Portal vein blood flow is very important for the normal function of transplanted liver. The author reviewed the management methods of different portal vein thrombosis classification in the liver transplantation (LT). The prognosis of LT in the patients with Yerdel 1–3 thrombosis is similar to that the patients without thrombosis. The portal vein reconstruction of the patients with Yerdel 4 thrombosis can be realized by varicose vein to portal anastomosis, renoportal anastomosis or cavoportal hemitransposition. When anastomosis is made at the proximal side of a spontaneous shunt between the portal and cava system, the blood shunted from portal system can be reintroduced into the donor liver, which is crucial for the management of Yerdel 4 thrombosis. The establishments of artificial shunt by distal splenic vein, mesenteric vein or “multiple to one” anastomosis are effective attempts to drain the blood from portal system to the donor liver. For more severe diffuse thrombosis of portal vein system, multivisceral transplantation, including liver and small intestine, should be considered. The cases of LT in the patients with complex portal vein thrombosis are increasing, however the prognosis remains to be determined after accumulation of the cases.
Surgerical treatment has been used for portal hypertension over a hundred years, and has evolved from various portosystemic shunts to devascularizations and selective shunts. Selective shunting, which has the advantages of long-term prevention from recurrent variceal bleeding and maintenance of hepatic portal vein perfusion, has developed from single distal splenorenal shunt to various procedures including distal splenocaval shunt, coronary caval shunt, coronary renal shunt, etc. Selective shunting can also be achieved after reconstruction of spontaneous portosystemic shunt. Preoperative portal venous system CT angiography, intraoperative ultrasound Doppler and portal vein pressure measurements may provide patients with a more reasonable treatment of choice.
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 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.
Objective To evaluate the effect of triplex operations (splenopneumopexy, portal azygous devascularization and ligation of splenic artery) for children with extrahepatic portal hypertension. Methods From March 1993 to November 1998, 7 children with extrahepatic portal hypertension underwent triplexoperations. The diagnosis for these patients were confirmed by gastroscopy, barium meal and Doppler ultrasonography. The number of WBCand platelet and the hepatic function were checked before and after operations.And the free portal pressures were checked before and after ligations of the splenic artery. All patients were followed up for 2 to 8 years (5.6 years on average). The episodes of upper gastrointestinal bleeding were recorded. The degrees of varices of distal esophagus and proximal stomach were assessed by barium mealand gastroscopy. The diameters of the splenic and portal veins were obtained byBultrasound. The portopulmonary shunt and portal blood flow were evaluated by color Doppler flow image. The indices of hemorheology such as hematocrit, viscosity of whole blood and plasma, and the index of deformability and aggregability of RBC were obtained through viscometer (R-20 Seerle, Beijing). Results There was no operative fatal case in this group. Postoperatively, hemorrhage from the esophagus and gastric varices was completely controlled. Although the diameter of spleen reduced progressively, no patient’s spleen recovered to normal size during the follow up period. The degree of varices was mitigated and the free portal pressure was significantly decreased to （34.48±5.71） cm H2 O from the preoperative one （42.62±6.72） cm H2 O (P＜0.05). The rate of portal flow was alsodecreased. The direction of portal vein was bidirection (one part was away from the liver and the other was toward the liver). The number of WBC and platelet and the viscosity of whole blood and hematocrit were increased to normal value after operation. Conclusion The triplex operation is an effective procedure for the control of hemorrhage from varices in children with extrahepatic portal hypertension.
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.
ObjectiveTo summarize research progress of vascular physiological function of epoxyeicosatrienoic acid and its impact on pathogenesis of cirrhotic portal hypertension. MethodLiteratures about recent studies on epoxyeicosatrienoic acid in different organs and different animal models including cirrhotic portal hypertension were reviewed according to the results searched from PubMed and Wanfang databases. ResultsEpoxyeicosatrienoic acid in the different organs and the different animal models showed the complex functions, and it might affect the development of cirrhosis portal hypertension disease through its vascular physiological function. ConclusionIncreasing or decreasing epoxyeicosatrienoic acid might affect development of cirrhosis portal hypertension disease, which could provide a new method for treatment of cirrhosis portal hypertension.
ObjectiveTo summarize the related researches of pancreatic portal hypertension (PPH) in recent years in order to diagnose and treat the disease more timely and effectively. MethodThe literatures relevant to etiology, mechanism, clinical features, diagnostic criteria, and treatment of PPH were searched and reviewed. ResultsThe occurrence of PPH was related to its anatomical structure. Its clinical manifestations were not characteristic, but it was not difficult to diagnose by the assistance of auxiliary examinations. The treatment of PPH was mainly targeted at pancreatic diseases and portal hypertension, and the treatment targeted at portal hypertension was performed according to the situation with or without gastrointestinal bleeding. So, in clinical practice, different treatment measures should be taken according to different situations. ConclusionAt present, the clinical diagnosis and treatment of PPH is relatively mature, but its preventive treatment is still controversial, which will be the focus of future research.
Transjugular intrahepatic portosystemic shunt (TIPS) has been used in the treatment of cirrhotic portal hypertension for more than 30 years. With the development of stent technology and clinical practice technology, TIPS is becoming more and more perfect in the treatment of portal hypertension. From the single-use of bare stent in the past to the application of bare stent combined with coated stent or particular Viatorr stent, the patency of stent has been significantly improved. In addition, the selection of stent caliber and the puncture part of shunt gradually reduces the occurrence of hepatic encephalopathy, liver failure and other complications caused by excessive shunt. TIPS technology has the advantages of minimally invasive, safe and reducing portal vein pressure. It has gradually become one of the primary surgical methods in the treatment of portal hypertension, esophagogastric variceal bleeding, intractable ascites, and so on.
Portal hypertension caused by viral post hepatic liver cirrhosis has brought a heavy burden to medical treatment in China. In addition to liver transplantation, the treatments include drugs, endoscopy, intervention and surgery, but the effect is not satisfactory. At present, the consensus and guideline for portal hypertension often focuse on a single treatment, and there is an urgent need for reasonable, standardized and individualized treatment to minimize the risk of upper gastrointestinal bleeding and improve the long-term survival of patients, which should also be the ultimate goal of multi-disciplinary treatment (MDT) mode of portal hypertension. The MDT diagnosis and treatment method of portal hypertension needs to be obtained in combination with the general situation of patients (including liver function level, upper gastrointestinal bleeding risk, hypersplenism, etc.) and local medical advantages. For patients with acute upper gastrointestinal bleeding, the treatment with less trauma and good hemostatic effect should be selected as far as possible. Patients with previous bleeding history or bleeding cessation should improve the relevant evaluation as soon as possible and submit it to MDT for discussion and selection of the next appropriate treatment. Drugs and endoscopy can be used for high-risk groups of upper gastrointestinal bleeding. Whether surgical preventive treatment can benefit patients or not needs further large sample research support. Minimally invasive surgery is the development direction of surgical treatment. Combination of internal and external treatment may give full play to their respective advantages, reducing the risk of bleeding and improving long-term survival.