BACKGROUND:Hypersplenism is commonly seen in patients with non-cirrhotic portal hypertension(NCPH).While a splenectomy alone can effectively relieve the hypersplenism,it does not address the underlying portal hyperten...BACKGROUND:Hypersplenism is commonly seen in patients with non-cirrhotic portal hypertension(NCPH).While a splenectomy alone can effectively relieve the hypersplenism,it does not address the underlying portal hypertension.The present study was undertaken to analyze the impact of shunt and non-shunt operations on the resolution of hypersplenism in patients with NCPH.The relationship of symptomatic hypersplenism,severe hypersplenism and number of peripheral cell line defects to the severity of portal hypertension and outcome was also assessed.METHODS:A retrospective analysis of NCPH patients with hypersplenism managed surgically between 1999 and 2009 at our center was done.Of 252 patients with NCPH,64(45 with extrahepatic portal vein obstruction and 19 with non-cirrhotic portal fibrosis) had hypersplenism and constituted the study group.Statistical analysis was done using GraphPad InStat.Categorical and continuous variables were compared using the chi-square test,ANOVA,and Student’s t test.The MannWhitney U test and Kruskal-Wallis test were used to compare non-parametric variables.RESULTS:The mean age of patients in the study group was 21.81±6.1 years.Hypersplenism was symptomatic in 70.3% with an incidence of spontaneous bleeding at 26.5%,recurrent anemia at 34.4%,and recurrent infection at 29.7%.The mean duration of surgery was 4.16±1.9 hours,intraoperative blood loss was 457±126(50-2000) mL,and postoperative hospital stay 5.5±1.9 days.Following surgery,normalization of hypersplenism occurred in all patients.On long-term followup,none of the patients developed hepatic encephalopathy and 4 had a variceal re-bleeding(2 after a splenectomy alone,1 each after an esophago-gastric devascularization and proximal splenorenal shunt).Patients with severe hypersplenism and those with defects in all three peripheral blood cell lineages were older,had a longer duration of symptoms,and a higher incidence of variceal bleeding and postoperative morbidity.In addition,patients with triple cell line defects had elevated portal pressure(P=0.001),portal biliopathy(P=0.02),portal gastropathy(P=0.005) and intraoperative blood loss(P=0.001).CONCLUSIONS:Hypersplenism is effectively relieved by both shunt and non-shunt operations.A proximal splenorenal shunt not only relieves hypersplenism but also effectively addresses the potential complications of underlying portal hypertension and can be safely performed with good long-term outcome.Patients with hypersplenism who have defects in all three blood cell lineages have significantly elevated portal pressures and are at increased risk of complications of variceal bleeding,portal biliopathy and gastropathy.展开更多
AIM:To report our experience in the surgical management of severe injuries of the gastrointestinal tract due to corrosive ingestion.METHODS:A retrospective review of patients who underwent emergency surgery for severe...AIM:To report our experience in the surgical management of severe injuries of the gastrointestinal tract due to corrosive ingestion.METHODS:A retrospective review of patients who underwent emergency surgery for severe gastrointestinal injuries following corrosive ingestion between 1983 and 2010 was carried out.Data was extracted from a prospectively maintained esophageal disease database.Severe corrosive injuries were defined as full thickness necrosis with perforation of the esophagus or the stomach(with or without involvement of the adjacent viscera) with resultant mediastinitis or peritonitis.RESULTS:Between 1983 and 2010,209 patients with corrosive injury of the esophagus were managed.Of these,13(6.2%) patients underwent emergency surgery for severe corrosive injury.The median age of the patients was 22 years and the median interval between ingestion of the corrosive substance and surgery was 24 h.The surgical procedures done included esophagogastrectomy alone(n = 6),esophagogastrectomy withduodenectomy(n = 4),esophagogastrectomy with pancreaticoduodenectomy(n = 1),esophagogastrectomy with splenectomy(n = 1) and distal gastrectomy with duodenectomy(n = 1).Two patients died in the postoperative period and one after discharge awaiting the second surgery.The factors significantly predictive of mortality following such an injury included renal failure at the time of initial presentation,presence of metabolic acidosis,delay of more than 24 h between corrosive ingestion and surgery,and corrosive induced adjacent organ injury(pancreatic)(P < 0.001,0.02,0.005 and 0.015 respectively).Ten patients underwent subsequent surgery for restoration of the alimentary tract continuity with a colonic pull-up(n = 8) and gastrojejunostomy(n = 1).In one patient,the attempted colon pull-up failed due to extensive scarring of the mesocolon.The median follow up(following restoration of continuity of the gastrointestinal tract) was 36.5 mo.One patient developed dysphagia due to a stricture at the anastomotic site,which was successfully managed by dilatation.Another patient developed severe aspiration,necessitating laryngeal inlet closure and permanent tracheostomy,and 3 patients complained of occasional regurgitation.CONCLUSION:Management of severe corrosive injury involves prompt resuscitation and urgent surgical debridement.Although the subsequent restoration of continuity may be complicated and may not always be possible,long term outcomes are acceptable in the majority.展开更多
文摘BACKGROUND:Hypersplenism is commonly seen in patients with non-cirrhotic portal hypertension(NCPH).While a splenectomy alone can effectively relieve the hypersplenism,it does not address the underlying portal hypertension.The present study was undertaken to analyze the impact of shunt and non-shunt operations on the resolution of hypersplenism in patients with NCPH.The relationship of symptomatic hypersplenism,severe hypersplenism and number of peripheral cell line defects to the severity of portal hypertension and outcome was also assessed.METHODS:A retrospective analysis of NCPH patients with hypersplenism managed surgically between 1999 and 2009 at our center was done.Of 252 patients with NCPH,64(45 with extrahepatic portal vein obstruction and 19 with non-cirrhotic portal fibrosis) had hypersplenism and constituted the study group.Statistical analysis was done using GraphPad InStat.Categorical and continuous variables were compared using the chi-square test,ANOVA,and Student’s t test.The MannWhitney U test and Kruskal-Wallis test were used to compare non-parametric variables.RESULTS:The mean age of patients in the study group was 21.81±6.1 years.Hypersplenism was symptomatic in 70.3% with an incidence of spontaneous bleeding at 26.5%,recurrent anemia at 34.4%,and recurrent infection at 29.7%.The mean duration of surgery was 4.16±1.9 hours,intraoperative blood loss was 457±126(50-2000) mL,and postoperative hospital stay 5.5±1.9 days.Following surgery,normalization of hypersplenism occurred in all patients.On long-term followup,none of the patients developed hepatic encephalopathy and 4 had a variceal re-bleeding(2 after a splenectomy alone,1 each after an esophago-gastric devascularization and proximal splenorenal shunt).Patients with severe hypersplenism and those with defects in all three peripheral blood cell lineages were older,had a longer duration of symptoms,and a higher incidence of variceal bleeding and postoperative morbidity.In addition,patients with triple cell line defects had elevated portal pressure(P=0.001),portal biliopathy(P=0.02),portal gastropathy(P=0.005) and intraoperative blood loss(P=0.001).CONCLUSIONS:Hypersplenism is effectively relieved by both shunt and non-shunt operations.A proximal splenorenal shunt not only relieves hypersplenism but also effectively addresses the potential complications of underlying portal hypertension and can be safely performed with good long-term outcome.Patients with hypersplenism who have defects in all three blood cell lineages have significantly elevated portal pressures and are at increased risk of complications of variceal bleeding,portal biliopathy and gastropathy.
文摘AIM:To report our experience in the surgical management of severe injuries of the gastrointestinal tract due to corrosive ingestion.METHODS:A retrospective review of patients who underwent emergency surgery for severe gastrointestinal injuries following corrosive ingestion between 1983 and 2010 was carried out.Data was extracted from a prospectively maintained esophageal disease database.Severe corrosive injuries were defined as full thickness necrosis with perforation of the esophagus or the stomach(with or without involvement of the adjacent viscera) with resultant mediastinitis or peritonitis.RESULTS:Between 1983 and 2010,209 patients with corrosive injury of the esophagus were managed.Of these,13(6.2%) patients underwent emergency surgery for severe corrosive injury.The median age of the patients was 22 years and the median interval between ingestion of the corrosive substance and surgery was 24 h.The surgical procedures done included esophagogastrectomy alone(n = 6),esophagogastrectomy withduodenectomy(n = 4),esophagogastrectomy with pancreaticoduodenectomy(n = 1),esophagogastrectomy with splenectomy(n = 1) and distal gastrectomy with duodenectomy(n = 1).Two patients died in the postoperative period and one after discharge awaiting the second surgery.The factors significantly predictive of mortality following such an injury included renal failure at the time of initial presentation,presence of metabolic acidosis,delay of more than 24 h between corrosive ingestion and surgery,and corrosive induced adjacent organ injury(pancreatic)(P < 0.001,0.02,0.005 and 0.015 respectively).Ten patients underwent subsequent surgery for restoration of the alimentary tract continuity with a colonic pull-up(n = 8) and gastrojejunostomy(n = 1).In one patient,the attempted colon pull-up failed due to extensive scarring of the mesocolon.The median follow up(following restoration of continuity of the gastrointestinal tract) was 36.5 mo.One patient developed dysphagia due to a stricture at the anastomotic site,which was successfully managed by dilatation.Another patient developed severe aspiration,necessitating laryngeal inlet closure and permanent tracheostomy,and 3 patients complained of occasional regurgitation.CONCLUSION:Management of severe corrosive injury involves prompt resuscitation and urgent surgical debridement.Although the subsequent restoration of continuity may be complicated and may not always be possible,long term outcomes are acceptable in the majority.
