2018 SCIENCELINE

Journal of Life Science and Biomedicine

J Life Sci Biomed, 8(2): 24-30, 2018

License: CC BY 4.0

ISSN 2251-9939

Azygoportal Total Dissociative Procedures for Portal

Hypertension Treatment; Evolution of Surgical

Techniques

Feruz Gafurovich NAZIROV, Andrey Vasilyevich DEVYATOV, Azam Khasanovich BABADJANOV,

Umid Ravshanovich SALIMOV ^, and Dilshodbek Mamadaliyevich KHAKIMOV

Republican Specialized Center of Surgery named after acad.V.Vakhidov. Tashkent. Uzbekistan.

Corresponding author’s Email: ussalimov@gmail.com

ABSTRACT

Original Article

PII: S225199391800005-8

The aim of the study was to determine the efficiency of azygoportal collector total

dissociation in patients with portal hypertension. Depending on the procedure, the

patients were divided into two groups. An original method of azygoportal

dissociation was performed in 63 patients (the first group). In the second group a

modified version of azygoportal dissociation was performed. Patients were

Rec. 16 Dec. 2017

Acc. 18 Feb. 2018

Pub. 25 Mar. 2018

comparable in the main pathology and course of the disease. Edematous ascites Keywords

syndrome; liver failure; insufficiency of gasto-gastral anastamosis and

haemorrhagic syndrome, were observed in 28.6%; 23.8%; 11.1%; and 14.3 % of patients

operated by the original method vs. 16.5%; 7,7%; 0%; and 4.4% for patients operated

in the modified technique, respectively. From the results it can be concluded that,

proposed modified method of azygoportal collector dissociation on a prosthesis is

more effective method for hemorrhagic syndrome control, and also allows to

significantly reduce the incidence of severe complications in the immediate

postoperative period.

Liver Cirrhosis,

Portal Hypertension,

Dissociative

Operations,

Ligature Transection

Method,

Bleeding from

Esophageal Varices.

INTRODUCTION

Hemorrhagic syndrome is one of the most severe and unpredictable complication of liver cirrhosis (LC)

with portal hypertension (PH). The bleeding from esophago-gastric varicose (EV), is observed in 20-50% of

patients with LC and clinically significant PH [1-10]. Endoscopic interventions used to control varices bleeding,

due to their low invasiveness and ease of execution, are the first-line methods in treatment and prophylactics of

hemorrhage. However, they remain unsuccessful in 17-37% of patients [11]. Nowadays many different surgical

procedures are known and are frequently used as a second line method in the bleeding control and

prophylactics. Among such methods, liver transplantation (LT), a surgical portosystemic shunting (PSS),

transjugular intrahepatic portosystemic shunting (TIPS) and dissociative interventions are the most frequently

used. It is known that LT is the only curative option for patients suffering from LC. At the same time deficit of

donor organs is still a quite acute problem and many patients in the waiting list will not have a donor organ in

time [12].

To cite this paper: Nazirov F.G., Devyatov A.V., Babadjanov A.Kh., Salimov U.R. and Khakimov D.M. 2018. Azygoportal Total Dissociative Procedures for

Portal Hypertension Treatment; Evolution of Surgical Techniques. J. Life Sci. Biomed. 8(2): 24-30; www.jlsb.science-line.com

From the other hand traditional surgical PSS give a good long time results in bleeding control, but due to

its complexity, its application is limited. Besides in the last decade one can observe significant decrees of

surgical PSS application in contrast to TIPS. But by the opinion of many investigators and with the accordance

to last studies wide popularization of the TIPS is not often reasonable due to some significant lacks of the

method [6, 13, 14]. At the same time, surgical PSS which are more effective in prevention of hemorrhagic

syndrome cannot be performed in all patients. A wide group of patients is out of the possibility for PSS

application due to the liver decomposition or not-typical angioarchitechtonics of the portal pool. In such

circumstances dissociation procedures still remain as the only method choice.

Therefore aim of study was to determine the efficiency of azygoportal collector total dissociation in

patients with portal hypertension.

MATERIAL AND METHODS

A comparative investigation of two azygoportal collector dissociation methods in patients with PH

syndrome has been carried out. Treatment results of 155 patients who were operated at the Republican

Specialized Centre of Surgery (RSCS) named after academician V.Vakhidov from 1997 to 2017 were analyzed.

With the accordance of the total dissociative method, 2 groups of patients were formed. For the patients

of the 1^stgroup, original disconnection method of azygoportal collector was performed. Dissociation of the

gastroesophageal collector in the modified type was performed in patients of the 2^ndgroup. There were 63

patients with PH syndrome in the 1^stgroup: 40 (63.5%) of them had liver cirrhosis and 23 (36.5%) patients were

suffered from extrahepatic form of PH. In 19 (30.2%) cases, the surgery was performed at the peak of the

hemorrhage. Dissociation of the azygoportal collector in combination with splenectomy was carried out in 19

(11.9%) patients. The 2^ndgroup contained 92 patients with portal hypertension. Liver cirrhosis was observed in

57 (62.6%) of patients, 33 (36.3%) – had extra hepatic form of PH. One patient (1.1%) was admitted with Budd-

Chiari syndrome. In 28 (30.7%) cases, the surgery was performed at the peak of the hemorrhage. Dissociation of

the azygoportal collector in combination with splenectomy was carried out in 12 (13.2%) cases. In the other 7

(7.7%) patients, the azygoportal disconnection was supplemented with the ligation of a splenic artery.

F.G. Nazirov’s original method (the 1^stgroup) [Invention №IAP 20080375]

Devascularization of the stomach is carried out after upper laparotomy up to the abdominal part of the

esophagus along both parts of the stomach. The organ blood supply is kept due to right gastric and two

gastroepiploic arteries. Left gastric artery is ligated and dissected out of the organ. Double circular suture is

formed at the subcardial level and the ligature is tightened. Thereby two gastric cameras are formed. The next

stage is the formation of anterior gastro-gastral anastomosis between the upper and the lower parts of the

stomach (were formed by the ligature and transection).

The size of anastomosis camera is up to 3 cm. The important advantage of the surgery is in keeping the

cardioesophageal connection and in the prevention of reflux esophagitis in the postoperative period (Figure 1).

The pointed method allows achieving an effective hemostasis in patients with bleeding from EV. But this

method had the number of complications associated, as a rule, with an imposition of gastro-gastral anastomosis

(GGA). The complications of the nearest postoperative period are presented in the Table 1.

The most dangerous complication of the nearest postoperative period was insufficiency of GGA which

had led to the development of peritonitis. Hepatic failure progresses proportionally to the level of a surgical

injury and its combination with GGA insufficiency was registered in all 11 patients with those complications.

Hereby, the modification of the offered method was developed at the RSCS to eliminate the most frequent and

dangerous complication such as GGA insufficiency.

F.G. Nazirov’s modified method (the 2nd group) [Second invention].

Surgical approach and stomach devascularization are carried out in the same extent as in the original

method. Then a transversal gastrostomy up to 3 cm is carried out in the medium part of the stomach along the

anterior wall. A synthetic polyvinyl prosthesis in the form of corrugated tube with the length of 2,5-3 cm and 2,5

in diameter is introduced through the formed hole to the gastric lumen. That prosthesis is set up in the lumen

of the stomach’s cardial part. Sewing of the stomach both parts through all the layers with capron thread № 5 is

carried out from the anterior wall of the stomach and by medial wall of the intraorgan prosthesis, ligature

divides the stomach to the upper 1/3 and the lower 2/3 parts. The next ligature is imposed in the same way but

To cite this paper: Nazirov F.G., Devyatov A.V., Babadjanov A.Kh., Salimov U.R. and Khakimov D.M. 2018. Azygoportal Total Dissociative Procedures for

Portal Hypertension Treatment; Evolution of Surgical Techniques. J. Life Sci. Biomed. 8(2): 24-30; www.jlsb.science-line.com

it is tighten directly over the prosthesis in the direction of lesser curvature and at the same time the prosthesis

is fixed with surgeon’s finger which is placed in the lumen. In such way we can control the location of the

prosthesis and the tension of the ligature. Then a repeated ligature is imposed near the first one. Thereby we

perform a cross-clamping of intramural venous vessels. A corrugated prosthesis provides the fixing of the

ligatures and blocks their displacement. A nasogastric tube is conducted through the prosthesis with the aim of

decompression in the postoperative period.

Gastrotomic hole is sutured by double-row stitch. A number of sero-serous stitches are also imposed over

the stomach ligature. A Heineke-Mikulicz pyloroplasty is carried out to prevent gastrostasis. The endoscopic

investigation with a removal of the prosthesis is performed after 1-1.5 months and the imposed ligatures are

also removed.

Ethical approval

The review board and ethics committee of Republican Specialized Center of Surgery named after

acad.V.Vakhidov. Tashkent. Uzbekistan approved the study protocol and gave permission.

Table 1. The frequency of postoperative complications in patients operated by the original method

Complication

Abs. frequency

% frequency

23.8%

11,1%

Hepatic failure

Insufficiency of GGA

Hemorrhagic syndrome,(including erosive anastomositis of GGA

Insufficiency of pylorotomic hole

Suppuration of the spleen bed

Arrosive hemorrhage

14.3%

3.2%

Splenic infarction

3.2%

Gastrostasis

1.6%

39.7%

40%

28.6%

30%

23.8%

19.8%

20%

16.5%

14.3%

11.1%

10%

7.7%

6.3%

0.0%

4.4%

3.3%

3.2%

1.6%

3.2%

2.2%

1.1%

2.2%

1.6%

1.1%

0.0%

Oroginal (63)

Modified (91)

Liver insufficience

GGA insufficience

Rebleeding and erosive anastamositis

Gastrostasis

Pylorotomic insufficience

Edemo-ascitic syndrome

Splenic infarction

Spleenic bed supuration

Arosive bleeding

Acute gastric ulcer

Resperatory failier

Intestinal eventration

Disseminated intravascular coagulation

Pulmonary embolism

Insufficiency of dissociation zone

Intestine injury

Suppuration of the spleen bed

Patients with complications

Figure 1. Comparative characteristics of postoperative complications

To cite this paper: Nazirov F.G., Devyatov A.V., Babadjanov A.Kh., Salimov U.R. and Khakimov D.M. 2018. Azygoportal Total Dissociative Procedures for

Portal Hypertension Treatment; Evolution of Surgical Techniques. J. Life Sci. Biomed. 8(2): 24-30; www.jlsb.science-line.com

RESULTS

From 63 patients of the 1^stgroup and 91 patients of the 2^ndwe observed a complicated nearest

postoperative period in 25 (39,7 %) and 18 (19,8%) patients respectively. The structure of complications was as

follows: the edematous ascites syndrome; hepatic failure; insufficiency of GGA and hemorrhagic syndrome the

frequency of which made up 28.6%; 23.8%; 11.1%; and 14.3% versus 16.5%; 7,7%; 0%; and 4.4% for the 1^stand the

2nd groups respectively.

Already as a result of a comparative analysis of the nearest postoperative period, it is possible to judge

the degree of effectiveness of bleeding control is higher in the modified technique. Thus, the frequency of

recurrence of hemorrhagic syndrome in the immediate postoperative period was 3 times higher in patients

operated by the original method and amounted to 14.3% compared with 4.4% of patients operated by a modified

procedure. The overall incidence of complications of the immediate postoperative period is shown in Figure 1.

In addition, an important prediction factor in the effectiveness of surgical treatment is the liver

parenchymal decompensation degree. Thus, the incidence of complications in patients operated in an

emergency was 2-3 times higher, the fact is explained by a higher operational risk in patients with severe

parenchymal decompensation on the background of bleeding. This fact is also confirmed by the incidence of

liver failure in patients hospitalized in urgent order in comparison with those who were operated in a planned

manner.

Thus, , among patients hospitalized on an emergency basis in the 1^stand 2^ndcomparison group, hepatic

insufficiency in the postoperative period was observed in 42.1% (in 8 of 19 patients) against 10.7% (in 3 of 28

patients operated urgently) of patients respectively.

Liver cirrhosis

In consideration of the severity of PH syndrome course in patients with LC we have analyzed the

frequency of complications development in this group of patients who were performed the original and

modified methods. In the nearest postoperative period the frequency of the hepatic failure predominated in

both groups and it complicated a restorative period course in 15 (38.5%) patients of the 1st group and in 7 (12.3%)

patients of the 2nd group. The recurrence of hemorrhagic syndrome was in 7 (17.9%) patients (the 1st group) and

in 4 (7.0%) patients of the 2nd group. The edematous ascitic syndrome rarely occurred in the group of patients

who were performed the original method of surgery – 35.9% vs. 21.1%. The mentioned results are explained by

the direct correlation of edematous ascitic syndrome with the rate of hepatic dysfunction. In connection with

the reduction of the liver protein-synthetic function, both volume and adiaphoria of ascitic syndrome are risen.

The frequency and resistance of the edematous ascitic syndrome is decreased due to significantly less

traumatism of the original method of the surgery and the less rate of hepatocellular failure. In 2 (3.5%) cases of

the 2^ndgroup we registered the development of dissociative zone’s failure. In 1 case the mentioned complication

was developed in the patient who was performed the surgery having an active hemorrhage and a severe form of

diabetes mellitus. In the second case that complication was developed in the patient with a total thrombosis of

the portal vein and massive collateral circulation of cardioesophageal transition and retroperitoneal space (that

case required a total devascularization of the stomach). In both cases the complication was solved by

conservative procedures. There were 18 (46.2%) patients with different complications (the 1^stgroup) and 15

(26.3%) patients in the 2^ndgroup.

Extra hepatic form of portal hypertension

It is known that the prognosis of the disease in patients with extrahepatic portal hypertension (APH) is

more favorable then in patients with a compromised liver. But according to some literary data, only in 12% of

patients recanalization of the portal vein is observed in the rest of cases a clinically significant PH syndrome is

formed and it is required an operative correction. The operative treatment results of the patients with the safe

live function who were performed original and modified surgeries were studied. We did not observe the

laboratory manifestations of hepatic failure in patients of both groups. But an occurrence of the edematous

ascitic syndrome was observed in 4 (16.7%) cases of the 1st and in 3 (9.1%) patients of the 2nd groups. The

recurrence of hemorrhagic syndrome was registered in 2 (8.3%) patients of the 1^stgroup. There was no

hemorrhage recurrence in the 2^ndgroup. The postoperative period was complicated in 7 (29,2%) and 3 (9.1%)

patients with APH.

To cite this paper: Nazirov F.G., Devyatov A.V., Babadjanov A.Kh., Salimov U.R. and Khakimov D.M. 2018. Azygoportal Total Dissociative Procedures for

Portal Hypertension Treatment; Evolution of Surgical Techniques. J. Life Sci. Biomed. 8(2): 24-30; www.jlsb.science-line.com

The lethality of patients who undergone original and modified methods of the surgery

The patient’s lethality also differed in both groups - it proves that a modified method is more effective.

The lethality of the 1^stgroup (original method) made up 10 (15.9%) cases, and in the 2^ndgroup it was 10 (11%)

patients . At the same time, even a lethality rate reaching 15.9% significantly differs from the stated rate which

is typical for many other methods used in the world today. For example, by different authors data, a hospital

lethality of the nearest postoperative period is observed in (35-75%) cases after a surgery offered by Boerema et

al. [4] and in 20-55% - after the Sugiura’s surgery [1, 2, 4, 14]. The hospital lethality after the M.D. Patsiora’s

surgery does not exceed 15% vs. 11% for the patients who were performed F.G.Nazirov’s modified surgery.

According to a comparatively low postoperative lethality which is typical for M.D.Patsiora’s surgery the

frequency of the hemorrhagic syndrome recurrence in the nearest postoperative period reaches 20% vs. 4.4% of

F.G.Nazirov’s modified surgery.

In our investigation the causes of the hospital lethality in the 1^stgroup were: the hemorrhagic syndrome;

hepatic failure; insufficiency of pylorotomic hole, corrosion hemorrhage which made up 4 (6%), 4 (6%), 1 (2%) and

1 (2%). In the 2^ndgroup the causes of the hospital lethality were the hemorrhagic syndrome; hepatic failure;

insufficiency of pylorotomic hole; corrosion hemorrhage and intestinal perforation which were observed in 3

(3.3%); 3 (3.3%); 2 (2.2%); 1 (1.1%); and 1 (1.1%) patients.

DISCUSSION

Azygoportal dissociation method in patients with LC is of a less risk of hepatic failure and

encephalopathy. Dissociative procedures can be applied at the peak of hemorrhage and are easy to perform. But,

in spite of a big quantity of such surgeries, almost all of them are followed by either early hemorrhage

recurrence, or high operative trauma and low survival rates. As an example the frequency of hemorrhage

recurrence following N. Tanner’s surgery is 35-45% [1, 16]. After M.D. Patsiora’s surgery this index can make up

to 20% and more. Besides, in 8-14% of cases it is impossible to achieve bleeding control during the surgery [1, 16].

The M.A. Hassab’s surgery which is widely-spread among the Asian-Pacific countries allows to reliably

control the hemorrhagic syndrome. At the same time, a negative peculiarity of this method is a conservation of

plethoric intramural veins of esophagus and stomach which also stipulates a high frequency of the hemorrhage

recurrence (up to 25-34%) up to 5 years of observation [1, 17, 18].

One of the well-known and inconsistent methods of azygoportal total dissociation is the Sugiura’s and S.

Futagava’s surgery. The method has been upgraded many times with the aim of saving hemorrhage control

results on the background of operative trauma reductions and [1, 19]. Though more than 20 modifications of the

surgery has been offered but sill postoperative lethality remains high and can reach 50%.

The development and adoption of TIPS seemed to be a perspective method [15, 20]. But the recent wide

investigations showed that this method also had serious disadvantages. A number of the late researches give

significant defects of TIPS vs. porto-systemic shunting. Hosokawa et al. [21] states that a frequency of the

hepatic encephalopathy was observed by them 1.5 times more frequent in patients performed TIPS vs.

traditional interventions (39% vs. 26%) [21].

Shunt occlusion was developed in 26% of patients after TIPS and was not observed in patients after the

surgical portosystemic shunting. But, as it is mentioned above, in spite of the advantages of surgical shunting

interventions it is not always possible to perform them.

Thereby, nowadays there is no operative technique in the world which can be called “a golden standard”

in the treatment of bleedings from esophageal varices. In this connection we have developed an original type of

the operative intervention in our

Hereby, the results of this study allowed regarding the F.G.Nazirov’s surgery as a competitive prevention

and treatment method for hemorrhagic syndrome in patients with the PH in the conditions of impossibility to

perform surgical shunting and at the ineffective endoscopic hemostasis.

CONCLUSION

In conclusion it can be said that postoperative complication rates and lethality, showed a significantly

lower rates in the modified technique group than in any of known analogues. A modification of the original

method of gastroesophageal collector dissociation allowed to reduce the frequency of such complications as

To cite this paper: Nazirov F.G., Devyatov A.V., Babadjanov A.Kh., Salimov U.R. and Khakimov D.M. 2018. Azygoportal Total Dissociative Procedures for

Portal Hypertension Treatment; Evolution of Surgical Techniques. J. Life Sci. Biomed. 8(2): 24-30; www.jlsb.science-line.com

edematous ascitic syndrome; hepatic failure; insufficiency of GGA and hemorrhagic syndrome from 28.6%;

23.8%; 11.1%; and 14.3 in the original method up to 16.5%; 7,7%; 0%; and 4.4% for the modified method.

DECLARATIONS

Authors’ Contributions

All authors contributed equally to this work.

Acknowledgements

This work was supported by Republican Specialized Center of Surgery named after acad.V.Vakhidov.

Tashkent.

Competing interests

The authors declare that they have no competing interests.

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To cite this paper: Nazirov F.G., Devyatov A.V., Babadjanov A.Kh., Salimov U.R. and Khakimov D.M. 2018. Azygoportal Total Dissociative Procedures for

Portal Hypertension Treatment; Evolution of Surgical Techniques. J. Life Sci. Biomed. 8(2): 24-30; www.jlsb.science-line.com