Justification of the Principles of Minimally Invasive Surgery in the Prevention and Treatment of Bleeding from Varicose Dilated Esophageal Veins

The dissertation is devoted to the justification of the principles of minimally invasive surgery in the prevention and treatment of bleeding from varicose dilated oesophageal veins in patients with portal hypertension syndrome. The research encompasses comprehensive examination and treatment of this category of patients, including ultrasonic diagnosis of portal blood flow, endoscopic haemostasis methods, including endoscopic ligation of varicose dilated oesophageal veins, transjugular intrahepatic portosystemic shunting (TIPS), and pharmacotherapy with synthetic somatostatin analogues. The study develops risk assessment criteria for the first haemorrhagic episode, optimal treatment and prevention schemes for bleeding, and an algorithm for managing patients with portal hypertension syndrome and varicose dilated oesophageal veins. Special attention is given to the evaluation of the effectiveness of minimally invasive methods, their complications, and remote observation of patients.

Relevance of the problem: The treatment of complications of portal hypertension is one of the most urgent and complex unresolved problems in medicine. Over the past decades, there has been an increase in the number of patients with liver cirrhosis worldwide — the most common cause of the development of portal hypertension [30,431]. According to the World Health Organization (WHO), mortality from liver cirrhosis and its complications currently ranks eighth in the structure of overall mortality [30,121]. Many authors associate these unfavourable trends with increased alcohol consumption, rising incidence of viral hepatitis, increased consumption of medications, and insufficient knowledge of many aspects of the pathogenesis of liver diseases in general [18,43,209].

The danger of the development of portal hypertension syndrome is primarily associated with the occurrence of a whole range of complications that pose a real threat to the patient's life, among which are bleeding from varicose veins of the oesophagus and stomach, ascites, and hepatic encephalopathy. The most formidable, by right, is considered to be bleeding from varicose dilated oesophageal and gastric veins (Oesophageal and Gastric Varices, OG), as mortality from the first episode of bleeding amounts to 50–70% [8,38,68,208]. Yet another 30–50% of the remaining patients eventually die from recurrence of bleeding, as within the first two years from the moment of the first haemorrhagic episode, bleeding recurs in 100% of patients [8,24,38,77,91,271]. The high percentage of complications and low survival rate of patients dictate the necessity of improving the treatment strategy for oesophago-gastric bleeding of portal origin, which should be based on knowledge of the pathogenesis of their occurrence and a differentiated approach to their treatment.

At present, to arrest and prevent recurrent bleeding from oesophageal varices, agents of conservative, surgical, radiological-endovascular, and endoscopic haemostasis are used, although such a variety of methods speaks rather of their overall unsatisfactory results. On the other hand, poor tolerance of patients with liver cirrhosis of any surgical interventions has led to the active search and development of a rational combination of minimally invasive procedures. By way of expression, minimal invasiveness has become the main direction in the evolution of modern surgery of portal hypertension [71,85,107,170]. One of the most important minimally invasive directions in the treatment of this category of patients is associated with the development of endoscopic techniques, the appearance of new reliable methods of endoscopic haemostasis, and above all this concerns the method of endoscopic ligation. At present, both worldwide and in our country, a certain experience has been accumulated in the application of this technique; however, the dangers and possible complications of the method have not been fully studied, clear timings of its performance have not been determined, clear indications and contraindications have not been established, and finally, its role and place in complex therapy of patients with oesophageal varices have not been clarified [8,148].

The second important step in improving the results of treatment of patients with portal hypertension syndrome and bleeding from oesophageal varices was the development and introduction into practice of methods of endovascular haemostasis, and in particular the method of transjugular intrahepatic portosystemic shunting. Since the publication of Rosch S. et al. in 1969 [232] on the first successful experimental attempt at transjugular intrahepatic portosystemic shunting (TIPS) in some specialised foreign clinics, a certain experience in such manipulations has been accumulated. In our country, this technique has not yet received wide dissemination due to its high cost. (Isolated reports encountered in domestic literature do not allow an adequate assessment of the effectiveness of the technique and its significance in the treatment of bleeding of portal origin [57,59].

High mortality during the first episode of bleeding from oesophageal varices determines the significance of developing clear risk criteria for the development of the first haemorrhagic episode, which would allow determining indications for primary prophylaxis of bleeding and the timings of its performance.

The relevance of the problem is also determined by the fact that at present there is no standard treatment programme for this complication of portal hypertension syndrome, which dictates the necessity of developing a clear surgical strategy for managing patients, encompassing the full arsenal of conservative, endoscopic, endovascular, and surgical haemostasis methods.

The unresolved nature of the indicated questions, their indisputable practical significance justify the relevance of the problem associated with the treatment of patients with portal hypertension syndrome complicated by bleeding from oesophageal varices. Thus, the aim of our work was:

To improve the results of treatment of patients with portal hypertension syndrome and bleeding from varicose dilated oesophageal veins.

In accordance with the aim, the following tasks were determined:

1) To study the ultrasonic characteristics of blood flow in the portal vein system in healthy volunteers and compare them with similar values in patients with portal hypertension syndrome;

2) Based on computer processing of endoscopic, clinical-anamnestic, laboratory, and ultrasonic data to determine risk factors for the development of the first episode of bleeding from varicose dilated oesophageal veins and to develop a mathematical model for its prognosis.

3) To assess the effectiveness of endoscopic ligation in primary prophylaxis of bleeding from varicose dilated oesophageal veins.

4) To determine indications for the application of endoscopic ligation in the treatment of patients with ongoing and established bleeding from varicose dilated oesophageal veins and to assess its effectiveness;

5) Based on comprehensive remote examination of patients to assess the remote results of endoscopic ligation,

6) To study the most frequent complications of endoscopic ligation of varicose dilated oesophageal veins, to develop optimal methods for their prevention and treatment.

7) To assess the early and remote results of transjugular intrahepatic portosystemic shunting in the treatment of bleeding from oesophageal varices; to determine the role and place of this method in the comprehensive treatment programme for this category of patients;

8) Based on a comprehensive assessment of the dynamics of portal blood flow to determine the effectiveness of synthetic analogues of somatostatin in the treatment of patients with bleeding from oesophageal varices.

9) Taking into account the obtained results, to develop and justify an algorithm for the prevention and treatment of bleeding from oesophageal varices.

Novelty of the research:

For the first time, criteria for the threat of the first haemorrhagic episode in patients with portal hypertension syndrome and oesophageal varices have been developed, and the optimal method of primary prophylaxis of bleeding has been determined.

An analysis has been conducted and the effectiveness of endoscopic ligation as a method for prophylaxis of bleeding from varicose dilated oesophageal veins has been assessed.

An optimal scheme for conservative treatment of patients with bleeding from oesophageal varices has been determined, which includes synthetic analogues of somatostatin, the effectiveness of which has been proven on a sufficiently large clinical material.

For the first time, a method for intravariceal endoscopic manometry of oesophageal varices has been developed and introduced into practice, which allows assessing the dynamics of changes in pressure in oesophageal varices during the administration of various agents of conservative haemostasis.

The effectiveness of endoscopic ligation in the prevention of recurrence of haemorrhage in patients with established bleeding from varicose dilated oesophageal veins has been proven on a large clinical material.

Among the first in our country, the complications of endoscopic ligation have been studied and possible ways of their prevention and treatment have been justified.

Analysis of the results of the conducted research has made it possible to determine optimal groups of patients for whom endoscopic ligation is indicated.

It has been proven that effective eradication of varicose dilated oesophageal veins is achieved by performing repeated sessions of endoscopic ligation at remote observation timings.

The role and place of transjugular intrahepatic portosystemic shunting in the treatment of patients with bleeding from oesophageal varices have been determined, and recommendations for remote observation of patients who have undergone TIPS have been developed.

An algorithm for managing patients with portal hypertension syndrome and oesophageal varices has been proposed.

Practical significance of the research.

Criteria for the threat of the first episode of bleeding from oesophageal varices have been determined, based on clinical-anamnestic, endoscopic data, and ultrasonic parameters of blood flow in the portal system. When there is a high threat of the first haemorrhagic episode from oesophageal varices, endoscopic ligation of varicose dilated oesophageal veins is recommended as the most optimal method of prophylaxis of bleeding from oesophageal varices.

It has been proven that endoscopic ligation of oesophageal veins during ongoing bleeding is practically impossible due to poor visibility. Endoscopic ligation is advisable to perform after achieving temporary haemostasis using a probe-tamponade and medication.

It has been proven that the use of endoscopic ligation in cases of bleeding from oesophageal varices allows avoiding recurrence of bleeding in the majority of patients.

It has been proven on a large clinical material that the most frequently encountered complications after endoscopic ligation are recurrence of bleeding, subfebrile temperature, and sensation of a foreign body in the oesophagus; methods for their prevention and treatment have been developed.

The role and place of transjugular intrahepatic portosystemic shunting in the management scheme of patients with bleeding from oesophageal varices and cirrhosis of class C, in whom endoscopic haemostasis methods proved ineffective and surgical interventions are intolerable due to pronounced hepatopulmonary insufficiency, have been determined.

Remote observation of the adequacy of functioning of the transjugular intrahepatic portosystemic shunt is performed using comprehensive ultrasonic examination with measurement of blood flow parameters in the shunt and in the portal vein system, and in case of suspicion of shunt thrombosis or stenosis, angiographic examination should be performed.

It has been established that effective drugs reducing pressure in the portal vein system are synthetic analogues of somatostatin.

Based on the obtained results, an algorithm for managing patients with portal hypertension syndrome and oesophageal varices has been determined.

II appendices presented for defence.

Patients with portal hypertension syndrome and oesophageal varices are subject to comprehensive examination with mandatory determination of criteria for the threat of the first episode of bleeding from oesophageal varices.

When forecasting a high risk of the first haemorrhagic episode, the patient is subject to prophylaxis of bleeding. The optimal method of prophylaxis is endoscopic ligation.

A patient with ongoing bleeding must have a probe-tamponade inserted, and after achieving temporary haemostasis, endoscopic ligation should be performed as a method for preventing recurrent bleeding.

For the prevention of recurrence of bleeding from varicose dilated oesophageal veins in patients with portal hypertension syndrome, endoscopic ligation is used as an independent, and for most patients — a definitive procedure.

When endoscopic ligation is ineffective and recurrence of bleeding from oesophageal varices occurs, the patient is subject to surgical treatment or placement of a transjugular intrahepatic portosystemic shunt.

After endoscopic ligation, dynamic observation must be maintained for patients. In case of recurrence of bleeding, repeated sessions of endoscopic ligation are advisable.

Implementation of the research results:

The main provisions and recommendations of the dissertation have been introduced into practice in the general surgical departments of urban clinical hospitals No. 36 and No. 57.

Publications:

Based on the materials of the dissertation, 60 printed works have been published, including six methodological recommendations and one handbook for physicians. The materials of the dissertation have been presented at Russian and international surgical and endoscopic congresses and scientific-practical conferences.

Volume and structure of the dissertation:

The dissertation is written in Russian, spans 213 pages of typed text, and consists of an introduction, 6 chapters, discussion, conclusions, practical recommendations, and a bibliography. The work is illustrated with 33 figures, 35 tables, and two schemes. The bibliography includes 288 publications, including 87 domestic sources and 201 foreign authors' sources.