J. Life Sci. Biomed. 6(5): 115-119, September, 2016

JLSB

Journal of

ISSN 2251-9939

Life Science and Biomedicine

Results of Gastroesophageal Collector Total Dissociation

in Patients with Portal Hypertension

Nazyrov Firuz Gafurovich, Devyatov Andrey Vasilyevich, Babadjanov Azam Khasanovich^and

Ruziboev Sandjar Abdusalomovich

¹Republican Specialized Centre of Surgery named after academician V.Vakhidov, Tashkent city, Uzbekistan

²Tashkent Pediatric Medical Institute, Tashkent city, Uzbekistan

Corresponding author’s Email: azam746@mail.ru

Received 27 Apr. 2016 • Accepted 18 Jul. 2016 • Revised 20 Sep. 2016

ABSTRACT: The purpose of research was to study long-term results of the modified technique of

gastroesophageal collector total dissociation (GECTD) in patients with portal hypertension. Materials and

methods. Currently a modified version of the operation has been performed in 73 patients with the portal

hypertension (PH) syndrome. In 36 patients the cause of PH was liver cirrhosis, 30 patients were diagnosed

with extrahepatic form of PH, mixed form of PH was determined in 8 patients. The age of patients ranged from

13 to 65 years, thus the median was 31.6 ± 1.7 years. Patients randomizing by gender was as follows: men - 44,

women - 29. In 53 cases patients were admitted in a planned order, and 20 patients were delivered urgently

with the clinical picture of gastroesophageal bleeding. Results and discussion remote period was followed up

in 46 patients with primary procedure and in 66 patients with a modified technique of GECTD. Rebleeding was

observed in 15.2% of patients, 6.5% on the background of anastomositis. Gastrostasis occurrence was

detected in 3 of 46 patients. Liver failure occurred in 23.9% of patients, 15.2% patients died on the

background of these complications. In the group with a modified procedure bleeding was observed in 6.0%

cases. Bleedings from erosion in the area of ligature transection were stopped conservatively. Mortality in

long-term period of observation was 7.6% (5 patients). Overall mortality for the near and distant periods in

the comparison groups was 22.2% and 16.4%, respectively. Conclusion –dissociation of gastroesophageal

venous reservoir by ligature transection on synthetic prosthesis, unlike previously proposed methods of

GECTD allows not only to ease technique of operation, but also provides prevention of early postoperative

complications associated with traumatism of previous methods, as well as the stomach gross functional

disorders in the long term period.

Author Keywords: Liver Cirrhosis, Portal Hypertension, Dissociative Operations, Technique of Ligature

Transection, Bleeding from Esophageal Varices

INTRODUCTION

Among all gastrointestinal hemorrhages from esophageal varices in patients suffering from liver cirrhosis

(LC) with portal hypertension (PH) are distinguished by specific severity of clinical presentations, serious

complications and high probability of lethal outcome. Without indications to radical cure of LC – liver

transplantation, the basic direction of surgical treatment for such patients is of portal pool vessels reconstruction

[1-3]. But there are particular indications for portosystemic shunting and it is a big patients group among those in

which such intervention is impossible because of some reasons and it is required to perform another type of

surgical treatment. Among mentioned portoasigos dissociation surgeries remain as a method of choice. The main

advantages of them are maintenance of constant liver portal perfusion, absence of post-shunting encephalopathy

and wider facilities at performing in emergency surgery of esophageal bleedings [4-6]. Besides there is strategic

deficiency in emergency and planned dissociative operation types and a lack of stable late fates. So, after a year

or less active restoration of varices with increasing risk of bleeding recurrence has place [7-9]. The worked-out

and adopted into practice original techs of gastroesophageal collector total dissociation (GECTD) in RSCS named

after acad. V.Vakhidov, have high hemostatic efficiency and are directed on elimination of known surgeries

To cite this paper: Nazyrov FG, Devyatov AV, Babadjanov AKh and Ruziboev SA. 2016. Results of Gastroesophageal Collector Modified Total Dissociation in Patients

with Portal Hypertension. J. Life Sci. Biomed. 6(5): 115-119; www.jlsb.science-line.com

115

defects. The analysis of long-term results of these surgeries with the estimation of their prophylaxis efficiency of

esophageal bleedings and patients survivability presents particular interest.

Original method of GECTD with ligature transection of subcardinal part of stomach with following forming of

gastrogastal collateral anastomosis has been initially worked out (such surgeries has been performed in 63

patients from 1998 to 2007). Surgery stages have included: stomach mobilization through greater stomach

transaction by ligature type at the subcardinal part level; forming of gastrogastal collateral anastomosis above the

ligature. Such type of surgery has two variants of performing: using ligatures or steplers. By gaining an

experience we came to conclusion that a ligature type is more preferable [7, 10].

Analysis of long-term results (from 3 months to 10 years) of performed dissociative operations has been

carried out in 46 patients. Rebleeding has been registered in 10.9% patients, and in 6,5% cases on the background

of anastomositis. Occurrence of gastrostasis have been revealed in 5 of 46 patients. Control endoscopy 3 months

after surgery has revealed stomach recanalization in the area of ligature transection with forming of two ways for

food passage – recanalized natural one and through gastrogastal anastomosis. 19.6% patients died on the

background of complications. Mentioned facts allowed to suppose a probability of performing ligature transection

of stomach subcardinal part on wireframe base with the saving of natural way for food passage without

gastrogastal anastomosis.

MATERIAL AND METHODS

GECTD modified method (F.G. Nazirov’s operation) was adopted in clinical practice in 2008 [10]. Distinctive

feature of new method was that dissociation is achieved because of use intraluminal prosthesis installed during

the surgery.

Method is carried out as follows: approach – upper-midline laparotomy. Proximal devascularization of

stomach up to esophagus abdominal part through greater and lesser curvature is carried out. Organ blood flow is

saved through right gastric and two gastroepiploic arteries. The left gastric artery is ligated and transected. All

short vessels of stomach are also ligated and transected (Figure 1). Then transversal gastrotomy is carried out in

medium part of stomach body along anterior wall and through a formed hole synthetic prosthesis is introduced

into stomach lumen and is located in the lumen of stomach subcardinal part. Above the prosthesis introduced into

stomach lumen, over serous membrane ligature is put in which divides stomach to upper 1/3 and lower 2/3

parts. Ligature is tightened over the prosthesis and at the same time the prosthesis is fixed by surgeon’s finger

introduced into its lumen. So, the prosthesis location and ligature’s tension is controlled. Then repeated ligature is

put in over the first one. Corrugation of the prosthesis provides ligatures’ fixation preventing their displacement

(Figure 2). Nasogastric probe is passed through the prosthesis with the aim of decompression in the

postoperative period. Gastrotomic hole is sutured by double-row suture. A number of sero-serous sutures are

also pit in over stomach ligature. Pyloroplasty is carried out additionally.

Endoscopic investigation is performed after 1-1.5 month and the prosthesis is removed out of stomach

lumen. By this time put in ligatures over it are penetrated into stomach lumen and venous reservoir is dissociated.

Figure 1. Stage of stomach and esophagus

abdominal part devascularization with

gastrotomy.

Figure 2. Stage of ligature transection on the

ring- prosthesis.

To cite this paper: Nazyrov FG, Devyatov AV, Babadjanov AKh and Ruziboev SA. 2016. Results of Gastroesophageal Collector Modified Total Dissociation in Patients

with Portal Hypertension. J. Life Sci. Biomed. 6(5): 115-119; www.jlsb.science-line.com

116

Currently operation has been performed in 73 patients with PH syndrome. In 36 patients the cause of PH

was LC, in 30 patients it has been diagnosed a hepatic form of PH and in 8 cases a combined form of PH has been

determined. Patients age has been varied from 13 to 65 years, thus the median was 31.6 ± 1.7 years. Patients

randomizing by gender was as follows: men - 44, women – 29. In 53 cases patients were admitted in a planned

order, and 20 patients were delivered urgently with the clinical picture of gastroesophageal bleeding. Patients

were underwent both general (clinical and biochemical blood tests, ECG, chest X-ray) and special (liver

radioisotopic investigation, angiographic) investigation methods.

The grade of esophageal varices is estimated by Shertsinger’s classification [11]. The second grade of

esophageal varices has been revealed in all patients. All patients had esophagogastric bleeding in anamnesis and

40 (54.8%) of them - many times. In 13 cases patients additionally have been undergone splenectomy. In 8

(11.0%) patients at admission diabetes mellitus has been revealed.

RESULTS

At the nearest postoperative period the most frequent complication of earlier worked out dissociative

methods were cardiofundal anastomosis insufficiency (11.7% - at planned surgeries and 21.1% - at emergency

interventions). Unlike them, an offered new method is carried out through small gastrotomic hole and such

complications has not been observed. From other side in more 11.1% patients anastomositis development has

been noted which significantly increased the risk of bleeding development from anastomosis zones. Hepatic

failure and encephalopathy have been noted in 15 (23.8%) patients. General lethality in the nearest period made

up 11.1% (7 patients).

Modified ligature transection allowed to level completely the risk of anastomosis failure and to reduce a

frequency of hepatic failure and lethality (Table 1). Radiologic-contrast investigation 10 days after surgery

showed that prosthesis is freely passable; stomach evacuation functions failure has not been observed. One

month after surgery at control endoscopic investigation a synthetic cylinder was removed without technical

difficulties. Regress of esophageal varices has been noted in all cases.

Table 1. Comparative frequency of early postoperative complications in patients with GECTD by different

methods

Complications

Original method

Modified method

Anastomosis failure

7 (11.1%)

2 (3.2%)

Stomach wall necrosis in ligature transection area

2 (2.7%)

12 (16.4%)

7 (9.6%)

Hepatic failure

Lethality

15 (23.8%)

7 (11.1%)

The analysis showed that predisposing factor to stomach wall evident ischemia development with necrosis

probability in ligature area and above prosthesis is because of presence of concomitant diabetes in patients.

Performing stomach devascularization with following ligature transection on the background of diabetic

angiopathy significantly disturbs organ’s trophics and it was a cause of necrosis. At the absence of diabetes

mellitus we did not observe such type of complications. In comparative aspect the risk of stomach necrosis in the

area of transection at diabetes mellitus presence increased up to 25% (in 2 from 8 patients with diabetis). This

fact has influenced to technical aspects of performing dissociative operations in patients with decompensated

stage of diabetes. Currently a surgery is limited only by stomach devascularization with additional ligation of left

gastric vein as basic afflux to gastroesophageal venous reservoir at PH.

Remote period has been observed in 46 patients with primary procedure and in 66 patients with a modified

technique of GECTD. Rebleeding was observed in 15.2% of patients, and 6.5% on the background of

anastomositis. Gastrostasis occurrence was detected in 3 of 46 patients. The phenomena of liver failure occurred

in 23.9% of patients. 15.2% patients died on the background of these complications (Table 2). In the group with a

modified procedure bleeding was observed in 6.0% cases. Two patients with bleeding from esophagus lower one

third were successfully underwent sclerotherapy and there was not noted a following recurrence. Bleedings from

erosion in the area of ligature transection were stopped conservatively. Mortality in long-term period of

observation was 7.6% (5 patients). Overall mortality for the near and distant periods in the comparison groups

was 22.2% and 16.4%, respectively.

To cite this paper: Nazyrov FG, Devyatov AV, Babadjanov AKh and Ruziboev SA. 2016. Results of Gastroesophageal Collector Modified Total Dissociation in Patients

with Portal Hypertension. J. Life Sci. Biomed. 6(5): 115-119; www.jlsb.science-line.com

117

Table 2. Comparative frequency of complications after GECTD in remote period

Complications

Original method

Modified method

Bleeding from esophageal varices

4 (8.7%)

3 (6.5%)

2 (3.0%)

1 (1.5%)

Bleeding from anastomosis area (anastomositis) or ligature transection

Gastrostasis

Hepatic failure

11 (23.9%)

7 (15.2%)

14 (22.2%)

8 (12.1%)

5 (7.6%)

Mortality

Overall mortality in 12 months period

12 (16.4%)

Advantages of GECTD modified method are: refusal from performing cardiofundus anastomosis – natural

tract trough stomach by means of prosthesis fixed in cardinal part is saved; reduction of surgery duration due to

performing gastrotomy without cardiofundal anastomosis; decrease of the risk of gastrotomic hole failure

development – the length of gastrotomy is 3 cm, absence of cardiofundal anastomosis; broad intramural zone of

stomach cardinal part veins dissociation – external application of two ligatures above prosthesis introduced into

stomach cardinal part creates the length of sclerosis up to 1 cm.

Analysis of patients survivability with LC and PH after GECTD showed that the lowest index has been

revealed in the groups with large nodular cirrhotic transformation (survivability median – 24 months), in patients

with bleeding in anamnesis (survivability median – 36 months) and with decompensation by edematous ascitic

syndrome before operative intervention (survivability median – 12 months). Investigation has shown performing

GECTD to patients with LC and high portal pressure increases the risk of hemorrhagic complications development

in early and late postoperative period and respectively decreases survivability indexes till 1 year observation to

62%, 3 years – up to 47% and it is connected not only with hypertension but also with forced technical aspects of

surgery (ligature transection and gastrogastra-anastomosis) on the background of portal gastropathy.

Performing GECTD to patients with LC on the background of edematic-ascitic syndrome decreases

survivability indexes in the period of observation till 1 year up to 48%, 3 years – up to 43% and it is connected

with progressing of two main factors in remote period – portal hypertension and increasing hepatic failure with

functional decompensation of hepatocytes.

GECTD in patients without vascular and edematic-ascitic decompensation of LC with PH increases

survivability indexes in the period of observation till 1 year up to 87%, 3 years – up to 67% and 5 years up to

58%. In other cases on the background of progressing above mentioned complications, it is reasonable to

perform different types of intersystem vascular bypass as basic type of intervention directed to portal system

decompression.

CONCLUSIONS

Dissociation of gastroesophageal venous reservoir by ligature transection on synthetic prosthesis previously

implanted in stomach unlike previously proposed methods of GECTD allows not only to ease the technique of

operation, but also provides prevention of early postoperative complications associated with traumatism of

previous methods, as well as the stomach gross functional disorders in the long term period.

Advanced original tech of GECTD is the most perspective operative method in emergency surgery and in

planned operative interventions in patients with PH syndrome undergone repeated operative treatment or it can

be alternative to portosystemic shunting method, at impossibility of performing the last one. Our investigation

shows that described technique had showed it reliability and efficiency.

Acknowledgements

This work was supported by Republican Specialized Centre of Surgery, Tashkent City, Uzbekistan.

Competing interests

The authors declare that they have no competing interests.

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To cite this paper: Nazyrov FG, Devyatov AV, Babadjanov AKh and Ruziboev SA. 2016. Results of Gastroesophageal Collector Modified Total Dissociation in Patients

with Portal Hypertension. J. Life Sci. Biomed. 6(5): 115-119; www.jlsb.science-line.com

119