BACKGROUND:Various surgical procedures can be used to treat liver cirrhosis and portal hypertension.How to select the most appropriate procedure for patients with portal hypertension has become a difficult problem.Thi...BACKGROUND:Various surgical procedures can be used to treat liver cirrhosis and portal hypertension.How to select the most appropriate procedure for patients with portal hypertension has become a difficult problem.This study aimed to analyze the relationship between the value of intraoperative free portal pressure(FPP)and postoperative complications,and to explore the significance of intraoperative FPP measurement with respect to surgical procedure selection.METHODS:The clinical data of 187 patients with portal hypertension who received pericardial devascularization and proximal splenorenal shunt combined with devascularization(combined operation)at the Department of General Surgery in our hospital from January 2001 to September 2008 were retrospectively analyzed.Among the patients who received pericardial devascularization,those with a postoperative FPP ≥22 mmHg were included in a high-pressure group(n=68), and those with FPP<22 mmHg were in a low-pressure group(n=49).Seventy patients who received the combined operation comprised a combined group.The intraoperative FPP measurement changes at different times,and the incidence of postoperative complications in the three groups of patients were compared.RESULTS:The postoperative FPP value in the high-pressure group was 27.5±2.3 mmHg,which was significantly higher than that of the low-pressure(20.9±1.8 mmHg)or combined groups(21.7±2.5 mmHg).The rebleeding rate in the high-pressure group was significantly higher than that in the low-pressure and combined groups.The incidence rates of postoperative hepatic encephalopathy and liver failure were not statistically different among the three groups.The mortality due to rebleeding in the low-pressure and combined groups(0.84%) was significantly lower than that of the high-pressure group.CONCLUSIONS:The study demonstrates that FPP is a critical measurement for surgical procedure selection in patients with portal hypertension.A FPP value≥22 mmHg after splenectomy and devascularization alone is an important indicator that an additional proximal splenorenal shunt needs to be performed.展开更多
Shunts and devascularizations have totally dif-ferent effects on the hemodynamics of the portal venous system.The actual results of pericardial devascularization(PCDV)alone and conventional splenorenal shunt com-bined...Shunts and devascularizations have totally dif-ferent effects on the hemodynamics of the portal venous system.The actual results of pericardial devascularization(PCDV)alone and conventional splenorenal shunt com-bined with pericardial devascularization(combined pro-cedure,CP)should be determined by more clinical observations.This study aimed to evaluate effects on hemodynamics in the portal venous system after CP and PCDV only.In 20 patients who received CP and 18 who received PCDV,hemodynamic parameters of the portal venous system were studied by magnetic resonance angio-graphy 1 week before and 2 weeks after operation.Free portal pressure(FPP)was continuously detected by a transducer during the operations.Compared to the pre-operative data,a decreased flow in the portal vein(PVF)[(563.12±206.42)mL/min vs(1080.63±352.85)mL/min,P,0.05],a decreased portal vein diameter(PVD)[(1.20±0.11)cm vs(1.30±0.16)cm,P<0.01],a decreased FPP[(21.50±2.67)mmHg vs(29.88±2.30)mmHg,P<0.01]and an increased flow in the superior mesenteric vein(SMVF)[(1105.45±309.03)mL/min vs(569.13±178.46)mL/min,P<0.05]were found in the CP group after operation;a decreased PVD[(1.27±0.16)cm vs(1.40±0.23)cm,P<0.05],a decreased PVF[(684.60±165.73)mL/min vs(1175.64±415.09)mL/min,P<0.05],a decreased FPP[(24.40±3.78)mmHg vs(28.80±3.56)mmHg,P<0.05]and an increased SMVF[(697.91±121.83)mL/min vs(521.30±115.82)mL/min,P<0.05]were observed in the PCDV group.After operation,PVF in the CP group[(563.12±206.42)mL/min vs(684.60±165.73)mL/min,P<0.05]had no significant decrease,while FPP[(21.50±2.67)mmHg vs(24.40±3.78)mmHg,P<0.01]had a significant decrease as compared with that in the PCDV group.PVF and FPP could be decreased by both surgical procedures,but the effect of decreasing FPP was much better in the combined procedure than in PCDV alone.Further,there was no significant difference in PVF between the two groups.It is suggested that the combined surgical procedure could integrate the advan-tages of shunting with those of devascularization,as well as maintaining the normal anatomic structure of hepatic portal system,thus it should be one of the best choices for patients with portal hypertension when surgical interven-tions are considered.展开更多
Partial portosystemic shunts have been popularized because of a reported low rate of mortality and morbidity(especially encephalopathy,liver failure and occlusion).The results of partial portacaval shunts[small-diamet...Partial portosystemic shunts have been popularized because of a reported low rate of mortality and morbidity(especially encephalopathy,liver failure and occlusion).The results of partial portacaval shunts[small-diameter expanded polytetrafluoroethylene(ePTFE)H-graft portacaval shunt]were retrospectively reviewed to evaluate the clinical efficacy in the treatment of portal hypertension.Forty-three patients with portal hypertension were treated by small-diameter H-graft of ePTFE portacaval shunt from May 1995 to April 2006.Thirty-three had externally ringed grafts and ten had non-ringed ones.Ten had grafts of 10 mm in diameter and 33 had grafts of 8 mm.The left gastric artery and coronary vein were ligated in all the cases.Six had pericardial devascularization and splenectomy was performed in 42.An average decrease of free portal pressure(FPP)from(33.24 P4.78)cmH2O before shunting and(13.65P5.65)cmH2O after shunting was observed.The portal blood flow was reduced by one-third of that before shunt.Thirty-eight patients survived and no upper gastro-intestinal rebleeding occurred in the follow-up period(50.5 months in average).Two were out of contact.Color Doppler ultrasonography and/or portography revealed the shunts were patent in 38 cases and were occluded in three cases(3/41,7.3%).Encephalopathy developed in five cases(5/41,12.2%).Partial(small-diameter ePTFE H-graft)portacaval shunting can reduce the portal pressure effectively.Majority of the hepatic flow from the portal vein can be maintained adequately.The shunts with reinforced grafts can keep a higher rate of patency.The morbidity of encephalopathy was lower than those with total shunt.The partial portacaval shunt is effective in preventing recurrent variceal bleeding.展开更多
BACKGROUND Partial splenic embolization(PSE)has been suggested as an alternative to splenectomy in the treatment of hypersplenism.However,some patients may experience recurrence of hypersplenism after PSE and require ...BACKGROUND Partial splenic embolization(PSE)has been suggested as an alternative to splenectomy in the treatment of hypersplenism.However,some patients may experience recurrence of hypersplenism after PSE and require splenectomy.Currently,there is a lack of evidence-based medical support regarding whether preoperative PSE followed by splenectomy can reduce the incidence of complications.AIM To investigate the safety and therapeutic efficacy of preoperative PSE followed by splenectomy in patients with cirrhosis and hypersplenism.METHODS Between January 2010 and December 2021,321 consecutive patients with cirrhosis and hypersplenism underwent splenectomy at our department.Based on whether PSE was performed prior to splenectomy,the patients were divided into two groups:PSE group(n=40)and non-PSE group(n=281).Patient characteristics,postoperative complications,and follow-up data were compared between groups.Propensity score matching(PSM)was conducted,and univariable and multivariable analyses were used to establish a nomogram predictive model for intraoperative bleeding(IB).The receiver operating characteristic curve,Hosmer-Lemeshow goodness-of-fit test,and decision curve analysis(DCA)were employed to evaluate the differentiation,calibration,and clinical performance of the model.RESULTS After PSM,the non-PSE group showed significant reductions in hospital stay,intraoperative blood loss,and operation time(all P=0.00).Multivariate analysis revealed that spleen length,portal vein diameter,splenic vein diameter,and history of PSE were independent predictive factors for IB.A nomogram predictive model of IB was constructed,and DCA demonstrated the clinical utility of this model.Both groups exhibited similar results in terms of overall survival during the follow-up period.CONCLUSION Preoperative PSE followed by splenectomy may increase the incidence of IB and a nomogram-based prediction model can predict the occurrence of IB.展开更多
Objective:Emerging evidence suggest that antibiotic prophylaxis may be omitted in early cirrhosis patients with upper gastrointestinal bleeding(UGIB),which question the benefits of antibiotic prophylaxis on rebleeding...Objective:Emerging evidence suggest that antibiotic prophylaxis may be omitted in early cirrhosis patients with upper gastrointestinal bleeding(UGIB),which question the benefits of antibiotic prophylaxis on rebleeding,mortality related to ongoing bleeding,and the need for salvage therapy.As the management of UGIB has improved over time since the last review a decade ago,we performed an updated meta‐analysis to review the benefits of antibiotic prophylaxis in cirrhosis patients with UGIB.Method:Six electronic databases including PubMed/MEDLINE,EMBASE,Scopus,Web of Science,Cochrane library,and ClinicalTrial.gov were systematically searched up to December 1,2021.The primary outcome was 6 weeks mortality.Secondary outcomes include the risk of infection,rebleeding at 7 days and 6 weeks,mortality related to ongoing bleeding,need for salvage therapy,and infection‐related mortality.Result:Eighteen studies(12 randomized controlled trials[RCT],6 non‐RCT)from 3180 subjects were identified among 2129 citations.Antibiotic prophylaxis reduces mortality at 6 weeks,risk of infection,and infectionrelated mortality(pooled relative risk:0.72,0.39,and 0.41,respectively).Although antibiotics reduce the risk of rebleeding and the amount of blood transfusion,they did not reduce the risk of mortality from ongoing bleeding nor the need for salvage therapy.Antibiotic prophylaxis may shorten the length of stay in the intensive care unit.Conclusion:Antibiotic prophylaxis reduces rebleeding,6‐week mortality,and infection‐related mortality.Due to the low risk of infection and death,dedicated studies are warranted to evaluate the benefit of antibiotic prophylaxis in early cirrhosis with UGIB.展开更多
This study aimed to investigate the treatment outcomes of esophageal variceal bleeding(EVB)in China.A total of 1087 cases were collected from 19 hospitals in 16 large and medium sized cities across China between Janua...This study aimed to investigate the treatment outcomes of esophageal variceal bleeding(EVB)in China.A total of 1087 cases were collected from 19 hospitals in 16 large and medium sized cities across China between January 1st,2005 and January 1st,2006.There were 313 cases(29.0%)of mild(<400 mL),494 cases(45.8%)of moderate(400–1500 mL)and 272 cases(25.2%)of severe(>1500 mL)bleeding.Successful hemostasis was achieved in 89.8%of cases.Seven hundred and eighty-five cases were treated by medication with a hemostasis rate of 91.8%.Seventy-one cases were treated using a Sengstaken-Blakemore tube with a hemostasis rate of 54.9%.Thirty-seven cases were treated with emergency endoscopic variceal ligation with a hemostasis rate of 83.8%.Seventy-seven cases were treated with endoscopic sclerotherapy with a hemostasis rate of 94.8%.Forty-three cases were treated with emergency surgical operation with a hemostasis rate of 95.3%.Sixty-six cases were treated with combined therapy with a hemostasis rate of 97.0%.There was a significant difference(P<0.01)in the successful hemostasis rate between different treatments.The overall mortality was 10.1%,among which 6.6%was directly caused by bleeding.The multivariate logistic regression analysis shows that the severity of bleeding,treatment methods,liver dysfunction and activation of hepatitis were predictive factors for suc-cessful hemostasis.Most cases of EVB were mild and mod-erate in severity.The first-line treatment for EVB is medication.Emergency endoscopic intervention has not been widely available yet.The overall management out-come of EVB has been improved.展开更多
文摘BACKGROUND:Various surgical procedures can be used to treat liver cirrhosis and portal hypertension.How to select the most appropriate procedure for patients with portal hypertension has become a difficult problem.This study aimed to analyze the relationship between the value of intraoperative free portal pressure(FPP)and postoperative complications,and to explore the significance of intraoperative FPP measurement with respect to surgical procedure selection.METHODS:The clinical data of 187 patients with portal hypertension who received pericardial devascularization and proximal splenorenal shunt combined with devascularization(combined operation)at the Department of General Surgery in our hospital from January 2001 to September 2008 were retrospectively analyzed.Among the patients who received pericardial devascularization,those with a postoperative FPP ≥22 mmHg were included in a high-pressure group(n=68), and those with FPP<22 mmHg were in a low-pressure group(n=49).Seventy patients who received the combined operation comprised a combined group.The intraoperative FPP measurement changes at different times,and the incidence of postoperative complications in the three groups of patients were compared.RESULTS:The postoperative FPP value in the high-pressure group was 27.5±2.3 mmHg,which was significantly higher than that of the low-pressure(20.9±1.8 mmHg)or combined groups(21.7±2.5 mmHg).The rebleeding rate in the high-pressure group was significantly higher than that in the low-pressure and combined groups.The incidence rates of postoperative hepatic encephalopathy and liver failure were not statistically different among the three groups.The mortality due to rebleeding in the low-pressure and combined groups(0.84%) was significantly lower than that of the high-pressure group.CONCLUSIONS:The study demonstrates that FPP is a critical measurement for surgical procedure selection in patients with portal hypertension.A FPP value≥22 mmHg after splenectomy and devascularization alone is an important indicator that an additional proximal splenorenal shunt needs to be performed.
文摘Shunts and devascularizations have totally dif-ferent effects on the hemodynamics of the portal venous system.The actual results of pericardial devascularization(PCDV)alone and conventional splenorenal shunt com-bined with pericardial devascularization(combined pro-cedure,CP)should be determined by more clinical observations.This study aimed to evaluate effects on hemodynamics in the portal venous system after CP and PCDV only.In 20 patients who received CP and 18 who received PCDV,hemodynamic parameters of the portal venous system were studied by magnetic resonance angio-graphy 1 week before and 2 weeks after operation.Free portal pressure(FPP)was continuously detected by a transducer during the operations.Compared to the pre-operative data,a decreased flow in the portal vein(PVF)[(563.12±206.42)mL/min vs(1080.63±352.85)mL/min,P,0.05],a decreased portal vein diameter(PVD)[(1.20±0.11)cm vs(1.30±0.16)cm,P<0.01],a decreased FPP[(21.50±2.67)mmHg vs(29.88±2.30)mmHg,P<0.01]and an increased flow in the superior mesenteric vein(SMVF)[(1105.45±309.03)mL/min vs(569.13±178.46)mL/min,P<0.05]were found in the CP group after operation;a decreased PVD[(1.27±0.16)cm vs(1.40±0.23)cm,P<0.05],a decreased PVF[(684.60±165.73)mL/min vs(1175.64±415.09)mL/min,P<0.05],a decreased FPP[(24.40±3.78)mmHg vs(28.80±3.56)mmHg,P<0.05]and an increased SMVF[(697.91±121.83)mL/min vs(521.30±115.82)mL/min,P<0.05]were observed in the PCDV group.After operation,PVF in the CP group[(563.12±206.42)mL/min vs(684.60±165.73)mL/min,P<0.05]had no significant decrease,while FPP[(21.50±2.67)mmHg vs(24.40±3.78)mmHg,P<0.01]had a significant decrease as compared with that in the PCDV group.PVF and FPP could be decreased by both surgical procedures,but the effect of decreasing FPP was much better in the combined procedure than in PCDV alone.Further,there was no significant difference in PVF between the two groups.It is suggested that the combined surgical procedure could integrate the advan-tages of shunting with those of devascularization,as well as maintaining the normal anatomic structure of hepatic portal system,thus it should be one of the best choices for patients with portal hypertension when surgical interven-tions are considered.
文摘Partial portosystemic shunts have been popularized because of a reported low rate of mortality and morbidity(especially encephalopathy,liver failure and occlusion).The results of partial portacaval shunts[small-diameter expanded polytetrafluoroethylene(ePTFE)H-graft portacaval shunt]were retrospectively reviewed to evaluate the clinical efficacy in the treatment of portal hypertension.Forty-three patients with portal hypertension were treated by small-diameter H-graft of ePTFE portacaval shunt from May 1995 to April 2006.Thirty-three had externally ringed grafts and ten had non-ringed ones.Ten had grafts of 10 mm in diameter and 33 had grafts of 8 mm.The left gastric artery and coronary vein were ligated in all the cases.Six had pericardial devascularization and splenectomy was performed in 42.An average decrease of free portal pressure(FPP)from(33.24 P4.78)cmH2O before shunting and(13.65P5.65)cmH2O after shunting was observed.The portal blood flow was reduced by one-third of that before shunt.Thirty-eight patients survived and no upper gastro-intestinal rebleeding occurred in the follow-up period(50.5 months in average).Two were out of contact.Color Doppler ultrasonography and/or portography revealed the shunts were patent in 38 cases and were occluded in three cases(3/41,7.3%).Encephalopathy developed in five cases(5/41,12.2%).Partial(small-diameter ePTFE H-graft)portacaval shunting can reduce the portal pressure effectively.Majority of the hepatic flow from the portal vein can be maintained adequately.The shunts with reinforced grafts can keep a higher rate of patency.The morbidity of encephalopathy was lower than those with total shunt.The partial portacaval shunt is effective in preventing recurrent variceal bleeding.
基金Supported by National Natural Science Foundations of China,No.82174160and Anhui Natural Science Foundation,No.2008085QH389。
文摘BACKGROUND Partial splenic embolization(PSE)has been suggested as an alternative to splenectomy in the treatment of hypersplenism.However,some patients may experience recurrence of hypersplenism after PSE and require splenectomy.Currently,there is a lack of evidence-based medical support regarding whether preoperative PSE followed by splenectomy can reduce the incidence of complications.AIM To investigate the safety and therapeutic efficacy of preoperative PSE followed by splenectomy in patients with cirrhosis and hypersplenism.METHODS Between January 2010 and December 2021,321 consecutive patients with cirrhosis and hypersplenism underwent splenectomy at our department.Based on whether PSE was performed prior to splenectomy,the patients were divided into two groups:PSE group(n=40)and non-PSE group(n=281).Patient characteristics,postoperative complications,and follow-up data were compared between groups.Propensity score matching(PSM)was conducted,and univariable and multivariable analyses were used to establish a nomogram predictive model for intraoperative bleeding(IB).The receiver operating characteristic curve,Hosmer-Lemeshow goodness-of-fit test,and decision curve analysis(DCA)were employed to evaluate the differentiation,calibration,and clinical performance of the model.RESULTS After PSM,the non-PSE group showed significant reductions in hospital stay,intraoperative blood loss,and operation time(all P=0.00).Multivariate analysis revealed that spleen length,portal vein diameter,splenic vein diameter,and history of PSE were independent predictive factors for IB.A nomogram predictive model of IB was constructed,and DCA demonstrated the clinical utility of this model.Both groups exhibited similar results in terms of overall survival during the follow-up period.CONCLUSION Preoperative PSE followed by splenectomy may increase the incidence of IB and a nomogram-based prediction model can predict the occurrence of IB.
文摘Objective:Emerging evidence suggest that antibiotic prophylaxis may be omitted in early cirrhosis patients with upper gastrointestinal bleeding(UGIB),which question the benefits of antibiotic prophylaxis on rebleeding,mortality related to ongoing bleeding,and the need for salvage therapy.As the management of UGIB has improved over time since the last review a decade ago,we performed an updated meta‐analysis to review the benefits of antibiotic prophylaxis in cirrhosis patients with UGIB.Method:Six electronic databases including PubMed/MEDLINE,EMBASE,Scopus,Web of Science,Cochrane library,and ClinicalTrial.gov were systematically searched up to December 1,2021.The primary outcome was 6 weeks mortality.Secondary outcomes include the risk of infection,rebleeding at 7 days and 6 weeks,mortality related to ongoing bleeding,need for salvage therapy,and infection‐related mortality.Result:Eighteen studies(12 randomized controlled trials[RCT],6 non‐RCT)from 3180 subjects were identified among 2129 citations.Antibiotic prophylaxis reduces mortality at 6 weeks,risk of infection,and infectionrelated mortality(pooled relative risk:0.72,0.39,and 0.41,respectively).Although antibiotics reduce the risk of rebleeding and the amount of blood transfusion,they did not reduce the risk of mortality from ongoing bleeding nor the need for salvage therapy.Antibiotic prophylaxis may shorten the length of stay in the intensive care unit.Conclusion:Antibiotic prophylaxis reduces rebleeding,6‐week mortality,and infection‐related mortality.Due to the low risk of infection and death,dedicated studies are warranted to evaluate the benefit of antibiotic prophylaxis in early cirrhosis with UGIB.
文摘This study aimed to investigate the treatment outcomes of esophageal variceal bleeding(EVB)in China.A total of 1087 cases were collected from 19 hospitals in 16 large and medium sized cities across China between January 1st,2005 and January 1st,2006.There were 313 cases(29.0%)of mild(<400 mL),494 cases(45.8%)of moderate(400–1500 mL)and 272 cases(25.2%)of severe(>1500 mL)bleeding.Successful hemostasis was achieved in 89.8%of cases.Seven hundred and eighty-five cases were treated by medication with a hemostasis rate of 91.8%.Seventy-one cases were treated using a Sengstaken-Blakemore tube with a hemostasis rate of 54.9%.Thirty-seven cases were treated with emergency endoscopic variceal ligation with a hemostasis rate of 83.8%.Seventy-seven cases were treated with endoscopic sclerotherapy with a hemostasis rate of 94.8%.Forty-three cases were treated with emergency surgical operation with a hemostasis rate of 95.3%.Sixty-six cases were treated with combined therapy with a hemostasis rate of 97.0%.There was a significant difference(P<0.01)in the successful hemostasis rate between different treatments.The overall mortality was 10.1%,among which 6.6%was directly caused by bleeding.The multivariate logistic regression analysis shows that the severity of bleeding,treatment methods,liver dysfunction and activation of hepatitis were predictive factors for suc-cessful hemostasis.Most cases of EVB were mild and mod-erate in severity.The first-line treatment for EVB is medication.Emergency endoscopic intervention has not been widely available yet.The overall management out-come of EVB has been improved.
