The treatment of partal hypertension in the era of liver transplantation-- paraesophageal varices devascularization without splenectomy

In stage 1 and 2 liver cirrhosis patients, endoscopic treatments may be enough. Stage 3 patients still bleeding after receiving conservative treatments may require shunts, devascularization or combined operations according to their specific situation. Stage 4 liver cirrhosis patients however, may undergo liver function failure and may require a liver transplantation. We tried to perform a modified devascularization surgery to treat Portal Hypertension and GI bleeding in stage 2 or 3 patients. The main points of this surgery are: 1) to avoid cutting off the coronary, paraesophageal and paragastric veins in order to keep the natural collateral circulation, and 2) to avoid performing a splenectomy in order to prevent portal vein thrombosis (PVT) from occurring. Current devascularization surgeries present some problems, such as a high incidence of rebleeding, huge surgical trauma including a high risk of PVT, and a prolonged operation time when a splenectomy is required. According to the references, after liver cirrhosis patients receive a splenectomy, the PVT incidence is approximately 40%. This modified devascularization surgery consists of cutting off the gastric coronary vein and periesophageal cross vessels, submucous variceal vessels on the stomach antrum and body and intermuscular area of the esophaguis, while preserving other spontaneous circulation pathways between the portal vein and systemic circulation. The surgical procedure entails: 1) preserving the spleen by cutting off only the vasa brevia and retrogastric vein; 2) transecting the cross vessels of both curvatures of the proximal stomach and the vessels of 6 to 8cm on the lower esophagus while preserving the integrity of the major gastric coronary and perisophageal veins; and finally 3) transecting the lower esophagus and performing re-anastomosis and pyloroplasty.