SPLENECTOMY WITH OESOPHAGOGASTRIC DEVASCULARIZATION IN PORTAL HYPERTENSION WITH HYPERSPLENISM

Introduction to SPLENECTOMY WITH OESOPHAGOGASTRIC DEVASCULARIZATION IN PORTAL HYPERTENSION WITH HYPERSPLENISM

1. EVALUATION OF ROLE OF SPLENECTOMY WITH OESOPHAGO GASTRIC DEVASCULARIZATION IN PORTAL HYPERTENSION WITH HYPERSPLENISM Dr. Varun Teja Pudota Under the guidance of Dr.Prabhat Nichkaode Professor and HOU Department of General Surgery

2. Introduction Portal hypertension is a clinical syndrome characterized by splenomegaly, ascites, gastrointestinal varices, and encephalopathy and is defined by a hepatic vein pressure gradient (HVPG) exceeding 5 mm Hg . 1  Portal hypertension is the major cause of severe complications and death in patients with cirrhosis . 1   Portal hypertension also can develop in the absence of cirrhosis under the condition called noncirrhotic portal hypertension (NCPH). In both the goal is to diagnose and characterize the severity of portal hypertension to minimize potentially severe and deadly complications The major cause of mortality and morbidity in patients with NCPH are variceal bleeding and symptomatic hypersplenism . 2-4 The most common presenting symptoms in patients with NCPF are variceal upper gastrointestinal bleed (UGIB) (72%) and symptomatic (pain, transfusion-dependent anaemia, splenic infarct) splenomegaly (12%). 3 Dameshek 5 summarized that hypersplenism should be diagnosed in the presence of four conditions: i ) monolineage or mutilineage peripheral cytopenias ; ii) compensatory hyperplasia of bone marrow; iii) splenomegaly; and iv) correction of cytopenias after splenectomy. Although these four conditions do not always apply to all cases, they have been commonly cited in the literature, and are important in the diagnosis of hypersplenism.

3. Acute variceal bleeding has a 30% chance of recurrent bleeding. 6 There is 50% mortality associated with recurrent bleeding in patients treated with endoscopic variceal ligation. 6 Since patients with hypersplenism are likely to have thrombocytopenia this further increases the risk of bleeding from varices. Definitive Surgery is reserved for patients with Sinistral portal hypertension to reduce the chances of rebleed who do not respond to pharmacologic and endoscopic treatments but can also be indicated in patients with failure to thrive, limited access to healthcare, or desiring a definitive one-time treatment. Some patients with symptomatic hypersplenism (such as repeated infections or bleeding, physical discomfort from massive splenomegaly) may require simultaneous Porta Systemic Shunt and splenectomy. 1-3 .

4. The present study intends to show the role of splenectomy with esophagogastric devascularisation in patients with portal hypertension with hypersplenism as a surgery to prevent chances of rebleed after pharmaclogical /endoscopic therapy. This surgery for hypersplenism ( splenectomy ) and esophagogastric devascularization has advantage over porta systemic shunt surgery as an emergency / salvage therapy or elective surgery as emergency shunt surgery results are poor. As Devascularization preserves the anatomy of portal vein and portal vein circulation intact for future treatment by shunt surgery if the need arises.

5. AIM The aim of this study is to evaluate the role of esophagogastric devascularisation with splenectomy in patients with portal hypertension with hypersplenism to reduce the chance of bleeding from varices and to reduce chances of rebleeding and to reduce the effects of hypersplenism.

6. OBJECTIVES To study the causes of portal hypertension. To study the effects of portal hypertension in terms of hypersplenism and varices. To study chances of bleeding according to the grade of varices. To study devascularisation with splenectomy in reducing chances of bleeding from varices post surgery. To study mortality and morbidity post operatively in patients undergoing devascularisation with splenectomy.

7. INCLUSION CRITERIA All patients aged between 18-70years diagnosed of portal hypertension with hypersplenism. All Patients having oesophageal or oesophago - gastric varices on endoscopy with history of GI bleed at least once –haematemesis or melana and/or underwent band ligation or are on beta blockers. Patients falling under Child Pugh class A and B Patients who are not willing for Transjugular Intrahepatic porta systemic shunt.

8. EXCLUSION CRITERIA Patients falling under Child Pugh Class C will be excluded. Patients who are diagnosed with portal hypertension with splenomegaly without the signs of hypersplenism and have no episode of Hematemesis or melana . Patients who’s physical performance is poor to sustain surgical procedure. Patients who do not enrol in the study .

9. MATERIALS AND METHODS TYPE OF STUDY: A prospective -longitudinal study. PLACE OF STUDY: The study will be conducted in the department of general surgery at Dr. D.Y Patil Medical college Hospital and Research centre, Pimpri Pune. PERIOD OF STUDY: JANUARY 2023 – JUNE 2025 Session. STUDY DESIGN : This study is a prospective study to evaluate the role of splenectomy with gastric devascularisation in patients with portal hypertension with hypersplenism. SAMPLE SIZE - 30 or more

10. METHODOLOGY After attaining approval from the Hospital Ethics Committee and taking informed written consent from the patients. All the patients admitted and referred to surgery department in DY PATIL HOSPITAL who are diagnosed with portal hypertension with hypersplenism in which oesophageal varices were noted on endoscopic evaluation. All patients with active bleeding from varices or with a single episode of GI bleed – hematemesis or malena will be considered for the study. The following patients will be studied and patients who underwent medical management of oesophageal varices such as band ligation / beta blockers or did not undergo, will be considered for surgical management and enrolled in the study.Pre -operative abdominal doppler will be performed. Hassab’s procedure will be performed in selected patients after all the routine investigations and preparing the patient for surgery.

11. All patients undergoing splenectomy will be vaccinated pre operatively . All patients undergoing splenectomy will be startred on T.PENICLLIN 800MG OD for 2 years. The surgery will be performed by a surgeon at a level of professor who has performed more than 50 splenectomies. Patients enrolled in the study post operatively will be evaluated for early and late benefits of splenectomy with devascularization. All the patients enrolled in the study will be followed up for a period of 1.5 years. Using the following parameters and if any episode of GI Bleed has occurred. Upper GI Endoscopy –Pre-Operatively ,6 months ,1 year and 1.5 year after surgery will done to evaluate the grade of varices and any chance of recurrence of bleeding. CBC –3 months after surgery To evaluate cytopenias associated with hypersplenism and its correction post surgery.

12. Abdominal Doppler- 3 months after surgery to study portal vein and circulation.

13. Investigations Done Pre-operatively : CBC ABDOMINAL DOPPLER OESOPHAGOGASTRODUODENOSCOPY

14. End Point Study CBC Immediately 30 minutes after splenic artery ligation with 2 units of FFP transfused. On 3 rd day post operatively On 7 th day post operatively If Thrombocytosis greater than 700,000 – T.ASPIRIN WITH CLOPIDOGRIL will be given.

15. REFERENCES 1.Sanyal AJ, Bosch J, Blei A, Arroyo V. Portal hypertension and its complication. Gastroenterology 2008;134:1715-1728. 2. Sarin SK, Agarwal SR. Extrahepatic portal vein obstruction. Semin Liver Dis 2002;22:43-58. 3. Dhiman RK, Chawla Y, Vasishta RK, Kakkar N, Dilawari JB, Trehan MS, et al. Non-cirrhotic portal fibrosis (idiopathic portal hypertension): experience with 151 patients and a review of the literature. J Gastroenterol Hepatol 2002;17:6-16. 4 . Schouten JN, Nevens F, Hansen B, Laleman W, van den Born M, Komuta M, et al. Idiopathic noncirrhotic portal hypertension is associated with poor survival: results of a long-term cohort study. Aliment Pharmacol Ther 2012;35:1424-1433. 5.Dameshek W. Hypersplenism.  Bull NY Acad Med.  1955;31:113–136. 6. Cho H, Nagata N, Shimbo T, Sakurai T, Sekine K, Okubo H, Imbe K, Watanabe K, Mikami S, Yokoi C, Kobayakawa M, Mizokami M, Yanase M, Akiyama J, Uemura N. Recurrence and prognosis of patients emergently hospitalized for acute esophageal variceal bleeding: A long-term cohort study. Hepatol Res. 2016 Dec;46(13):1338-1346. doi : 10.1111/hepr.12692. Epub 2016 May 16. PMID: 26946225.

16. Thank you