Standardized management of multi-disciplinary treatment in portal hypertension_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

WANG Dong , YIN Jikai , DONG Rui ,  LU Jianguo

Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi’an 710038, P. R. China;

Corresponding author：

LU Jianguo, Email: lujguo@fmmu.edu.cn

Keywords：

portal hypertension; multi-disciplinary treatment; standardized management

DOI：

10.7507/1007-9424.202204041

Video：

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Portal hypertension caused by viral post hepatic liver cirrhosis has brought a heavy burden to medical treatment in China. In addition to liver transplantation, the treatments include drugs, endoscopy, intervention and surgery, but the effect is not satisfactory. At present, the consensus and guideline for portal hypertension often focuse on a single treatment, and there is an urgent need for reasonable, standardized and individualized treatment to minimize the risk of upper gastrointestinal bleeding and improve the long-term survival of patients, which should also be the ultimate goal of multi-disciplinary treatment (MDT) mode of portal hypertension. The MDT diagnosis and treatment method of portal hypertension needs to be obtained in combination with the general situation of patients (including liver function level, upper gastrointestinal bleeding risk, hypersplenism, etc.) and local medical advantages. For patients with acute upper gastrointestinal bleeding, the treatment with less trauma and good hemostatic effect should be selected as far as possible. Patients with previous bleeding history or bleeding cessation should improve the relevant evaluation as soon as possible and submit it to MDT for discussion and selection of the next appropriate treatment. Drugs and endoscopy can be used for high-risk groups of upper gastrointestinal bleeding. Whether surgical preventive treatment can benefit patients or not needs further large sample research support. Minimally invasive surgery is the development direction of surgical treatment. Combination of internal and external treatment may give full play to their respective advantages, reducing the risk of bleeding and improving long-term survival.

Citation： WANG Dong, YIN Jikai, DONG Rui, LU Jianguo. Standardized management of multi-disciplinary treatment in portal hypertension. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2022, 29(8): 981-986. doi: 10.7507/1007-9424.202204041 Copy

1.	Wang FS, Fan JG, Zhang Z, et al. The global burden of liver disease: the major impact of China. Hepatology, 2014, 60(6): 2099-2108.
2.	Wu J, Han M, Li J, et al. Immunopathogenesis of HBV Infection. Adv Exp Med Biol, 2020, 1179: 71-107.
3.	Blachier M, Leleu H, Peck-Radosavljevic M, et al. The burden of liver disease in Europe: a review of available epidemiological data. J Hepatol, 2013, 58(3): 593-608.
4.	中华医学会外科学分会脾及门静脉高压外科学组. 肝硬化门静脉高压症食管、胃底静脉曲张破裂出血诊治专家共识(2019版). 中华外科杂志, 2019, 57(12): E002.
5.	de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno Ⅶ - Renewing consensus in portal hypertension. J Hepatol, 2022, 76(4): 959-974.
6.	Jakab SS, Garcia-Tsao G. Evaluation and management of esophageal and gastric varices in patients with cirrhosis. Clin Liver Dis, 2020, 24(3): 335-350.
7.	Thiele M, Krag A, Rohde U, et al. Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices. Aliment Pharmacol Ther, 2012, 35(10): 1155-1165.
8.	Jing L, Zhang Q, Chang Z, et al. Nonsurgical secondary prophylaxis of esophageal variceal bleeding in cirrhotic patients: a systematic review and network meta-analysis. J Clin Gastroenterol, 2021, 55(2): 159-168.
9.	Tripathi D, Stanley AJ, Hayes PC, et al. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut, 2020, 69(7): 1173-1192.
10.	Lv Y, Zuo L, Zhu X, et al. Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study. Gut, 2019, 68(7): 1297-1310.
11.	Orloff MJ. Fifty-three years’ experience with randomized clinical trials of emergency portacaval shunt for bleeding esophageal varices in cirrhosis: 1958-2011. JAMA Surg, 2014, 149(2): 155-169.
12.	Garcia-Tsao G, Bosch J. Varices and variceal hemorrhage in cirrhosis: a new view of an old problem. Clin Gastroenterol Hepatol, 2015, 13(12): 2109-2117.
13.	Veldhuijzen van Zanten D, Buganza E, Abraldes JG. The role of hepatic venous pressure gradient in the management of cirrhosis. Clin Liver Dis, 2021, 25(2): 327-343.
14.	Sarin SK, Wadhawan M, Agarwal SR, et al. Endoscopic variceal ligation plus propranolol versus endoscopic variceal ligation alone in primary prophylaxis of variceal bleeding. Am J Gastroenterol, 2005, 100(4): 797-804.
15.	Kawanaka H, Akahoshi T, Kinjo N, et al. Effect of laparoscopic splenectomy on portal haemodynamics in patients with liver cirrhosis and portal hypertension. Br J Surg, 2014, 101(12): 1585-1593.
16.	Huang N, Ji F, Zhang S, et al. Effect of splenectomy on serum cytokine profiles in hepatitis B virus-related cirrhosis patients with portal hypertension. Viral Immunol, 2018, 31(5): 371-378.
17.	Yamamoto N, Okano K, Oshima M, et al. Laparoscopic splenectomy for patients with liver cirrhosis: Improvement of liver function in patients with Child-Pugh class B. Surgery, 2015, 158(6): 1538-1544.
18.	Lv X, Yang F, Guo X, et al. Hypersplenism is correlated with increased risk of hepatocellular carcinoma in patients with post-hepatitis cirrhosis. Tumour Biol, 2016, 37(7): 8889-8900.
19.	Luo HP, Zhang ZG, Long X, et al. Combined laparoscopic splenectomy and esophagogastric devascularization versus open splenectomy and esophagogastric devascularization for portal hypertension due to liver cirrhosis. Curr Med Sci, 2020, 40(1): 117-122.
20.	Chen H, Yang F, Li TT, et al. Comparison of efficacy of laparoscopic and open splenectomy combined with selective and nonselective pericardial devascularization in portal hypertension patients. Surg Laparosc Endosc Percutan Tech, 2018, 28(6): 401-403.
21.	Wang D, Chen X, Lv L, et al. Laparoscopic splenectomy and devascularization for massive splenomegaly in portal hypertensive patients: a retrospective study of a single surgical team’s experience with 6-year follow-up data. Ann Transl Med, 2022, 10(4): 207. doi: 10.21037/atm-22-502.
22.	Dong W, Zhang Z, Rui D, et al. Laparoscopic splenectomy and esophagogastric devascularization combined with fast-track principles offers greater benefit for patients with portal hypertension. Videosurgery and Other Miniinvasive Techniques, 2022. doi: 10.5114/wiitm.2021.112680.
23.	Bai DS, Xia BL, Zhang C, et al. Warfarin versus aspirin prevents portal vein thrombosis after laparoscopic splenectomy and azygoportal disconnection: A randomized clinical trial. Int J Surg, 2019, 64: 16-23.
24.	Vecchio R, Cacciola E, Cacciola RR, et al. Portal vein thrombosis after laparoscopic and open splenectomy. J Laparoendosc Adv Surg Tech A, 2011, 21(1): 71-75.
25.	Chen H, Lei J, Liang S, et al. Safety and efficacy of anticoagulation in patients with cirrhosis: A meta-analysis. Can J Gastroenterol Hepatol, 2021, 2021: 8859602. doi: 10.1155/2021/8859602.
26.	Dong S, Qi H, Li Y, et al. A systematic review and meta-analysis of anticoagulation therapy for portal vein thrombosis in patients with cirrhosis: to treat or not to treat? Hepatol Int, 2021, 15(6): 1356-1375.
27.	Noronha Ferreira C, Reis D, Cortez-Pinto H, et al. Anticoagulation in cirrhosis and portal vein thrombosis is safe and improves prognosis in advanced cirrhosis. Dig Dis Sci, 2019, 64(9): 2671-2683.
28.	Lee KC, Hsu WF, Hsieh YC, et al. Dabigatran reduces liver fibrosis in thioacetamide-injured rats. Dig Dis Sci, 2019, 64(1): 102-112.
29.	Vilaseca M, García-Calderó H, Lafoz E, et al. The anticoagulant rivaroxaban lowers portal hypertension in cirrhotic rats mainly by deactivating hepatic stellate cells. Hepatology, 2017, 65(6): 2031-2044.
30.	Habermalz B, Sauerland S, Decker G, et al. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc, 2008, 22(4): 821-848.
31.	Casaccia M, Sormani MP, Palombo D, et al. Laparoscopic splenectomy versus open splenectomy in massive and giant spleens: Should we update the 2008 EAES Guidelines? Surg Laparosc Endosc Percutan Tech, 2019, 29(3): 178-181.
32.	Tsamalaidze L, Stauffer JA, Permenter SL, et al. Laparoscopic splenectomy for massive splenomegaly: Does size matter? J Laparoendosc Adv Surg Tech A, 2017, 27(10): 1009-1014.
33.	Li Y, Liu Z, Liu C. Efficacy and safety of laparoscopic splenectomy for hypersplenism secondary to portal hypertension after transjugular intrahepatic portosystemic shunt. BMC Gastroenterol, 2021, 21(1): 61. doi: 10.1186/s12876-021-01647-2.
34.	He FL, Qi RZ, Zhang YN, et al. Transjugular intrahepatic portosystemic shunt and splenectomy are more effective than endoscopic therapy for recurrent variceal bleeding in patients with idiopathic noncirrhotic portal hypertension. World J Clin Cases, 2020, 8(10): 1871-1877.
35.	Zhou J, Wu Z, Wu J, et al. Transjugular intrahepatic portosystemic shunt (TIPS) versus laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in the treatment of recurrent variceal bleeding. Surg Endosc, 2013, 27(8): 2712-2720.

1. Wang FS, Fan JG, Zhang Z, et al. The global burden of liver disease: the major impact of China. Hepatology, 2014, 60(6): 2099-2108.
2. Wu J, Han M, Li J, et al. Immunopathogenesis of HBV Infection. Adv Exp Med Biol, 2020, 1179: 71-107.
3. Blachier M, Leleu H, Peck-Radosavljevic M, et al. The burden of liver disease in Europe: a review of available epidemiological data. J Hepatol, 2013, 58(3): 593-608.
4. 中华医学会外科学分会脾及门静脉高压外科学组. 肝硬化门静脉高压症食管、胃底静脉曲张破裂出血诊治专家共识(2019版). 中华外科杂志, 2019, 57(12): E002.
5. de Franchis R, Bosch J, Garcia-Tsao G, et al. Baveno Ⅶ - Renewing consensus in portal hypertension. J Hepatol, 2022, 76(4): 959-974.
6. Jakab SS, Garcia-Tsao G. Evaluation and management of esophageal and gastric varices in patients with cirrhosis. Clin Liver Dis, 2020, 24(3): 335-350.
7. Thiele M, Krag A, Rohde U, et al. Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices. Aliment Pharmacol Ther, 2012, 35(10): 1155-1165.
8. Jing L, Zhang Q, Chang Z, et al. Nonsurgical secondary prophylaxis of esophageal variceal bleeding in cirrhotic patients: a systematic review and network meta-analysis. J Clin Gastroenterol, 2021, 55(2): 159-168.
9. Tripathi D, Stanley AJ, Hayes PC, et al. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut, 2020, 69(7): 1173-1192.
10. Lv Y, Zuo L, Zhu X, et al. Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study. Gut, 2019, 68(7): 1297-1310.
11. Orloff MJ. Fifty-three years’ experience with randomized clinical trials of emergency portacaval shunt for bleeding esophageal varices in cirrhosis: 1958-2011. JAMA Surg, 2014, 149(2): 155-169.
12. Garcia-Tsao G, Bosch J. Varices and variceal hemorrhage in cirrhosis: a new view of an old problem. Clin Gastroenterol Hepatol, 2015, 13(12): 2109-2117.
13. Veldhuijzen van Zanten D, Buganza E, Abraldes JG. The role of hepatic venous pressure gradient in the management of cirrhosis. Clin Liver Dis, 2021, 25(2): 327-343.
14. Sarin SK, Wadhawan M, Agarwal SR, et al. Endoscopic variceal ligation plus propranolol versus endoscopic variceal ligation alone in primary prophylaxis of variceal bleeding. Am J Gastroenterol, 2005, 100(4): 797-804.
15. Kawanaka H, Akahoshi T, Kinjo N, et al. Effect of laparoscopic splenectomy on portal haemodynamics in patients with liver cirrhosis and portal hypertension. Br J Surg, 2014, 101(12): 1585-1593.
16. Huang N, Ji F, Zhang S, et al. Effect of splenectomy on serum cytokine profiles in hepatitis B virus-related cirrhosis patients with portal hypertension. Viral Immunol, 2018, 31(5): 371-378.
17. Yamamoto N, Okano K, Oshima M, et al. Laparoscopic splenectomy for patients with liver cirrhosis: Improvement of liver function in patients with Child-Pugh class B. Surgery, 2015, 158(6): 1538-1544.
18. Lv X, Yang F, Guo X, et al. Hypersplenism is correlated with increased risk of hepatocellular carcinoma in patients with post-hepatitis cirrhosis. Tumour Biol, 2016, 37(7): 8889-8900.
19. Luo HP, Zhang ZG, Long X, et al. Combined laparoscopic splenectomy and esophagogastric devascularization versus open splenectomy and esophagogastric devascularization for portal hypertension due to liver cirrhosis. Curr Med Sci, 2020, 40(1): 117-122.
20. Chen H, Yang F, Li TT, et al. Comparison of efficacy of laparoscopic and open splenectomy combined with selective and nonselective pericardial devascularization in portal hypertension patients. Surg Laparosc Endosc Percutan Tech, 2018, 28(6): 401-403.
21. Wang D, Chen X, Lv L, et al. Laparoscopic splenectomy and devascularization for massive splenomegaly in portal hypertensive patients: a retrospective study of a single surgical team’s experience with 6-year follow-up data. Ann Transl Med, 2022, 10(4): 207. doi: 10.21037/atm-22-502.
22. Dong W, Zhang Z, Rui D, et al. Laparoscopic splenectomy and esophagogastric devascularization combined with fast-track principles offers greater benefit for patients with portal hypertension. Videosurgery and Other Miniinvasive Techniques, 2022. doi: 10.5114/wiitm.2021.112680.
23. Bai DS, Xia BL, Zhang C, et al. Warfarin versus aspirin prevents portal vein thrombosis after laparoscopic splenectomy and azygoportal disconnection: A randomized clinical trial. Int J Surg, 2019, 64: 16-23.
24. Vecchio R, Cacciola E, Cacciola RR, et al. Portal vein thrombosis after laparoscopic and open splenectomy. J Laparoendosc Adv Surg Tech A, 2011, 21(1): 71-75.
25. Chen H, Lei J, Liang S, et al. Safety and efficacy of anticoagulation in patients with cirrhosis: A meta-analysis. Can J Gastroenterol Hepatol, 2021, 2021: 8859602. doi: 10.1155/2021/8859602.
26. Dong S, Qi H, Li Y, et al. A systematic review and meta-analysis of anticoagulation therapy for portal vein thrombosis in patients with cirrhosis: to treat or not to treat? Hepatol Int, 2021, 15(6): 1356-1375.
27. Noronha Ferreira C, Reis D, Cortez-Pinto H, et al. Anticoagulation in cirrhosis and portal vein thrombosis is safe and improves prognosis in advanced cirrhosis. Dig Dis Sci, 2019, 64(9): 2671-2683.
28. Lee KC, Hsu WF, Hsieh YC, et al. Dabigatran reduces liver fibrosis in thioacetamide-injured rats. Dig Dis Sci, 2019, 64(1): 102-112.
29. Vilaseca M, García-Calderó H, Lafoz E, et al. The anticoagulant rivaroxaban lowers portal hypertension in cirrhotic rats mainly by deactivating hepatic stellate cells. Hepatology, 2017, 65(6): 2031-2044.
30. Habermalz B, Sauerland S, Decker G, et al. Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc, 2008, 22(4): 821-848.
31. Casaccia M, Sormani MP, Palombo D, et al. Laparoscopic splenectomy versus open splenectomy in massive and giant spleens: Should we update the 2008 EAES Guidelines? Surg Laparosc Endosc Percutan Tech, 2019, 29(3): 178-181.
32. Tsamalaidze L, Stauffer JA, Permenter SL, et al. Laparoscopic splenectomy for massive splenomegaly: Does size matter? J Laparoendosc Adv Surg Tech A, 2017, 27(10): 1009-1014.
33. Li Y, Liu Z, Liu C. Efficacy and safety of laparoscopic splenectomy for hypersplenism secondary to portal hypertension after transjugular intrahepatic portosystemic shunt. BMC Gastroenterol, 2021, 21(1): 61. doi: 10.1186/s12876-021-01647-2.
34. He FL, Qi RZ, Zhang YN, et al. Transjugular intrahepatic portosystemic shunt and splenectomy are more effective than endoscopic therapy for recurrent variceal bleeding in patients with idiopathic noncirrhotic portal hypertension. World J Clin Cases, 2020, 8(10): 1871-1877.
35. Zhou J, Wu Z, Wu J, et al. Transjugular intrahepatic portosystemic shunt (TIPS) versus laparoscopic splenectomy (LS) plus preoperative endoscopic varices ligation (EVL) in the treatment of recurrent variceal bleeding. Surg Endosc, 2013, 27(8): 2712-2720.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Standardized management of multi-disciplinary treatment in portal hypertension

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