Esophageal variceal bleeding secondary to portal hypertension: endoscopic sclerotherapy as the first-step treatment

Laparoscopic Splenectomy and Esophagogastric Devascularization for Liver Cirrhosis and Portal Hypertension Is a Safe, Effective, and Minimally Invasive Operation

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.

The collateral caval shunt as an alternative to classical shunt procedures in patients with recurrent duodenal varices and extrahepatic portal vein thrombosis

Upper gastrointestinal bleeding episodes from variceal structures are severe complications in patients with portal hypertension. Endoscopic sclerotherapy and variceal ligation are the treatment options preferred for upper variceal bleeding owing to extrahepatic portal hypertension due to portal vein thrombosis (PVT). Recurrent duodenal variceal bleeding in non-cirrhotic patients with diffuse porto-splenic vein thrombosis and subsequent portal cavernous transformation represent a clinical challenge if classic shunt surgery is not possible or suitable.

In this study, we represent a case of recurrent bleeding of duodenal varices in a non-cirrhotic patient with cavernous transformation of the portal vein that was successfully treated with a collateral caval shunt operation.

Laparoscopic splenectomy and periesophagogastric devascularization with endoligature for portal hypertension in children

BACKGROUND

Bleeding from esophagogastric varices is an importment complication of portal hypertension. Recently, significant progress in laparoscopic technology has enabled the devascularization of the lower esophagus and upper stomach in a less invasive way. In this article, we report our preliminary experience with laparoscopic splenectomy and periesophagogastric devascularization by endoligature and its effectiveness for bleeding varices with hypersplenism in children.

PATIENTS AND METHODS

Six children with bleeding portal hypertension and developed severe thrombocytopenia and/or leukopenia underwent laparoscopic splenectomy and selective pericardial devascularization by using silk endoligature combined with a Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, OH). The patients included 5 males and 1 female, who ranged in age from 8 to 17 years. After a massive splenectomy was performed, we devascularized the periesophagogastric collateral vessels and perforating veins of the upper stomach to the level of the incisura angularis and the lower esophagus 5 or 6 cm away from the esophagocardia junction. The stem of the gastric coronary vein and paraesophageal collateral veins were not dissected in order to reserve portal blood flow toward the azygous shunt.

RESULTS

All the procedures were completed successfully under a whole laparoscope. The operative time ranged from 180 to 270 minutes. Intraoperative blood loss was estimated to be from 80 to 200 mL. None of the patients required a blood transfusion. There were no significant complications either intra- operatively or postoperatively, and all patients had returned to usual activity by 5 days. Postoperative platelet count and white blood cell count increased in individual patients. The data were statistically significant (p = 0.006 and 0.002, respectively). During a postoperative follow-up period of 8-40 months, all children were asymptomatic, with improved growth and hematology and no rebleeding, sepsis, or encephalopathy.

CONCLUSIONS

Laparoscopic massive splenectomy with selective periesophagogastric devascularization is a feasible, effective, and safe surgical procedure and has all the benefits of minimally invasive surgery. It offers a new alternative modality for children with bleeding portal hypertension and hypersplenism.

Mesenterico left portal bypass for variceal bleeding owing to extrahepatic portal hypertension caused by portal vein thrombosis

BACKGROUND/PURPOSE

Portosystemic shunt operations are indicated in patients with extrahepatic portal hypertension owing to portal vein thrombosis (EPH-PVT) suffering from recurrent variceal bleeding despite endoscopic sclerotherapy. Mesenterico left portal bypass procedure (MLPB) is an alternative procedure to the portosystemic shunt operations in patients with EPH-PVT. MLPB operation reestablishes hepatopetal portal blood flow. We herein present our experience with MLPB in children with EPH-PVT.

METHODS

Six patients were treated for EPH-PVT with recurrent bleeding despite endoscopic sclerotherapy (2 boys and 4 girls) in our unit. All patients were evaluated preoperatively with complete blood count, portal duplex system Doppler ultrasonography, magnetic resonance angiography, and upper gastrointestinal (GI) endoscopy. MLPB operation was performed as described by de Ville de Goyet. During the postoperative period, patients were evaluated with complete blood count, portal duplex system Doppler ultrasonography, upper GI endoscopy, and magnetic resonance angiography.

RESULTS

Six patients were assessed to be candidates for MLPB procedure and were operated to perform the MLPB procedure. Left portal veins were found to be patent during the operation in 4 patients, and the MLPB procedure was performed. Internal jugular vein was used in 3 patients and enlarged inferior mesenteric vein in 1 patient. Left portal veins of the remaining 2 patients were found to be obliterated; therefore, mesocaval shunt was performed. The postoperative course of the patients was uneventful except for 1 patient. During the following period, the leukocyte and the platelet counts were significantly increased in 3 of the 4 patients after the MLPB procedure. Upper GI bleeding occurred in the early postoperative period in 1 patient with MLPB procedure because of prepyloric ulcer that was successfully treated by endoscopic sclerotherapy. Internal jugular vein graft thrombosis was detected on the 10th postoperative day. This patient underwent a second laparotomy, the distal half of the graft was found to be sclerosed and narrowed that the graft was revised with a synthetic allograft.

CONCLUSIONS

Based on a review of the literature, the MLPB functions well in patients with portal hypertension caused by portal vein thrombosis and appears to have a physiologic advance over shunts that decompress but do not return blood directly to the liver. Because intra-abdominal veins appear to function well as a conduit in this operation, it may be favored by eliminating additional incision and increased risk in such patients.

Equality of the left and right renal venous flow predicts the severity of variceal bleeding in portal hypertensive children

Portasystemic collaterals develop as a result of portal hypertension. The collaterals in the cardioesophageal region is the leading cause of bleeding from esophageal varices. Some of the portal hypertensive patients present with bleeding episodes but the others do not, and some of the bleeders do not respond to endoscopic sclerotherapy procedure, although the underlying pathology is the same. The capacity of the natural collateral vessels might be a determining factor about the hemorrhagic events. Since the first step of portasystemic collateralization takes place in the naturally existent vascular channels, the present study, with its anatomic and clinical parts, was focused on these venous structures.