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Background: Conventional open and conventional laparoscopic splenectomy and azygoportal disconnection (CLSD) result in poor quality of life because of damage to the vagal nerve. We have developed vagus nerve-preserving laparoscopic splenectomy and azygoportal disconnection (VLSD). This study aimed to evaluate whether VLSD is effective and safe, and to determine whether a reduction in the incidence of postoperative complications improves postoperative quality of life compared with CLSD., Methods: We retrospectively evaluated outcomes in 72 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism who underwent CLSD (n = 40) or VLSD (n = 32) between April 2015 and December 2016. Their demographic, intraoperative, and postoperative variables were compared., Results: No patients required conversion to laparotomy in CLSD and VLSD. There was no difference in estimated intraoperative blood loss, volume of intraoperative blood transfused, time to first flatus, time to off-bed activity, and postoperative hospital stay between the two groups. VLSD was associated with a shorter operation time (P = 0.020) and less postoperative complications (P < 0.0001), including less diarrhea (P < 0.0001), epigastric fullness (P < 0.0001), and delayed gastric emptying (P < 0.0001), compared with CLSD. With VLSD, there was a significant increase in body weight and plasma albumin levels at 6 months postoperatively compared with preoperative values (all P < 0.05). The curative effect of improving esophageal/gastric variceal bleeding was similar in the groups., Conclusions: VLSD is effective and safe for reducing the incidence of postoperative complications, contributing to improving postoperative quality of life.

Introduction: Laparoscopic splenectomy and azygoportal disconnection (LSD) has been reported to be safe, feasible, and minimally invasive for cirrhotic patients with portal hypertension. There is still controversy as to whether it is necessary to perform synchronous splenectomy for patients with moderate hypersplenism who undergo azygoportal disconnection for esophagogastric variceal hemorrhage (EGVB)., Methods: We retrospectively evaluated the outcomes in 51 cirrhotic patients with EGVB and moderate hypersplenism (PLT ≥50 × 10 9 /L) who underwent LSD (n = 28) or laparoscopic azygoportal disconnection (LD) (n = 23) between January 2014 and October 2015. Their demographic, intraoperative, and postoperative variables were compared., Results: LSD and LD were successful in all the patients. When compared with LSD, LD had a significantly shorter operation time, less intraoperative blood loss, shorter postoperative hospital stay, fewer days of postoperative body temperature >38.0 °C, lower rate of fever postoperatively, and lower C-reactive protein concentration and procalcitonin concentration on postoperative day (POD) 7 (all P < 0.05). The incidences of portal vein system thrombosis in the LD group on PODs 7, 30, and 90 were significantly lower than those in the LSD group at all the time points (all P < 0.05). According to the postoperative serum proportions of CD4 + and CD8 + and the CD4+/CD8+ ratio (all P < 0.05), the LSD group had significantly lower immune function than the LD group on POD 90., Conclusions: LD is safe and effective for EGVB with moderate hypersplenism secondary to portal hypertension in selected patients., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Aim: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy and azygoportal disconnection (MLSD) with intraoperative autologous cell salvage., Methods: We retrospectively evaluated outcomes in 79 patients admitted to the Clinical Medical College of Yangzhou University with cirrhosis, portal hypertensive bleeding and secondary hypersplenism who underwent MLSD without (n = 46) or with intraoperative cell salvage and autologous blood transfusion, including splenic blood and operative hemorrhage (n = 33), between February 2012 and January 2014. Their intraoperative and postoperative variables were compared. These variables mainly included: operation time; estimated intraoperative blood loss; volume of allogeneic blood transfused; visual analog scale for pain on the first postoperative day; time to first oral intake; initial passage of flatus and off-bed activity; perioperative hemoglobin (Hb) concentration; and red blood cell concentration., Results: There were no significant differences between the groups in terms of duration of surgery, estimated intraoperative blood loss and overall perioperative complication rate. In those receiving salvaged autologous blood, Hb concentration increased by an average of 11.2 ± 4.8 g/L (P < 0.05) from preoperative levels by the first postoperative day, but it had fallen by 9.8 ± 6.45 g/L (P < 0.05) in the group in which cell salvage was not used. Preoperative Hb was similar in the two groups (P > 0.05), but Hb on the first postoperative day was significantly higher in the autologous blood transfusion group (118.5 ± 15.8 g/L vs 102.7 ± 15.6 g/L, P < 0.05). The autologous blood transfusion group experienced significantly fewer postoperative days of temperature > 38.0°C (P < 0.05)., Conclusion: Intraoperative cell salvage during MLSD is feasible and safe and may become the gold standard for liver cirrhosis with portal hypertensive bleeding and hypersplenism.

Objective: To compare the efficacies between transjugular intrahepatic portosystemic shunt (TIPS) and portoazygos devascularization (PAD) in the treatment of portal hypertension with variceal bleeding., Methods: From December 1993 to December 2010, 309 patients with portal hypertension and variceal bleeding were admitted. According to their general conditions and Child-Pugh grades, they were assigned to undergo TIPS (group A, n = 235) or PAD (group B, n = 74). Before operation, compared with the PAD group, the TIPS group possessed worse liver functions, more severe ascites and a greater frequency of bleeding. After operation, the therapeutic efficacies and changes of portal hemodynamics, recurrent variceal bleeding, post-operative encephalopathy and long-term survival were evaluated between two groups., Results: The postoperative portal pressure in the TIPS group ((42.6 ± 7.0) vs (26.3 ± 4.1) cm H2O) decreased much more than that in the PAD group ((38.7 ± 5.2) vs (33.5 ± 5.8) cm H2O, P < 0.01). The rebleeding rates during early postoperation were 0.85% (2/235) and 6.76% (5/74) in TIPS and PAD groups respectively, the occurring rates of hepatic encephalopathy 4.68% (11/235) and 4.05% (3/74) and the rates of operative mortality 1.70% (4/235) and 6.76% (5/74) respectively. Survival rates of 1, 3, 5 and 10 years were 98.30% (231/235) vs 92.24% (69/74), 92.41% (146/158) vs 88.06% (59/67), 80.77% (84/104) vs 79.25% (42/53), 51.43% (36/79) vs 51.85% (14/27) in TIPS and PAD groups respectively., Conclusions: As compared with PAD, TIPS offers the such advantages as less trauma, wider indication, faster hemostasis and satisfactory therapeutic efficacies. Especially for the emergency treatment of a patient with massive variceal bleeding and Child-Pugh C grade liver function, TIPS is a better option than PAD.

Background: Intraoperative blood salvage can reduce or avoid perioperative allogeneic blood transfusion. Salvaging the blood in the portal hypertension-induced enlarged spleen becomes an issue of concern during devascularization surgery because an enlarged spleen accommodates a large red cell pool. We report 20 cases of laparoscopic splenectomy and azygoportal disconnection and present the advantages of the use of intraoperative splenic blood salvage during the procedure., Methods: A total of 20 cirrhotic patients with esophagogastric variceal bleeding refractory to treatment with β-blockers and endoscopic therapy were studied. Laparoscopic splenectomy with azygoportal disconnection was performed. During the procedure, an intraoperative autologous blood salvage device recovered the splenic blood. The perioperative data were recorded from various viewpoints., Results: The operative time was 3.1 ± 0.3 h and the blood loss was 70.5 ± 32.5 ml. The weight of the excised and morcellated spleen was 826.0 ± 155.1 g. The volume of autotransfused blood was 541.0 ± 150.4 ml. No patient received a perioperative allogeneic blood transfusion. There were no significant complications either intraoperatively or postoperatively. The hemoglobin value increased from 9.3 ± 0.8 to 11.5 ± 1.1 g/dl at postoperative day 1 (p < 0.01). During a postoperative follow-up period of 18.0 ± 9.0 months for 18 patients, neither esophageal variceal bleeding nor encephalopathy recurred., Conclusion: Laparoscopic splenectomy with azygoportal disconnection is a feasible, effective, and safe surgical method for the treatment of bleeding portal hypertension. Intraoperative splenic blood salvage can avoid the risk associated with allogeneic transfusion during the procedure, with an advantage of significantly increased postoperative hemoglobin levels.

Objective: The results of TIPS and the combined TIPS and portal-azygous disconnection for portal hypertension and variceal bleeding were evaluated., Methods: 358 patients with portal hypertension were admitted to our clinical ward because of variceal bleeding. 263 patients underwent TIPS and 95 patients with combined TIPS and portal-azygous disconnection. Portal hemodynamics was evaluated by pressure measurements, venography and Doppler ultrasound before and 2 weeks after the procedure. The rates of shunt patency, rebleeding, encephalopathy and survival were observed during the follow-up period from 1 to 10 years., Results: The portal pressure and HVPG were decreased significantly after TIPS. TIPS procedure was successfully performed in 97.50% patients. During 1 month after treatment, acute shunt occlusion occurred in 3.42% patients with TIPS and there were no occluded shunts in patients with combined TIPS and portal-azygous disconnection. Encephalopathy was observed in 36.50% patients with TIPS and 18.95% with combined TIPS and portal-azygous disconnection. Recurrent variceal bleeding was documented in 6.46% patients with TIPS and none of patients with combined TIPS and azygous portal disconnection. Thirty-three patients with TIPS and two patients with combined TIPS and portal-azygous disconnection died. During follow-up periods, the patency of shunts in patients with TIPS and patients combined TIPS and azygous portal disconnection was 68.47, 43.84 and 87.06, 57.65% in 12 and 24 months after operation, respectively. The rates of rebleeding, and encephalopathy in patients with TIPS and patients with combined TIPS and azygous portal disconnection were 17.95, 31.79 and 7.04, 16.47%, respectively. The survival rate in 1, 5, 10 years in patients with TIPS and patients combined TIPS and azygous portal disconnection was 87.68, 51.23, 39.90 and 94.12, 81.18, 76.47%., Conclusion: Combined TIPS and portal-azygous disconnection can improve the effect of TIPS for portal hypertension.

Background: Bleeding from esophageal varices is an important cause of morbidity and mortality in patients with portal hypertension. The ideal surgical procedure should control bleeding with as little impairment of liver function as possible and with low rates of encephalopathy. Recently, significant progress in laparoscopic technology has enabled laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach in a less invasive way. In this paper, we present preliminary results for 25 patients in whom laparoscopic splenectomy and azygoportal disconnection were performed., Patients and Methods: Laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach were performed in 25 patients with cirrhosis, bleeding portal hypertension, and secondary hypersplenism between January 2000 and October 2006. Among them, 5 patients underwent a laparoscopic modified Sugiura procedure, the lower esophagus was transected, and then reanastomosed with a circular stapler., Results: Laparoscopic splenectomy and azygoportal disconnection were completed in all patients, except in 1 conversion, without significant morbidity. The operation time ranged from 4.0 to 5.5 hours and the blood loss was 100-400 mL. The postoperative hospital stay was 6-15 days. During a postoperative follow-up period of 3 months to 5 years in 22 patients, neither esophagus variceal bleeding nor encephalopathy has recurred., Conclusions: Laparoscopic splenectomy and azygoportal disconnection are feasible, effective, and safe surgical procedures, and have all the benefits of minimally invasive surgery for patients with bleeding portal hypertension and hypersplenism. Laparoscopic splenectomy and azygoportal disconnection offer a new operative method for treatment of bleeding portal hypertension with hypersplenism.

Two original organ-saving surgical technologies are suggested for surgical prophylaxis of bleedings from esophageal and gastric varicose veins dilatation. The azygoportal disconnection surgery has been performed at 42 patients. The rate of bleeding recurrences was 4.8%. This surgical procedure may be regarded as the stage of complex treatment of patients with liver cirrhosis and as the final treatment at the patients with extrahepatic portal hypertension.

Based on experience at their department since 1983 the authors analyze the position of the azygoportal disconnection in the treatment of complications of portal hypertension. During the observation period the number of operations declined due to extensive use of endoscopic diagnosis and treatment. However the azygoportal disconnection still remains part of surgical intervention in indicated cases, in particular in secondary hypersplenism and profuse haemorrhage.

Controversy remains about the best treatment for patients with esophagogastric variceal bleeding. In spite of different therapeutic alternatives and recent progress, such as liver transplantation of TIPS, many patients will finally be treated by standard surgery. With the aim to know the results of surgery in shunting vs non-shunting procedures, we have analyzed a recent and consecutive series of 68 cirrhotics patients operated on for variceal hemorrhage. According to the surgical technique there were three groups: I) 30 patients underwent a total portacaval shunt; II) 18 cases with an azygosportal disconnection; III) 20 patients with a partial portacaval shunt (8-10 mm H-portacaval PTFE graft). All groups were homogeneous considering age, sex etiology, Child-Pugh grade and timing of surgery (elective vs urgent). The complications and mortality rates were similar for the three groups. The overall operative mortality was 10%, and 5% in selected cases (Child-Pugh A-B, non urgent cases). With a follow-up for I, II and III group of 47, 44 and 27 months respectively, chronic encephalopathy have been seen in 61%, 15% and 15% respectively (p < .05). No patient in group I has rebled, and only one case in the II and III groups had a recurrence of hemorrhage. The actuarial three years survival was 76%, 86% and 85% (p NS), and the five year survival was 41% vs 86% for the groups I and II respectively (p < .05). In conclusion, in selected cases, surgery gives excellent immediate and long term results. In patients with variceal bleeding and failure of first line treatments, such as sclerosis or pharmacology, the partial H-portacaval shunt and non-shunting procedures are good alternatives, with low incidence of rebleeding and chronic encephalopathy.

The consequence of an acute mesenteric venous thrombosis following porta-azygos disconnection for the treatment of bleeding esophageal varices due to mansonian schistosomiasis has not been well defined in the literature. The clinical manifestations reported were fever, spasmodic abdominal pain associated with food intake. We treated three patients with thrombosis of the portal-mesenteric trunk following porta-azygos disconnection and adopted a conservative clinical approach in two patients while one had to have a surgical small bowel ressection.

Azygo-portal disconnection by the abdominal route consists of devascularization of the lower oesophagus, cardiac orifice and greater gastric tuberosity by ligation of the varices and section of the oesophagus, combined in every case with truncular vagotomy and gastric bypass. In emergencies the abdominal approach enables the bleeding points to be accurately localized. In the treatment of haemorrhages due to portal hypertension, this technique offers an alternative to porto-caval bypasses when these cannot be performed (thrombosis or portal cavernoma) or when the risk of encephalitis is too high. However, contrary to liver transplantation, it is a palliative technique for cirrhotic patients.

The authors report about the results of 20 azygoportal deconnections for the treatment of hemorrhagic cirrhosis caused by the rupture of esophageal or cardiotuberosal varices. All patients had an ethylic cirrhosis of Child-Pugh classes A (1), B (15) or C (4). All had a contraindication to calibrated laterolateral portocaval shunting. Azygoportal deconnection was performed with a thoracic approach in 7 cases, using a Bérard eso-clip in 6 cases and a Prioton button in 1. In 13 cases the approach was abdominal, using EEA circular mechanical clamps. In this cases, trunk vagotomy was performed in 12 cases, in association with pyloroplasty in 10 cases and gastroenteroanastomosis in 2 cases. Splenectomy was performed in 3 patients and the ligation of the splenic artery in a 4th patient. Mortality at 2 months is of 30%, the 6 deaths being caused by hepatic insufficiency in 3 cases, heart and esophageal fistula after an eso-clip was laid in 1 case. The two patients with chronic ascites died of hepatic insufficiency. Mortality at 2 months is of 23% for patients operated in an elective period, and 43% for semiergent operations. Twenty-six percent of the Child B patients and 50% of the Child C patients died. The percentage of residual varices is 57% in the surviving patients. Every second patient had complementary sclerosis. All had had azygoportal deconnection with mechanical clamps. Bleeding recurred in 2 patients (16.6%). Survival is 50% at 1 year and 39% at 3 years.

The authors studied 30 patients with bleeding from esophageal varices due to portal hypertension. They underwent the disconnection of portal and azygos veins and splenectomy. The immediate postoperative complications were: portal thrombosis in four patients (13.3%); subphrenic abscess in two (6.6%); pulmonary embolism in one (3.3%) and esophageal perforation in one (3.3%). The manifestations of portal thrombosis were ascites, and fever (without leukocytosis). One patient with portal thrombosis who had intractable ascite was submitted to peritoneovenous shunting.

Between 1971 and 1982, 20 portoazygous disconnections (modified Tanner's operation) were performed in patients with bleeding esophagogastric varices who were anatomically portosystemic shunting. Immediate control of variceal hemorrhage was achieved in all patients, although rebleeding occurred after eight operations at intervals from 2 days to 7.5 years postoperatively, requiring additional surgery at a mean interval of 2.5 years. There were eight perioperative deaths. Analysis has suggested increased mortality in patients with more severely impaired liver function according to Child's classification, and in patients who require urgent or emergent operations. There was an 80 percent incidence of major and minor complications. Portoazygous disconnection is not a satisfactory alternative to portosystemic shunting, except in a selected group of patients with intact hepatic function and with anatomic characteristics that preclude usual shunting procedures.

One of the main drawbacks attributed to azygoportal disconnection operations in the surgical treatment of bleeding esophageal varices is recurrence of hemorrhage. The present paper reviews the results obtained as regards hemorrhage recurrence in 4,975 patients who underwent azygoportal disconnection in 41 series published in the western literature in recent years. An analysis is also made of the factors that, according to different authors, could be related to the failure of these procedures to prevent eventual variceal hemorrhage.

Many procedures are described to solve the problem of the massive hemorrhages due to esophageal varices in children with Portal Hypertension in which it's not possible to do a porto-systemic shunt by cause of the age. It's possible to treat them by sclerotherapy but in case of massive hemorrhages in which the patient life is at risk we have used the azygo-portal disconnection following the SUGIURA technique making the esophageal transection with autosuture instrument. We believe that this technical simplification account for more instances in which it's indicated. And it could be preferred to other procedures used with the same objective. We have done it in two male patients which came to our Center in several occasions due to massive hemorrhages. In both cases the Portal Hypertension is of extrahepatic cause. Follow up it is been satisfactory in both cases. Being one of them more than 3 1/2 years without hemorrhagic episodes, remaining under clinical and endoscopic controls. We have used in this cases the Proximate ILS of 21 mm. of Ethicon.

We present 64 patients with bleeding esophageal varices who have been treated with portoazygos disconnection, devascularization of the esophagogastric junction, and esophageal transection with the button of Boerema (32 patients) and EEA stapler (32 patients). The patients were treated between 1973 and 1983. Their ages ranged from 50 to 70 years. Based on Child's classification, 26 (37.5%) of the patients fell into class A, 35 (54.6%) in class B, and five (7.8%) in class C. These patients were also divided into three subgroups: group I--21 patients (32.8%) underwent emergency operations; group II--40 patients (62.5%) underwent semiemergency operations; and group III--three patients (4.7%) underwent elective operations. The perioperative mortality rate was 10.8%. With the Fischer exact test, we found the combined death rate of Child's classes A and B to be significantly lower than that for class C patients. The duration of follow-up ranged from 6 months to 9 years (average 32.9 months) in the 80% of the patients that we were able to follow. There was a 6.5% incidence of recurrent gastrointestinal bleeding and a 28% incidence of late encephalopathy. The incidence of transitory dysphagia was 40% when the button of Boerema was used as compared with 9% when the EEA stapler was used. The surgical approach presented herein is an attractive alternative to portosystemic decompression for patients in whom hepatic dysfunction is complicated by uncontrolled variceal hemorrhage.

A one stage, complete abdominal portoazygos disconnection procedure is a safe and efficient method for the treatment of acute variceal bleeding. This method was performed upon five patients who were bleeding due to severe cirrhosis of the liver, with no operative mortality. No recurrence of bleeding occurred during a follow-up study of one to four years.