Objective To explore the risk factors of postoperative portal vein system thrombus (PVST) after laparoscopic splenectomy in treatment of portal hypertension and hypersplenism. Methods Clinical data of 76 patients with portal hypertension and hypersplenism who underwent laparoscopic splenectomy in the Sichuan Provincial People’s Hospital from January 2012 to January 2017 were analyzed. Results There were 31 patients suffered from PVST (PVST group), and other 45 patients enrolled in non-PVST group.There were significant differences on age, diameter of splenic vein, diameter of portal vein, blood flow velocity of portal vein, level of D-dimer, and platelet count between the PVST group and the non-PVST group (P<0.05), but there were no significant difference on gender, Child-Pugh classification, etiology of cirrhosis, operation time, intraoperative blood loss, postoperative complications, and prothrombin time between the two groups (P>0.05). Multivariate logistic regression analysis showed that, patients with age >50 years (RR=1.31, P=0.02), splenic vein diameter >12 mm ( RR=1.29, P<0.01), portal vein diameter >13 mm (RR=1.55, P=0.01), blood flow velocity of portal vein <18 cm/s ( RR=1.47, P<0.01), increases level of D-dimer (RR=2.89, P=0.03), and elevated platelet count (RR=1.82 P=0.02) had higher risk of postoperative PVST than those patients with age ≤50 years, splenic vein diameter ≤12 mm, portal vein diameter ≤13 mm, blood flow velocity of portal vein ≥18 cm/s, normal level of D-dimer and platelet count. Conclusion For patients with portal hypertension and hypersplenism who underwent laparoscopic splenectomy, we should pay more attention to the risk factor, such as D-dimer and so on, to avoid the occurrence of postoperative PVST.
Objective To investigate safety and therapeutic effect of total pancreatectomy plus splenectomy for patient with pancreatic cancer. Methods The preoperative clinical data, surgical treatment, and postoperative conditions of 1 patient with pancreatic cancer who underwent the total pancreatectomy plus splenectomy in the Affiliated Hospital of Qinghai University in January 2018 were retrospectively analyzed. Results Combination of the patient clinical history, physical examination, laboratory and radiologic results, the patient was diagnosed with the pancreatic cancer. Then the patient underwent the Whipple procedure. During the operation, it was found that the texture of the pancreas was hard, and the spleen arteriovenous were considered to be invaded, and the multiple frozen section analysis during the operation showed that the surgical margin was positive. Eventually, the total pancreatectomy plus splenectomy was performed. The postoperative pathological analysis results revealed to the well-moderately differentiated tubular adenocarcinoma. When the condition of patient became stable, the pancreatin and insulin were required for long time. No severe complications occurred. The patient survived well after the surgery and no recurrence was observed for following-up of 3 months. Conclusion With improvement of surgical techniques and enhancement of postoperative management, total pancreatectomy can be used as a treatment for pancreatic cancer and it is still safe and feasible.
Pancreatic sinistral portal hypertension (PSPH) is a clinical syndrome resulting from pancreatic disease that blocks splenic vein return, which includes acute and chronic pancreatitis, pancreatic tumors, and iatrogenic factors related to pancreatic surgery. Most PSPH patients present with isolated gastric varices, splenomegaly and hypersplenism, with normal liver function, and upper gastrointestinal bleeding caused by varices in the fundus of the stomach is the most serious clinical manifestation. The treatment of PSPH can be divided into the treatment of portal hypertension in the spleen and stomach region, including close follow-up, medication, endoscopic therapy, splenic artery embolization and splenectomy, etc. The primary diseases of pancreas are mainly treated for acute pancreatitis, chronic pancreatitis and pancreatic tumor. In particular, PSPH related to pancreatic surgery should be concerned.
Objective To summarize the experience of single center for radical antegrade modular pancreatosplenectomy (RAMPS) in the treatment of pancreatic body and tail cancer. Methods The clinical data of 52 patients with pancreatic body and tail cancer who underwent RAMPS surgery in the First Affiliated Hospital of Xinjiang Medical University from January 2013 to December 2016 were retrospectively analyzed. Results All operations of the 52 patients were successfully completed, with no death during hospitalization and 30 days after surgery. The operative time was (463±137) min (198–830 min), the median of intraoperative blood loss was 400 mL (100–2 800 mL), of which 19 cases (36.5%) received intraoperative blood transfusion. The median of hospital stay was 19.5 days (7–58 days). After operation, 18 patients suffered from pancreatic fistula, 5 patients suffered from delay gastric emptying, 7 patients suffered from peritoneal effusion, 3 patients suffered from pleural effusion, 4 patients suffered from abdominal infection, 2 patients suffered from abdominal bleeding. Reoperations were performed in 2 patients. There were 51 patients were followed up for 3–35 months (the median of 18 months) with the median survival time were 16.2 months. During the follow-up period, 21 patients suffered from recurrence or metastasis, of which 8 patients died. The results of Cox partial hazard model showed that, surgical margin ［RR=3.65, 95% CI was (0.06, 5.11), P=0.026］ and adjuvant therapy ［RR=6.43, 95% CI was (1.51, 27.43), P=0.012］ were statistically related with prognosis, the prognosis of patients with negative surgical margin and underwent adjuvant therapy were better than those patients with positive surgical margin and didn’t underwent adjuvant therapy. Conclusions RAMPS is safe and feasible in the treatment of pancreatic body and tail cancer, and it may improve the R0 resection rate. RAMPS combins with adjuvant therapy can contribute to better prognosis.
ObjectiveTo analyze risk factors of rebleeding after laparoscopic selective pericardial devascularization combined with splenectomy.MethodsThe clinical data of 147 cases of portal hypertension treated by the laparoscopic selective devascularization combined with splenectomy from February 2014 to September 2018 were retrospectively analyzed. The univariate analysis was used to find the difference between the rebleeding group (n=20) and the non-bleeding group (n=127), then the multivariate logistic regression analysis was selected for screening out the most closely related risk factors for the rebleeding.ResultsThe rebleeding occurred in 20 of 147 patients (13.6%). There were differences in the platelet count, prothrombin time, serum albumin, diameter of main portal vein, classification of liver function, ascites, hepatic encephalopathy, and portal hypertensive gastropathy between the rebleeding group and the non-bleeding group (P<0.050). The classification of liver function ［OR=3.444, 95% CI (1.211. 9.793）, P=0.020］, ascites ［OR=2.859, 95% CI (1.069, 7.645), P=0.036］, hepatic encephalopathy ［OR=4.265, 95% CI（1.121, 16.230）, P=0.033］, and portal hypertensive gastropathy ［OR=6.744, 95% CI (1.675, 27.156), P=0.007］, and platelet count ［OR=4.744, 95% CI (1.073, 20.969), P=0.040］ were the independent factors for the postoperative rebleeding by the logistic regression analysis.ConclusionFor patients with risk factors of rebleeding, preoperative treatment should be actively taken and postoperative prevention of rebleeding should be highly vigilant.
ObjectiveTo summarize the pathogenesis, epidemiology, and risk factors of portal vein thrombosis after splenectomy, and combined with the latest advances in clinical prevention, diagnosis, and treatment of portal vein thrombosis after splenectomy, so as to provide some references for clinical prevention and treatment in the future.MethodLiteratures on portal vein thrombosis after splenectomy were collected and reviewed.ResultsThe incidence of portal vein thrombosis after splenectomy was high and its occurrence was the result of multiple factors. It was mainly related to the change of splenic venous blood flow mechanics after splenectomy. In terms of diagnosis, enhanced CT scan was the first choice. Currently, there was no consensus on treatment options, which mainly focused on individualized treatment and emphasized that preventive anticoagulant use of low-molecular-weight heparin may reduce the risk of portal vein thrombosis.ConclusionThe concept of tertiary prevention of portal vein thrombosis after splenectomy should be established, and individualized treatment should be adopted in combination with the patient’s condition.
ObjectiveTo analyze risk factors of intraoperative massive hemorrhage in patients with pancreatitis-induced sinistral portal hypertension (SPH) and to explore its strategies of treatment.MethodsThe clinical data of patients with pancreatitis-induced SPH admitted to the West China Hospital of Sichuan University from January 2015 to March 2018 were retrospectively analyzed. The intraoperative massive hemorrhage was defined as the blood loss exceeding 30% blood volume. The factors closely associated with the intraoperative massive hemorrhage were analyzed by the forward logistic regression model.ResultsA total of 128 patients with pancreatitis-induced SPH were enrolled in this study, including 104 males and 24 females, with an average age of 47 years old and a median intraoperative bleeding volume of 482 mL. Among them, 93 patients with pancreatitis-induced SPH caused by the pancreatic pseudocyst after acute pancreatitis and 35 caused by the chronic pancreatitis. There were 36 patients with history of upper gastrointestinal bleeding and 46 patients with hypersplenism. Thirty-six patients suffered from the massive hemorrhage. Among them, 30 patients underwent the distal pancreatectomy concomitant with splenectomy, 1 patient underwent the duodenum- preserving resection of pancreatic head, and 5 patients underwent the pseudocyst drainage. The univariate analysis showed that the occurrence of intraoperative massive hemorrhage in the patients with pancreatitis-induced SPH was not associated with the gender, age, body mass index, albumin level, upper gastrointestinal bleeding, hypersplenism, type of pancreatitis, course of pancreatitis, number of attacks of pancreatitis, size of spleen, maximum diameter of lesions in the splenic vein obstruction site, or number of operation (P>0.05), which was associated with the diameter of varicose vein more than 5.0 mm (χ2=19.83, P<0.01), the intraperitoneal varices regions (χ2=13.67, P<0.01), the location of splenic vein obstruction (χ2=5.17, P=0.03), the operation time (t=–3.10, P<0.01), or the splenectomy (χ2=17.46, P<0.01). Further the logistic regression analysis showed that the varicose vein diameter more than 5.0 mm (OR=6.356, P=0.002) and splenectomy (OR=4.297, P=0.005) were the independent risk factors for the intraoperative massive hemorrhage in the patients with pancreatitis-induced SPH.ConclusionsSplenectomy and having a collateral vein more than 5.0 mm in diameter are independent risk factors for intraoperative massive blood loss in surgeries taken on patients with pancreatitis-induced SPH. Attention should be paid to dilation of gastric varices and choice of splenectomy.
ObjectiveTo evaluate the feasibility and safety of laparoscopic radical antegrade modular pancreatosplenectomy through the ligament of Treitz approach for pancreatic body and tail cancer. MethodsOn 13th November 2017, we selected a patient with a suspicious malignant tumor in the body of pancreas but no evidence of metastasis or local invasion of the retroperitoneum for laparoscopic antegrade modular pancreatosplenectomy through the ligament of Treitz approach. The time of operation, the estimated blood loss, and post-operative complications were observed. ResultsThe procedure was completed successfully in 255 min, and the estimated blood loss was 200 mL, there was no need of transfusion and no significant post-operational complications had been observed. No tumor recurrence or distal metastasis was found after a 12 month’s follow-up. ConclusionLaparoscopic radical antegrade modular pancreatosplenectomy through the ligament of Treitz approach is a feasible and safe procedure for pancreatic body and tail malignant tumor in strictly selected patients.
Objective To evaluate the efficacy of the subtotal splenectomy versus total splenectomy with gastroesophageal devascularization for patients of hepatic cirrhosis and portal hypertension. Methods We searched the Cochrane Library (Issue 2, 2008), MEDLINE (1966 to August, 2008), EMbase (1966 to August, 2008), the China Biological Medicine Database (1978 to August, 2008), Chinese Sci-tech Periodical Full-text Database (1989 to August, 2008) and Chinese Periodical Full-text Database (1994 to August, 2008), as well as hand-searched several related journals and conference proceedings for the randomized controlled trials involving the comparison of the efficacy of the subtotal splenectomy with the total splenectomy for the patients of the hepatic cirrhosis and portal hypertension. Results Three studies involving 136 patients were identified. The results of two studies indicated that both of the subtotal splenectomy increased less the peripheral platelet count and there was a statistically significant difference between the two groups [WMD= – 39.27, 95%CI (– 62.57, – 15.97)]. Two studies indicated that the serum tuftsin level was increased significantly after the subtotal splenectomy [WMD= 165.28, 95%CI (159.36, 171.21)]. One study indicated that both of the subtotal splenectomy and total splenectomy with gastroesophageal devascularization increased the peripheral white blood cell count and there was statistical difference between the two groups [WMD= – 0.93, 95%CI (– 1.52, – 0.34)]. There was no statistical difference in serum IgA level between the two groups. One study indicated the average fever time after the total splenectomy was longer than the subtotal splenectomy; there was statistical differences in 5 years survival rate between the two groups (Plt;0.05). Conclusions After the subtotal splenectomy the hypersplenism of patients suffered from hepatic cirrhosis and portal hypertension was corrected obviously and the blood cells were increased smoothly so that high blood viscosity was prevented and occurrence of the thrombotic diseases was decreased. And the immune system reserve functions of the patients with hepatic cirrhosis and portal hypertension were maintained. More randomized controlled trials, with large sample sizes, may lead to more accurate results.
Objective To summarize the effect of the splenectomy in patients with portal hypertension on the occurrence and recurrence of hepatocellular carcinoma. Methods The related literatures about the splenectomy in patients with hepatocirrhosis combined with portal hypertension or patients with hepatocellular carcinoma combined with portal hypertension in recent years were reviewed. Results At present, most academics considered that, for patients with hepatocirrhosis combined with portal hypertension, splenectomy could reduce the occurrence of hepatocellular carcinoma. For patients with hepatocellular carcinoma combined with portal hypertension, splenectomy+hepatectomy didn’t increase the perioperative mortality, and it could reduce the recurrence rate of hepatocellular carcinoma. Conclusion Splenectomy for patients with portal hypertension is safe, and it can inhibit the occurrence and progress of hepatocellular carcinoma, however, the specific mechanism remain needs further study.