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      Laparoscopic gastric devascularization without splenectomy is effective for the treatment of gastric varices

      case-report

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          Highlights

          • •

            Devascularization without splenectomy for gastric varices reduces the complication.

          • •

            Laparoscopic devascularization without splenectomy is effective and less invasive.

          • •

            Further improvement of laparoscopic devices will enhance the safety operation.

          • •

            The new preoperative criteria to predict the difficulty of surgery is required.

          Abstract

          Introduction

          Laparoscopic gastric devascularization of the upper stomach in patients with gastric varices has rarely been reported. Perioperative clinical data were compared with patients who underwent open surgery.

          Presentation of cases

          From 2009 to 2012, we performed laparoscopic gastric devascularization without splenectomy for the treatment of gastric varices in eight patients. The patients included four males and four females. Peri-gastric vessels were divided using electrical coagulating devices or other devices according to the diameter of the vessels. Two patients underwent conversion to open surgery due to intraoperative bleeding.

          Discussion

          Intraoperative blood loss in patients who accomplished laparoscopic devascularization was very small (mean 76 ml). However, once bleeding occurs, there is a risk of causing massive bleeding.

          Conclusion

          With further improvement of laparoscopic devices, laparoscopic gastric devascularization without splenectomy must be an effective and less-invasive surgical procedure in the treatment of gastric varices.

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          Most cited references17

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          Prospective study of the incidence and risk factors of postsplenectomy thrombosis of the portal, mesenteric, and splenic veins.

          Stylianos Katsaragakis, Socrates Nakos, Eustathios Krespis … (2006)
          Splenectomy is recognized as a cause of portal, mesenteric, and splenic vein thrombosis. The exact incidence of the complication and its predisposing factors are not known. Prospective observational cohort study. The median follow-up time of the patients was 22.6 months. University surgical clinic in a teaching hospital. A total of 147 consecutive patients who underwent splenectomy in a 4-year period were enrolled in the study. Preoperative and postoperative evaluation included ultrasonography with color Doppler flow imaging of the portal system, results of blood coagulation tests, fibrinogen levels, D-dimer levels, and complete blood counts. Operative sheets were recorded and reviewed. When portal system thrombosis (PST) was diagnosed, a complete control for acquired and congenital thrombophilia disorders was obtained. Primary end points of the study were the assessment of the incidence of postsplenectomy PST and the identification of risk factors for its occurrence. Portal system thrombosis occurred in 7 (4.79%) of 146 patients who underwent splenectomy. The age, sex, type or length of the operation, and use of preoperative and postoperative thromboprophylaxis with low molecular weight heparin did not prove to be significant factors in the occurrence of PST. Platelet count of more than 650 x 10(3)/microL and greater spleen weight (>650 g) was associated with the development of PST (P = .01, P = .03). Normal D-dimer levels on diagnosis of the complication showed a negative predictive value of 98%. Two of the affected patients were diagnosed with thrombophilia disorders. In a median follow-up period of 22.6 months, no other case of PST was recorded. Postsplenectomy PST occurs in approximately 5% of patients. Possible risk factors are thrombocytosis, splenomegaly, and congenital thrombophilia disorders.
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            High incidence of thrombosis of the portal venous system after laparoscopic splenectomy: a prospective study with contrast-enhanced CT scan.

            Masataka Ikeda, Mitsugu Sekimoto, Shuji Takiguchi … (2005)
            The aims of this prospective study were to investigate the true incidence of portal or splenic vein thrombosis (PSVT) after elective laparoscopic splenectomy using contrast-enhanced computed tomography (CT) scan, and outcome of anticoagulant therapy for PSVT. Although rare, thrombosis of the portal venous system is considered a possible cause of death after splenectomy. The reported incidence of ultrasonographically detected PSVT after elective open splenectomy ranges from 6.3% to 10%. Twenty-two patients underwent laparoscopic splenectomy (LS group), and 21 patients underwent open splenectomy (OS group). Preoperative and postoperative helical CT with contrast were obtained in all patients, and the extent of thrombosis was investigated. Prothrombotic disorder was also determined. PSVT occurred in 12 (55%) patients of the LS group, but in only 4 (19%) of the OS group. The difference was significant (P = 0.03). Clinical symptoms appeared in 4 of the 12 LS patients. Thrombosis occurred in the intrahepatic portal vein (n = 9), extrahepatic portal vein (n = 2), mesenteric veins (n = 1), proximal splenic vein (n = 4), and distal splenic vein (n = 8). Prothrombotic disorder was diagnosed in 1 patient. Anticoagulant therapy was initiated once the diagnosis was established, and complete recanalization, except for distal splenic vein, was observed without any adverse event. Patients with splenomegaly were at high risk of PSVT. PSVT is a more frequent complication of laparoscopic splenectomy than previously reported but can be treated safely following early detection by CT with contrast.
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              Partial splenic embolization.

              Hiroshi Yoshida, Yasuhiro Mamada, Nobuhiko Taniai … (2008)
              Partial splenic embolization (PSE) is a non-surgical procedure developed to treat hypersplenism as a result of hepatic disease and thus avoid the disadvantages of splenectomy. A femoral artery approach is used for selective catheterization of the splenic artery. Generally, the catheter tip is placed as distally as possible in an intrasplenic artery. After an injection of antibiotics and steroids, embolization is achieved by injecting 2-mm gelatin sponge cubes suspended in a saline solution containing antibiotics. PSE can benefit patients with thrombocytopenia, esophagogastric varices, portal hypertensive gastropathy, encephalopathy, liver dysfunction, splenic aneurysm, and splenic trauma. The contraindications of PSE include secondary splenomegaly and hypersplenism in patients with terminal-stage underlying disease; pyrexia or severe infections are associated with a high risk of splenic abscess after PSE. Complications of PSE include daily intermittent fever, abdominal pain, nausea and vomiting, abdominal fullness, appetite loss, and postembolization syndrome. Decreased portal-vein flow and a rapid increase in the platelet count after excessive embolization may cause portal-vein or splenic-vein thrombosis.
              Article 0 comments Cited 23 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Toru Zuiki
                Journal
                Journal ID (nlm-ta): Int J Surg Case Rep
                Journal ID (iso-abbrev): Int J Surg Case Rep
                Title: International Journal of Surgery Case Reports
                Publisher: Elsevier
                ISSN (Electronic): 2210-2612
                Publication date PMC-release: 24 December 2015
                Publication date Collection: 2016
                Publication date (Electronic): 24 December 2015
                Volume: 19
                Pages: 119-123
                Affiliations
                [a ]Jichi Medical University, Clinical Institute of Digestive Diseases, Surgical Branch, Yakushiji 3311-1, Shimotsuke City, Tochigi, Japan
                [b ]Jichi Medical University, Clinical Institute of Digestive Diseases, Medical Branch, Yakushiji 3311-1, Shimotsuke City, Tochigi, Japan
                Author notes
                [* ]Corresponding author at: Department of Surgery, Jichi Medical University, Yakushiji 3311-1, Shimotsuke City, Tochigi, Japan. Fax: +81 285 44 3234. th-zuiki@ 123456jichi.ac.jp
                Article
                Publisher ID: S2210-2612(15)00551-9
                DOI: 10.1016/j.ijscr.2015.12.036
                PMC ID: 4756216
                PubMed ID: 26745317
                SO-VID: da28f30b-9519-4bc2-8ebb-f87bf06fd0a5
                Copyright © © 2015 The Authors
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 10 November 2015
                Date revision received : 26 November 2015
                Date accepted : 19 December 2015
                Categories
                Subject: Case Report

                Keywords: devascularization,gastric varices,laparoscopy,minimally invasive surgery,liver cirrhosis,splenectomy
                Data availability:
                Keywords: devascularization, gastric varices, laparoscopy, minimally invasive surgery, liver cirrhosis, splenectomy

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