Research Of Modified Laparoscopic Splenectomy Plus Pericardial Devascularization For Treatment Of Portal Hypertension

Objectives:1. This study is aimed to evaluate the clinical effectiveness (feasibility、safety and efficacy) of laparoscopic splenectomy plus devascularization (LSPD) for portal hypertension by modified and simplified operation by comparing with open splenectomy plus pericardial devascularization.2. To evaluate the effectiveness of modified LSPD with modified and simplified techniques for portal hypertension, and to explore strategies to reduce intraoperative hemorrhage and improve the successful rate.3. To perfect and summary reasonable operating procedures and to establish operating standards for modified LSPD.Methods:From Jun2012to Jan2015, LSPD were performed on149patients (Group LSPD,GLS) and open splenectomy plus pericardial devascularization (OSPD) were performed on110patients (Group OSPD,GOS) with portal hypertension in our medical center.The patients of GLS were allocated into two Groups by date of operation and length of spleens. Group A:149patients in GLS and110patients in GOS. Group B:46cases from Jun2012to Des2012received traditional LSPD were categorized as Group earlier stage (Group Earlier Stage,ES);103cases from Jan2013to Jan2015underwent modified LSPD categorized as Group Later Stage(Group Later Stage, LS). Group C:of103cases in LS,39cases with spleens larger than20cm were categorized as MS(Group massive splenomegaly,MS); the other64cases with spleens less than20cm were categorized as NMS(Group non-massive splenomegaly, NMS). Perioperative variables of the patients were compared and analyzed of every Groups retrospectively.Preoperative data include age、gender、etiology、Child-Pugh classification length of spleen; intraoperative and postoperative data include average operating time、intraoperative hemorrhage、oral diet intake、postoperative hospitalization、postoperative complication、conversion rate and the results of follow-up. All data was displayed as ’M±SD’ Student’s t-test, Chi-square test, Fisher’s exact test and Mann-Whitney U test were used for statistical analysis based on data type respectively in SPSS19.0with a p value of <0.05indicated statistical significance. Results:Group A:The operations of two Groups were successfully fulfilled, no perioperative death, all patient recovered and were discharged from hospital, no complications in the six months of postoperative follow-up. In Group GLS,4cases converted to laparotomy (conversion rate2.68%). The mean operation time was longer in the GLS than that in the GOS (344.16min vs241.73min,p=0.027), In the GLS the blood loss (793.25ml vs914.54ml,p=0.009)、the mean time of oral diet intake (42.66h vs56.25h,p=0.011) and postoperative hospitalization (7.5d vs 8.93d, p=0.043) decreased significantly than the GOS(p<0.05). The incidence of postoperative complications(p>0.05)has no statistical significance.Group B:Laparoscopic operations were successfully fulfilled in all but three patients in ES and one patient in LS who were converted to laparotomy. There is no perioperative death or reoperation, and all patients recovered and were discharged from hospital with no serious complications in the six months of postoperative follow-up. The average time in the Group ES was longer (344.2min vs214.3min,p <0.05) and intraoperative hemorrhage was more(907.4ml vs715.3ml, p<0.05) than that in the Group LS. But in terms of oral diet intake(41.3h vs51.2h, p <0.05)> postoperative hospitalization(7.6d vs9.1d, p<0.05)、postoperative complication(4.3%vs11.1%, p<0.05) and conversion rate(0.97%vs6.52%, p <0.05), LS also outperformed that in the ES.Group C:Except one patient in MS who was converted to laparotomy, the other102cases were all performed modified LSPD successfully. Compared to NMS,the average time of MS was longer (246.5min vs184.3min, p<0.05), there were more blood loss (876.4ml vs492.5ml, p<0.05) and higher conversion rate (2.56%vs0%, p<0.05) in MS. There were no significant differences between the two Groups in average time of oral diet intake(41.2h vs40.4h, p>0.05)、 postoperative hospital stay (7.9d vs7.Id, p>0.05) and overall complication rate (5.13%vs4.68%,p>0.05). Conclusions:1. Modify LSPD is a safe and feasible procedure for portal hypertension. It has the advantages of less intraoperative hemorrhage、earlier recovery of gastrointestinal function and shorter postoperative hospitalization by comparing to open surgery.2. Modified LSPD simplify and modify the procedure by creating a tunnel above the splenic pedicle and a tunnel behind the lower esophagus, which can shorten the operation time、reduce intraoperative hemorrhage、speed up the recovery of gastrointestinal function、reduce postoperative hospitalization、 decrease the incidence of postoperative complications and the conversion to laparotomy. It can improve the safety and efficacy of the surgery dramatically.3. It is concluded that splenomegaly and severe varices are not absolute contraindications,Modified LSPD can be carried out selectivity by surgeon with rich experiences and proficient laproscopic techniques.4. Reasonable operating procedures、operating standards、modified and simplified techniques of modified LSPD can improve the feasibility and the successful rate of operation, and also can promote the application of modified LSPD for portal hypertension.