Helmy A, Abdelkader Salama I, Schwaitzberg S D
Department of Surgery, National Liver Institute, Menouphyia University, Shibin Elkom, Egypt.
Surg Endosc. 2003 Oct;17(10):1614-9. doi: 10.1007/s00464-002-8928-1. Epub 2003 Jul 21.
Bleeding from esophageal varices is the major cause of death in patients with portal hypertension. The ideal surgical procedure should effectively control bleeding and maintain liver function with low rates of encephalopathy. Based on this objective, laparoscopic devascularization of the lower esophagus and upper stomach was studied.
Eighteen patients were studied prospectively who underwent a laparoscopic esophagogastric devascularization procedure for variceal hemorrhage. The diaphragmatic hiatus and esophagus are dissected. The lower 7 or 8 cm of esophagus is devascularized. Devascularization of the gastric fundus is then accomplished by meticulous dissection and ligation of the short gastric vessels. The hepatogastric ligament is opened, permitting identification and isolation/ligation of the left gastric vessels. The dissection and ligation of the vessels at lesser curvature proceeded up to the diaphragmatic hiatus with devascularization of the external varices from the retroperitoneum or mediastinum at the esophagogastric junction.
Mean operating room time was 111 min (range, 80-140 min) (6 emergent/12 elective). Mean blood loss 388 ml (range, 150-650 ml). Intensive care unit stay averaged 48 h, with a mean hospitalization of 11 days. Liver function and coagulation parameters remained stable postoperatively. Duplex sonography on the portal and splenic veins revealed patency in all patients. The flow velocity in the portal vein decreased from 15.5 +/- 4.1 to 13.4 +/- 3.5 cm/s postoperatively ( p = 0.021). Splenic vein velocity was unchanged. Bleeding recurred in 6 patients, and grade 1 encephalopathy developed in 1 patient. Follow-up endoscopy (8-24 months) demonstrated substantial reduction in variceal grade.
Laparoscopic devascularization of the lower esophagus and the upper stomach is technically feasible and promising. Rapid recovery and control of variceal hemorrhage are accomplished in most patients without exposing them to the risk of open surgery.
食管静脉曲张出血是门静脉高压患者的主要死亡原因。理想的手术方法应能有效控制出血并维持肝功能，同时降低肝性脑病的发生率。基于这一目标，对腹腔镜下食管下段和胃上段去血管化进行了研究。
对18例因静脉曲张出血接受腹腔镜食管胃去血管化手术的患者进行前瞻性研究。解剖膈裂孔和食管。对食管下段7或8厘米进行去血管化。然后通过仔细解剖和结扎胃短血管完成胃底去血管化。打开肝胃韧带，以便识别和分离/结扎胃左血管。在小弯处对血管进行解剖和结扎，直至膈裂孔，同时对食管胃交界处的后腹膜或纵隔外静脉曲张进行去血管化。
平均手术时间为111分钟（范围80 - 140分钟）（6例急诊/12例择期）。平均失血量388毫升（范围150 - 650毫升）。重症监护病房平均住院时间为48小时，平均住院时间为11天。术后肝功能和凝血参数保持稳定。门静脉和脾静脉的双功超声检查显示所有患者血管通畅。门静脉血流速度术后从15.5±4.1降至13.4±3.5厘米/秒（p = 0.021）。脾静脉血流速度未改变。6例患者出血复发，并发生1例1级肝性脑病。随访内镜检查（8 - 24个月）显示静脉曲张程度显著降低。
腹腔镜下食管下段和胃上段去血管化在技术上是可行且有前景的。大多数患者能快速康复并控制静脉曲张出血，且无需承受开放手术的风险。
