Abstract: Objective:To investigate the clinical efficacy of pericardial devascularization (PCDV) combined with splenectomy and partial gastric fundus resection (PGFR) in the treatment of portal hypertensioninduced severe gastric varices complicated with gastrorenal shunt (GRS).
Methods:The retrospective crosssectional study was conducted. The clinicopathological data of 18 patients with portal hypertensioninduced severe gastric varices complicated with GRS who were admitted to the Fujian Provincial Hospital from January 2010 to December 2015 were collected. According to the stage of technical development, open surgery or laparoscopic surgery was selected based on patients′ and their family's wishes. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative pathological examination; (3) followup and survival. The followup using outpatient examination and telephone interview was performed once every 3 months within 1 year postoperatively and once every 6 months after 1 year to detect longterm complications and survival up to June 2017. The reexaminations of gastroscopy, enhanced scan of X-ray computed tomography (CT) on the epigastric region or magnetic resonance imaging (MRI) were done at 1 month postoperatively for detecting resection of fundus ventriculi varicosity. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). The survival rate was calculated by the Kaplan-Meier method.
Results:(1) Surgical and postoperative recovery situations: 18 patients underwent successful PCDV combined with splenectomy and PGFR, including 12 with open surgery and 6 with laparoscopic surgery (1 with conversion to open surgery due to intraoperatively uncontrollable bleeding). There was no perioperative death. The operation time, volume of intraoperative blood loss, recovery time of gastrointestinal function, time of postoperative drainagetube removal and duration of hospital stay were (192±20)minutes, (280±30)mL, (33±6)hours, 8 days (range, 5-9 days), 8 days (range, 5-12 days) in 12 patients with open surgery and (208±40)minutes, (210±10)mL, (28±5)hours, 7 days (range, 5-26 days), 7 days (range, 5-10 days) in 6 patients with laparoscopic surgery, respectively. One patient with laparoscopic surgery had intraoperative condensed erythrocyte infusion with 2 U. Seven, 1, 0 patients with open surgery and 4, 1, 1 patients with laparoscopic surgery were respectively complicated with pleural effusion, delayed gastric emptying and pancreatic leakage in level A, and they were cured by conservative treatment. (2) Postoperative pathological examination: results of postoperative pathological examination in 18 patients showed that a large number of varicose veins in the mucous and serosal layers of gastric fundus and moderate or severe hepatic cirrhosis. (3) Followup and survival: 18 patients were followed up for 8-78 months with a median time of 39 months. The gastroscopy and enhanced scan of X-ray CT at 1 month postoperatively showed that no varicose veins in the gastric fundus. During the followup, there was no recurrence of gastric varices with GRS and esophageal stenosis. Of 4 patients with portal vein thrombosis, 1 died of portal hypertensive gastropathyinduced upper gastrointestinal bleeding due to stop taking warfarin, and other 3 patients had portal vein patency by warfarin therapy. One patient was complicated with liver cancer at 32 months postoperatively and received radiofrequency ablation therapy. Two patients died, including 1 dying of hepatic failure at 35 months postoperatively and 1 dying of advanced liver cancer at 54 months postoperatively. The 1, 3 and 5year overall survival rates of 18 patients were respectively 93.8%, 84.4% and 70.3%.
Conclusion:The PCDV combined with splenectomy and PGFR is safe and effective in the treatment of portal hypertensioninduced severe gastric varices with GRS, with a dissemination value for appropriate patients.