Skip to main content
Erschienen in:

08.06.2022 | Original Article

Vagus Nerve–Preserving Laparoscopic Splenectomy and Azygoportal Disconnection with Versus Without Intraoperative Endoscopic Variceal Ligation: a Randomized Clinical Trial

verfasst von: Dou-Sheng Bai, Sheng-Jie Jin, Xiao-Xing Xiang, Jian-Jun Qian, Chi Zhang, Bao-Huan Zhou, Tian-Ming Gao, Guo-Qing Jiang

Erschienen in: Journal of Gastrointestinal Surgery | Ausgabe 9/2022

Einloggen, um Zugang zu erhalten

Abstract

Background

Esophagogastric variceal bleeding is the most common lethal factor for patients with cirrhotic portal hypertension. We firstly developed a laparoscopic splenectomy and azygoportal disconnection (LSD) with intraoperative endoscopic variceal ligation (LSDL) technique. In this study, we aimed to evaluate whether LSDL is feasible and safe and whether LSDL can effectively prevent esophagogastric variceal re-bleeding (EVR), as compared with single LSD.

Methods

In this randomized controlled single-center study, 88 patients with cirrhosis who had esophagogastric variceal bleeding and hypersplenism were randomly assigned to receive either LSD (n = 44) or LSDL (n = 44) between January 2020 and December 2021. The primary outcome was EVR.

Results

No patients withdrew from the study. There were no significant differences in estimated blood loss, incidence of blood transfusion, time to first flatus and off-bed activity, or postoperative hospital stay between the two groups. Compared with that in the LSD group, operation time was significantly longer in the LSDL group (138.5 ± 19.4 min vs. 150.3 ± 19.0 min, P < 0.05); however, LSDL was associated with a significantly decreased EVR rate at 1-year follow-up (8/44 vs. 1/44, P < 0.05). Univariate analysis and multivariate logistic regression revealed that LSDL was a significant independent protective factor against EVR in comparison with LSD (relative risk: 0.105, 95% confidence interval 0.012–0.877; P = 0.037).

Conclusions

Our newly developed LSDL procedure is not only technically feasible and safe; it also contributed to lowering the EVR risk more so than single LSD.

Trial Registration

We registered our research at https://​www.​clinicaltrials.​gov/​. The name of research registered is “Laparoscopic Splenectomy and Azygoportal Disconnection with Intraoperative Endoscopic Variceal Ligation.” The trial registration identifier at clinicaltrials.gov is NCT04244487.
Literatur
1.
Zurück zum Zitat Wright AS, Rikkers LF. Current management of portal hypertension. J Gastrointestinal Surg. 2005;9:992-1005.CrossRef Wright AS, Rikkers LF. Current management of portal hypertension. J Gastrointestinal Surg. 2005;9:992-1005.CrossRef
2.
Zurück zum Zitat Bari K, Garcia-Tsao G. Treatment of portal hypertension. World J Gastroenterol. 2012;18:1166-1175.CrossRef Bari K, Garcia-Tsao G. Treatment of portal hypertension. World J Gastroenterol. 2012;18:1166-1175.CrossRef
3.
Zurück zum Zitat LaBerge JM, Somberg KA, Lake JR, et al. Two-year out-come following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology. 1995;108:1143-1151.CrossRef LaBerge JM, Somberg KA, Lake JR, et al. Two-year out-come following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients. Gastroenterology. 1995;108:1143-1151.CrossRef
4.
Zurück zum Zitat Casado M, Bosch J, García-Pagán JC, et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic fndings. Gastroenterology. 1998;114:1296–1303.CrossRef Casado M, Bosch J, García-Pagán JC, et al. Clinical events after transjugular intrahepatic portosystemic shunt: correlation with hemodynamic fndings. Gastroenterology. 1998;114:1296–1303.CrossRef
5.
Zurück zum Zitat Sanyal AJ, Freedman AM, Luketic VA, et al. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology. 1997;112:889–898.CrossRef Sanyal AJ, Freedman AM, Luketic VA, et al. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology. 1997;112:889–898.CrossRef
6.
Zurück zum Zitat Ma H. Gastroesophageal decongestion and splenectomy. A method of prevention and treatment of bleeding from esophageal varices associated with bilharzial hepatic fbrosis: preliminary report. J Int Coll Surg. 1964;41:232–248. Ma H. Gastroesophageal decongestion and splenectomy. A method of prevention and treatment of bleeding from esophageal varices associated with bilharzial hepatic fbrosis: preliminary report. J Int Coll Surg. 1964;41:232–248.
7.
Zurück zum Zitat de Cleva R, Herman P, D’Albuquerque L A, et al. Pre- and postoperative systemic hemodynamic evaluation in patients subjected to esophagogastric devascularization plus splenectomy and distal splenorenal shunt: a comparative study in schistomomal portal hypertension. World J Gastroenterol. 2007;13:5471-5475.CrossRef de Cleva R, Herman P, D’Albuquerque L A, et al. Pre- and postoperative systemic hemodynamic evaluation in patients subjected to esophagogastric devascularization plus splenectomy and distal splenorenal shunt: a comparative study in schistomomal portal hypertension. World J Gastroenterol. 2007;13:5471-5475.CrossRef
8.
Zurück zum Zitat de Cleva R, Pugliese V, Zilberstein B, et al. Systemic hemodynamic changes in mansonic schistosomiasis with portal hypertension treated by azygoportal disconnection and splenectomy. Am J Gastroenterol. 1999;94:1632-1637.CrossRef de Cleva R, Pugliese V, Zilberstein B, et al. Systemic hemodynamic changes in mansonic schistosomiasis with portal hypertension treated by azygoportal disconnection and splenectomy. Am J Gastroenterol. 1999;94:1632-1637.CrossRef
9.
Zurück zum Zitat Bai DS, Zhou BH, Qian JJ, et al. Effects of laparoscopic splenectomy and azygoportal disconnection on liver synthesis function and cirrhosis: a 2-year prospective study. Surg Endosc. 2020;34:5074-5082.CrossRef Bai DS, Zhou BH, Qian JJ, et al. Effects of laparoscopic splenectomy and azygoportal disconnection on liver synthesis function and cirrhosis: a 2-year prospective study. Surg Endosc. 2020;34:5074-5082.CrossRef
10.
Zurück zum Zitat Ushitora Y, Tashiro H, Takahashi S, et al. Splenectomy in chronic hepatic disorders: portal vein thrombosis and improvement of liver function. Dig Surg. 2011;28:9-14.CrossRef Ushitora Y, Tashiro H, Takahashi S, et al. Splenectomy in chronic hepatic disorders: portal vein thrombosis and improvement of liver function. Dig Surg. 2011;28:9-14.CrossRef
11.
Zurück zum Zitat Huang Y, Qiu F. Problems on the surgery of portal hypertension. Zhonghua Wai Ke Za Zhi. 1996;34:131-132.PubMed Huang Y, Qiu F. Problems on the surgery of portal hypertension. Zhonghua Wai Ke Za Zhi. 1996;34:131-132.PubMed
12.
Zurück zum Zitat Wang Q, Ding X. A Comparative Study of the Efficacy of the Modified Sugiura Procedure and the Hassab Procedure for Treatment of Rebleeding after Endoscopic Variceal Ligation Due to Portal Hypertension. Am Surg. 2016;82:557-64.CrossRef Wang Q, Ding X. A Comparative Study of the Efficacy of the Modified Sugiura Procedure and the Hassab Procedure for Treatment of Rebleeding after Endoscopic Variceal Ligation Due to Portal Hypertension. Am Surg. 2016;82:557-64.CrossRef
13.
Zurück zum Zitat Sun X, Zhang A, Zhou T, et al. Partial splenic embolization combined with endoscopic therapies and NSBB decreases the variceal rebleeding rate in cirrhosis patients with hypersplenism: a multicenter randomized controlled trial. Hepatol Int. 2021;15:741-752.CrossRef Sun X, Zhang A, Zhou T, et al. Partial splenic embolization combined with endoscopic therapies and NSBB decreases the variceal rebleeding rate in cirrhosis patients with hypersplenism: a multicenter randomized controlled trial. Hepatol Int. 2021;15:741-752.CrossRef
14.
Zurück zum Zitat Lo GH, Lai KH, Cheng JS, et al. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology. 2001;33:1060–1064CrossRef Lo GH, Lai KH, Cheng JS, et al. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology. 2001;33:1060–1064CrossRef
15.
Zurück zum Zitat Krige JE, Kotze UK, Bornman PC, et al. Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices. Ann Surg. 2006;244:764-770.CrossRef Krige JE, Kotze UK, Bornman PC, et al. Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices. Ann Surg. 2006;244:764-770.CrossRef
16.
Zurück zum Zitat Yu H, Guo S, Wang L, et al. Laparoscopic Splenectomy and Esophagogastric Devascularization for Liver Cirrhosis and Portal Hypertension Is a Safe, Effective, and Minimally Invasive Operation. J Laparoendoscopic Adv Surg Tech A. 2016;26:524-530.CrossRef Yu H, Guo S, Wang L, et al. Laparoscopic Splenectomy and Esophagogastric Devascularization for Liver Cirrhosis and Portal Hypertension Is a Safe, Effective, and Minimally Invasive Operation. J Laparoendoscopic Adv Surg Tech A. 2016;26:524-530.CrossRef
17.
Zurück zum Zitat Bai DS, Qian JJ, Chen P, et al. Modified laparoscopic and open splenectomy and azygoportal disconnection for portal hypertension. Surg Endosc. 2014;28:257-264.CrossRef Bai DS, Qian JJ, Chen P, et al. Modified laparoscopic and open splenectomy and azygoportal disconnection for portal hypertension. Surg Endosc. 2014;28:257-264.CrossRef
18.
Zurück zum Zitat Zheng X, Liu Q, Yao Y. Laparoscopic splenectomy and esophagogastric devascularization is a safe, effective, minimally invasive alternative for the treatment of portal hypertension with refractory variceal bleeding. Surgical innovation. 2013;20:32-39.CrossRef Zheng X, Liu Q, Yao Y. Laparoscopic splenectomy and esophagogastric devascularization is a safe, effective, minimally invasive alternative for the treatment of portal hypertension with refractory variceal bleeding. Surgical innovation. 2013;20:32-39.CrossRef
19.
Zurück zum Zitat Zhe C, Jian-wei L, Jian C, et al. Laparoscopic versus open splenectomy and esophagogastric devascularization for bleeding varices or severe hypersplenism: a comparative study. J Gastrointest Surg. 2013;17:654-659.CrossRef Zhe C, Jian-wei L, Jian C, et al. Laparoscopic versus open splenectomy and esophagogastric devascularization for bleeding varices or severe hypersplenism: a comparative study. J Gastrointest Surg. 2013;17:654-659.CrossRef
20.
Zurück zum Zitat Jiang G, Qian J, Yao J, et al. A new technique for laparoscopic splenectomy and azygoportal disconnection. Surg Innov. 2014;21:256-262.CrossRef Jiang G, Qian J, Yao J, et al. A new technique for laparoscopic splenectomy and azygoportal disconnection. Surg Innov. 2014;21:256-262.CrossRef
21.
Zurück zum Zitat Bai DS, Jin SJ, Qian JJ, et al. Modified (Bai-Jiang style) vagus nerve-preserving versus conventional laparoscopic splenectomy and azygoportal disconnection: a randomized clinical trial. Surg Endosc. 2021;35:1786-1795.CrossRef Bai DS, Jin SJ, Qian JJ, et al. Modified (Bai-Jiang style) vagus nerve-preserving versus conventional laparoscopic splenectomy and azygoportal disconnection: a randomized clinical trial. Surg Endosc. 2021;35:1786-1795.CrossRef
22.
Zurück zum Zitat Jiang GQ, Bai DS, Chen P, et al. Modified laparoscopic splenectomy and azygoportal disconnection combined with cell salvage is feasible and might reduce the need for blood transfusion. World J Gastroenterol. 2014;20:18420–18426.CrossRef Jiang GQ, Bai DS, Chen P, et al. Modified laparoscopic splenectomy and azygoportal disconnection combined with cell salvage is feasible and might reduce the need for blood transfusion. World J Gastroenterol. 2014;20:18420–18426.CrossRef
23.
Zurück zum Zitat Bai DS, Xia BL, Zhang C, et al. Warfarin versus aspirin prevents portal vein thrombosis after laparoscopic splenectomy and azygoportal disconnection: a randomized clinical trial. Int J Surg. 2019;64:16–23.CrossRef Bai DS, Xia BL, Zhang C, et al. Warfarin versus aspirin prevents portal vein thrombosis after laparoscopic splenectomy and azygoportal disconnection: a randomized clinical trial. Int J Surg. 2019;64:16–23.CrossRef
24.
Zurück zum Zitat Schulz KF, Altman DG, Moher D, et al. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152: 726–732.CrossRef Schulz KF, Altman DG, Moher D, et al. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152: 726–732.CrossRef
25.
Zurück zum Zitat Ba DS, Zhang C, Jin SJ, et al. Laparoscopic splenectomy and azygoportal disconnection combining with pre- and postoperative endoscopic intervention - a sandwich-style sequential therapy for portal hypertensive bleeding: a retrospective cohort study. Turkish J Gastroenterol. 2018;29:669–675.CrossRef Ba DS, Zhang C, Jin SJ, et al. Laparoscopic splenectomy and azygoportal disconnection combining with pre- and postoperative endoscopic intervention - a sandwich-style sequential therapy for portal hypertensive bleeding: a retrospective cohort study. Turkish J Gastroenterol. 2018;29:669–675.CrossRef
26.
Zurück zum Zitat Donner A. Approaches to sample size estimation in the design of clinical trials - a review. Stat Med. 1984;3:199–214.CrossRef Donner A. Approaches to sample size estimation in the design of clinical trials - a review. Stat Med. 1984;3:199–214.CrossRef
27.
Zurück zum Zitat Idezuki Y, Kokudo N, Sanjo K, et al. Sugiura procedure for management of variceal bleeding in Japan. World J Surg. 1994;18:216-221.CrossRef Idezuki Y, Kokudo N, Sanjo K, et al. Sugiura procedure for management of variceal bleeding in Japan. World J Surg. 1994;18:216-221.CrossRef
28.
Zurück zum Zitat Selzner M, Tuttle-Newhall JE, Dahm F, et al. Current indication of a modified Sugiura procedure in the management of variceal bleeding. J Am Coll Surg. 2001;193:166-173CrossRef Selzner M, Tuttle-Newhall JE, Dahm F, et al. Current indication of a modified Sugiura procedure in the management of variceal bleeding. J Am Coll Surg. 2001;193:166-173CrossRef
29.
Zurück zum Zitat Khuroo MS, Khuroo NS, Farahat KL, et al. Meta-analysis: endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding. Aliment Pharmacol Ther Feb. 2005;21:347-361.CrossRef Khuroo MS, Khuroo NS, Farahat KL, et al. Meta-analysis: endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding. Aliment Pharmacol Ther Feb. 2005;21:347-361.CrossRef
30.
Zurück zum Zitat Wu LF, Xiang XX, Bai DS, et al. Novel noninvasive liver fibrotic markers to predict postoperative re-bleeding after laparoscopic splenectomy and azygoportal disconnection: a 1-year prospective study. Surg Endosc. 2021;35:6158-6165.CrossRef Wu LF, Xiang XX, Bai DS, et al. Novel noninvasive liver fibrotic markers to predict postoperative re-bleeding after laparoscopic splenectomy and azygoportal disconnection: a 1-year prospective study. Surg Endosc. 2021;35:6158-6165.CrossRef
Metadaten
Titel
Vagus Nerve–Preserving Laparoscopic Splenectomy and Azygoportal Disconnection with Versus Without Intraoperative Endoscopic Variceal Ligation: a Randomized Clinical Trial
verfasst von
Dou-Sheng Bai
Sheng-Jie Jin
Xiao-Xing Xiang
Jian-Jun Qian
Chi Zhang
Bao-Huan Zhou
Tian-Ming Gao
Guo-Qing Jiang
Publikationsdatum
08.06.2022
Verlag
Springer US
Erschienen in
Journal of Gastrointestinal Surgery / Ausgabe 9/2022
Print ISSN: 1091-255X
Elektronische ISSN: 1873-4626
DOI
https://doi.org/10.1007/s11605-022-05374-1

Neu im Fachgebiet Chirurgie

Antibiotika bei Erwachsenen mit Appendizitis oft ausreichend

Bei etwa zwei Drittel aller Erwachsenen mit akuter Appendizitis könnte eine antibiotische Behandlung ausreichen, wie eine Metaanalyse nahelegt. Die Komplikationsrate war insgesamt gering, auch wenn letztlich doch eine Op. fällig wurde.

Katheterablation bei Vorhofflimmern: Ist frühe Intervention von Vorteil?

Bei Patienten mit Vorhofflimmern scheinen die Therapieergebnisse bezüglich Rezidivfreiheit bei frühzeitiger Katheterablation besser zu sein als bei später erfolgter Ablation. Dafür sprechen Ergebnisse einer aktuellen Registeranalyse. 

Beugt Tranexamsäure schweren Blutungen auch in der Allgemeinchirurgie vor?

Ergebnisse einer Subgruppenanalyse der POISE-3-Studie sprechen dafür, dass eine Prophylaxe mit Tranexamsäure auch bei allgemeinchirurgischen Eingriffen das Risiko für schwere Blutungen senkt.

Höhere Anspannung vor der Op. führt offenbar zu besserem Ergebnis

Ein gewisses Maß an Stress zu Beginn der Op. wirkt sich möglicherweise positiv auf das Gelingen aus, so ein Team aus Boston. Die Komplikationsrate ging unter diesen Umständen signifikant zurück.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.