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Abdulrasak M, Someili AM, Mohrag M. Cytopenias in Autoimmune Liver Diseases-A Review. J Clin Med 2025; 14:1732. [PMID: 40095848 PMCID: PMC11900928 DOI: 10.3390/jcm14051732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2025] [Revised: 02/22/2025] [Accepted: 03/01/2025] [Indexed: 03/19/2025] Open
Abstract
Autoimmune liver diseases (AiLDs), including autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC), are immune-mediated conditions associated with significant hepatic and systemic manifestations. Among these, cytopenias-defined as reductions in blood cell counts affecting single or multiple lineages-represent a clinically important, though often under-recognized, complication. Cytopenias in AiLDs arise from diverse mechanisms, including immune-mediated destruction, hypersplenism due to portal hypertension, bone marrow suppression, and nutritional deficiencies. These abnormalities can exacerbate bleeding, infections, or fatigue, complicating the disease course and impacting therapeutic strategies. Immune-mediated cytopenias, such as autoimmune hemolytic anemia (AIHA), immune thrombocytopenic purpura (ITP), and autoimmune neutropenia (AIN), are more frequently associated with AIH, whereas cytopenias in PBC and PSC are largely attributed to hypersplenism. Diagnostic evaluation involves a systematic approach combining clinical history, laboratory testing (e.g., complete blood counts, Coombs tests, and nutritional assessments), imaging studies, and bone marrow evaluation in complex cases. Treatment strategies aim to address the underlying cause of cytopenias, including immunosuppressive therapy for autoimmune mechanisms, beta-blockers or splenectomy for hypersplenism, and supplementation for nutritional deficiencies. Challenges include distinguishing between immune- and hypersplenism-related cytopenias, managing drug-induced cytopenias, and optimizing care in transplant candidates. The recently recognized IgG4-related disease, often mimicking cholestatic AiLDs, adds another layer of complexity, given its association with autoimmune cytopenias and hypersplenism. This review aims to act as a guide for the clinician dealing with patients with AiLDs with respect to the occurrence of cytopenias, with a specific focus on pathophysiology and management of these cytopenias. Furthermore, there need to be enhanced multidisciplinary discussions about those patients between the hematologists and hepatologists, with a maintenance of a high index of suspicion for the rarer causes of cytopenias in AiLDs on the part of the treating physician, and there is a need for further studies to elucidate the mechanisms behind the occurrence of cytopenias in AiLDs.
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Affiliation(s)
- Mohammed Abdulrasak
- Department of Gastroenterology and Nutrition, Skane University Hospital, 214 28 Malmo, Sweden
- Department of Clinical Sciences, Lund University, 221 00 Malmo, Sweden
| | - Ali M. Someili
- Department of Medicine, Faculty of Medicine, Jazan University, Jazan 45142, Saudi Arabia; (A.M.S.); (M.M.)
| | - Mostafa Mohrag
- Department of Medicine, Faculty of Medicine, Jazan University, Jazan 45142, Saudi Arabia; (A.M.S.); (M.M.)
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Yang T, Zhang Y, Duan C, Liu H, Wang D, Liang Q, Chen X, Ma J, Cheng K, Chen Y, Zhuang R, Yin J. CD300E + macrophages facilitate liver regeneration after splenectomy in decompensated cirrhotic patients. Exp Mol Med 2025; 57:72-85. [PMID: 39741181 PMCID: PMC11799435 DOI: 10.1038/s12276-024-01371-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 09/15/2024] [Accepted: 09/30/2024] [Indexed: 01/02/2025] Open
Abstract
Liver cirrhosis is prognostically associated with poor life expectancy owing to subsequent liver failure. Thus, understanding liver regeneration processes during cirrhotic injury is highly important. This study explored the role of macrophage heterogeneity in liver regeneration following splenectomy. We collected detailed clinical information from 54 patients with decompensated cirrhosis before and after splenectomy. Obvious liver regeneration was observed after splenectomy in cirrhotic patients. Single-cell RNA sequencing (scRNA-seq) was performed on three paired liver tissues from patients before and after surgery to explore the immune microenvironment map and the characteristics of liver regeneration-associated macrophages (RAMs). scRNA-seq analysis revealed that the composition of hepatic immune cells changed after splenectomy; among these changes, the proportion of CD300E+ RAMs significantly increased after surgery, and high expression levels of functional genes associated with cell proliferation promoted liver regeneration. Moreover, a mouse model of carbon tetrachloride-induced cirrhosis and a coculture system consisting of primary bone marrow-derived macrophages and hepatocytes were established for validation. We observed a similar phenomenon of liver regeneration in cirrhotic mice and further confirmed that CD300E+ monocyte-derived macrophages facilitated hepatocyte NAD+ synthesis via the secretion of NAMPT, which subsequently promoted hepatocyte proliferation. This study characterized the hepatic immune microenvironment in patients with cirrhosis following splenectomy. Our findings demonstrated that CD300E+ macrophages play a crucial role in remodeling the hepatic immune microenvironment after splenectomy, thereby promoting liver regeneration in patients with decompensated cirrhosis. CD300E+ macrophages are anticipated to emerge as a novel therapeutic strategy for the treatment of liver cirrhosis.
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Affiliation(s)
- Tao Yang
- Department of General Surgery, Tangdu Hospital of the Air Force Medical University, 569 Xin Si Road, Xi'an, 710038, Shaanxi, China
| | - Yuan Zhang
- Department of Immunology, Air Force Medical University, 169 West Changle Road, Xi'an, 710032, Shaanxi, China
| | - Chujun Duan
- Department of Immunology, Air Force Medical University, 169 West Changle Road, Xi'an, 710032, Shaanxi, China
| | - Hui Liu
- Department of General Surgery, Tangdu Hospital of the Air Force Medical University, 569 Xin Si Road, Xi'an, 710038, Shaanxi, China
| | - Dong Wang
- Department of General Surgery, Tangdu Hospital of the Air Force Medical University, 569 Xin Si Road, Xi'an, 710038, Shaanxi, China
| | - Qingshan Liang
- Department of General Surgery, Tangdu Hospital of the Air Force Medical University, 569 Xin Si Road, Xi'an, 710038, Shaanxi, China
| | - Xiao Chen
- Department of General Surgery, Tangdu Hospital of the Air Force Medical University, 569 Xin Si Road, Xi'an, 710038, Shaanxi, China
| | - Jingchang Ma
- Department of Immunology, Air Force Medical University, 169 West Changle Road, Xi'an, 710032, Shaanxi, China
| | - Kun Cheng
- Department of Immunology, Air Force Medical University, 169 West Changle Road, Xi'an, 710032, Shaanxi, China
| | - Yong Chen
- Department of Hepatobiliary Surgery, Xijing Hospital of the Air Force Medical University, 15 West Changle Road, Xi'an, 710032, Shaanxi, China
| | - Ran Zhuang
- Department of Immunology, Air Force Medical University, 169 West Changle Road, Xi'an, 710032, Shaanxi, China.
| | - Jikai Yin
- Department of General Surgery, Tangdu Hospital of the Air Force Medical University, 569 Xin Si Road, Xi'an, 710038, Shaanxi, China.
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Chen YF, Lin YX, Chi MM, Li DQ, Chen LT, Zhang Y, Wu RQ, Du ZQ. Preoperative serum total bilirubin-albumin ratio as a prognostic indicator in patients with hepatitis-related cirrhosis after splenectomy. World J Gastrointest Surg 2025; 17:96512. [PMID: 39872783 PMCID: PMC11757200 DOI: 10.4240/wjgs.v17.i1.96512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 09/06/2024] [Accepted: 10/28/2024] [Indexed: 12/27/2024] Open
Abstract
BACKGROUND Splenectomy is an effective yet invasive intervention for alleviating portal pressure in patients with hepatitis cirrhosis. However, the current prognostic indicators for predicting long-term overall survival of these patients have several limitations. AIM To assess the potential of preoperative total bilirubin-albumin (B/A) ratio as a prognostic indicator for patients with hepatitis cirrhosis undergoing splenectomy. METHODS A total of 257 patients diagnosed with hepatitis cirrhosis were retrospectively enrolled in the study. Normality test, t-test, Wilcoxon test, χ 2 test, or Fisher's exact test was employed to analyze the intraoperative and postoperative conditions of the patients. Receiver operating characteristic (ROC) curve analysis was utilized to depict the 10-year overall survival rate. RESULTS During the follow-up period, 85.99% of the patients survived, with a median survival time of 64.6 months. Multivariate analysis revealed that total serum B/A ratio was an independent risk factor for overall survival (P = 0.037). ROC curve analysis demonstrated that a B/A ratio of 0.87 was the optimal cut-off value. Consequently, the patients were categorized into two groups: High B/A group (n = 64) and low B/A group (n = 193). The median follow-up time for the high B/A group and low B/A group was 56.8 months and 67.2 months, respectively (P = 0.045). Notably, the high B/A group exhibited a significantly lower 10-year overall survival compared to the low B/A group (P < 0.001). Patients with hepatocellular carcinoma (HCC) had lower overall survival rates. Patients with a high B/A ratio exhibited a lower overall survival than those with a low B/A rate in the overall cohort and the subgroups of patients with HCC or not, early Child-Pugh grade, low albumin-bilirubin grade, and model for end-stage liver disease score ≥ 10 (log-rank test, P < 0.001 for all). CONCLUSION The B/A ratio can serve as an effective prognostic indicator for overall survival in patients with hepatitis B virus-related cirrhosis following splenectomy, and a higher B/A ratio may suggest a poorer prognosis.
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Affiliation(s)
- Yi-Fan Chen
- Department of Hepatobiliary Surgery, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
- Department of Gastroenterology, Peking University Third Hospital, Beijing 100191, China
| | - Yu-Xin Lin
- Department of Hepatobiliary Surgery, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
- Shanghai Institute of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Miao-Miao Chi
- Department of Hepatobiliary Surgery, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
- Department of Ophthalmology, Peking University Third Hospital, Beijing 100191, China
| | - Da-Qing Li
- Department of Hepatobiliary Surgery, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
| | - Lin-Tao Chen
- Department of Hepatobiliary Surgery, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
| | - Yu Zhang
- Department of Hepatobiliary Surgery, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
| | - Rong-Qian Wu
- National Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Zhao-Qing Du
- Department of Hepatobiliary Surgery, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
- National Engineering Research Center for Miniaturized Detection Systems, College of Life Sciences, Northwest University of Xi’an, Xi’an 710069, Shaanxi Province, China
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Patil L, Mehta G, Aggarwal A. Elderly-onset severe parkinsonism in Wilson disease: Expert commentary. Parkinsonism Relat Disord 2025; 130:106945. [PMID: 38565478 DOI: 10.1016/j.parkreldis.2024.106945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Laxmi Patil
- Wilson Disease Clinic and Movement Disorders Clinic, Center for Neurosciences, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, India.
| | - Gaurav Mehta
- Wilson Disease Clinic, Center for Hepatology and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, India.
| | - Annu Aggarwal
- Wilson Disease Clinic and Movement Disorders Clinic, Center for Neurosciences, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, India.
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Beppu T, Masuda T, Imai K, Hayashi H. Clinical benefits of partial splenic embolization for cancer patients. Hepatol Res 2024. [PMID: 39614706 DOI: 10.1111/hepr.14142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Revised: 11/05/2024] [Accepted: 11/09/2024] [Indexed: 12/01/2024]
Abstract
Partial splenic embolization (PSE) has developed as an alternative to surgical splenectomy, mainly to improve hypersplenism and esophagogastric varices in cirrhotic patients. We proposed the novel concept that splenic infarction volume, rather than the splenic infarction ratio, is essential for patients receiving PSE. A splenic infarction volume between 388 and 540 mL is suitable for a sufficient increase in platelet count and less severe PSE-related complications. When restricted to patients with massive splenomegaly >700 mL, the noninfarcted volume of the spleen plays an important role in increasing platelet counts. Based on the splenic volume concept, PSE or laparoscopic splenectomy should be selected. Partial splenic embolization is effective for cancer patients with hypersplenism. Hypersplenism can occur due to portal vein congestion by thrombosis or tumor thrombosis, and hepatic sinusoidal obstruction syndrome after oxaliplatin-including chemotherapy other than liver cirrhosis. Therefore, PSE has been emphasized as a pretreatment intervention for invasive treatments for cancer patients and is applied synchronously with systemic chemotherapy or chemoembolization for patients with liver malignancies. It was reported that additional PSE on chemoembolization can prolong progression-free survival for patients with hepatocellular carcinoma. Moreover, PSE can improve liver function and fibrosis, promote liver regeneration, and activate host immunity. Partial splenic embolization can result in thrombocytosis (<200 × 109/L), but this platelet count is unlikely to promote cancer progression. Partial splenic embolization can improve hypersplenism caused by various factors related to the patient's comorbidity and cancer treatment. Our splenic volume concept helps identify appropriate treatment procedures. A proper understanding of PSE and its dissemination is strongly required.
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Affiliation(s)
- Toru Beppu
- Department of Surgery, Yamaga City Medical Center, Yamaga, Japan
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Toshiro Masuda
- Department of Surgery, Yamaga City Medical Center, Yamaga, Japan
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiromitsu Hayashi
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
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Guixé-Muntet S, Quesada-Vázquez S, Gracia-Sancho J. Pathophysiology and therapeutic options for cirrhotic portal hypertension. Lancet Gastroenterol Hepatol 2024; 9:646-663. [PMID: 38642564 DOI: 10.1016/s2468-1253(23)00438-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 04/22/2024]
Abstract
Portal hypertension represents the primary non-neoplastic complication of liver cirrhosis and has life-threatening consequences, such as oesophageal variceal bleeding, ascites, and hepatic encephalopathy. Portal hypertension occurs due to increased resistance of the cirrhotic liver vasculature to portal blood flow and is further aggravated by the hyperdynamic circulatory syndrome. Existing knowledge indicates that the profibrogenic phenotype acquired by sinusoidal cells is the initial factor leading to increased hepatic vascular tone and fibrosis, which cause increased vascular resistance and portal hypertension. Data also suggest that the phenotype of hepatic cells could be further impaired due to the altered mechanical properties of the cirrhotic liver itself, creating a deleterious cycle that worsens portal hypertension in the advanced stages of liver disease. In this Review, we discuss recent discoveries in the pathophysiology and treatment of cirrhotic portal hypertension, a condition with few pharmacological treatment options.
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Affiliation(s)
- Sergi Guixé-Muntet
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sergio Quesada-Vázquez
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jordi Gracia-Sancho
- Liver Vascular Biology Research Group, IDIBAPS Biomedical Research Institute, CIBEREHD, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Leideck P, Nkontchou G, Elkrief L, Erard D, d'Alteroche L, Radenne S, Billioud C, Meszaros M, Regnault D, Pageaux GP, Hilleret MN, Tripon S, Guillaud O, Ollivier-Hourmand I, Ganne-Carrié N, Dumortier J. The role and evolution of partial splenic embolization over three decades: A multicentric retrospective single cohort study of 90 patients from French nationwide experience. Clin Res Hepatol Gastroenterol 2024; 48:102355. [PMID: 38679291 DOI: 10.1016/j.clinre.2024.102355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/10/2024] [Accepted: 04/25/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Partial splenic embolization (PSE) has been proposed to treat the consequences of hypersplenism in the context of portal hypertension, especially thrombocytopenia. However, a high morbidity/mortality rate has made this technique unpopular. We conducted a multicenter retrospective nationwide French study to reevaluate efficacy and tolerance. METHODS All consecutive patients who underwent PSE for hypersplenism and portal hypertension in 7 tertiary liver centers between 1998 and 2023 were included. RESULTS The study population consisted of 91 procedures in 90 patients, with a median age of 55.5 years [range 18-83]. The main cause of portal hypertension was cirrhosis (84.6 %). The main indications for PSE were (1) an indication of medical treatment or radiological/surgical procedure in the context a severe thrombocytopenia (59.3 %), (2) a chronic hemorrhagic disorder associated with a severe thrombocytopenia (18.7 %), and (3) a chronic pain associated with a major splenomegaly (9.9 %). PSE was associated with a transjugular intrahepatic portosystemic shunt in 20 cases. Median follow-up after PSE was 41.9 months [0.5-270.5]. Platelet count increased from a median of 48.0 G/L [IQR 37.0; 60.0] to 100.0 G/L [75.0; 148]. Forty-eight patients (52.7 %) had complications after PSE; 25 cases were considered severe (including 7 deaths). A Child-Pugh B-C score (p < 0.02) was significantly associated with all complications, a history of portal vein thrombosis (p < 0.01), and the absence of prophylactic antibiotherapy (p < 0.05) with severe complications. CONCLUSION Our results strongly confirm that PSE is very effective, for a long time, although a quarter of the patients experienced severe complications. Improved patient selection (exclusion of patients with portal vein thrombosis and decompensated cirrhosis) and systematic prophylactic antibiotherapy could reduce morbidity and early mortality in the future.
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Affiliation(s)
- Paul Leideck
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-Gastroentérologie, 03, Lyon CEDEX 69437, France
| | - Gisèle Nkontchou
- Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Service d'Hépato-Gastroentérologie, Bobigny, France
| | - Laure Elkrief
- CHU Tours, Hôpital Trousseau, Service d'Hépato-Gastroentérologie, Tours, France
| | - Domitille Erard
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, Service d'Hépato-Gastroentérologie, Lyon, France
| | - Louis d'Alteroche
- CHU Tours, Hôpital Trousseau, Service d'Hépato-Gastroentérologie, Tours, France
| | - Sylvie Radenne
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, Service d'Hépato-Gastroentérologie, Lyon, France
| | - Claire Billioud
- Hospices Civils de Lyon, Hôpital de la Croix Rousse, Service d'Hépato-Gastroentérologie, Lyon, France
| | - Magdalena Meszaros
- CHU Saint Eloi, Département d'Hépatologie et Transplantation Hépatique, Montpellier, France
| | - David Regnault
- CHU Tours, Hôpital Trousseau, Service d'Hépato-Gastroentérologie, Tours, France
| | | | | | - Simona Tripon
- CHRU Hautepierre, Service d'Hépato-Gastroentérologie, Strasbourg, France
| | - Olivier Guillaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-Gastroentérologie, 03, Lyon CEDEX 69437, France; Clinique de la Sauvegarde, Ramsay Générale de Santé, Lyon, France
| | | | - Nathalie Ganne-Carrié
- Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne, Service d'Hépato-Gastroentérologie, Bobigny, France
| | - Jérôme Dumortier
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d'Hépato-Gastroentérologie, 03, Lyon CEDEX 69437, France.
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S L H, Pottakkat B, Raja K, Gnanasekaran S. Early mobilization and delayed arterial ligation (EMDAL) as a surgical technique for splenectomy and shunt surgery in portal hypertension. Ann Hepatobiliary Pancreat Surg 2024; 28:48-52. [PMID: 38178692 PMCID: PMC10896686 DOI: 10.14701/ahbps.23-080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/10/2023] [Accepted: 09/13/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUNDS/AIMS Splenectomy is the most frequently performed procedure as definitive management or as part of shunt surgery or devascularization in portal hypertension. Splenectomy is technically challenging because of the frequent coexistence of multiple collateral varices, splenomegaly, poor liver function, and thrombocytopenia. Early arterial ligation and late mobilization (EALDEM) is the traditional method for splenectomy in portal hypertension. Early spleen mobilization offers good control of the hilum. We aim to compare the effect of the early mobilization and delayed arterial ligation (EMDAL) technique with that of the conventional splenectomy technique in patients with portal hypertension. METHODS During the study period from September 2011 to September 2022, 173 patients underwent surgical intervention for portal hypertension at our institution. Among these patients, 114 underwent the conventional method of splenectomy (early arterial ligation and late splenic mobilization) while 59 underwent splenectomy with the EMDAL technique. Demographics were compared between the two groups. Intraoperative and postoperative outcomes were analyzed using the Mann-Whitney test in each group. A minimum follow-up of 12 months was performed in each group. RESULTS Demographics and type of surgical procedure were comparable in the two surgical method groups. Median blood loss was higher in the conventional group than in the EMDAL method. The median duration of surgery was comparable in the two surgical procedures. Clavien-Dindo grade III/IV complications were reported more frequently in the conventional group. CONCLUSIONS The splenic hilum can be controlled well and bleeding can be minimised with early mobilization and delayed arterial ligation.
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Affiliation(s)
- Harilal S L
- Department of Surgical Gastroenterology, JIPMER, Puducherry, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, JIPMER, Puducherry, India
| | - Kalayarasan Raja
- Department of Surgical Gastroenterology, JIPMER, Puducherry, India
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Ng ZQ, Tan P, Theophilus M. Colorectal Surgery in Patients with Liver Cirrhosis: A Systematic Review. World J Surg 2023; 47:2519-2531. [PMID: 37212905 DOI: 10.1007/s00268-023-07069-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Colorectal surgery in patients with liver cirrhosis poses a significant challenge due to the associated peri-operative morbidity and mortality risks. The aim of this systematic review was to evaluate the outcomes in this cohort of patients following colorectal surgery. METHODS The PubMed, Embase and Cochrane databases and references were searched up to October 2022 using the PRISMA guidelines. The data collated included: patient demographics, pathology or type of colorectal operation performed, severity of liver cirrhosis, post-operative complication rates, mortality rates and prognostic factors. A quality assessment of included studies was performed with the Newcastle-Ottawa scale. RESULTS Sixteen studies reporting the outcomes of colorectal surgery in patients with liver cirrhosis were identified, including the results of 8646 patients. The indications, pathologies and/or type of operations varied. The overall complication rate ranged from 29 to 75%, minor complication ranged 14.5-37% and major complication ranged 6.7-59.3%. The mortality rates ranged from 0 to 37%. CONCLUSION Colorectal surgery in patients with liver cirrhosis still carries considerable morbidity and mortality rates. This group of patients needs to be managed in a multidisciplinary setting to achieve excellent outcomes. Future research should focus on uniform definitions to enable interpretable outcomes.
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Affiliation(s)
- Zi Qin Ng
- Department of General Surgery, Royal Perth Hospital, Wellington Street, Perth, WA, 6000, Australia.
- Department of General Surgery, St John of God Midland Hospital, Midland, WA, Australia.
| | - Patrick Tan
- Department of General Surgery, Royal Perth Hospital, Wellington Street, Perth, WA, 6000, Australia
| | - Mary Theophilus
- Department of General Surgery, Royal Perth Hospital, Wellington Street, Perth, WA, 6000, Australia
- Department of General Surgery, St John of God Midland Hospital, Midland, WA, Australia
- Curtin Medical School, Curtin University, Bentley, WA, Australia
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Lu H, Zheng C, Xiong B, Xia X. Efficacy and safety of heparin plus dexamethasone after partial splenic embolization for liver cirrhosis with massive splenomegaly. BMC Gastroenterol 2022; 22:470. [PMID: 36402985 PMCID: PMC9675231 DOI: 10.1186/s12876-022-02580-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The aim of this study was to investigate the efficacy and safety of the combination of low-molecular-weight heparin + dexamethasone after partial splenic embolization in cirrhotic patients with massive splenomegaly. METHODS This study included 116 patients with liver cirrhosis complicated with massive splenomegaly who underwent PSE in Union Hospital from January 2016 to December 2019, and they met the criteria. They were divided into two groups: PSE + Hep + Dex group (N = 54) and PSE group (N = 62). We conducted a retrospective study to analyze the efficacy and safety of the two groups of patients. RESULTS The volume of splenic embolization was 622.34 ± 157.06 cm3 in the PSE + Hep + DEX group and 587.62 ± 175.33 cm3 in the PSE group (P = 0.306). There was no statistically difference in the embolization rate of the spleen between the two groups (P = 0.573). WBC peaked 1 week after PSE and PLT peaked 1 month after PSE in both groups; it gradually decreased later, but was significantly higher than the preoperative level during the 12-month follow-up period. The incidences of abdominal pain (46.3% vs 66.1%, P = 0.039), fever (38.9% vs 75.8%, P < 0.001), PVT (1.9% vs 12.9%, P = 0.026), refractory ascites (5.6% vs 19.4%, P = 0.027) were lower in the PSE + Hep + DEX group than in the PSE group. The VAS score of abdominal pain in PSE group was higher than that in PSE + Hep + DEX group on postoperative days 2-8 (P < 0.05). Splenic abscess occurred in 1(1.6%) patient in the PSE group and none (0.0%) in the PSE + Hep + DEX group (P = 0.349). CONCLUSIONS The combined use of dexamethasone and low-molecular-weight heparin after PSE is a safe and effective treatment strategy that can significantly reduce the incidence of complications after PSE (such as post-embolization syndrome, PVT, refractory ascites).
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Affiliation(s)
- Haohao Lu
- grid.33199.310000 0004 0368 7223Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022 China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022 China
| | - Chuansheng Zheng
- grid.33199.310000 0004 0368 7223Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022 China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022 China
| | - Bin Xiong
- grid.33199.310000 0004 0368 7223Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022 China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022 China
| | - Xiangwen Xia
- grid.33199.310000 0004 0368 7223Department of Radiology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue #1277, Wuhan, 430022 China ,grid.412839.50000 0004 1771 3250Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022 China
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11
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Wu Y, Li H, Zhang T, Bai Z, Xu X, Levi Sandri GB, Wang L, Qi X. Splanchnic Vein Thrombosis in Liver Cirrhosis After Splenectomy or Splenic Artery Embolization: A Systematic Review and Meta-Analysis. Adv Ther 2021; 38:1904-1930. [PMID: 33687650 DOI: 10.1007/s12325-021-01652-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/03/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Splenectomy and splenic artery embolization are major treatment options for hypersplenism and portal hypertension in liver cirrhosis, but may lead to splanchnic vein thrombosis (SVT), which is potentially lethal. We conducted a systematic review and meta-analysis to explore the incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization and the risk factors for SVT. METHODS All relevant studies were searched through the PubMed, EMBASE, and Cochrane Library databases. The incidence of SVT in liver cirrhosis after splenectomy or splenic artery embolization was pooled. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Sixty-six studies with 5632 patients with cirrhosis were included. The pooled incidence of SVT after splenectomy and splenic artery embolization was 24.6% (95% CI 20.2-29.3%) and 11.7% (95% CI 7.1-17.3%), respectively. A meta-analysis of three comparative studies demonstrated that the incidence of SVT after splenectomy was statistically similar to that after splenic artery embolization (OR 3.15, P = 0.290). Platelet count, mean platelet volume, preoperative splenic or portal vein diameter, preoperative or postoperative portal blood velocity, splenic volume and weight, and periesophagogastric devascularization were significant risk factors for SVT after splenectomy. Postoperative use of preventive antithrombotic therapy was a significant protective factor against SVT after splenectomy. CONCLUSIONS SVT is common in liver cirrhosis after splenectomy and splenic artery embolization. Coagulation and hemostasis factors, anatomical factors, and surgery-related factors have been widely identified for the assessment of high risk of SVT after splenectomy. Prophylactic strategy after splenectomy, such as antithrombotic therapy, might be considered in such high-risk patients. STUDY REGISTRATION This study was registered in PROSPERO with a registration number of CRD42019129673.
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Affiliation(s)
- Yanyan Wu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
- Postgraduate College, Jinzhou Medical University, Jinzhou, People's Republic of China
| | - Hongyu Li
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
| | - Tiansong Zhang
- Department of Traditional Chinese Medicine, Jing'an District Central Hospital, Shanghai, China
| | - Zhaohui Bai
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | - Xiangbo Xu
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
- Postgraduate College, Shenyang Pharmaceutical University, Shenyang, People's Republic of China
| | | | - Le Wang
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China
- Postgraduate College, Dalian Medical University, Dalian, People's Republic of China
| | - Xingshun Qi
- Liver Cirrhosis Study Group, Department of Gastroenterology, General Hospital of Northern Theater Command (formerly called General Hospital of Shenyang Military Area), No. 83 Wenhua Road, Shenyang, 110840, Liaoning, People's Republic of China.
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Fifer H, Lewis A, Perin G, Balasubramanian SP. Letter to the Editor: Outcomes of Laparoscopic Splenectomy for Treatment of Splenomegaly: A Systematic Review and Meta-analysis. World J Surg 2021; 45:2306-2307. [PMID: 33782731 DOI: 10.1007/s00268-021-06090-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 11/29/2022]
Affiliation(s)
- H Fifer
- General surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, England.
| | - A Lewis
- The University of Sheffield, Sheffield, England
| | - G Perin
- General surgery, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, England
| | - S P Balasubramanian
- General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
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Kumar R, Anand U, Priyadarshi RN. Lymphatic dysfunction in advanced cirrhosis: Contextual perspective and clinical implications. World J Hepatol 2021; 13:300-314. [PMID: 33815674 PMCID: PMC8006079 DOI: 10.4254/wjh.v13.i3.300] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/31/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
The lymphatic system plays a very important role in body fluid homeostasis, adaptive immunity, and the transportation of lipid and waste products. In patients with liver cirrhosis, capillary filtration markedly increases, primarily due to a rise in hydrostatic pressure, leading to enhanced production of lymph. Initially, lymphatic vasculature expansion helps to prevent fluid from accumulating by returning it back to the systemic circulation. However, the lymphatic functions become compromised with the progression of cirrhosis and, consequently, the lymphatic compensatory mechanism gets overwhelmed, contributing to the development and eventual worsening of ascites and edema. Neurohormonal changes, low-grade chronic inflammation, and compounding effects of predisposing factors such as old age, obesity, and metabolic syndrome appear to play a significant role in the lymphatic dysfunction of cirrhosis. Sustained portal hypertension can contribute to the development of intestinal lymphangiectasia, which may rupture into the intestinal lumen, resulting in the loss of protein, chylomicrons, and lymphocyte, with many clinical consequences. Rarely, due to high pressure, the rupture of the subserosal lymphatics into the abdomen results in the formation of chylous ascites. Despite being highly significant, lymphatic dysfunctions in cirrhosis have largely been ignored; its mechanistic pathogenesis and clinical implications have not been studied in depth. No recommendation exists for the diagnostic evaluation and therapeutic strategies, with respect to lymphatic dysfunction in patients with cirrhosis. This article discusses the perspectives and clinical implications, and provides insights into the management strategies for lymphatic dysfunction in patients with cirrhosis.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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Splenectomy improves liver fibrosis via tumor necrosis factor superfamily 14 (LIGHT) through the JNK/TGF-β1 signaling pathway. Exp Mol Med 2021; 53:393-406. [PMID: 33654222 PMCID: PMC8080781 DOI: 10.1038/s12276-021-00574-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 01/31/2023] Open
Abstract
Splenectomy has been reported to improve liver fibrosis in patients with cirrhosis and hypersplenism. However, the mechanisms remain unclear. Tumor necrosis factor superfamily 14 (TNFSF14; also known as LIGHT) is highly expressed in the context of fibrosis and promotes disease progression in patients with fibrotic diseases such as pulmonary and skin fibrosis. Here, we determined whether splenectomy controls the production of LIGHT to improve liver fibrosis. Splenectomy reduced serum LIGHT levels in cirrhotic patients with hypersplenism and a ConA-induced liver fibrosis mouse model. Blocking LIGHT resulted in the downregulation of TGF-β1 in RAW264.7 cells. LIGHT treatment of RAW264.7 and JS1 cells in coculture regulated transforming growth factor-β1 (TGF-β1) expression through the activation of JNK signaling. Small interfering RNA-mediated silencing of lymphotoxin β receptor (LTβR) in macrophages resulted in pronounced decreases in the levels of fibrosis and αSMA in JS1 cells. These results indicated that LIGHT bound to LTβR and drove liver fibrosis in vitro. Blocking TGF-β1 abolished the effect of LIGHT in vitro. Furthermore, the administration of recombinant murine LIGHT protein-induced liver fibrosis with splenectomy, while blocking LIGHT without splenectomy improved liver fibrosis in vivo, revealing that the decrease in fibrosis following splenectomy was directly related to reduced levels of LIGHT. Thus, high levels of LIGHT derived from the spleen and hepatic macrophages activate JNK signaling and lead to increased TGF-β1 production in hepatic macrophages. Splenectomy attenuates liver fibrosis by decreasing the expression of LIGHT.
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Wang X, Luo X, Zhao M, Song J, Li X, Yang L. Prognostic Factors for Acute Transjugular Intrahepatic Portosystemic Shunt Occlusion Using Expanded Polytetrafluoroethylene-Covered Stent. Dig Dis Sci 2020; 65:3032-3039. [PMID: 31853780 DOI: 10.1007/s10620-019-06008-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/10/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND The expanded polytetrafluoroethylene (ePTFE)-covered stent has been widely used in the transjugular intrahepatic portosystemic shunt (TIPS) procedure. However, the epidemiologic data of acute TIPS occlusion (ATO) and the underlying mechanisms are scarce. AIMS The purpose of this study was to evaluate the incidence and prognostic factors for ATO within 1 week in TIPS recipients using ePTFE-covered stents. METHODS We identified 222 patients who underwent ePTFE-covered TIPS creation for complications of portal hypertension between June 2015 and June 2017 at a large tertiary center. Medical records and TIPS procedure data were retrospectively reviewed, and the influence of these variables on ATO was assessed by multivariate logistic regression analysis. RESULTS TIPS technical success was achieved in 219 patients (98.6%). Two patients were excluded due to missing data, leaving 217 patients for final analysis. ATO occurred in nine patients (4.1%). Blood flow was restored by balloon angioplasty (n = 4), additional stent insertion (n = 4), and parallel TIPS (n = 1). In multivariable logistic regression, intrastent stenosis (HR 43.871; 95% CI 3.816, 504.373; P = 0.002), previous splenectomy (HR 26.843; 95% CI 2.106, 342.124; P = 0.011), and stent shortening in the hepatic vein (HR 11.54; 95% CI 1.021, 130.416; P = 0.048) were demonstrated as independent significant risk factors for ATO. CONCLUSIONS These findings suggest that the intrastent stenosis, previous splenectomy, and stent shortening in the hepatic vein are vital prognostic factors for ATO in TIPS recipients. Individualized post-TIPS management strategy was required.
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Affiliation(s)
- Xiaoze Wang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xuefeng Luo
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, People's Republic of China.
| | - Ming Zhao
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jinlei Song
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center and Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100021, People's Republic of China
| | - Li Yang
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, People's Republic of China
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Qi R, Jin X, Shi H, Wang C, Li H, Shi X. Effect of laparoscopic splenectomy on portal vein thrombosis and serum YKL-40 in patients with cirrhotic portal hypertension. Ann Hepatol 2020; 18:898-901. [PMID: 31427175 DOI: 10.1016/j.aohep.2019.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Laparoscopic splenectomy (LS) is a supportive intervention for cirrhotic patients. However, its efficacy for patients with cirrhotic portal hypertension (CPH) still needs clarification. Studies indicated YKL-40 might be effective targets for treatment of splenomegaly, however deeper insights are unclear. The aim of this study was to investigate the effect of LS on the formation of portal vein thrombosis (PVT) and serum levels of a fibrosis marker, YKL-40, in patients with CPH. MATERIALS AND METHODS A total of 80 patients who underwent LS and 30 healthy controls were investigated in this study. Serum levels of YKL-40 were measured by enzyme-linked immunosorbent assay (ELISA). Demographic characteristics including age and gender were recorded. Clinicopathological and laboratory examinations included the severity of esophageal varices and the presence of viral hepatitis. The liver function was assessed according to the Child-Pugh classification. The incidence of PVT before and after operation was also monitored. RESULTS Serum YKL-40 was significantly increased in CPH patients, and was associated with Child-Pugh score and HBV infection. Furthermore, elderly patients had an increased risk for postoperative PVT. Higher serum YKL-40 was observed in patients with thrombus at postoperative 7, 14 and 21 days than those without thrombus. CONCLUSIONS LS could reduce serum YKL-40 levels and PVT progression and was a useful treatment for patients <40 years of age with CPH.
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Affiliation(s)
- Ruizhao Qi
- Department of General Surgery, 5th Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xin Jin
- Department of Hepatobilliary Surgery, 4th Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Haida Shi
- Department of Hepatobilliary Surgery, 4th Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Chengfang Wang
- Department of Hepatobilliary Surgery, Chinese PLA General Hospital, Beijing, China
| | - Huixing Li
- Department of General Surgery, Aerospace Center Hospital, Beijing, China
| | - Xianjie Shi
- Department of Hepatobilliary Surgery, Chinese PLA General Hospital, Beijing, China.
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Shao R, Li Z, Wang J, Qi R, Liu Q, Zhang W, Mao X, Song X, Li L, Liu Y, Zhao X, Liu C, Li X, Zuo C, Wang W, Qi X. Hepatic venous pressure gradient-guided laparoscopic splenectomy and pericardial devascularisation versus endoscopic therapy for secondary prophylaxis for variceal rebleeding in portal hypertension (CHESS1803): study protocol of a multicenter randomised controlled trial in China. BMJ Open 2020; 10:e030960. [PMID: 32580978 PMCID: PMC7312451 DOI: 10.1136/bmjopen-2019-030960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 02/15/2020] [Accepted: 04/28/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Gastro-oesophageal variceal bleeding is one of the most common and severe complications with high mortality in cirrhotic patients who developed portal hypertension. Hepatic venous pressure gradient (HVPG) is a globally recommended golden standard for the portal pressure assessment and an HVPG ≥16 mm Hg indicates a higher risk of death and rebleeding. This study aims to compare the effectiveness and safety of splenectomy and pericardial devascularisation (laparoscopic therapy) plus propranolol and endoscopic therapy plus propranolol for variceal rebleeding in cirrhotic patients with HVPG between 16 and 20 mm Hg. METHODS AND ANALYSIS This is a multicenter, randomised, controlled clinical trial. Participants will be 1:1 assigned randomly into either laparoscopic or endoscopic groups. Forty participants whose transjugular HVPG lies between 16 and 20 mm Hg with a history of gastro-oesophageal variceal bleeding will be recruited from three sites in China. Participants will receive either endoscopic therapy plus propranolol or laparoscopic therapy plus propranolol. The primary outcome measure will be the occurrence of gastro-oesophageal variceal rebleeding. Secondary outcome measures will include overall survival, occurrence of hepatocellular carcinoma, the occurrence of venous thrombosis, the occurrence of adverse events, quality of life and tolerability of treatment. Outcome measures will be evaluated at baseline, 12 weeks, 24 weeks, 36 weeks, 48 weeks and 60 weeks. Multivariate COX regression model will be introduced for analyses of occurrence data and Kaplan-Meier analysis with the log-rank test for intergroup comparison. ETHICS AND DISSEMINATION Ethical approval was obtained from all three participating sites. Primary and secondary outcome data will be submitted for publication in peer-reviewed journals and widely disseminated. TRIAL REGISTRATION NUMBER NCT03783065; Pre-results. TRIAL STATUS Recruitment for this study started in December 2018 while the first participant was randomised in January 2019. Recruitment is estimated to stop in October 2019.
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Affiliation(s)
- Ruoyang Shao
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiwei Li
- Department of Hepatobiliary Surgery, The Third People's Hospital of Shenzhen, Shenzhen, China
| | - Jitao Wang
- Department of Hepatobiliary Surgery, Xingtai Institute of Cancer Control, Xingtai, China
| | - Ruizhao Qi
- Department of General Surgery, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Qingbo Liu
- Department of Hepatobiliary Surgery, Shunde Hospital, Southern Medical University, Foshan, China
| | - Weijie Zhang
- Department of Hepatobiliary Surgery, Shunde Hospital, Southern Medical University, Foshan, China
| | - Xiaorong Mao
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaojing Song
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Lei Li
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yanna Liu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xin Zhao
- Department of Hepatobiliary Surgery, The Third People's Hospital of Shenzhen, Shenzhen, China
| | - Chuan Liu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xun Li
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Changzeng Zuo
- Department of Hepatobiliary Surgery, Xingtai Institute of Cancer Control, Xingtai, China
| | - Weidong Wang
- Department of Hepatobiliary Surgery, Shunde Hospital, Southern Medical University, Foshan, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
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Schizas D, Katsaros I, Karatza E, Kykalos S, Spartalis E, Tsourouflis G, Dimitroulis D, Nikiteas N. Concomitant Laparoscopic Splenectomy and Cholecystectomy: A Systematic Review of the Literature. J Laparoendosc Adv Surg Tech A 2020; 30:730-736. [PMID: 32202962 DOI: 10.1089/lap.2020.0004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Concomitant laparoscopic splenectomy and cholecystectomy (CLSC) is performed for concurrent pathologies of the spleen and gallbladder. This systematic review aimed to evaluate the available evidence on its indications, operative technique, and outcomes. Materials and Methods: The PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: December 6, 2019) for studies reporting on CLSC. The National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool was utilized for the evaluation of eligible articles. Results: Eight studies met inclusion criteria and concerned collectively 108 patients (53 males and 55 females) with a mean age of 27.02 ± 20.48 years (mean, SD). The most common surgery indications were hereditary spherocytosis (38.9%) and sickle cell disease or β-thalassemia (32.4%). Laparoscopic cholecystectomy preceded splenectomy in the majority of cases (75%). A five-trocar approach was most frequently (89.8%) utilized. The mean operation duration was 170.18 ± 53.07 minutes (mean, SD). Resected spleen weight was 601.82 ± 386.02 g (mean, SD) and had a length of 18.74 ± 5.3 cm (mean, SD). The conversion rate was 2.7%, while 20.4% of included cases experienced postoperative complications. Most frequent ones included pulmonary infection (6.5%) and portal/splenic vein thrombosis (4.6%). No postoperative death was recorded. Mean hospitalization period was 5.43 ± 3.18 days (mean, SD). Conclusions: CLSC is a safe and feasible operation for simultaneous diseases of the spleen and gallbladder that require elective procedures. High-quality clinical trials are essential to further elucidate clinical evidence and standardize operative technique.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery and National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Ioannis Katsaros
- First Department of Surgery and National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Elli Karatza
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Stylianos Kykalos
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Eleftherios Spartalis
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Gerasimos Tsourouflis
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Dimitroulis
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Nikolaos Nikiteas
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Tung W, Yang C, Tseng P, Hung C, Wang J, Chen C, Hu T, Lu S, Xu H. Revisiting the accuracy of splenomegaly by sonography in patients with chronic hepatitis B. ADVANCES IN DIGESTIVE MEDICINE 2020. [DOI: 10.1002/aid2.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Wei‐Ling Tung
- Division of Hepatogastroenterology, Department of Internal MedicineChiayi Chang Gung Memorial Hospital Chiayi Taiwan
| | - Chun‐Hsun Yang
- Division of Hepatogastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Po‐Lin Tseng
- Division of Hepatogastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Chao‐Hung Hung
- Division of Hepatogastroenterology, Department of Internal MedicineChiayi Chang Gung Memorial Hospital Chiayi Taiwan
| | - Jing‐Houng Wang
- Division of Hepatogastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Chien‐Hung Chen
- Division of Hepatogastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Tsung‐Hui Hu
- Division of Hepatogastroenterology, Department of Internal MedicineKaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Sheng‐Nan Lu
- Division of Hepatogastroenterology, Department of Internal MedicineChiayi Chang Gung Memorial Hospital Chiayi Taiwan
| | - Huang‐Wei Xu
- Division of Hepatogastroenterology, Department of Internal MedicineChiayi Chang Gung Memorial Hospital Chiayi Taiwan
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Yao S, Kaido T, Yagi S, Uozumi R, Iwamura S, Miyachi Y, Shirai H, Kamo N, Taura K, Okajima H, Uemoto S. Impact of imbalanced graft-to-spleen volume ratio on outcomes following living donor liver transplantation in an era when simultaneous splenectomy is not typically indicated. Am J Transplant 2019; 19:2783-2794. [PMID: 30830721 DOI: 10.1111/ajt.15337] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/04/2019] [Accepted: 02/19/2019] [Indexed: 02/06/2023]
Abstract
The impact of an imbalanced graft-to-spleen volume ratio (GSVR) on posttransplant outcomes other than postreperfusion portal hypertension remains unknown. The importance of GSVR might vary according to whether simultaneous splenectomy (SPX) is performed. This retrospective study divided 349 living donor liver transplantation (LDLT) recipients from 2006 to 2017 into 2 groups: low GSVR (≤0.70 g/mL) and normal GSVR (>0.70 g/mL). The cutoff value of GSVR was set based on the first quartile of the distributed data. Graft survival and associations with various clinical factors were investigated between the groups according to whether SPX was performed. Low GSVR did not affect outcomes when SPX was performed. In contrast, it was associated with an increased incidence of early graft loss (EGL) and poor graft survival by presenting posttransplant thrombocytopenia, cholestasis, coagulopathy, and massive ascites when the spleen was preserved. Among patients with a preserved spleen, the multivariable analysis results revealed that older donor age and low GSVR were independent risk factors for graft loss. In conclusion, low GSVR was an independent predictor of graft loss after LDLT when the spleen was preserved. Preserved spleen with extremely low GSVR may be related to persistent hypersplenism, impaired graft function, and consequent EGL.
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Affiliation(s)
- Siyuan Yao
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshimi Kaido
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shintaro Yagi
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryuji Uozumi
- Department of Biomedical Statistics and Bioinformatics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Sena Iwamura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Miyachi
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hisaya Shirai
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naoko Kamo
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kojiro Taura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideaki Okajima
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinji Uemoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Guadagni S, Gianardi D, Morelli L. Hand-Assisted Splenic Bed Laparoscopic Splenectomy for Massive Splenomegaly Secondary to Portal Hypertension and Liver Cirrhosis. Am Surg 2019. [DOI: 10.1177/000313481908500515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Simone Guadagni
- General Surgery Unit Department of Oncology, Transplantation and New Technologies University of Pisa Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit Department of Oncology, Transplantation and New Technologies University of Pisa Pisa, Italy
| | - Luca Morelli
- General Surgery Unit Department of Oncology, Transplantation and New Technologies University of Pisa Pisa, Italy
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The Effect of Splenectomy on the Reversal of Cirrhosis: a Prospective Study. Gastroenterol Res Pract 2019; 2019:5459427. [PMID: 31093275 PMCID: PMC6476033 DOI: 10.1155/2019/5459427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/13/2019] [Accepted: 02/21/2019] [Indexed: 12/14/2022] Open
Abstract
Background Studies have demonstrated that liver fibrosis can be reversed by medication treatments. After splenectomy, cirrhosis patients have short-term changes in several serum markers for cirrhosis and liver stiffness. Aims To investigate the effect of splenectomy on the severity of cirrhosis. Methods A total of 62 patients with cirrhosis and portal hypertension receiving splenectomy from December 2014 to July 2017 were enrolled. The degree of cirrhosis was preoperatively and postoperatively evaluated by serum markers, including hyaluronan (HA), laminin, amino-terminal propeptide of type III procollagen (PIIINP), type IV collagen (C-IV), liver stiffness (FibroScan), and liver volume. Results HA levels significantly increased at 1 week and 1 month postoperation (both P < 0.05), whereas the levels of PIIINP and C-IV significantly decreased from 1 month to 12 months postoperation (all P < 0.05). In addition, elastography examination demonstrated that the FibroScan score significantly reduced from 1 month to 24 months postoperation as compared with the baseline level (all P < 0.05). CT scan showed that the liver volume significantly increased at 6 months postoperation (P < 0.05). Furthermore, the alteration trends of these serum markers and the FibroScan score were further confirmed by the multivariate linear regression. Conclusions These observations suggested that splenectomy may result in long-term reversal of cirrhosis.
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Abstract
Liver cirrhosis is a major risk factor for increased mortality and morbidity in patients undergoing non-hepatic surgery with overall mortality rates as high as 45–50%. However, cirrhotic patients are often in need of surgical procedures including urological surgeries like cystectomies for muscle invasive bladder cancer. Data on the prognosis of these patients undergoing cystectomy for bladder cancer are scarce in the literature. In the present case-study, we describe the outcomes of 3 patients with liver cirrhosis who underwent radical cystectomy for muscle invasive bladder cancer. To the best of our knowledge, this is the first study reporting on this kind of urological surgery in patients with liver cirrhosis. Accordingly, we provide a review in the literature on prognosis and factors influencing the survival of cirrhotic patients who undergo surgical procedures.
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Huang Y, Wang XY, Wang K. Hand-assisted laparoscopic splenectomy is a useful surgical treatment method for patients with excessive splenomegaly: A meta-analysis. World J Clin Cases 2019; 7:320-334. [PMID: 30746373 PMCID: PMC6369387 DOI: 10.12998/wjcc.v7.i3.320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 12/26/2018] [Accepted: 01/03/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hand-assisted laparoscopic splenectomy (HALS) can help overcome the drawbacks of laparoscopic splenectomy (LS) while maintaining its advantages.
AIM To evaluate the efficacy and advantages of HALS for splenomegaly.
METHODS The relevant literature was reviewed using the PubMed, EMBASE, Cochrane, Ovid Medline, and Wanfang databases to compare the clinical outcomes of HALS and LS. Odds ratios or mean differences were calculated with 95% confidence intervals for fixed-effects and random-effects models. Overall, 754 patients from 16 trials who met the inclusion criteria were selected.
RESULTS In pure splenectomy, blood loss volume (P < 0.001) and conversion rate (P = 0.008) were significantly lower in the HALS group than in the LS group. Conversely, for splenomegaly, the operative time (P = 0.04) was shorter and blood loss volume (P < 0.001) and conversion rate (P = 0.001) were significantly lower in the HALS group than in the LS group. However, no significant difference was observed in hospital stay length, blood transfusion, time to food intake, complications, or mortality rate between the two groups. Moreover, in splenectomy and devascularization of the upper stomach (DUS), the operative time (P = 0.04) was significantly shorter and blood loss volume (P < 0.001) and conversion rate (P = 0.05) were significantly lower in the HALS + DUS group than in the LS + DUS group. However, no significant difference was observed in hospital stay length, timing of diet, and complications between the two groups.
CONCLUSION HALS is an ideal surgical treatment method for splenomegaly because it can maximize the benefits for patients while maintaining the advantages of LS.
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Affiliation(s)
- Yong Huang
- Department of General Surgery, Hepato-Biliary-Pancreatic Surgery Division, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Xiao-Yun Wang
- Department of Operating Room, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Kai Wang
- Department of General Surgery, Hepato-Biliary-Pancreatic Surgery Division, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Quest for the optimal technique of laparoscopic splenectomy - vessels first or hilar transection? Wideochir Inne Tech Maloinwazyjne 2018; 13:460-468. [PMID: 30524616 PMCID: PMC6280088 DOI: 10.5114/wiitm.2018.76071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 04/20/2018] [Indexed: 12/18/2022] Open
Abstract
Introduction Throughout our 20 years of experience, we have used several different techniques for laparoscopic splenectomy (LS). However, two methods have been used most frequently: "vessels first" and "hilar transection". Aim To evaluate the outcomes of LS performed with these two different approaches. Material and methods It was an observational study based on retrospective analysis of consecutive patients undergoing LS in a tertiary referral surgical center in the period 1998-2017. We excluded patients with splenic trauma, initially submitted to open surgery, stapled transection of splenic hilum, partial resections of the spleen and other spleen-preserving procedures. Patients were divided into two groups: group 1 ("vessels first") with 188 patients, and group 2 ("hilar transection") with 287 patients. Results Mean operative time was shorter (p < 0.001) and blood loss was lower (p < 0.001) in group 2. The need for blood transfusions and the conversion rate were higher in group 1 (p = 0.044 and p = 0.003 respectively). There was no difference in intraoperative adverse events (p = 0.179). Overall postoperative morbidity did not differ between groups (p = 0.081) and we noted mortality of 0.21% (1 patient of group 2). The morbidity rate associated with accidental injury of the pancreatic parenchyma was significantly higher in group 1 (p = 0.028). Median length of hospital stay was 4 days (range: 1-99) and did not differ between groups (p = 0.175). Conclusions The "vessels first" technique is associated with longer operative time, higher blood loss and increased risk of conversion. "Hilar transection" is associated with lower incidence of local complications related most likely to accidental injury of the pancreatic tail. In the case of a large caliber of splenic vessels the "vessels first" approach remains the technique of choice.
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Zheng S, Sun P, Liu X, Li G, Gong W, Liu J. Efficacy and safety of laparoscopic splenectomy and esophagogastric devascularization for portal hypertension: A single-center experience. Medicine (Baltimore) 2018; 97:e13703. [PMID: 30558084 PMCID: PMC6320041 DOI: 10.1097/md.0000000000013703] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Many patients in China have portal hypertension secondary to liver cirrhosis. Splenectomy and devascularization have become an efficacious surgical procedure for portal hypertension, and has been recommended in China as the first choice for the treatment of portal hypertension for a long time. As a result of advances in laparoscopic equipment and techniques, splenectomy and esophagogastric devascularization have been carried out with laparoscope.From January 2012 to December 2017, 453 patients who were diagnosed with portal hypertension and serious gastroesophageal varices received surgical management in our institution. 250 patients chose laparoscopic splenectomy and esophagogastric devascularization and 203 underwent open splenectomy and esophagogastric devascularization.We retrospectively analyzed the perioperative data and follow-up data of these patients. The operation time of laparoscopic group was longer than open group (P ≤ .001). Intraoperative blood loss was less (P ≤ .001), the passing of flatus was earlier (P = .042), and postoperative hospital stay was shorter (P = .001) in the laparoscopic group. During postoperative follow-up of 4 to 75 months, the incidence of esophagogastric variceal rebleeding, encephalopathy, and secondary liver cancer showed no significant differences.Laparoscopic splenectomy and esophagogastric devascularization were safe and more effective than open surgery for portal hypertension and gastroesophageal varices.
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Affiliation(s)
- Shunzhen Zheng
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong University
| | | | - Xihan Liu
- Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong Province, China
| | - Guangbing Li
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong University
| | - Wei Gong
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong University
| | - Jun Liu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong University
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Liver Retraction Using n-Butyl-2-Cyanoacrylate (NBCA) Glue during Laparoscopic Splenectomy and Azygoportal Disconnection in Cirrhotic Patients. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3064046. [PMID: 30211218 PMCID: PMC6120335 DOI: 10.1155/2018/3064046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/08/2018] [Indexed: 12/26/2022]
Abstract
Background Although liver retraction using n-butyl-2-cyanoacrylate (NBCA) glue has been applied to laparoscopic upper abdominal surgery in noncirrhotic patients, there is still no consensus on its safety and feasibility for cirrhotic patients. In this study, we aimed to investigate the safety and effectiveness of liver retraction using NBCA glue during laparoscopic splenectomy and azygoportal disconnection (LSD) for gastroesophageal varices and hypersplenism secondary to liver cirrhosis and portal hypertension. Methods Thirty-nine gastroesophageal varices and hypersplenism secondary to liver cirrhosis and portal hypertension patients were included in our study. We performed LSD in the presence of NBCA glue (n = 22, NBCA group) and absence of NBCA glue (n = 17, n-NBCA group), respectively. The operation time, blood loss, postoperative hospitalization, and liver function were compared between the two groups. Results There was no mortality during the operation. One patient in non-NBCA group received open surgery due to parenchyma hemorrhage. Postoperative pleural effusion occurred in 2 cases of the NBCA group and 1 of the non-NBCA group. One showed left subphrenic abscess in the non-NBCA group. No postoperative bleeding occurred after 9-30 months of follow-up. The time of operation in NBCA group was significantly shorter than those in n-NBCA group (198.86±17.86 versus 217.81±20.25min, P<0.01). Blood loss in NBCA group was significantly lower than non-NBCA group (159.09±56.98 versus 212.50±88.51 ml, P<0.05). The levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were increased on day 1 after LSD and decreased to normal level on day 7 after LSD in both groups. There was no significant difference in postoperative hospitalization and liver function between the two groups. Conclusion Liver retraction using NBCA glue during LSD for gastroesophageal varices and hypersplenism secondary to liver cirrhosis and portal hypertension is safe, effective, and feasible.
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Moris D, Dimitriou N, Griniatsos J. Laparoscopic Splenectomy for Benign Hematological Disorders in Adults: A Systematic Review. ACTA ACUST UNITED AC 2018; 31:291-302. [PMID: 28438854 DOI: 10.21873/invivo.11058] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Since its introduction in the early 1990s, laparoscopic splenectomy (LS) has gained worldwide acceptance for spleen removal, especially in hematological patients. AIM The present review summarizes the current knowledge and results of LS for the treatment of benign hematological diseases in adults. MATERIALS AND METHODS A MEDLINE/PubMed database research was performed using the terms: "laparoscopic splenectomy" OR "laparoscopy" OR "splenectomy" AND "hematological disorders" OR "hematological disease" OR "hematology" AND "adults" as key words. We set our analysis starting date as January 1st 2010 and the end date as December 31st 2016. We identified 247 relative articles. All the references from the identified articles were searched for relevant information. RESULTS Twenty-seven articles were deemed appropriate for our analysis. LS was found to be feasible and safe in the majority of patients with benign hematological disorders, with a mortality rate ranging from 0% to less than 4% and the postoperative complications rate from 0% to 35.7%. The conversion rate was also very low (4%) and response (complete or partial) was achieved in more than 80% of patients. Lateral approach with four trocars was the most commonly used approach with concommitant cholecystectomy being correlated with increased operative time and morbidity. CONCLUSION Current literature holds that whenever splenectomy is required for the treatment of hematological disorders in adults, a laparoscopic approach should be offered as the gold standard. However, to strengthen the clinical evidence in favor of LS, more high-quality clinical trials on several issues of the procedure are necessary.
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Affiliation(s)
- Demetrios Moris
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, U.S.A.
| | - Nikoletta Dimitriou
- First Department of Surgery, National and Kapodistrian University of Athens, Medical School, Laikon General Hospital, Athens, Greece
| | - John Griniatsos
- First Department of Surgery, National and Kapodistrian University of Athens, Medical School, Laikon General Hospital, Athens, Greece
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Lv Y, Yee Lau W, Wu H, Han X, Gong X, Liu N, Yue J, Li Q, Li Y, Deng J. Causes of peripheral cytopenia in hepatitic cirrhosis and portal hypertensive splenomegaly. Exp Biol Med (Maywood) 2017; 242:744-749. [PMID: 28299974 PMCID: PMC5363688 DOI: 10.1177/1535370217693113] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/11/2016] [Indexed: 12/14/2022] Open
Abstract
The clinical data of 183 patients with hepatitic cirrhosis and portal hypertensive splenomegaly complicated by peripheral cytopenia were retrospectively analyzed to investigate the causes of peripheral cytopenia, as well as the proportion of the causes in these patients. All patients underwent splenectomy. Before operation, these patients had one or more types of peripheral cytopenia (cumulative cytopenia: 390 patient-times). After splenectomy, blood counts in 79.2% (309/390) returned to normal, while in 15.9% (62/390) they increased but failed to reach to normal levels, and in 4.9% (19/390) they became lower than before the operations. For the last group of patients ( n = 19), long-term follow-up showed that blood counts returned to normal in five patients. In other words, in 80.5% [(309 + 5)/390 or 314/390] of patient-times, the peripheral cytopenia was due to hypersplenism, in 15.9% it was due to a combination of factors, and in 3.6% [14/390] it had nothing to do with the hypersplenism. Thus, hypersplenism is a major cause, but not the only cause, of peripheral cytopenia in patients with hepatic cirrhosis and portal hypertensive splenomegaly, and splenectormy is an effective treatment for these patients. Impact statement For a long time, the development of peripheral cytopenias as a complication to cirrhotic portal hypertension has been attributed to hypersplenism; however, this has never been fully demonstrated. Dameshek summarized that hypersplenism should be diagnosed by the presence of four conditions: (a) mono- or multi-lineage peripheral cytopenias; (b) compensatory hyperplasia of bone marrow; (c) splenomegaly; and (d) correction of cytopenias after splenectomy. We retrospectively analyzed the clinical data from 183 surgical patients, and found that 80.5% of peripheral cytopenias was caused by hypersplenism, 16% by a combination of factors, and 3.5% by other factors unrelated to hypersplenism. As the first quantitative findings in this field, our results verify that hypersplenism is a major, but not exclusive, cause of peripheral cytopenias, and provides important clinical evidence for investigating the cause of peripheral cytopenias.
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Affiliation(s)
- Yunfu Lv
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Wan Yee Lau
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Hongfei Wu
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - XiaoYu Han
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Xiaoguang Gong
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Ning Liu
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Jie Yue
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Qingqing Li
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - YeJuan Li
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
| | - Jie Deng
- Department of Emergency Surgery, Hainan Province People’s Hospital, Haikou 570311, China
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Sakamoto K, Honda G, Kurata M, Homma Y, Shinya S, Honjo M. Safe approach to the splenic hilum by first mobilizing the pancreatic tail in laparoscopic splenectomy. Asian J Endosc Surg 2017; 10:83-86. [PMID: 28045237 DOI: 10.1111/ases.12325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 07/21/2016] [Accepted: 07/27/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We employed a safe approach during laparoscopic splenectomy by first mobilizing the pancreatic tail and then dissecting the splenic vessels at the splenic hilum before mobilizing the spleen. MATERIALS AND SURGICAL TECHNIQUE Patients were placed in the lithotomy position, and only the upper body was twisted to the right side. Five trocars were placed. After the bursa omentalis was opened, an avascular layer was identified behind the pancreas. This avascular layer was bluntly dissected, and the pancreatic tail was isolated from the retroperitoneum. The tissue surrounding the splenic hilum was dissected by a handling tape that was placed around the pancreatic tail. Because the spleen remained connected to the retroperitoneum with the splenorenal ligament, a good operative view of the splenic hilum was obtained with proper extension. After sufficient space was secured between the pancreatic tail and the spleen, the splenic vessels were divided with a linear stapler. The spleen was detached in the final stage. DISCUSSION The current standardized procedure is highly recommended for a safe laparoscopic splenectomy.
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Affiliation(s)
- Katsunori Sakamoto
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Masanao Kurata
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Yuki Homma
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Satoshi Shinya
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Masahiko Honjo
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
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Wu T, Sun R, Huang Y, Wang Z, He J, Shen S, Yin X, Zhu Z, Yang W, Zhao Z. Partial splenic embolization of patients with hypersplenism by transradial or transfemoral approach: a prospective randomized controlled trial. Acta Radiol 2016; 57:1201-4. [PMID: 26671306 DOI: 10.1177/0284185115622076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 11/13/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Partial splenic artery embolization (PSE) is an effective treatment modality for patients with hypersplenism. It is less invasive and has a quicker recovery compared with surgical procedures. PSE is usually performed using a femoral artery approach that requires bedrest for a few hours, which is rarely the case for transradial PSE. PURPOSE To compare the transradial and transfemoral approaches for embolization of spleen in patients with hypersplenism. MATERIAL AND METHODS In all, 84 patients with hypersplenism who required PSE were recruited. They were randomly divided into two groups on the basis of the procedure followed: the transradial approach (R-PSE, n = 39) or transfemoral approach (F-PSE, n = 45). Technical success, puncture rate, total procedure time, X-ray exposure time, length of stay in hospital (LOS), and complications of the two groups were recorded. RESULTS The procedure time, X-ray exposure time, and LOS were found to be lower in the R-PSE group than in the F-PSE. However, this difference was not statistically significant. CONCLUSION The transradial artery approach for PSE in patients with hypersplenism is feasible with no major complications as compared to the femoral approach.
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Affiliation(s)
- Tao Wu
- Department of Interventional Radiology, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
| | - Ruimin Sun
- Department of Operation Room, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
| | - Yinuo Huang
- Department of Gastroenterology, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
| | - Zhixue Wang
- Department of Interventional Radiology, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
| | - Jue He
- Department of Interventional Radiology, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
| | - Songhe Shen
- Department of Interventional Radiology, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
| | - Xiaoxiang Yin
- Department of Interventional Radiology, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
| | - Zhixiang Zhu
- Department of Interventional Radiology, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
| | - Wenyi Yang
- Department of Gastroenterology, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
| | - Zhijun Zhao
- Department of Interventional Radiology, The First Affiliated Hospital of Henan University, Kaifeng, Henan, PR China
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Lv Y, Lau WY, Li Y, Deng J, Han X, Gong X, Liu N, Wu H. Hypersplenism: History and current status. Exp Ther Med 2016; 12:2377-2382. [PMID: 27703501 PMCID: PMC5038876 DOI: 10.3892/etm.2016.3683] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 08/19/2016] [Indexed: 12/16/2022] Open
Abstract
Hypersplenism is a common disorder characterized by an enlarged spleen which causes rapid and premature destruction of blood cells. This review summarizes the history of hypersplenism, discuss its classification and pathogenesis, and examines its diagnosis and treatment options. We performed a comprehensive literature search using PubMed, Web of Knowledge and the China National Knowledge Infrastructure (CNKI) database, reviewed hypersplenism-related articles and summarized the major findings. According to its etiological causes, hypersplenism is characterized by splenomegaly and peripheral cytopenias. It can be classified into three categories: i) primary hypersplenism; ii) secondary hypersplenism; and iii) occult hypersplenism. A number of mechanisms causing hypersplenism have been identified, and mainly involve retention in the spleen, phagocytosis, and autoimmunity. Treatment options for hypersplenism include etiological treatment, non-surgical treatment, total splenectomy and liver transplantation. In any case, treatment should be individualized for each patient.
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Affiliation(s)
- Yunfu Lv
- Department of General Surgery, Hainan Province People's Hospital, Haikou, Hainan 570311, P.R. China; Department of Molecular Biology, Hainan University, Haikou, Hainan 570228, P.R. China
| | - Wan Yee Lau
- Department of General Surgery, Hainan Province People's Hospital, Haikou, Hainan 570311, P.R. China; Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, P.R. China
| | - Yejuan Li
- Department of General Surgery, Hainan Province People's Hospital, Haikou, Hainan 570311, P.R. China; Department of Molecular Biology, Hainan University, Haikou, Hainan 570228, P.R. China
| | - Jie Deng
- Department of Molecular Biology, Hainan University, Haikou, Hainan 570228, P.R. China
| | - Xiaoyu Han
- Department of General Surgery, Hainan Province People's Hospital, Haikou, Hainan 570311, P.R. China
| | - Xiaoguang Gong
- Department of General Surgery, Hainan Province People's Hospital, Haikou, Hainan 570311, P.R. China
| | - Ning Liu
- Department of General Surgery, Hainan Province People's Hospital, Haikou, Hainan 570311, P.R. China
| | - Hongfei Wu
- Department of General Surgery, Hainan Province People's Hospital, Haikou, Hainan 570311, P.R. China
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Splenectomy versus Partial Splenic Embolization for Massive Splenomegaly Secondary to Hepatitis B-Related Liver Cirrhosis: A Case-Control Study. Gastroenterol Res Pract 2016; 2016:3471626. [PMID: 27418925 PMCID: PMC4933866 DOI: 10.1155/2016/3471626] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 05/23/2016] [Accepted: 05/31/2016] [Indexed: 12/18/2022] Open
Abstract
Background. Both splenectomy (SP) and partial splenic embolization (PSE) are used to treat massive splenomegaly (MSM) secondary to hepatitis B-related liver cirrhosis (HB-LC). This retrospective case-control study was conducted to compare the effects of SP and PSE on these patients. Methods. From July 2004 to January 2012, patients with MSM secondary to HB-LC who underwent SP or PSE were 1 : 1 : 1 matched with similar nonsurgery patients, respectively. Intraoperative situation, hematological indices, liver function, HBV DNA level, HBeAg seroconversion rate, morbidity, and mortality at 6 months postoperatively were compared. Results. Operative time, estimated blood loss, blood transfusion rate, severe pain, postoperative stay, and portal vein thrombosis (PVT) rate in the PSE group were significantly superior to the SP group, although SP and PSE were similar in liver function improvement, HBV suppression, morbidity, and mortality at 6 months postoperatively, and SP even improved WBC and PLT counts higher than PSE. Conclusion. Both SP and PSE are effective in improving liver function, increasing WBC and PLT counts, and suppressing replication of HBV for MSM secondary to HB-LC. Although postoperative improvement in WBC and PLT counts by SP can be higher than PSE, PSE is simple and minimally invasive and has a lower incidence of PVT.
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Okazaki T, Hifumi T, Manabe A, Matsumura H, Egawa S, Hamaya H, Shinohara N, Takano K, Shishido H, Abe Y, Kawakita K, Hagiike M, Kuroda Y. Invasive group B streptococcal infection in a patient with post splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension. World J Emerg Med 2016; 7:68-70. [PMID: 27006743 DOI: 10.5847/wjem.j.1920-8642.2016.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Splenectomy in patients with liver cirrhosis (LC) is expected to become more common owing to its efficacy on portal hemodynamics. In this report we describe an alarming case of group B streptococcus (GBS) infection after splenectomy in a patient with LC. METHODS A 72-year-old woman with a history of LC was admitted to our emergency department because of respiratory failure. The patient had received left lateral segmentectomy of the liver and splenectomy three months before admission. Pulmonary examination revealed significant wheezing during inspiration and expiration, but no crackles and stridor. Chest radiography and CT showed no infiltrates. A presumptive diagnosis of bronchial asthma caused by upper respiratory infection was made. Four days after admission, GBS infection was confirmed by blood culture and penicillin G was administered. Antibiotics were given intravenously for a total of 12 days. RESULTS The patient was discharged on the 12th day after admission. CONCLUSIONS Although efficacy of splenectomy in patients with LC has been reported, immune status should be evaluated for a longer period. Patients who have undergone splenectomy are highly susceptible to bacteria; moreover, LC itself is an independent risk factor for mortality in patients with sepsis. Since prophylaxis against GBS has not been established, immediate action should be taken. Emergency physicians should be aware of invasive GBS infection in the context of the critical risk factors related to splenectomy and LC, particularly the expected increase of splenectomy performed in LC patients.
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Affiliation(s)
- Tomoya Okazaki
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Toru Hifumi
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Arisa Manabe
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Hikari Matsumura
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Satoshi Egawa
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Hideyuki Hamaya
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Nastuyo Shinohara
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Koshiro Takano
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Hajime Shishido
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Yuko Abe
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Masanobu Hagiike
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
| | - Yasuhiro Kuroda
- Emergency Medical Center, Kagawa University Hospital, Kita, Kagawa, 761-0793, Japan
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Jiang X, Gao F, Ma Y, Feng S, Liu X, Zhou H. Percutaneous Microwave Ablation in the Spleen for Treatment of Hypersplenism in Cirrhosis Patients. Dig Dis Sci 2016; 61:287-92. [PMID: 26031423 PMCID: PMC4700057 DOI: 10.1007/s10620-015-3732-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/23/2015] [Indexed: 12/15/2022]
Abstract
AIM The aim of this study was to estimate the feasibility and therapeutic effectiveness of percutaneous microwave ablation in the treatment of hypersplenism in cirrhosis. METHODS Forty-one cirrhosis patients with hypersplenism were treated with ultrasonography-guided percutaneous microwave ablation between February 2007 and August 2011. Peripheral blood cell counts, portal vein diameter, splenic vein diameter, and blood flow of splenic vein were evaluated before and after the operation, and complications of the treatment were also investigated. All patients were followed up for 24 months. RESULTS The levels of platelets and white blood cells were increased, while the splenic vein diameter narrowed gradually after the therapy and 24 months later. Moreover, patients received percutaneous microwave ablation had much lower splenic venous flow velocity. The portal vein diameter did not change significantly 6 months after the treatment, although it narrowed gradually within 3 months after the treatment. Furthermore, no complications such as uncontrollable bleeding, splenic abscess, spleen rupture, and damage in surrounding organ happened after the therapy. CONCLUSIONS Graded percutaneous microwave ablation, as a minimally invasive therapy, could damage the spleen, increase the levels of platelets and white blood cells, and reduce portal hypertension effectively without serious complications. Percutaneous microwave ablation is an effective, safe, and feasible method for cirrhosis patients with hypersplenism.
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Affiliation(s)
- XiangWu Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Fei Gao
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - Yan Ma
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - ShuFen Feng
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - XueLian Liu
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
| | - HongKe Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 China
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Reich H, Ramzy D, Czer L, Esmailian F, Moriguchi J, Ihnken K, Yusufali T, D'Attellis N, Arabia F, Annamalai A. Hemodynamic Consequences of Laparoscopy for Patients on Mechanical Circulatory Support. J Laparoendosc Adv Surg Tech A 2015; 25:999-1004. [PMID: 26523797 DOI: 10.1089/lap.2015.0295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Technologic advances and superior survival with mechanical circulatory support (MCS) have led to an expanding population that develops intraabdominal conditions requiring intervention. Whether laparoscopy can be performed without detrimental effects on hemodynamics and device function is not well described. MATERIALS AND METHODS Effects of laparoscopy performed on MCS were retrospectively assessed. Intraoperative hemodynamics and device function were compared with the same time interval 24 hours prior to surgery using intrapatient paired t tests. Outcomes included survival, transfusion, thromboembolic events, and infection. RESULTS Twelve patients with ventricular assist devices or total artificial hearts underwent laparoscopy from 2012 to 2014. Median follow-up was 116 days. Operations included cholecystectomy, diagnostic laparoscopy, gastrojejunostomy, and gastrostomy. There were no differences between preoperative and intraoperative mean arterial pressure, heart rate, and inotrope or vasopressor requirements (P > .05). Device fill volume, flow, rate, and power were unchanged (P > .05), whereas pulsatility index decreased by 0.2 (95% confidence interval, 0.03, 0.36) with laparoscopy (P = .03). All intraoperative fluctuations in hemodynamics and device function improved with reduction of pneumoperitoneum, adjusting device speed, or pharmacologic support. There were no operative mortalities. Thirty-day survival and survival to discharge were 75% and 50%, respectively. Despite antiplatelet therapy and preoperative international normalization ratio of 2.2 ± 0.9, there were no re-operations for bleeding, and 50% did not require transfusion. Two patients with recent cardiac surgery had thromboembolic events: one stroke and one device thrombus. None had postoperative bacteremia or driveline infection. CONCLUSIONS Laparoscopy can be performed on MCS with low morbidity and mortality and minimal perturbations in hemodynamics and device function.
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Affiliation(s)
- Heidi Reich
- 1 Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center , Los Angeles, California.,2 Department of Surgery, Cedars-Sinai Medical Center , Los Angeles, California
| | - Danny Ramzy
- 1 Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center , Los Angeles, California
| | - Lawrence Czer
- 1 Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center , Los Angeles, California
| | - Fardad Esmailian
- 1 Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center , Los Angeles, California
| | - Jaime Moriguchi
- 1 Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center , Los Angeles, California
| | - Kai Ihnken
- 1 Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center , Los Angeles, California
| | - Taizoon Yusufali
- 3 Department of Anesthesiology, Cedars-Sinai Medical Center , Los Angeles, California
| | - Nicola D'Attellis
- 3 Department of Anesthesiology, Cedars-Sinai Medical Center , Los Angeles, California
| | - Francisco Arabia
- 1 Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center , Los Angeles, California
| | - Alagappan Annamalai
- 2 Department of Surgery, Cedars-Sinai Medical Center , Los Angeles, California
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Qi X, Li H, Liu X, Yao H, Han G, Hu F, Shao L, Guo X. Novel insights into the development of portal vein thrombosis in cirrhosis patients. Expert Rev Gastroenterol Hepatol 2015; 9:1421-32. [PMID: 26325361 DOI: 10.1586/17474124.2015.1083856] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The prognostic impact of portal vein thrombosis (PVT) in liver cirrhosis remains controversial among studies, primarily because the risk stratification of PVT is often lacking. A definition of clinically significant PVT should be proposed and actively improved. Moreover, the risk factors for the development of PVT in liver cirrhosis should be fully recognized to screen and identify high-risk patients. Currently, well-recognized risk factors include a reduced portal vein flow velocity, a worse liver function, splenectomy, liver transplantation, and factor V Leiden and prothrombin G20210A mutations. Novel risk factors include an increased flow volume of portosystemic collateral vessel, thrombopoietin receptor agnonists, and non-selective beta-blockers. In contrast to the traditional perspectives, the abnormalities of procoagulant and anticoagulant factors may not contribute to the development of PVT in liver cirrhosis. Further studies should explore the role of other risk factors, such as antiphospholipid antibodies, methylenetetrahydrofolate reductase C677T gene mutation, hyperhomocysteinemia, and myeloproliferative neoplasms.
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Affiliation(s)
- Xingshun Qi
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
| | - Hongyu Li
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
| | - Xu Liu
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
| | - Hui Yao
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
| | - Guohong Han
- b 2 Department of Liver Diseases and Digestive Interventional Radiology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, 710032, China
| | - Fengrong Hu
- c 3 Department of Digestive Diseases, No. 2 Hospital of Xi'an, Xi'an, 710003, China
| | - Lichun Shao
- d 4 Department of Gastroenterology, No. 463 Hospital of Chinese PLA, Shenyang, 110045, China
| | - Xiaozhong Guo
- a 1 Liver Cirrhosis Group, Department of Gastroenterology, General Hospital of Shenyang Military Area, No. 83 Wenhua Road, Shenyang, 110840, China
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