Effect of Laparoscopic Splenectomy on Portal Hypertensive Gastropathy in Cirrhotic Patients With Portal Hypertension

Effect of Laparoscopic Splenectomy and Portal Hypertensive Gastropathy

Go Anegawa; Hirofumi Kawanaka; Hideo Uehara; Tomohiko Akahoshi; Kozo Konishi; Daisuke Yoshida; Nao Kinjo; Naotaka Hashimoto; Morimasa Tomikawa; Makoto Hashizume; Yoshihiko Maehara

Disclosures

J Gastroenterol Hepatol. 2009;24(9):1554-1558. 

In This Article

Methods

Consecutive patients with laparoscopic splenectomy seen at the Department of Surgery and Sciences at Kyushu University from January 2003 to December 2006 were included if they had cirrhosis and underwent endoscopic examination before and 1 month after laparoscopic splenectomy. Exclusion criteria were: (i) treatment with ß-blockers or any drugs to alter portal and gastric hemodynamics; or (ii) sclerotherapy or banding therapy for esophagogastric varices scheduled after the operation. Of 97 cirrhotic patients who underwent laparoscopic splenectomy, 70 were included in this study. The severity of PHG was classified according to the criteria established by the McCormack classification. The clinical characteristics of these patients and the outcomes of surgery are summarized in Table 1, Table 2 and Table 3.

At enrollment, a detailed demographic, clinical, and biochemical assessment was made of each patient. The origin of liver cirrhosis was established according to hepatitis B virus (HBV) and hepatitis C virus (HCV) serology. A history of alcohol intake > 60 g for men and > 40 g for women in the absence of positive viral serology was considered indicative of alcoholic cirrhosis. The Child-Pugh score was used to evaluate the severity of liver disease in all of the patients.

Endoscopic Findings of PHG

Upper gastrointestinal endoscopy was performed using an Olympus GIF (H-260 or Q-260, Olympus Optical, Tokyo, Japan) endoscope. The stomach and the upper duodenum were carefully examined by taking the tip of the endoscope close to the mucosa. The fundus of the stomach was especially screened by retroflexion of the endoscope to detect the presence of PHG and gastric varices. The protocol for upper gastrointestinal endoscopy, including the criteria for PHG grading, was written in a manual of procedures and members at all centers were trained in the PHG scoring system. The severity of PHG was classified according to the McCormack classification: mild PHG, snakeskin pattern and/or fine pink speckling; severe PHG, cherry-red spots and/or bleeding PHG. All endoscopic examinations were carried out with the video endoscope by the same senior endoscopists to eliminate any possible influence of inter-observer variability. Cases in which the severity of PHG was not clear were solved by discussion with other endoscopic team members. After laparoscopic splenectomy, endoscopy was performed within 1 month and 1 year.

Operative Findings

Laparoscopic splenectomy was performed by a lateral approach with the left side of the patient elevated 30 to 45 degrees and a small roll under the right flank. The operating-room table was tilted to the patient's left for trocar placement and then to the right to achieve a right lateral decubitus position. The ligaments and short gastric vessels were treated with an Ultracision Harmonic Scalpel (Ethicon Endosurgery, Inc, Cincinnati, OH) or LigaSure (Valleylab, Tyco Healthcare Group, Boulder, CO). The hilar vessels were treated with an Endo GIA stapler 30 to 2.5 mm (United States Surgical Corp, Norwalk, CT).

Abdominal computed tomography was preoperatively performed to evaluate the portal venous collaterals around the spleen and to estimate spleen volume. In cases where there was development of portal venous collaterals around the spleen and an estimated spleen volume of over 1000 g, hand-assisted laparoscopic splenectomy (HALS splenectomy) was performed. An incision was made in the upper midline, approximately 7 cm in diameter (equivalent to the surgeon's glove size), and the HALS device (HandPort, Smith & Nephew, Andover, MA, USA) was placed. The ligaments, short gastric vessels and hilar vessels were treated in the same manner as in a laparoscopic splenectomy.

Statistical Analysis

Values are expressed as means ± standard deviation. Differences between the mean values were evaluated using the Student's t-test and Fisher's exact probability test. Comparisons of data among multiple groups were evaluated using ANOVA followed by Tukey-Kramer's post hoc test. Logistic regression analysis was used to identify variables that best predicted PHG. Odds ratio and the 95% confidence interval were calculated. A P-value of less than 0.05 was considered statistically significant.

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