A new technique for laparoscopic splenectomy and azygoportal disconnection

Clinical effects of cluster technology optimization and innovations on laparoscopic splenectomy and azygoportal disconnection: a single-center retrospective study with 500 consecutive cases

BACKGROUND

In Asia, laparoscopic splenectomy and azygoportal disconnection (LSD) has been widely regarded as a preferential treatment modality for cirrhotic portal hypertension (PH). However, LSD involves high surgical risk, technical challenges, and many potential postoperative complications. Technology optimization and innovation in LSD aiming to solve to these difficulties has scarcely been reported. In this retrospective study, we aimed to evaluate the clinical therapeutic effect of our cluster technology optimization and innovation on LSD for PH.

METHODS

From February 2012 to January 2020, 500 patients with cirrhosis who had esophagogastric variceal bleeding and hypersplenism underwent LSD in our department. According to different operation periods, patients were divided into the early-, intermediate-, and late-period groups. We collected information regarding clinical characteristics of all patients as well as their preoperative and postoperative follow-up data.

RESULTS

Compared with the early-period group, operation time and postoperative hospital stay were all significantly different and gradually declined from the intermediate- and late-period groups, respectively (all P < 0.05). Intraoperative blood loss of these three groups was gradually decreased, with significant differences (P < 0.05). The incidences of delayed gastric emptying and diarrhea in the late-period group were all significantly lower than those in the early- and intermediate-period groups, respectively (all P < 0.05). Compared with the early-period group, the incidence of variceal re-bleeding was significantly lower in the intermediate- and late-period groups (all P < 0.05).

CONCLUSION

Our cluster technology optimization and innovation of LSD not only contributed to faster recovery and fewer complications but also enhanced surgical safety for patients. It is worth promoting this approach among patients with EVB and hypersplenism secondary to cirrhotic PH.

Vagus Nerve-Preserving Laparoscopic Splenectomy and Azygoportal Disconnection with Versus Without Intraoperative Endoscopic Variceal Ligation: a Randomized Clinical Trial

BACKGROUND

Esophagogastric variceal bleeding is the most common lethal factor for patients with cirrhotic portal hypertension. We firstly developed a laparoscopic splenectomy and azygoportal disconnection (LSD) with intraoperative endoscopic variceal ligation (LSDL) technique. In this study, we aimed to evaluate whether LSDL is feasible and safe and whether LSDL can effectively prevent esophagogastric variceal re-bleeding (EVR), as compared with single LSD.

METHODS

In this randomized controlled single-center study, 88 patients with cirrhosis who had esophagogastric variceal bleeding and hypersplenism were randomly assigned to receive either LSD (n = 44) or LSDL (n = 44) between January 2020 and December 2021. The primary outcome was EVR.

RESULTS

No patients withdrew from the study. There were no significant differences in estimated blood loss, incidence of blood transfusion, time to first flatus and off-bed activity, or postoperative hospital stay between the two groups. Compared with that in the LSD group, operation time was significantly longer in the LSDL group (138.5 ± 19.4 min vs. 150.3 ± 19.0 min, P < 0.05); however, LSDL was associated with a significantly decreased EVR rate at 1-year follow-up (8/44 vs. 1/44, P < 0.05). Univariate analysis and multivariate logistic regression revealed that LSDL was a significant independent protective factor against EVR in comparison with LSD (relative risk: 0.105, 95% confidence interval 0.012-0.877; P = 0.037).

CONCLUSIONS

Our newly developed LSDL procedure is not only technically feasible and safe; it also contributed to lowering the EVR risk more so than single LSD.

TRIAL REGISTRATION

We registered our research at https://www.

CLINICALTRIALS

gov/ . The name of research registered is "Laparoscopic Splenectomy and Azygoportal Disconnection with Intraoperative Endoscopic Variceal Ligation." The trial registration identifier at clinicaltrials.gov is NCT04244487.

Adverse factors responsible for below-normal platelet count after laparoscopic splenectomy and azygoportal disconnection

BACKGROUND/AIMS

Splenectomy is regarded as an effective curative treatment for thrombocytopenia caused by hypersplenism in patients with cirrhosis. However, in clinical practice, thrombocytopenia is not resolved by splenectomy in all patients. This study aimed to evaluate the adverse factors responsible for platelet (PLT) counts below the normal lower limit following laparoscopic splenectomy and azygoportal disconnection (LSD).

MATERIALS AND METHODS

We retrospectively evaluated the outcomes of 123 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism, who underwent LSD and who had PLT counts <125×109/L (non-normal group) or >125×109/L (normal group) at the postoperative month (POM) 3, between April 2014 and March 2017.

RESULTS

Sixteen patients (13.01%) had PLT counts <125×109/L at POM 3 after LSD, while the remaining 107 patients had normal counts. We analyzed 25 perioperative variables in both groups. A logistic multivariate regression identified age (relative risk [RR] 1.082, 95% confidence interval [CI] 1.018-1.150) and longitudinal spleen diameter (RR 0.977, 95% CI 0.955-1.000) as significant independent factors for the PLT count <125×109/L at POM 3. Bivariate correlation analysis showed that age >50 years and longitudinal spleen diameter <160 mm were threshold values for an increased risk of the PLT count <125×109/L at POM 3 after LSD.

CONCLUSION

Age was an independent positive predictor and longitudinal spleen diameter an independent negative predictor of PLT count <125×109/L at POM 3 after LSD.

Laparoscopic splenectomy and azygoportal disconnection combining with pre- and postoperative endoscopic intervention - A sandwich-style sequential therapy for portal hypertensive bleeding: A retrospective cohort study

BACKGROUND/AIMS

In patients who survive the first esophageal variceal bleeding (EVB) resulting from portal hypertension, the probability of fatal esophageal variceal re-bleeding (EVR) is high. We have developed a sandwich-style sequential therapy combining laparoscopic splenectomy and azygoportal disconnection (LSD) with preoperative and postoperative endoscopic intervention (LSDE). The aim of the present study was to investigate whether LSDE is safe and effective and to evaluate whether the postoperative EVR rate for LSDE was lower than that for LSD without periodical postoperative endoscopic intervention (NLSDE).

MATERIALS AND METHODS

We retrospectively investigated the outcomes of 226 patients with cirrhosis with EVB and secondary hypersplenism who all received preoperative endoscopic variceal ligation (EVL) to manage emergency EVB then underwent NLSDE (n=106) or LSDE (n=120) between February 2012 and April 2016. The perioperative and follow-up variables of the two groups were evaluated.

RESULTS

Between the two groups, there were no differences in number of blood transfusions, intraoperative blood loss, postoperative complications, and hospital stay. LSDE showed shorter operation time (p=0.001) and lower EVR rates during the periods ranging from 1 to 12 months, 4 to 6 months, 4 to 12 months, and 7 to 12 months (all p<0.05) than NLSDE. Dynamic changes in the diameter of the esophageal varices and the rates of EVL in the LSDE group both decreased gradually and significantly over the 12-month follow-up period (all p<0.0001).

CONCLUSION

Laparoscopic splenectomy and azygoportal disconnection with periodical postoperative endoscopy is safe and effective for reducing the EVR rate in cirrhotic portal hypertension.

Use of Iodized Oil and Gelatin Sponge Embolization in Splenic Artery Coiling Reduces Bleeding from Laparoscopic Splenectomy for Cirrhotic Portal Hypertension Patients with Complicating Hypersplenic Splenomegaly: A Comparative Study

OBJECTIVE

Laparoscopic splenectomy (LS) is relatively contraindicated in cirrhotic portal hypertension (CPH) patients with complicating hypersplenic splenomegaly (HS). This study aimed to evaluate the effectiveness and safety of incorporation of iodized oil and gelatin sponge embolization to conventional splenic artery embolization (cSAE) with coiling in CPH/HS patients undergoing LS.

PATIENTS AND METHODS

Between April 2012 and March 2014, eligible CPH/HS patients (n = 56) were assigned to preoperative modified SAE (mSAE) with LS (mSAE+LS group, n = 16), cSAE with LS (cSAE+LS group, n = 20) or LS alone (LS group, n = 20). Main outcome measures included frequency of conversion to laparotomy, operative time, intraoperative bleeding, and transfusion.

RESULTS

The three groups had similar baseline characteristics (all P > .05). mSAE and cSAE similarly decreased LS conversion frequency (mSAE+LS versus cSAE+LS versus LS, 0.0% versus 10.0% versus 30.0%, P = .030) and operative time (155 ± 23 minutes versus 170 ± 26 minutes versus 221 ± 42 minutes, P < .001) compared with LS alone. mSAE significantly reduced bleeding (178 ± 22 mL versus 250 ± 27 mL versus 328 ± 67 mL, P < .001) compared with cSAE and LS alone. The three groups had similar postoperative recovery times and surgical morbidities (all P > .05).

CONCLUSIONS

In CPH/HS patients, preoperative SAE reduced LS conversion frequency and reduced operative time compared with LS alone, while mSAE further decreased volume of blood loss.

A Novel Technique for Synchronous Laparoscopic Splenectomy and Azygoportal Disconnection With Hepatectomy

BACKGROUND

Liver resection was not formerly recommended in patients with both hepatocellular carcinoma (HCC) and portal hypertension because of difficult perioperative bleeding control and postoperative liver failure. Splenectomy is a proven method with which to overcome these problems. To investigate the safety and feasibility of synchronous laparoscopic splenectomy and azygoportal disconnection with hepatectomy (LSDH) for treatment of portal hypertension accompanied with HCC, we describe a clinical cohort of 10 patients who underwent a new technique of synchronous LSDH.

METHODS

A cohort of 10 cirrhotic patients with HCC, esophageal/gastric variceal bleeding, and hypersplenism received LSDH. A 6-port method was used for LSDH. This procedure comprises 5 steps: laparoscopic splenectomy, intraoperative splenic blood salvage, laparoscopic azygoportal disconnection, laparoscopic partial hepatectomy, and removal of spleen and liver specimens. Intraoperative autologous cell salvage was performed before hepatectomy.

RESULTS

LSDH was successful in all patients. There was no conversion to open operations. The operative time was 220.5 ± 19.8 minutes, blood loss was 264.0 ± 160.3 mL, and postoperative hospital stay was 10.2 ± 1.8 days.

CONCLUSIONS

Selective synchronous LSDH is a feasible, effective, and safe surgical procedure with satisfactory short-term efficacy. It is a promising minimally invasive treatment option for patients with cirrhotic HCC and portal hypertension.

Vagus nerve-preserving versus conventional laparoscopic splenectomy and azygoportal disconnection

BACKGROUND

Conventional open and conventional laparoscopic splenectomy and azygoportal disconnection (CLSD) result in poor quality of life because of damage to the vagal nerve. We have developed vagus nerve-preserving laparoscopic splenectomy and azygoportal disconnection (VLSD). This study aimed to evaluate whether VLSD is effective and safe, and to determine whether a reduction in the incidence of postoperative complications improves postoperative quality of life compared with CLSD.

METHODS

We retrospectively evaluated outcomes in 72 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism who underwent CLSD (n = 40) or VLSD (n = 32) between April 2015 and December 2016. Their demographic, intraoperative, and postoperative variables were compared.

RESULTS

No patients required conversion to laparotomy in CLSD and VLSD. There was no difference in estimated intraoperative blood loss, volume of intraoperative blood transfused, time to first flatus, time to off-bed activity, and postoperative hospital stay between the two groups. VLSD was associated with a shorter operation time (P = 0.020) and less postoperative complications (P < 0.0001), including less diarrhea (P < 0.0001), epigastric fullness (P < 0.0001), and delayed gastric emptying (P < 0.0001), compared with CLSD. With VLSD, there was a significant increase in body weight and plasma albumin levels at 6 months postoperatively compared with preoperative values (all P < 0.05). The curative effect of improving esophageal/gastric variceal bleeding was similar in the groups.

CONCLUSIONS

VLSD is effective and safe for reducing the incidence of postoperative complications, contributing to improving postoperative quality of life.

Laparoscopic Splenectomy and Azygoportal Disconnection: a Systematic Review

Background and Objectives:

Given the technical difficulty of laparoscopic splenectomy and azygoportal disconnection (LSD), data are limited that compare the laparoscopic to the open procedure. As the technique becomes more widespread, questions regarding its safety, feasibility, and reproducibility must be addressed. This review assesses the current status of LSD.

Methods:

We conducted our literature review with a search of the PubMed database. All published series of 5 or more laparoscopic splenectomy and azygoportal disconnection procedures were examined. The demographic, intraoperative, and postoperative data analyzed included number of ports, conversion rate, operative duration, estimated intraoperative blood loss, postoperative hospital stay, and complications.

Results:

Fifteen articles met the review criteria. Of 412 laparoscopic procedures, traditional laparoscopic splenectomy and azygoportal disconnection (TLSD) was used in 322 patients (78.2%), a modified laparoscopic procedure (MLSD) in 79 (19.2%), and a single-incision laparoscopic procedure (SLSD) in 11 (2.7%). Compared with the traditional and single-incision laparoscopic procedures, the MLSD procedure was associated with shorter operative duration and less blood loss. Furthermore, although the incidence of postoperative portal vein system thrombosis was higher in the laparoscopic than in the open splenectomy with azygoportal disconnection (OSD) procedure, the LSD procedure was associated with less pulmonary infection and pleural effusion and fewer incisional and overall complications than the open procedure. The rate of conversion to an open procedure was 5.4%.

Conclusions:

LSD is feasible and safe for selected patients when performed by an expert laparoscopic surgeon. It has perioperative advantages over OSD, but studies with longer follow-up periods and larger samples of patients are needed.

Modified laparoscopic hepatectomy for hepatic hemangioma

BACKGROUND

Laparoscopic hepatectomy (LH) using many different surgical techniques has become increasingly popular for the management of hepatic tumors. The performance of surgical procedures involving the least possible impairment is expected increasingly more often by both surgeons and patients. We herein describe a clinical cohort of ten patients with hepatic cavernous hemangioma (HCH) who underwent modified LH (MLH) with a new technique. We herein present the advantages of the low level of impairment during performance of this modified procedure and compare the outcomes of MLH with those of traditional LH (TLH) for HCH.

METHODS

We retrospectively evaluated the treatment outcomes in 24 patients with HCH who underwent MLH (n = 10) or TLH (n = 14) from February 2008 to January 2013. Their demographic, intraoperative, and postoperative variables were compared.

RESULTS

MLH was successful in all patients. An electromechanical morcellator allowed for easy extraction of the entire HCH without the use of a cumbersome retrieval bag, enlarged incision, or hand-assisted incision. There was no conversion to an open operation or significant perioperative complications. The operation time (P = 0.037), time to removal of the HCH (P < 0.0001), visual analog scale pain score on the first postoperative day (P = 0.012), time to off-bed activity (P = 0.036), and postoperative hospital stay (P = 0.048) were significantly lower in the MLH group than in the TLH group.

CONCLUSIONS

MLH involving the use of an electromechanical morcellator provides expedient recovery and minimal postoperative pain and scarring. It is a feasible, effective, and safe surgical procedure and embodies all of the benefits of minimally invasive surgery for patients with HCH.

Modified laparoscopic splenectomy and azygoportal disconnection combined with cell salvage is feasible and might reduce the need for blood transfusion

AIM: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy and azygoportal disconnection (MLSD) with intraoperative autologous cell salvage.

METHODS: We retrospectively evaluated outcomes in 79 patients admitted to the Clinical Medical College of Yangzhou University with cirrhosis, portal hypertensive bleeding and secondary hypersplenism who underwent MLSD without (n = 46) or with intraoperative cell salvage and autologous blood transfusion, including splenic blood and operative hemorrhage (n = 33), between February 2012 and January 2014. Their intraoperative and postoperative variables were compared. These variables mainly included: operation time; estimated intraoperative blood loss; volume of allogeneic blood transfused; visual analog scale for pain on the first postoperative day; time to first oral intake; initial passage of flatus and off-bed activity; perioperative hemoglobin (Hb) concentration; and red blood cell concentration.

RESULTS: There were no significant differences between the groups in terms of duration of surgery, estimated intraoperative blood loss and overall perioperative complication rate. In those receiving salvaged autologous blood, Hb concentration increased by an average of 11.2 ± 4.8 g/L (P < 0.05) from preoperative levels by the first postoperative day, but it had fallen by 9.8 ± 6.45 g/L (P < 0.05) in the group in which cell salvage was not used. Preoperative Hb was similar in the two groups (P > 0.05), but Hb on the first postoperative day was significantly higher in the autologous blood transfusion group (118.5 ± 15.8 g/L vs 102.7 ± 15.6 g/L, P < 0.05). The autologous blood transfusion group experienced significantly fewer postoperative days of temperature > 38.0 °C (P < 0.05).

CONCLUSION: Intraoperative cell salvage during MLSD is feasible and safe and may become the gold standard for liver cirrhosis with portal hypertensive bleeding and hypersplenism.

Perioperative advantages of modified laparoscopic vs open splenectomy and azygoportal disconnection

AIM: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy or open splenectomy and azygoportal disconnection for portal hypertension.

METHODS: This study included 44 patients who underwent modified laparoscopic splenectomy and azygoportal disconnection (MLSD) and 71 who underwent open procedures for portal hypertension. Blood samples were collected before surgery and on days 1, 3, and 7 after surgery. Markers of liver and renal function, C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) were measured, and perioperative variables were compared between the two groups.

RESULTS: The modified laparoscopic group showed significantly better and faster recovery, better liver and renal function, and fewer complications than the open group. CRP, IL-6, and PCT concentrations on postoperative days 1, 3, and 7 were significantly lower in the modified laparoscopic group than in the open group.

CONCLUSION: MLSD was associated with lower inflammatory immune responses, less impairment of liver and renal function, and faster and better recovery.

Laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension

Since the first laparoscopic splenectomy (LS) was reported in 1991, LS has become the gold standard for the removal of normal to moderately enlarged spleens in benign conditions. Compared with open splenectomy, fewer postsurgical complications and better postoperative recovery have been observed, but LS is contraindicated for hypersplenism secondary to liver cirrhosis in many institutions owing to technical difficulties associated with splenomegaly, well-developed collateral circulation, and increased risk of bleeding. With the improvements of laparoscopic technique, the concept is changing. This article aims to give an overview of the latest development in laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension. Despite a lack of randomized controlled trial, the publications obtained have shown that with meticulous surgical techniques and advanced instruments, LS is a technically feasible, safe, and effective procedure for hypersplenism secondary to cirrhosis and portal hypertension and contributes to decreased blood loss, shorter hospital stay, and less impairment of liver function. It is recommended that the dilated short gastric vessels and other enlarged collateral circulation surrounding the spleen be divided with the LigaSure vessel sealing equipment, and the splenic artery and vein be transected en bloc with the application of the endovascular stapler. To support the clinical evidence, further randomized controlled trials about this topic are necessary.