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

Analysis of risk factors of lower extremity deep venous thrombosis in patients undergoing hepatobiliary surgery

This study analyzed records of 200 patients who underwent hepatobiliary surgery to identify factors that contribute to lower extremity venous thromboembolism (VTE). 19 patients (9.50%) developed lower extremity deep vein thrombosis. Univariate analysis revealed significant differences between the study group and the control group in terms of age, body mass index, previous thromboembolic history, hypertension, type 2 diabetes, hyperlipidemia, smoking history, times of lower extremity venipuncture, operation time, postoperative bedrest time, postoperative platelet count, postoperative D-dimer level, and postoperative C-reactive protein level (P<0.05). Multivariable logistic regression analysis identified age ≥60 years, body mass index ≥24 kg/m2, previous history of thromboembolism, hypertension, type 2 diabetes mellitus, hyperlipidemia, smoking history, number of lower extremity venipunctures ≥5, operation time ≥2 hours, postoperative bedrest time ≥48 hours, postoperative blood platelet count ≥300×109/L, postoperative D-dimer level ≥200 g/L, and postoperative C-reactive protein ≥8.0 mg/L as significant predisposing factors for lower extremity VTE. The study concludes that patients undergoing hepatobiliary surgery are at an increased risk of developing lower extremity VTE, and prevention strategies must be tailored to each patient's unique set of risk factors. This includes careful management of postoperative bed rest, monitoring of platelet count, D-dimer and C-reactive protein levels, controlling hypertension, type 2 diabetes mellitus, hyperlipidemia, and cessation of smoking. This study highlights the importance of early identification of patients at high risk of lower extremity VTE following hepatobiliary surgery and comprehensive prevention measures.

Individualized total laparoscopic surgery based on 3D remodeling for portal hypertension: A single surgical team experience

Background and aims

Portal hypertension (PHT) is common in end-stage cirrhosis, and variceal bleeding is the main complication associated with mortality. Surgery is usually performed in patients with PHT with a high risk of variceal bleeding in China. This study aimed to introduce an individualized and precise total laparoscopic surgical procedure based on 3D remodeling for PHT.

Methods

From March 2013 to December 2018, 146 patients with cirrhotic PHT underwent a laparoscopic surgical procedure in our department. An individualized 3D remodeling evaluation was carried out for surgical planning.

Results

The operation time was 319.96 ± 91.53 min. Eight of 146 patients were converted to open surgery. Acute portal vein system thrombosis occurred in 10 patients (6.85%). During the first year, 11 patients (8.15%) experienced rebleeding and two (1.48%) died. 18 patients (13.33%) experienced rebleeding and three died, giving a 3-year mortality rate of 3.66%. Compared with preoperatively, the portal vein showed significant postoperative decreases in diameter, flow velocity, and flow amount, while the hepatic artery showed significant postoperative increases in diameter, flow velocity, and flow amount. A 3D liver volume evaluation found that 19 of 21 patients had a significantly increased liver volume postoperatively, and a significantly decreased MELD score.

Conclusion

This retrospective study introduced a safe, feasible, and effective individualized surgical procedure. Our results show that this surgical treatment may not only act as an effective symptomatic treatment for PHT to prevent esophageal and gastric hemorrhage, but also as an etiological treatment to increase liver function and long-term survival.

Acquired Hepatocerebral Degeneration After a Splenorenal Shunt in the Sub-Saharan Africa Context: A Case Report and Brief Review of Literature

Acquired hepatocerebral degeneration (AHD) is a neurologic syndrome caused by liver dysfunction and long-standing portosystemic shunting. The pathogenesis of the condition is predominantly considered to be related to the deposition of manganese in parts of the brain due to shunting. We report a case of a 25-year-old male who underwent splenectomy and splenorenal shunt for recurrent upper GI bleeding (UGIB) due to esophageal varices caused by non-cirrhotic portal hypertension (NCPH). He presented with bradykinesia, hypophonia, gait instability, and rigidity of the lower extremities 18 months after the procedure was done.

Risk Factors of Portal Vein Thrombosis after Devascularization Treatment in Patients with Liver Cirrhosis: A Nested Case-Control Study

Methods

We retrospectively reviewed medical records from cirrhosis patients who underwent devascularization for the treatment of portal hypertension in our hospital between January 1, 2008, and December 20, 2014. Patients were followed up to investigate the PVT incidence at different times after surgery. Patients were divided into two groups (PVT, no PVT), and the risk factors for PVT after surgery were determined.

Results

Until October 16, 2015, the median follow-up time of the 124 patients enrolled into this study was 41.43 months (range, 5.47–95.30 months). 61 patients had perioperative PVT, and 21 (16.94%) patients had PVT diagnosed during the follow-up period. Those who had lower preoperative white blood cell counts, larger preoperative portal vein trunk diameter, and no gastric varices were more likely to have perioperative thrombosis. In those without perioperative PVT, a history of hypertension, higher grade of splenomegaly, and higher preoperative levels of creatinine were independent predictors of PVT occurrence during the follow-up period.

Conclusions

The risk factors for perioperative PVT in cirrhotic patients after devascularization were lower preoperative white blood cell count and larger portal vein trunk diameter, with no gastric varices. A history of hypertension, a larger spleen, and higher preoperative creatinine level are independent predictors of PVT during follow-up after surgery in patients without perioperative PVT.

Comparison of simplified and traditional pericardial devascularisation combined with splenectomy for the treatment of portal hypertension

AIM

To compare the clinical outcomes of patients with portal hypertension (PH) who underwent treatment with splenectomy plus simplified pericardial devascularisation (SSPD) or splenectomy plus traditional pericardial devascularisation (STPD).

METHODS

We conducted a single-centre retrospective study of 1045 PH patients treated with either SSPD (S Group, 357 patients) or STPD (T Group, 688 patients) between January 2002 and February 2017. In all, 37 clinical indicators were compared to evaluate the efficacy of SSPD.

RESULTS

Perioperative indicators in the S Group were significantly better than those in the T Group (P < 0.05). In both groups, the postoperative long-term portal vein diameter and Model for End-Stage Liver Disease score were significantly lower than those in the preoperative and postoperative short-term groups (P < 0.05). The incidence of complications in the S Group was significantly lower than that in the T Group (P < 0.05). Compared to the T Group, postoperative short-term WBC (white blood cell) and platelet counts were significantly lower and the short-term Hb (haemoglobin) level was significantly higher in the S Group (P < 0.05). In the S Group, postoperative long-term total bilirubin, direct bilirubin, alanine transaminase, and aspartate transaminase and postoperative serum creatinine and cystatin C levels were significantly lower than those in the T Group (P < 0.05), and postoperative albumin was significantly higher than that in the T Group (P < 0.05).

CONCLUSION

Compared to STPD, SSPD is a simple and easy procedure resulting in less tissue damage. Patients recovered smoothly and steadily with fewer complications. Short-term liver and kidney function damage was less severe, and long-term liver function recovery was better. Therefore, SSPD is worthy of clinical promotion and application for the treatment of PH.

Microwave ablation versus hepatic resection for the treatment of hepatocellular carcinoma and oesophageal variceal bleeding in cirrhotic patients

PURPOSE

The aim of this study was to compare the results of microwave ablation (MWA) and hepatic resection (HR) when combined with pericardial devascularisation plus splenectomy (PCDV) for the treatment of patients with cirrhosis complicated by small hepatocellular carcinoma (HCC) and oesophageal variceal bleeding (EVB).

MATERIALS AND METHODS

Between 2001 and 2013, 73 patients (median age 53.2 years, 67% male) with small HCC and concomitant EVB who underwent MWA or HR for HCC and PCDV for cirrhotic portal hypertension were selected retrospectively for inclusion in this study. The overall survival curves and recurrence-free survival curves were calculated using the Kaplan-Meier method and compared using log-rank tests. Multivariate analysis was performed using the Cox regression model.

RESULTS

The 1-, 3- and 5-year overall survival rates were 95.2%, 71.4% and 38.1% and 96.7%, 53.3% and 43.3% for the HR and MWA groups, respectively; these did not differ significantly between the two groups. However, patients in the HR group had more post-operative complications (52.3% vs. 13.7%; p = 0.002). Multivariate analysis identified albumin and bilirubin levels and tumour size to be statistically significant and independent prognostic factors for overall survival, while BCLC stage was associated with poor recurrence-free survival. Furthermore, albumin levels were shown to be an independent predictive factor for post-operative complications.

CONCLUSIONS

For patients with small HCC and concomitant EVB, MWA plus PCDV may reduce the incidence of post-operative complications relative to and provide similar therapeutic benefits as HR plus PCDV, especially for patients with low albumin levels.

A Comparative Study of the Efficacy of the Modified Sugiura Procedure and the Hassab Procedure for Treatment of Rebleeding after Endoscopic Variceal Ligation Due to Portal Hypertension

Although the modified Sugiura procedure and Hassab procedure have been used for many years, it remains unclear as to which is more effective for the treatment of rebleeding due to portal hypertension (PHT) after endoscopic variceal ligation (EVL). Hence, we conducted a retrospective study to compare the efficacy of these two procedures for treatment of rebleeding due to PHTafter EVL. Of 66 patients diagnosed with PHT and rebleeding after EVL in our institute from January 2007 to January 2014, 31 underwent the modified Sugiura procedure (Group S), whereas 35 underwent the Hassab procedure (Group H). The surgical duration, blood loss volume, blood transfusion rate, postoperative complication rate, postoperative rebleeding rate, postoperative hospital stay, and long-term complication rates were compared between groups. Greater blood loss volume ( P = 0.036), higher blood transfusion rate ( P = 0.002), and longer surgical duration ( P < 0.001) were observed in Group S than in Group H. There was no significant difference in the rate of short-term postoperative rebleeding between the groups ( P = 0.695), although the rate of long-term rebleeding was lower ( P = 0.031) in Group S. Recurrence of esophageal varices in Group S was less frequent in Group H ( P = 0.002), although there was no significant difference between the groups in the rates of recurrence of gastric varices and other long-term complications ( P > 0.05). The modified Sugiura procedure is more effective than the Hassab procedure for the treatment of rebleeding after EVL.

Therapeutic effects and complications of simplified pericardial devascularization for patients with portal hypertension

OBJECTIVES

To evaluate the therapeutic effects and complications of simplified pericardial devascularization for patients with portal hypertension.

METHODS

By means of prospective study, 212 patients who underwent simplified pericardial devascularization (Group A) and 309 patients who underwent traditional pericardial devascularization (Group B) were followed up from 2003' to 2011'. Results were performed with the general condition of the patients and the incidence of complications to assess the value of the two operating methods.

RESULTS

The operating time was 1.0-3.83 hours (mean 1.94 ± 0.32 hours) in Group A versus 1.67-4.50 hours (mean 2.86 ± 0.40 hours) in Group B. The amount of bleeding, postoperative hospital stay and hospitalization expenses were 110-500 ml (mean 224.81 ± 78.44 ml), 7-22 days (mean 10.41 ± 4.01 days) and 15700-27500 yuan with an average of 19300 ± 1600 yuan in Group A and 200-700 ml (mean 423.50 ± 85.19 ml), 9-32 days (mean 14.76 ± 4.52 days) and 18700-44500 yuan with an average of 23400 ± 2200 yuan in Group B. In September 2012', successful follow-up was completed for 438 patients, of which, 181 underwent the simplified devascularization with 31 patients lost (follow-up rate 85.4%). Meanwhile, 257 patients in Group B were followed up completely and 52 patients were lost (follow-up rate 83.2%). The follow-up time ranged from 1 to 9.5 years and the average time was 5.03 ± 2.13 years. The mortality, rebleeding rate, rate of hepatic encephalopathy, rate of ascites and the incidence of gastric fistula and (or) esophageal fistula were 6.1%, 6.1%, 1.7%, 8.3% and 0 in Group A versus 14.0%, 15.2%, 4.3%, 17.7% and 3.1% in Group B.

CONCLUSIONS

The final results suggested that simplified pericardial devascularization performed more effectively and conveniently than the traditional method, depending on the mitigated operative wound and the shortened operation time. We concluded that simplified pericardial devascularization was better in treatment of portal hypertension compared than the traditional method.