Kazan medical journalKazan medical journal0368-48142587-9359Eco-Vector1154710.17816/KMJ2019-333Research ArticlePrevention of recurrent bleeding from varicose veins of the esophagus and stomach among patients with decompensated liver cirrhosisOnnitsevI Eionnicev@mail.ruBugaevS Aionnicev@mail.ruIvanusaS Yaionnicev@mail.ruDzidzavaI Iionnicev@mail.ruKhokhlovA Vionnicev@mail.ruKotivB Nionnicev@mail.ruS.M. Kirov Military Medical AcademyA.V. Vishnevsky Institute of Surgery29032019100233333929032019Copyright © 2019, Onnitsev I.E., Bugaev S.A., Ivanusa S.Y., Dzidzava I.I., Khokhlov A.V., Kotiv B.N.2019<p><strong>Aim.</strong> To evaluate the efficiency of laparoscopic devascularization of the esophagus and stomach with endoscopic ligation of varicose esophageal veins in the prevention of esophageal-gastric bleeding among patients with decompensated liver cirrhosis.</p>
<p><strong>Methods.</strong> The results of treatment of 73 patients with decompensated liver cirrhosis and high risk of bleeding were analyzed. To prevent recurrent bleeding from esophageal and gastric veins, all patients underwent endoscopic ligation at the first step of treatment. In case of inefficiency of ligation and recurrence of varicose veins of esophagus, laparoscopic devascularization of esophagus and stomach was performed. The efficiency of laparoscopic devascularization with intraoperative endoscopic ligation of varicose esophageal veins and ligation as an independent method of treatment for the prevention of upper gastrointestinal bleeding was estimated by comparison of the frequency of recurrence of esophageal and gastric bleeding and recurrence of esophageal varices according to upper endoscopy in comparison groups.</p>
<p><strong>Results.</strong> In 6 months, 1 and 2 years after laparoscopic devascularization of the esophagus and stomach in combination with endoscopic ligation, the risk of bleeding is less compared to endoscopic ligation as an isolated treatment method (p=0.05; p=0.052; p=0.06). Laparoscopic devascularization with ligation reduces the risk of recurrence of esophageal varices during the first year after surgery by 20% (2=2.61; p=0.106), in 2 years by 23% (2=1.75; p=0.091) compared to endoscopic ligation only.</p>
<p><strong>Conclusion.</strong> Patients with liver cirrhosis with decompensated hepatic failure satisfactorily postpone endovideosurgical interventions; laparoscopic gastric devascularization with the intersection of the main inflows to the esophageal varicose veins is an effective method to prevent esophageal-gastric hemorrhage among patients with decompensated liver cirrhosis after ineffective endoscopic ligation.</p>liver cirrhosisportal hypertensionesophageal variceslaparoscopic devascularization of esophagusцирроз печенипортальная гипертензияварикозное расширение вен пищеводалапароскопическая деваскуляризация вен пищевода[Nazyrov F.G., Devyatov A.V., Babadzhanov A.H., Dzhumaniyazov D.A. Efficiency of endoscopic interventions at patients with cirrhosis. Annaly khirurgicheskoy gepatologii. 2017; 22 (2): 45–53. (In Russ.)][Kotiv B.N., Dzidzava I.I., Soldatov S.A. Results of selective and partial portocaval shunting and prognostic factors of long-term survival of patients with cirrhosis. Annaly khirurgicheskoy gepatologii. 2015; 20 (2): 46–58. (In Russ.)][Габриэль С.А., Гучетль А.Я., Дурлештер В.М. Эффективность эндоскопического лигирования варикозно-][Gabriel S.A., Guchetl A.Ya., Durleshter V.M. Efficiency of an endoscopic ligation of varicose veins of an esophagus. Vestnik MUZGB. 2016; 23 (13): 25. (In Russ.)][Shertsinger A.G., Zhigalova S.B., Semenova T.S. Endoscopy role in the choice of treatment of patients with a portal hypertensia. Annaly khirurgicheskoy gepatologii. 2015; 20 (2): 20–30. (In Russ.)][Jiang M., Liu F., Xiong W. Combined MELD and blood lipid level in evaluating the prognosis of decompensated cirrhosis. World J. Gastroenterol. 2010; 16 (11): 1397–1401. DOI: 10.3748/wjg.v16.i11.1397.][Costa Lacet C., Neto J., Ribeiro L., Oliveira F. Schistosomal portal hypertension: Randomized trial comparing endoscopic therapy alone or preceded by esophagogastric devascularization and splenectomy. Ann. Hepatol. 2016; 15 (5): 738–744. PMID: 27493113.][Kotiv B.N. Surgical prophylaxis and treatment of esophageal and gastric bleedings at a portal hypertension. Thesis of the doctor of medical sciences. Saint Petersburg. 1998; 195 р. (In Russ.)][Helmy A., Abdulkader Salama I., Schwaitzberg S.D. Laparoscopic esophagogastric devascularization in bleeding varices. Surg. Endosc. 2003; 17 (1): 1614–1619. DOI: 10.1007/s00464-002-8928-1.][Akahoshi T., Uehara H., Tomikawa M. et al. Comparison of open, laparoscopic, and hand-assisted laparoscopic devascularization of the upper stomach and splenectomy for treatment of esophageal and gastric varices: a single-center experience. Asian J. Endosc. Surg. 2014; 7 (1): 138–144. DOI: 10.1111/ases.12096.][Danis J., Hubmann R., Pichler P. Novel technique of laparoscopic azygoportal disconnection for treatment of esophageal varicosis: preliminary experience with five patients. Surg. Endosc. 2004; 18 (4): 702–705. DOI: 10.1007/s00464-003-9096-7.][Tomikawa M. Effectiveness of gastric devascularization and splenectomy for patients with gastric varices. J. Am. Coll. Surg. 2000; 191 (5): 498–500. DOI: 10.1016/S1072-7515(00)00735-3.][Kobayashi T., Miura K., Ishikawa H. et al. Hand-assisted laparoscopic Hassab’s procedure for esophagogastric varices with portal hypertension. Surg. Case Rep. 2017; 3 (3): 111. DOI: 10.1186/s40792-017-0387-y.]