Hand-assisted Laparoscopic Splenectomy and Devascularization of the Upper Stomach in the Management of Gastric Varices

Yamamoto, Joji; Nagai, Motoki; Smith, Barry; Tamaki, Satoshi; Kubota, Tadao; Sasaki, Ken; Ohmori, Toshihiro; Maeda, Kiyotaka

BACKGROUND: Bleeding from esophagogastric varices is the major cause of death in patients with portal hypertension. Although esophageal varices can be treated with endoscopic procedures, the treatment for gastric varices is still controversial. The aim of this study was to describe a surgical technique and our preliminary results of hand-assisted laparoscopic Hassab’s procedure. METHODS: Between February 2002 and May 2005, we performed 7 cases of gastric varices with this type of operation. The patients included 4 men and 3 women who ranged in age from 23 to 74 years (underlying liver disease: 5 case of liver cirrhosis, 1 case of polycystic disease, 1 case of extrahepatic portal vein obstruction). After splenctomy was performed, we devascularized the vessels of the upper stomach and the esophagus 5 cm away from the esophago-cardia junction. RESULTS: The operative time ranged from 132 to 290 minutes. Intraoperative blood loss was estimated to be from 50 ml to 475 ml. The weight of removed spleen ranged from 110 g to 800 g. During the follow-up period, all gastric varices disappeared and no bleeding from varicose veins was observed. All patients had hypersplenism with thrombocytopenia before surgery (mean: 11.1 ± 7.4 × 10(4)/ml), which was improved postoperatively (mean: 30.8 ±19.0 × 10(4)/ml). This data were statistically significant (P = 0.033). One patient died of aspiration pneumonia related to postoperative pyloric stricture. CONCLUSIONS: Although there is no agreement concerning the best treatment of gastric varices, the hand-assisted laparoscopic Hassab’s operation is a safe, moderately invasive method, and its outcome appears to be equal to that of other open procedures.