULTS

Compared with group A, patients in group C had longer operative time, less blood loss and shorter post-operative hospitalization time. However, for perioperative data, there was no significant difference between group A and group B. During post-operative follow-up, compared with pre-operative condition, all haematology and liver function parameters significantly changed, except for alanine aminotransferase. For post-operative complications, only the portal vein system thrombosis rate was significantly higher in group C than group A. No significant difference was found in the overall survival rate among three groups, when non-variceal-rebleeding-related deaths were excluded.

CONCLUSION

OGDS remains safe and effective to treat PH secondary to liver cirrhosis and it can be performed successfully in elderly patients and achieve a curative effect that is not inferior to young patients.

Elective Splenectomy Combined with Modified Hassab's or Sugiura Procedure for Portal Hypertension in Decompensated Cirrhosis

OBJECTIVE

Portal hypertension is a major complication of decompensated cirrhosis. In China, modified Hassab's and Sugiura procedure are the two major methods of nonshunting surgery. This study aims to compare the efficacy and safety of the two procedures for portal hypertension.

METHOD

Between January 1994 and December 2009, 172 elective patients diagnosed with decompensated cirrhosis with significant hypersplenism adopted elective splenectomy for hypersplenism, and also modified Hassab's (n = 91) or Sugiura (n = 81) procedure was additionally performed to reduce the risk of variceal bleeding. Postoperative mortality and morbidity data were collected, and a retrospectively comparative analysis was conducted.

RESULTS

All of the patients were treated successfully without death during operation, and no variceal bleeding occurred during hospitalization. There were 4 (4.4%) deaths in Hassab's group and 3 (3.7%) deaths in Sugiura group postoperatively (P > 0.05). During follow-up, the survival rate was 90.2%, 82.42%, and 71.43% in Hassab's group and 96.29%, 81.48%, and 75.31% in Sugiura group in 1, 3, and 5 years (P > 0.05). There were 22/71 and 12/63 patients in each groups who suffered no deadly variceal bleeding (P = 0.11). Bleeding related death and no bleeding related death occurred in 7/23 and 3/13 patients in each group (P = 0.26 and 0.14, respectively).

CONCLUSION

Elective splenectomy combined with modified Sugiura procedure seemed to be associated with a reduced trend of no deadly variceal bleeding compared with Hassab's procedure. As statistical significance was not found, further large scale and prospective study was warranted.

Surgical portosystemic shunts versus devascularisation procedures for prevention of variceal rebleeding in people with hepatosplenic schistosomiasis

BACKGROUND

Hepatosplenic schistosomiasis is an important cause of variceal bleeding in low-income countries. Randomised clinical trials have evaluated the outcomes of two categories of surgical interventions, shunts and devascularisation procedures, for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis. The comparative overall benefits and harms of these two interventions are unclear.

OBJECTIVES

To assess the benefits and harms of surgical portosystemic shunts versus oesophagogastric devascularisation procedures for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, LILACS, reference lists of articles, and proceedings of relevant associations for trials that met the inclusion criteria (date of search 11 January 2018).

SELECTION CRITERIA

Randomised clinical trials comparing surgical portosystemic shunts versus oesophagogastric devascularisation procedures for the prevention of variceal rebleeding in people with hepatosplenic schistosomiasis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trials and extracted data using methodological standards expected by Cochrane. We assessed risk of bias according to domains and risk of random errors with GRADE and Trial Sequential Analysis. We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We found two randomised clinical trials including 154 adult participants, aged between 18 years and 65 years, diagnosed with hepatosplenic schistosomiasis. One of the trials randomised participants to proximal splenorenal shunt versus distal splenorenal shunt versus oesophagogastric devascularisation with splenectomy, and the other randomised participants to distal splenorenal shunt versus oesophagogastric devascularisation with splenectomy. In both trials the diagnosis of hepatosplenic schistosomiasis was made based on clinical and biochemical assessments. The trials were conducted in Brazil and Egypt. Both trials were at high risk of bias.We are uncertain as to whether surgical portosystemic shunts improved all-cause mortality compared with oesophagogastric devascularisation with splenectomy due to imprecision in the trials (risk ratio (RR) 2.35, 95% confidence interval (CI) 0.55 to 9.92; participants = 154; studies = 2). We are uncertain whether serious adverse events differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy (RR 2.26, 95% CI 0.44 to 11.70; participants = 154; studies = 2). None of the trials reported on health-related quality of life. We are uncertain whether variceal rebleeding differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy (RR 0.39, 95% CI 0.13 to 1.23; participants = 154; studies = 2). We found evidence suggesting an increase in encephalopathy in the shunts group versus the devascularisation with splenectomy group (RR 7.51, 95% CI 1.45 to 38.89; participants = 154; studies = 2). We are uncertain whether ascites and re-interventions differed between surgical portosystemic shunts and oesophagogastric devascularisation with splenectomy. We computed Trial Sequential Analysis for all outcomes, but the trial sequential monitoring boundaries could not be drawn because of insufficient sample size and events. We downgraded the overall certainty of the body of evidence for all outcomes to very low due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

Given the very low certainty of the available body of evidence and the low number of clinical trials, we could not determine an overall benefit or harm of surgical portosystemic shunts compared with oesophagogastric devascularisation with splenectomy. Future randomised clinical trials should be designed with sufficient statistical power to assess the benefits and harms of surgical portosystemic shunts versus oesophagogastric devascularisations with or without splenectomy and with or without oesophageal transection.

Laparoscopic azygoportal disconnection with and without splenectomy for portal hypertension

INTRODUCTION

Laparoscopic splenectomy and azygoportal disconnection (LSD) has been reported to be safe, feasible, and minimally invasive for cirrhotic patients with portal hypertension. There is still controversy as to whether it is necessary to perform synchronous splenectomy for patients with moderate hypersplenism who undergo azygoportal disconnection for esophagogastric variceal hemorrhage (EGVB).

METHODS

We retrospectively evaluated the outcomes in 51 cirrhotic patients with EGVB and moderate hypersplenism (PLT ≥50 × 10⁹/L) who underwent LSD (n = 28) or laparoscopic azygoportal disconnection (LD) (n = 23) between January 2014 and October 2015. Their demographic, intraoperative, and postoperative variables were compared.

RESULTS

LSD and LD were successful in all the patients. When compared with LSD, LD had a significantly shorter operation time, less intraoperative blood loss, shorter postoperative hospital stay, fewer days of postoperative body temperature >38.0 °C, lower rate of fever postoperatively, and lower C-reactive protein concentration and procalcitonin concentration on postoperative day (POD) 7 (all P < 0.05). The incidences of portal vein system thrombosis in the LD group on PODs 7, 30, and 90 were significantly lower than those in the LSD group at all the time points (all P < 0.05). According to the postoperative serum proportions of CD4⁺ and CD8⁺ and the CD4+/CD8+ ratio (all P < 0.05), the LSD group had significantly lower immune function than the LD group on POD 90.

CONCLUSIONS

LD is safe and effective for EGVB with moderate hypersplenism secondary to portal hypertension in selected patients.

Individualized Laparoscopic Therapy for Portal Hypertension: A Preliminary Single Center Experience

BACKGROUND

To investigate the effects and technical points of several individualized laparoscopic therapies for patients suffering from cirrhotic portal hypertension.

METHODS

In total, 385 cirrhotic patients who underwent the treatment of individualized laparoscopic therapy from February 2012 to December 2015 at the Clinical Medical College of Yangzhou University were enrolled in this study. We retrospectively analyzed the clinical data and the key technical points.

RESULTS

Individualized laparoscopic therapies were successfully performed on 379 of 385 cases. Six cases were converted to a laparotomy (the rate of conversion to laparotomy was 1.6%). Modified laparoscopic splenectomy (MLS) for cirrhotic patients with hypersplenism was successfully performed on 103 of 105 cases. Laparoscopic azygoportal disconnection for cirrhotic patients with esophagogastric variceal bleeding (EGVB) or F3 varices was successfully performed on 61 of 62 cases, and modified laparoscopic splenectomy and azygoportal disconnection (MLSD) for cirrhotic patients with hypersplenism and EGVB or F3 varices was successfully performed on 196 of 201 cases. Synchronous MLS and laparoscopic partial hepatectomy (SLSH) for cirrhotic patients with hypersplenism and hepatocellular carcinoma (HCC) and synchronous MLSD and laparoscopic partial hepatectomy (SLSDH) for cirrhotic patients with hypersplenism, EGVB or F3 varices and HCC were all successfully implemented on 12 and 5 patients, respectively. From May 2013, we used the intraoperative autologous cell salvage during each individualized laparoscopic procedure.

CONCLUSIONS

An individualized laparoscopic therapy was beneficial for different state of selected cirrhotic patients with portal hypertension with or without HCC.

Massive upper gastrointestinal bleeding due to splenoportal axis thrombosis in a patient with a tested JAK2 mutation: A case report and review literature

Portal hypertension is a clinical syndrome defined as a portal venous pressure that exceeds 10mmHg. Cirrhosis is the most common cause of portal hypertension and thrombosis of the splenoportal axis not associated with liver cirrhosis is the second cause of portal hypertension in the Western world. The primary myeloproliferative disorders are the main cause of portal venous thrombosis and somatic mutation of Janus Kinase 2 gene (JAK2 V617F) can be found in approximately 90% of polycythemia vera, 50% of essential thrombocyrosis and 50% primary myelofibrosis. A a 55-year-old man with JAK2 mutation-associated splenoportal axis hypertension and bleeding complications due to oesophageal varices is reported. A massive upper bleeding episode made an emergent surgery to be done immediatelly at seventh day. The patient was discharged home at fifteenth day after surgery.

Current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding

OBJECTIVE

Esophageal variceal bleeding is the most dangerous complication in patients with liver cirrhosis, and it is accompanied by high mortality. Their treatment can be complex, and requires a multidisciplinary approach. This review examines current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding.

METHODS

PubMed, Google Scholar, and Cochrane Systematic Reviews were searched for articles published between 1987 and 2015. Relevant articles were identified using the following terms: 'esophageal variceal bleeding', 'portal hypertension' and 'complications of liver cirrhosis'. The reference lists of articles identified were also searched for other relevant publications. Inclusion criteria were restricted to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding.

RESULTS

It is currently recommended to combine vasoactive drugs (preferable somatostatin or terlipressin) and endoscopic therapies (endoscopic band ligation as first choice, sclerotherapy if endoscopic band ligation not feasible) for the initial treatment of acute variceal bleeding. Antibiotic prophylaxis must be regarded as an integral part of the treatment. The use of a Sengstaken-Blakemore tube is appropriate only in cases of refractory bleeding if the above methods cannot be used. An alternative to balloon tamponade may be the installation of self-expandable metal stents. The transjugular intrahepatic portosystemic shunt is an extremely useful technique for the treatment of acute bleeding from esophageal varices. Although most current clinical guidelines classify it as second-line therapy, the Baveno VI workshop recommends early transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stents within 72 h (ideally <24 h) in patients with esophageal variceal bleeding at high risk of treatment failure (e.g. Child-Turcotte-Pugh class C < 14 points or Child-Turcotte-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. Urgent surgical intervention is rarely performed and can be considered only in case of failure of conservative and/or endoscopic therapy and being unable to use a transjugular intrahepatic portosystemic shunt. Among surgical operations described in the literature are a variety of portocaval anastomosis and azygoportal disconnection procedures.

CONCLUSIONS

To improve the results of treatment for patients with liver cirrhosis who develop acute esophageal variceal bleeding, it is important to stratify patients into risk groups, which will allow one to tailor therapeutic approaches to the expected results.

Esophagogastric devascularization without splenectomy in portal hypertension: safe and effective?

BACKGROUND

Esophagogastric variceal hemorrhage is a life-threatening complication of portal hypertension. In this study, we compared the therapeutic effect of a novel surgical procedure, esophagogastric devascularization without splenectomy (EDWS), with the widely used modified esophagogastric devascularization (MED) with splenectomy for the treatment of portal hypertension.

METHODS

Fifty-five patients with portal hypertension were included in this retrospective study. Among them, 27 patients underwent EDWS, and the other 28 patients underwent MED. Patients' characteristics, perioperative parameters and long-term follow-up were analyzed.

RESULTS

The portal venous pressure was decreased by 20% postoperatively in both groups. The morbidity rate of portal venous system thrombosis in the EDWS group was significantly lower than that in the MED group (P=0.032). The 1- and 3-year recurrence rates of esophagogastric variceal hemorrhage were 0% and 4.5% in the EDWS group, and 0% and 8.7% in the MED group, respectively (P=0.631).

CONCLUSIONS

EDWS is a safe and effective treatment for esophagogastric varices secondary to portal hypertension in selected patients. Patients treated with EDWS had a lower complication rate of portal venous system thrombosis compared with those treated with conventional MED.

Management of variceal hemorrhage: current concepts

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.

Two surgical procedures for esophagogastric variceal bleeding in patients with portal hypertension

AIM: To determine the clinical value of a splenorenal shunt plus pericardial devascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding.

METHODS: From January 2008 to November 2012, 290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding: 207 patients received a routine PCVD procedure (PCVD group), and 83 patients received a PCVD plus a splenorenal shunt procedure (combined group). Changes in hemodynamic parameters, rebleeding, encephalopathy, portal vein thrombosis, and mortality were analyzed.

RESULTS: The free portal pressure decreased to 21.43 ± 4.35 mmHg in the combined group compared with 24.61 ± 5.42 mmHg in the PCVD group (P < 0.05). The changes in hemodynamic parameters were more significant in the combined group (P < 0.05). The long-term rebleeding rate was 7.22% in the combined group, which was lower than that in the PCVD group (14.93%), (P < 0.05).

CONCLUSION: Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT. It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered.

Transumbilical single-incision laparoscopic splenectomy plus pericardial devascularization using conventional instruments: initial experience of 5 cases

PURPOSE

Laparoendoscopic single-site surgery (LESS) has been proposed for several intra-abdominal surgical interventions. However, application of the LESS technique in portal hypertension is still in its infancy. We report in this article a new technique of LESS splenectomy plus pericardial devascularization with conventional laparoscopic instruments in patients with portal hypertension.

PATIENTS AND METHODS

From January 2010 to April 2012, LESS splenectomy plus pericardial devascularization was performed on 5 patients with portal hypertension. Surgical techniques and short-term outcomes were summarized and analyzed retrospectively.

RESULTS

All the operations were successful with a mean operative duration of 252 minutes (range, 220-270 minutes), intraoperative blood loss of 290 mL (range, 250-350 mL), and hospital stay of 8.2 days (range, 7-9 days). No intraoperative or postoperative complications were recorded. The umbilical incision healed well with a satisfactory cosmetic effect.

CONCLUSIONS

LESS splenectomy plus pericardial devascularization is feasible when performed by experienced laparoscopic surgeons and may offer safety comparable to that of the conventional laparoscopic operation.

Role of self-expandable metal stents in acute variceal bleeding

Acute variceal bleeding continues to be associated with significant mortality. Current standard of care combines hemodynamic stabilization, antibiotic prophylaxis, pharmacological agents, and endoscopic treatment. Rescue therapies using balloon tamponade or transjugular intrahepatic portosystemic shunt are implemented when first-line therapy fails. Rescue therapies have many limitations and are contraindicated in some cases. Placement of fully covered self-expandable metallic stent is a promising therapeutic technique that can be used to control bleeding in cases of refractory esophageal bleeding as an alternative to balloon tamponade. These stents can be left in place for as long as two weeks, allowing for improvement in liver function and institution of a more definitive treatment.