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

Discussion

The present study suggests that: (i) spleen volume is significantly related to PHG severity; and (ii) laparoscopic splenectomy is one of the effective therapies for PHG in patients with liver cirrhosis and splenomegaly. The prevalence of severe PHG at the beginning of our study was 24.2% and significantly reduced to 1.4% at 1 month after laparoscopic splenectomy.

Previous reports have shown that the development of PHG correlates with the duration and severity of liver disease, presence and size of gastroesophageal varices, and previous variceal eradication by endoscopic variceal sclerotherapy or banding.[13,14] Although PHG is usually observed in association with esophagogastric varices, no direct linear correlation has been made between portal pressure and the presence or severity of PHG.[14,15] In the present study, the presence of PHG was significantly related to the severity of liver disease and the resected spleen volume.

It has been shown that chronic elevation in portal pressure and increased splenic circulation may increase gastric mucosal blood flow, and this may be one explanation for the development of PHG. However, actual measurement of gastric blood flow using Doppler sonography has shown variable results, which suggests that there may be other explanations for the pathogenesis of PHG.[16,17,18,19,20]

In experimental models, noxious agents such as aspirin, bile acids or alcohol have been shown to produce gastric mucosal damage in animals with portal hypertension compared with controls.[21] Other experimental evidence shows that gastric mucosal defense mechanisms are impaired in the presence of portal hypertension.[21,22,23,24,25,26] Endothelin-1 and peroxynitrite overproduction in the gastric mucosa may contribute to the increase in susceptibility to gastric mucosal damage.[27,28] In the present study, laparoscopic splenectomy significantly improved severe PHG and the resected spleen volume was significantly correlated with the severity of PHG. These results indicate that splenomegaly is one of the mechanisms involved in the development of PHG.

Severe PHG can cause lethal hemorrhage, and therefore much effort has been concentrated on the treatment of PHG. Previous studies have shown that non-selective ß-blockers are useful for the therapy of PHG. In a previous study, bleeding was significantly lower in the treated group compared with the placebo group at 12 and 30 months. Multivariate analysis showed that absence of propranolol treatment was the only predictive variable for re-bleeding.[7,8] However, there are some cirrhotic patients who do not respond to propranolol administration because of its insufficient portal decompression.[8,9,29,30] Endoscopic treatment for PHG is limited to an active bleeding site; however, it does not have a significant role in the management of PHG bleeding because of the mild and diffuse bleeding. Both TIPS and shunt surgery have been shown to be effective therapy for PHG.[10,12] In a small previous study, TIPS improved severe PHG in six of eight patients.[12] However, TIPS and shunt surgery both have a risk of complications such as portosystemic encephalopathy and liver dysfunction because of the large extent of surgical invasion. Recently, the only treatment that could be recommended for prophylaxis of PHG bleeding was non-selective ß-blockers such as propranolol.[2] In the present study, laparoscopic splenectomy was safely performed and improved severe PHG in 16 of 17 (94.1%) patients. Laparoscopic splenectomy is likely to be an effective therapy for severe PHG, and useful for prophylaxis of PHG bleeding.

PHG is considered to be related to increased portal venous pressure because of the effectiveness of TIPS, non-selective ß-blockers and shunt surgery.[2,10,12] In the forward theory of portal hypertension, splenomegaly is associated with elevated portal pressure as a result of increased inflow to the portal venous system.[31] Splenectomy can decrease portal pressure and inflow to the portal venous system. This may be one explanation for the improvement of PHG after splenectomy.

Recently, the indications for laparoscopic splenectomy have expanded to include a bleeding tendency, treatment of esophagogastric varices and induction of interferon. In the present study, laparoscopic splenectomy significantly improved hypersplenism and the Child-Pugh score. The interaction between splenectomy and improvement of liver function in liver cirrhosis remains unknown and so requires investigation.

In summary, our results suggest that when severe PHG is present and tolerant of propranolol treatment, laparoscopic splenectomy may be beneficial for uncontrollable PHG. In addition to treatment for PHG, laparoscopic splenectomy significantly improved liver function in liver cirrhosis.

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