Clinical efficacy of splenectomy combined with coronary-caval shunt in treatment of portal hypertension / 中华消化外科杂志

ABSTRACT

Objective To investigate the clinical efficacy of splenectomy combined with coronary-caval shunt in treatment of portal hypertension (PHT).Methods The retrospective descriptive study was conducted.The clinical data of 21 patients with PHT who underwent splenectomy combined with coronary-caval shunt at the First Affiliated Hospital of Xi'an Jiaotong University from January 2001 to December 2015 were collected.Observation indicators included (1) operation situations,changes of pre-and post-operative portal hemodynamics including operation time and volume of intraoperative blood loss,diameter and blood flow velocity of portal vein (PV),gastric coronary vein and superior mesenteric vein (SMV).(2) Clinical indexes in perioperative period (before operation,at postoperative 1 week and 1 month):① blood routine test:the counts of red blood cell (RBC),white blood cell (WBC) and platelet (PLT),② liver function:Child-Pugh score,alanine transaminase (ALT),total bilirubin (TBil),albumin (Alb),extended time of prothrombin time (PT) and international normalized ratio (INR).(3) Follow-up:postoperative 1-,3-,5-year complications [upper gastrointestinal re-bleeding,peritoneal effusion,hepatic encephalopathy,hepatic failure,portal vein thrombosis (PVT) and anastomotic stoma thrombosis].The follow-up using outpatient examination and telephone interview was regularly conducted once every 3 months within postoperative 1 year and once every 6 months after postoperative 1 year up to March 2016 or end of follow-up (death).Measurement data with normal distribution were presented as x ± s.The comparison of different time-point was analyzed by the repeated measures ANOVA and Student t test.Measurement data with sknewed distribution were presented as M (range).Results (1) Operation situations and changes of pre-and post-operative portal hemodynamics:21 patients underwent successful splenectomy combined with coronary-caval shunt,including 19 receiving splenic vein bypass combined with anastomosis of gastric coronary vein and inferior vena cava and 2 receiving anastomosis of gastric coronary vein and inferior vena cava.Operation time,volume of intraoperative blood loss were (187 ± 33)minutes and (233 ± 114)mL.Diameter and blood flow velocity of PV,gastric coronary vein and SMV were (1.39±0.20)cm,(0.66±0.15)cm,(0.74±0.32)cm,(11.2±3.4)cm/s,(6.6± 1.3)cm/s,(7.0 ±2.2)cm/s before operation and (1.36 ±0.22)cm,(0.42 ±0.11)cm,(0.81 ±0.23)cm,(10.4 ± 2.5) cm/s,(8.2 ± 2.5) cm/s,(6.9 ± 2.4) cm/s after operation,respectively,showing no statistically significant difference in the diameter and blood flow velocity of PV and SMV before and after operation (t =0.46,-0.81,0.87,0.14,P ＞ 0.05)and with statistically significant differences in the diameter and blood flow velocity of gastric coronary vein before and after operation (t =5.9 1,-2.60,P ＜ 0.05).(2) Clinical indexes in perioperative period:① routine blood test:the counts of RBC,WBC and PLT were (2.70 ± 0.50) × 1012/L,(2.6 ±2.3) × 109/L,(55 ±28) × 109/L before operation and (3.10 ±0.60) × 1012/L,(2.8 ±2.0) × 109/L,(248 ± 182) × 109/L at postoperative 1 week and (3.70 ±0.20) × 1012/L,(6.2 ± 1.9) × 109/L,(457 ± 184) × 109/L at postoperative 1 month,respectively,with statistically significant differences (F =31.91,11.03,30.74,P ＜ 0.05).There were statistically significant differences in the counts of RBC and PLT between 1 week postoperatively and before operation (t =-2.35,-4.81,P ＜ 0.05) and between 1 month postoperatively and 1 week postoperatively (t =-4.35,-5.65,-3.71,P ＜ 0.05).② Liver function:Child-Pugh score,ALT,TBil,Alb,extended time of PT and INR were 6.3 ± 1.2,(23 ± 17) U/L,(28 ± 18) μmol/L,(31.1 ± 6.8) g/L,(4.8 ±2.1) s,1.40 ± 0.20 before operation and 6.2 ± 0.9,(44 ± 24) U/L,(26 ± 11) μmol/L,(35.0 ± 7.4) g/L,(3.4 ± 2.0) s,1.30 ± 0.20 at postoperative 1 week and 6.0 ± 0.6,(36 ± 22) U/L,(23 ± 8) μmol/L,(34.2 ± 2.2) g/L,(3.7 ± 3.0) s,1.50 ± 0.30 at postoperative 1 month,respectively,showing no statistically significant difference (F =1.97,2.60,1.18,1.45,P ＞0.05).There were statistically significant differences in the ALT and extended time of PT (F =7.97,4.37,P ＜ 0.05) and in the ALT and extended time of PT between 1 week postoperatively and before operation (t =3.23,2.21,P ＜ 0.05).(3) Follow-up:21 patients were followed up for 3-168 months with a median time of 37 months.During follow-up,3 patients were dead.One,1,2 patients were complicated with upper gastrointestinal re-bleeding at postoperative 1,3,5 years and received hemostatic therapy under endoscopy,and then 2 were dead.Three,2 and 2 patients had peritoneal effusion and were improved by symptomatic treatment.One patient had hepatic encephalopathy and hepatic failure at postoperative 5 years and was dead after conservative treatment.PVT and anastomotic stoma thrombosis at postoperative 1,3,5 years were detected in 2,2,1 and 2,1,1 patients,with anticoagulant therapy,and 1 patient received vascular recanalization.Conclusion Coronary-caval shunt is a highly selective portosystemic shunt,it can significantly down regulate the regional pressure while ensure the normal blood flow of liver and decrease the rate of rebleeding,hepatic encephalopathy and thrombosis,meanwhile,it might be a potential therapy in management of PHT.