The Effects Of Splenorenal Shunt Plus Pericardial Devascularization For Esophagogastric Variceal Bleeding In Patients With Portal Hypertension

Portal hypertension (PHT) is a major health threat in patients with hepatitis-relatedcirrhosis. PHT usually leads to multiple complications including splenomegaly, ascites,hepatorenal syndrome, encephalopathy, and even variceal hemorrhage. Varicealhemorrhage is a common and devastating complication of portal hypertension and is aleading cause of death in patients with cirrhosis. Thus, control bleeding is the mainpurpose of treatment in these patients. Devascularization and shunts are two widelyaccepted surgical techniques for the management of portal hypertension. However,pericardial devascularization and the shunt procedure have their advantages anddisadvantages. Hence, over the last two decades, we have performed a new combinedoperation (splenorenal shunt plus devascularization) to combine the advantages ofdevascularization and the shunt, and to reduce the disadvantages of both techniques. Theaim of this study is to determine the clinical value of a splenorenal shunt plus pericardialdevascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding. Inaddition, we aimed to identify a more suitable treatment for those patients who have noother conditions or are unsuitable for liver transplantation.Part1Two surgical procedures for esophagogastric variceal bleeding inpatients with portal hypertension ObjectiveTo determine the clinical value of a splenorenal shunt plus pericardialdevascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding.MethodsFrom January2008to November2012,290patients with cirrhotic portalhypertension were treated surgically in our department for the prevention ofgastroesophageal variceal bleeding:207patients received a routine PCVD procedure(PCVD group), and83patients received a PCVD plus a splenorenal shunt procedure(combined group). Changes in hemodynamic parameters, rebleeding, encephalopathy,portal vein thrombosis, and mortality were analyzed.ResultsThe free portal pressure decreased to21.43±4.35mmHg in the combined groupcompared with24.61±5.42mmHg in the PCVD group (P <0.05). The changes inhemodynamic parameters were more significant in the combined group (P <0.05). Thelong-term rebleeding rate was7.22%in the combined group, which was lower than that inthe PCVD group (14.93%),(P <0.05).ConclusionA comparison of two surgical techniques for esophagogastric variceal bleeding inpatients with cirrhotic portal hypertension was performed. Pericardial devascularizationand shunt are the main surgical strategies for the prevention of esophagogastric varicealbleeding in patients with portal hypertension (PHT). In this study, we found thatdevascularization plus splenorenal shunt was an effective and safe strategy for controllingesophagogastric variceal bleeding in PHT patients. We can conclude that splenorenal shuntplus devascularization is an effective choice in patients with esophagogastric varicealbleeding due to PHT. Part2Splenorenal shunt plus pericardial devascularization versuspericardial devascularization only for treatment of portal hypertension:A Meta-analysisObjectiveTo systematically evaluate the effects of splenorenal shunt plus pericardialdevascularization (PCVD) versus pericardial devascularization only in the management ofportal hypertension (PHT) patients with variceal bleeding.MethodsThe literatures about the therapeutic effect of splenorenal shunt plus PCVD andPCVD only on PHT patients with variceal bleeding were collected from CNKI, Wanfangdatabases, PubMed, Elsevier, MEDLINE, and Elsevier from2000to2013. We screenedthe retrieved literature according to the inclusion and exclusion criteria. After the relevantdate was identified, RevMan5.2was used for data analysis.ResultsAccording to the included criteria, a total of3895patients from20studies wereincluded for the analysis, including1800patients who performed combined operation and2095patients who performed PCVD only. The results of the Meta analysis showed thatthe recurrent variceal bleeding rate in the combined group was lower than in the PCVDgroup (OR=0.28,95%CI=0.22-0.36，P<0.00001). The survival rate of1,3,5years in thein the combined group was also lower than in the PCVD group (OR=0.43,95%CI=0.27-0.69，P=0.0004；OR=0.44,95%CI=0.33-0.60，P＜0.00001；OR=0.58,95%CI=0.42-0.80， P＜0.0009). However, the encephalopathy rate (OR=1.38,95%CI=0.98-1.93， P=0.06＞0.05) and the10years survival rate (OR=0.75,95%CI=0.55-1.03，P=0.08) in the two groups were similar.. ConclusionThe combined operation for portal hypertension patients with variceal bleeding offerseffects as well as or better than those with PCVD only. Although the surgical risk in thecombined group was equal to the PCVD group, the combined procedure resulted in alower rate of complications and maintained liver function. This surgical technique shouldbe recommended as a first-line treatment for the prevention of bleeding in PHT patientswhen surgical interventions are considered.