Accepted Manuscript Selective double disconnection for cirrhotic portal hypertension Guang-quan Zong , M.D. Yang Fei , M.D. Jian Chen , M.D. Ren-min Liu , M.D. PII:

S0022-4804(14)00532-0

DOI:

10.1016/j.jss.2014.05.065

Reference:

YJSRE 12765

To appear in:

Journal of Surgical Research

Received Date: 25 March 2014 Revised Date:

1 May 2014

Accepted Date: 21 May 2014

Please cite this article as: Zong G-q, Fei Y, Chen J, Liu R-m, Selective double disconnection for cirrhotic portal hypertension, Journal of Surgical Research (2014), doi: 10.1016/j.jss.2014.05.065. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Revised May 1st 2014

ACCEPTED MANUSCRIPT

Selective

double

disconnection

for

cirrhotic

portal

hypertension

RI PT

Guang-quan Zonga M.D., Yang Fei*a M.D., Jian Chen M.D. and Ren-min Liu M.D.

Department of General Surgery, the 81st Hospital of P.L.A., P.L.A. Cancer Center,

SC

Nanjing 210002, China.

* a

First co-authors

E-mail: [email protected] Telephone: +86-25-86648090

TE D

Fax: +86-25-80864499

M AN U

Corresponding author

EP

Contributors: Guang-quan Zong, Yang Fei wrote the paper, organized the figures and patient data and did the analysis; Ren-min Liu carried out the statistical analysis

AC C

and corrected the paper; Yang Fei supervised the writing and organization process.

ACCEPTED MANUSCRIPT

Abstract Object: To evaluate the effect of selective double portazygous disconnection with preserving vagus ( SDPDPV ) for patients with portal hypertension in the authors’ hospital.

RI PT

Methods: 453 patients with cirrhotic portal hypertension who underwent either SDPDPV or pericardial devascularization with splenectomy (PDS) for variceal bleeding from Feb 2007 to January 2013 were retrospectively reviewed. The

complications and clinical outcomes were analyzed.

SC

operation-relevant information, change of lavatory examination data, postoperative

Results: There were no significant difference between the SDPDPV group and the

M AN U

PDS group of mean operative time and intraoperative blood loss (P

0.05). The FPP

( free portal pressure) in the SDPDPV group was much lower than PDS group significantly after operation (P

0.05). The test of biochemical profile of hepatocyte

functions and Child-Pugh’s score at the end of the first postoperative year were significantly more altered in the SDPDPV group than in the PDS group (P

0.05).

TE D

Except encephalopathy, occurrences or development of postoperative complications including rebleeding, ascites and gastric stasis showed great difference between the two groups (P < 0.05). The operative mortality rate and the 3-year survival rates were

EP

great difference between the two groups too (P < 0.05). Conclusion: The SDPDPV not only controls recurrent bleeding from varices with

AC C

portal hypertension effectively but also maintains normal dynamics of stomach and physiological function of intestine and hepatobiliary.

Key words

portal hypertension; variceal hemorrhage; devascularization; vagus

Introduction

ACCEPTED MANUSCRIPT Portal hypertension (PHT) is defined as portal venous pressure exceeding 10 mmHg (14 cm of H2O). In China, the most common cause of PHT is cirrhosis[1]. This syndrome develops in the majority of patients with cirrhosis and is responsible for a frequent and severe complication of cirrhosis, massive bleeding from ruptured

RI PT

gastroesophageal varices is the main complication of PHT. Approximately 90% of patients with cirrhosis will develop gastroesophageal varices over 10 years and one-third of these will bleed from them. The risk of bleeding from gastroesophageal varices is about 25% within 2 years of diagnosis[2]. Catastrophic bleeding from

SC

gastroesphageal varices rupture is a life-threatening emergency. In many instances pharmacological therapy such as β- adrenergic blockers, and nitrates or endoscopic

M AN U

therapy such as band ligation cannot stop the bleeding and this area is also beyond the field of sclerotherapy[3,4]. Surgery seems the only definite therapy, which may offer chances for survival. Devascularization and shunting are the two widely accepted approaches

for

the

control

of

such

bleeding[5-8].

In

China,

pericardial

devascularization with splenectomy (PDS) has been widely used in patients with portal

TE D

hypertension as an effective haemostatic method, because it is less of a burden and is associated with a lower incidence of encephalopathy compared to shunt procedures[9]. But PDS truncated the diversion from portal vein to azygos vein, the reduction of portal vein

EP

pressure was not significant postoperatively[8,10]. It may promote the establishment of

collateral circulation rapidly, establish the path between portal vein and azygos vein again. Then, recurrence of gastroesophageal varices will appear and portal hypertensive gastric

AC C

mucosal lesions will be further aggravated. Thus PDS was shown to have a high rebleeding rate[11-13]. If patients with ascites undergone PDS, ascites was often difficult to be

controlled postoperatively[14]. On the other hand, once the vagus especially vagus trunk is interrupted during PDS procedure, it is easy for patients to suffer from delayed gastric emptying and gastric stasis[15]. In order to prevent these postoperative complications, a new procedure, selective pericardial vascular disconnection plus pericardial submembranous varices ligation by preserving vagus trunks (Selective double portazygous disconnection with preserving vagus, SDPDPV) has been performed in our department for the treatment of patients with cirrhotic portal

ACCEPTED MANUSCRIPT hypertension, since Feb 2007. The efficacy, safety, postoperative complications and survival were compared with those of single PDS performed during the same period.

Materials and methods

RI PT

General Information

The study population comprised 453 variceal bleeders with cirrhosis PHT

managed by surgery in the period between February 2007 and January 2013 at the 81st

SC

Hospital of P.L.A. in Nanjing, China. Consecutively 266 patients received SDPDPV and 187 PDS. The diagnoses of these patients were all confirmed by endoscopy,

M AN U

barium meal and Doppler ultrasonography. Our indications for operations include episodes of gastroesophageal variceal hemorrhage with a 1-month interval between the last attack and date of surgical procedure, which could not be controlled by medical means and endoscopic therapy, or thrombocytopenia (platelets count under 80×103/mm3) with gastroesophageal varices due to hypersplenism related to cirrhosis.

TE D

All of the patients accompanied with no serious cardiopulmonary diseases and concomitant chronic duodenal ulcers. The characteristics of the two surgical groups including age, gender, Child-Pugh’s score, preoperative variceal grade defined according to the criteria of Calès et al[16], follow-up time, preoperative biochemical

EP

tests were summarized in Table 1. Biochemical tests were examined within 1-3 days preoperatively, endoscopy or a barium meal examination was performed within

AC C

fourteen days before the operation to define the grade of varices.

Operative technique SDPDPV procedure was performed through an expanded left subcostal incision

of the left upper abdomen. The FPP (free portal pressure) is measured by inserting a catheter into the portal trunk through a branch of the right gastroepiploic vein. After conventional extreme splenectomy, The FPP is measured again. The proximal stomach was devascularized close to the gastric wall just above the crow’s foot along the lesser curvature from the incisura angularis up to the esophagus, we paid attention to avoid ligating the vagus nerve. Dissecting anterior Serosa layer and the left lateral

ACCEPTED MANUSCRIPT peritoneum covering the esophagus, and separating the muscle layer carefully, paraesophageal vein was exposed,. Following by lifting the stomach and dissecting gastropancreatic fold around the gastroesophageal junction, the left gastric artery and left gastric vein (coronary vein) were exposed. The gastric branch of left gastric vein

RI PT

and branches of left gastric artery were disconnected and suture ligated close to the gastric wall of lesser curvature in order to preserve the trunk of left gastric vein and artery. Then perforating branches from paraesophageal vein to the lower part of

esophagus were disconnected and suture ligated, tried to keep paraesophageal vein

SC

entirely. Dissection the lower part of esophagus was performed up to 7-10 cm above the cardia (the esophageal hiatus level). During the course of procedure, trunk of

M AN U

vagus nerve may be preserved. Whole layer discontinuous suture guided by a stomach tube with 3-0 prolene threads (Ethicon, Inc.) was performed around the lower part of esophagus at the area of 2-10cm above the cardia. The overlap length between the two needles was about two mm, and the direction of suture lines were not on the same horizontal level but showed zigzag-like to prevent esophageal stricture

TE D

postoperatively. The seromuscular layers of the lesser curvature were closed with interrupted silk sutures. After checking peritoneal cavity hemorrhage and circulation of free zone in the stomach and esophagus, we covered the wound of splenic fossa

EP

and retroperitoneal with omentum. Finally, the FPP was remeasured. A peritoneal cavity drainage tube was placed at left subphrenic location, before suturing the abdominal incision, a biopsy specimen of the liver was taken.

AC C

The technique of standard PDS was applied as described by Hassab[17].

Follow-up Studies

All patients had undergone follow-up from one to seven years (4.6+ 1.2 years). Clinical variables including episodes of recurrent hemorrhage, encephalopathy, ascites et al. were examined postoperatively, laboratory variables including biochemical tests were systematically examined at two weeks postoperatively, and then reperformed at six months and one year thereafter. In our studies, rebleeding was defined as at least 400ml blood transfusion

ACCEPTED MANUSCRIPT requirement and/or a decrease in the hematocrit to less than 30%, operative mortality was defined as death within thirty days of surgery[18].

Statistical Analysis All statistical analyses were performed using SPSS15.0 software (SPSS, Chicago,

RI PT

IL). Continuous data were expressed as mean values + standard deviation (SD). Significant differences between groups were determined by chi-squared analysis and unpaired Student's t test. Overall survival estimates were calculated by the Kaplan-Meier method and compared with similar estimates obtained using the

M AN U

SC

log-rank test. P-values