Laparoscope-assisted Hassab’s Operation for Esophagogastric Varices After Living Donor Liver Transplantation: A Case Report T. Kobayashi, K. Miura, H. Ishikawa, H. Oya, Y. Sato, M. Minagawa, J. Sakata, K. Takano, K. Takizawa, H. Nogami, S.-I. Kosugi, and T. Wakai ABSTRACT This is the first successful report of a laparoscope-assisted Hassab’s operation for esophagogastric varices after living donor liver transplantation (LDLT). A 35-year-old man underwent LDLT using a right lobe graft as an aid for primary sclerosing cholangitis (PSC) in 2005. Follow-up endoscopic and computed tomography (CT) examinations showed esophagogastric varices with splenomegaly in 2009 that increased (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2]; gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderator enlarged, beady varices [F2], absent red color signs [RC0]). A portal venous flow to the esophagogastric varices through a large left gastric vein was also confirmed. Preoperative Child-Pugh was grade B and score was 9. Because these esophagogastric varices had a high risk of variceal bleeding, we proceeded with a laparoscope-assisted Hassab’s operation. Operative time was 464 minutes. Blood loss was 1660 mL. A graft liver biopsy was also performed and recurrence of PSC was confirmed histologically. It was suggested that portal hypertension and esophagogastric varices were caused by recurrence of PSC. Postoperative complications were massive ascites and enteritis. Both of them were treated successfully. This patient was discharged on postoperative day 43. Follow-up endoscopic study showed improvement in the esophagogastric varices (esophageal varices [EV]: locus superior [Ls], no varicose appearance [F0], absent red color signs [RC0], gastric varices [GV]: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) at 6 months after the operation. We also confirmed the improvement of esophagogastric varices by serial examinations of CT.
E
SOPHAGOGASTRIC variceal bleeding is a major life-threatening complication of portal hypertension resulting from liver cirrhosis [1]. Although most patients can be treated endoscopically, some still require surgery such as esophagogastric decongestion and splenectomy (Hassab’s procedure) [2]. We herein report a rare case of severe esophagogastric varices in a recipient 4 years after living donor liver transplantation (LDLT) for primary sclerosing cholangitis (PSC) with successful result by laparoscopeassisted Hassab’s procedure. CASE REPORT This 35-year-old man underwent LDLT using a right lobe graft as an aid for PSC in 2005. Follow-up endoscopic and computed tomography (CT) examinations showed esophagogastric varices with 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.10.047 986
splenomegaly in 2009 that increased (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], F2, absent red color signs [RC0]) (Figs 1A, 1B) [3]. A portal venous flow to the esophagogastric varices through a large left gastric vein was also confirmed. Because these
From the Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan. Address reprint requests to Takashi Kobayashi, MD, PhD, Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachi-dori, Chu-o-ku, Niigata, Japan, 951-8510. E-mail: [email protected] ª 2014 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 986e988 (2014)
LAPAROSCOPE-ASSISTED HASSAB’S OPERATION
987
Fig 1. (A, B) A preoperative endoscopic study showed esophagogastric varices (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderator enlarged, beady varices [F2], absent red color signs [RC0]). (C, D) A follow-up endoscopic study showed the improvement of esophagogastric varices (EV: no varicose appearance [F0], absent red color signs [RC0], GV: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) [3] at 6 months after the operation.
esophagogastric varices had a high risk of variceal bleeding, we proceeded with a laparoscope-assisted Hassab’s operation. Preoperative Child-Pugh was grade B and score was 9. For surgery, the patient was placed in a semi-lateral position with the left flank elevated at a 45 angle. While dissecting the spleno-gastric ligaments and the splenic hilar pedicle, the operating table was rotated to render the patient into a horizontal position. A 7.5-cm midline incision was made to introduce a hand port (GelPort, Applied Medical, Rancho Santa Margarita, Calif, United States). A 12-mm laparoscope trocar was inserted through an incision on the umbilicus, and a flexible-type laparoscope (LTF Type V3, Olympus, Tokyo, Japan) was introduced through the trocar. Two other 12-mm trocars were inserted under visual control into the left side of the umbilicus and the left flank of the anterior axillar line, respectively, and one 5-mm trocar was inserted into the left subcostal area. Splenic attachments were divided using electrocautery, an ultrasound dissector, and the LigaSure vessel-sealing system (Covidien, Boulder, Colo, United States). The splenogastric ligaments were first dissected using the LigaSure vessel-sealing system. Next, we dissected the splenocolic ligament and mobilized the spleen to visualize the retroperitoneal attachments. After the upper pole of the spleen was entirely dissected away from the diaphragm, we transected the splenic hilar pedicles with an endoscopic linear vascular stapler (Endo-GIA, United States Surgical, Norwalk, Conn, United States). The resected spleen was placed in a plastic bag for extraction through the hand port. Then, devascularization of the upper stomach was performed in an inferior-to-superior direction with the LigaSure vessel-sealing system. After isolation of the anterior and posterior vagus nerves, they were dissected superior to a point approximately 7 cm from the esophagogastric junction. The weight of the spleen was 1835 grams. Operative time was 464 minutes. Blood loss was
1660 mL. A graft liver biopsy was also performed and recurrence of PSC was confirmed histologically. It was suggested portal hypertension and esophagogastric varices were caused by recurrence of PSC. Postoperative complications were massive ascites and enteritis. Both of them were treated successfully. This patient was discharged on postoperative day 43. Follow-up endoscopic study showed the improvement in the esophagogastric varices (EV: locus superior [Ls], no varicose appearance [F0], absent red color signs [RC0], GV: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) [3] at 6 months after the operation (Figs 1C, 1D). We also confirmed the improvement of esophagogastric varices by serial examinations of CT.
DISCUSSION
This is the first successful report of a laparoscope-assisted Hassab’s operation for esophagogastric varices after LDLT. Esophagogastric variceal bleeding is a major life-threatening complication of portal hypertension resulting from liver cirrhosis. Liver transplantation is the definitive and final treatment in patients with terminal liver disease. At the same time, it restores normal portal circulation. Unfortunately, our patient was diagnosed with the severe esophagogastric varices because of the recurrence of PSC 4 years after LDLT. Although endoscopic treatment by endoscopic sclerotherapy or endoscopic variceal ligation is now the main treatment for esophagogastric varices, Hassab’s procedure is sometimes used for recurrent cases of esophagogastric varices or solitary gastric varices [4]. Because of the cumulative experiences of
988
laparoscopic surgeries and recent advances in operating devices, especially vessel sealing systems, laparoscopic approaches have been increasingly indicated in various fields, including for patients with liver cirrhosis and portal hypertension [5]. In our institute, laparoscope-assisted Hassab’s operation is indicated for the treatment of patients diagnosed with esophagogastric varices with hypersplenism, gastric varices difficult to treat by interventional radiology, and esophageal varices resistant to endoscopic treatment; however, the procedure is contraindicated for cases of ChildPugh grade C. The laparoscope-assisted Hassab’s operation for esophagogastric varices was effective in a short follow-up period. However, continued follow-up will be necessary to determine the long-term efficacy of the laparoscope-assisted Hassab’s operation.
KOBAYASHI, MIURA, ISHIKAWA ET AL
REFERENCES [1] El-Serag HB, Everhart JE. Improved survival after variceal hemorrhage over an 11-year period in the Department of Veterans Affairs. Am J Gastroenterol 2000;95:3566e73. [2] Yamamoto J, Nagai M, Smith B, et al. Hand-assisted laparoscopic splenectomy and devascularization of the upper stomach in the management of gastric varices. World J Surg 2006;30:1520e5. [3] Tajiri T, Yoshida H, Obara K, et al. General rules for recording endoscopic findings of esophagogastric varices (2nd edition). Dig Endosc 2010;22:1e9. [4] Wu YK, Wang YH, Tsai CH, et al. Modified Hassab procedure in the management of bleeding esophageal varicesda twoyear experience. Hepatogastroenterology 2002;49:205e7. [5] Wang Y, Zhan X, Zhu Y, et al. Laparoscopic splenectomy in portal hypertension: a single-surgeon 13-year experience. Surg Endosc 2010;24:1164e9.
E
SOPHAGOGASTRIC variceal bleeding is a major life-threatening complication of portal hypertension resulting from liver cirrhosis [1]. Although most patients can be treated endoscopically, some still require surgery such as esophagogastric decongestion and splenectomy (Hassab’s procedure) [2]. We herein report a rare case of severe esophagogastric varices in a recipient 4 years after living donor liver transplantation (LDLT) for primary sclerosing cholangitis (PSC) with successful result by laparoscopeassisted Hassab’s procedure. CASE REPORT This 35-year-old man underwent LDLT using a right lobe graft as an aid for PSC in 2005. Follow-up endoscopic and computed tomography (CT) examinations showed esophagogastric varices with 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.10.047 986
splenomegaly in 2009 that increased (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], F2, absent red color signs [RC0]) (Figs 1A, 1B) [3]. A portal venous flow to the esophagogastric varices through a large left gastric vein was also confirmed. Because these
From the Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan. Address reprint requests to Takashi Kobayashi, MD, PhD, Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757, Asahimachi-dori, Chu-o-ku, Niigata, Japan, 951-8510. E-mail: [email protected] ª 2014 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 986e988 (2014)
LAPAROSCOPE-ASSISTED HASSAB’S OPERATION
987
Fig 1. (A, B) A preoperative endoscopic study showed esophagogastric varices (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderator enlarged, beady varices [F2], absent red color signs [RC0]). (C, D) A follow-up endoscopic study showed the improvement of esophagogastric varices (EV: no varicose appearance [F0], absent red color signs [RC0], GV: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) [3] at 6 months after the operation.
esophagogastric varices had a high risk of variceal bleeding, we proceeded with a laparoscope-assisted Hassab’s operation. Preoperative Child-Pugh was grade B and score was 9. For surgery, the patient was placed in a semi-lateral position with the left flank elevated at a 45 angle. While dissecting the spleno-gastric ligaments and the splenic hilar pedicle, the operating table was rotated to render the patient into a horizontal position. A 7.5-cm midline incision was made to introduce a hand port (GelPort, Applied Medical, Rancho Santa Margarita, Calif, United States). A 12-mm laparoscope trocar was inserted through an incision on the umbilicus, and a flexible-type laparoscope (LTF Type V3, Olympus, Tokyo, Japan) was introduced through the trocar. Two other 12-mm trocars were inserted under visual control into the left side of the umbilicus and the left flank of the anterior axillar line, respectively, and one 5-mm trocar was inserted into the left subcostal area. Splenic attachments were divided using electrocautery, an ultrasound dissector, and the LigaSure vessel-sealing system (Covidien, Boulder, Colo, United States). The splenogastric ligaments were first dissected using the LigaSure vessel-sealing system. Next, we dissected the splenocolic ligament and mobilized the spleen to visualize the retroperitoneal attachments. After the upper pole of the spleen was entirely dissected away from the diaphragm, we transected the splenic hilar pedicles with an endoscopic linear vascular stapler (Endo-GIA, United States Surgical, Norwalk, Conn, United States). The resected spleen was placed in a plastic bag for extraction through the hand port. Then, devascularization of the upper stomach was performed in an inferior-to-superior direction with the LigaSure vessel-sealing system. After isolation of the anterior and posterior vagus nerves, they were dissected superior to a point approximately 7 cm from the esophagogastric junction. The weight of the spleen was 1835 grams. Operative time was 464 minutes. Blood loss was
1660 mL. A graft liver biopsy was also performed and recurrence of PSC was confirmed histologically. It was suggested portal hypertension and esophagogastric varices were caused by recurrence of PSC. Postoperative complications were massive ascites and enteritis. Both of them were treated successfully. This patient was discharged on postoperative day 43. Follow-up endoscopic study showed the improvement in the esophagogastric varices (EV: locus superior [Ls], no varicose appearance [F0], absent red color signs [RC0], GV: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) [3] at 6 months after the operation (Figs 1C, 1D). We also confirmed the improvement of esophagogastric varices by serial examinations of CT.
DISCUSSION
This is the first successful report of a laparoscope-assisted Hassab’s operation for esophagogastric varices after LDLT. Esophagogastric variceal bleeding is a major life-threatening complication of portal hypertension resulting from liver cirrhosis. Liver transplantation is the definitive and final treatment in patients with terminal liver disease. At the same time, it restores normal portal circulation. Unfortunately, our patient was diagnosed with the severe esophagogastric varices because of the recurrence of PSC 4 years after LDLT. Although endoscopic treatment by endoscopic sclerotherapy or endoscopic variceal ligation is now the main treatment for esophagogastric varices, Hassab’s procedure is sometimes used for recurrent cases of esophagogastric varices or solitary gastric varices [4]. Because of the cumulative experiences of
988
laparoscopic surgeries and recent advances in operating devices, especially vessel sealing systems, laparoscopic approaches have been increasingly indicated in various fields, including for patients with liver cirrhosis and portal hypertension [5]. In our institute, laparoscope-assisted Hassab’s operation is indicated for the treatment of patients diagnosed with esophagogastric varices with hypersplenism, gastric varices difficult to treat by interventional radiology, and esophageal varices resistant to endoscopic treatment; however, the procedure is contraindicated for cases of ChildPugh grade C. The laparoscope-assisted Hassab’s operation for esophagogastric varices was effective in a short follow-up period. However, continued follow-up will be necessary to determine the long-term efficacy of the laparoscope-assisted Hassab’s operation.
KOBAYASHI, MIURA, ISHIKAWA ET AL
REFERENCES [1] El-Serag HB, Everhart JE. Improved survival after variceal hemorrhage over an 11-year period in the Department of Veterans Affairs. Am J Gastroenterol 2000;95:3566e73. [2] Yamamoto J, Nagai M, Smith B, et al. Hand-assisted laparoscopic splenectomy and devascularization of the upper stomach in the management of gastric varices. World J Surg 2006;30:1520e5. [3] Tajiri T, Yoshida H, Obara K, et al. General rules for recording endoscopic findings of esophagogastric varices (2nd edition). Dig Endosc 2010;22:1e9. [4] Wu YK, Wang YH, Tsai CH, et al. Modified Hassab procedure in the management of bleeding esophageal varicesda twoyear experience. Hepatogastroenterology 2002;49:205e7. [5] Wang Y, Zhan X, Zhu Y, et al. Laparoscopic splenectomy in portal hypertension: a single-surgeon 13-year experience. Surg Endosc 2010;24:1164e9.
