Splenectomy associated with ligature of the left gastric vein in children with surgical schistosomiasis: analysis of the hepatic functional reserve

Esplenectomia associada a ligadura da veia gástrica esquerda em crianças com esquistosomíase: análise da reserva funcional hepática

2 – ORIGINAL ARTICLE

SPLENECTOMY ASSOCIATED WITH LIGATURE OF THE LEFT GASTRIC VEIN IN CHILDREN WITH SURGICAL SCHISTOSOMIASIS: ANALYSIS OF THE HEPATIC FUNCTIONAL RESERVE.¹

Carlos Teixeira Brandt²

Dione Souza Tavares Maciel³

Oyama Arruda Frei Caneca³

BRANDT, C.T.; TAVARES MACIEL, D.S.; CANECA, O.A.F. - Splenectomy associated with ligature of the left gastric vein in children with schistosomiasis: analysis of the hepatic functional reserve. Acta Cir. Bras., 12(3):150-3, 1997.

SUMMARY: Splenectomy and ligature of the left gastric vein in children with hepatosplenic schistosomiasis mansoni and bleeding esophageal varices produce a decrease of the portal hepatic blood flow and increase in the hepatic arterial flow. The effects of these hemodinamic changes in the liver could, theoretically, deteriorate the hepatic functional reserve of these patients. Forty children with this pathology underwent that kind of treatment and they were followed-up, prospectively , mean follow up of 48 months, regard to their hepatic functional reserve. Before surgery, thirteen children were classified as "good risk - grade A" in the Child’s criteria for assessment of the hepatic reserve and twenty seven as "moderate risk - grade B". The mean serum albumin concentration was 3.16g/dl ± 0.62g/dl. Only in one patient the serum bilirubin concentration was slightly greater than 2mg/dl. After surgery, fifteen patients were diagnosed as "good risk - A" and twenty five as "moderate risk - B". The mean serum albumin concentration was 3.25g/dl ± 0.50g/dl. Similarly one patient in the post-operative follow-up has presented with serum bilirubin concentration greater than 2mg/dl. Additionally, after surgery there was a significant improvement in the plasma prothrombin levels. These findings support the idea that there has been no deterioration of the hepatic functional reserve of these patients.

SUBJECT HEADINGS: Schistosomiasis mansoni. Portal hypertension. Splenectomy. Hepatic functional reserve.

INTRODUCTION

Although the prevalence of the more severe forms of schistosomiasis mansoni has reduced in north-eastern Brazil^10,15, as result of mass treatment with oxamniquine for the parasite, there are still approximately 100,000 patients in this hyperendemic region, including children, with hepatosplenomegaly and bleeding esophageal varices who require surgical treatment for the portal hypertension. The main elective surgical treatment for these patients is splenectomy associated with obliterative suture of the varices at the ‘the vulnerable zone’ of the distal esophagus^9,11. Alternatively, splenectomy can be associated with ligature of the left gastric vein. For the past ten years the treatment for the esophageal varices has been done progressively and preferably by endoscopic sclerosis^16,17.

There are some evidence that, in children with surgical hepatosplenic schistosomisais mansoni, splenectomy and ligature of the left gastric vein produce a significant reduction of the mean diameter and blood flow velocity of the portal vein, and a significant increase in the mean diameter of the hepatic artery¹. What have been investigated are the physiological implications of these hemodynamic changes in the long term follow-up.

The aim of this investigation was, prospectevely, to evaluate the hepatic functional reserve in children with hepatosplenic schistosomiasis mansoni and esophageal varices who had undergone splenectomy, ligature of the left gastric vein and autoimplantation of splenic tissue into the great omentum.

METHOD

Forty children, from 8 to 16 years of age (23 males and 17 females), with proven hepatosplenic schistosomiasis mansoni and recurrent hematemesis were included in this study. They underwent splenectomy, ligature of the left gastric vein and autoimplantation of 100g of the upper pole of the spleen into the great omentum in the general pediatric surgical service of the University Hospital, Pernambuco, Brazil, from January 1990 to December 1994. Liver biopsy from all patients was sent for histopathology. The schistosomiasis of all patients was treated with a single doses of oxamniquine approximately thirty days before surgical treatment.

Liver function tests and tests for hepatitis B antigenemia were done in all patients. The Child’s criteria for assessment of hepatic reserve were used. The parameter nutrition was assessed using body weight and height, and also bone mineral content (BMD): growth and development have been assessed throughout the follow-up which ranges from 24 to 78 months (mean 48 months). In addition the prothrombin time (protime) was assessed and the patients were divided, regarded to this parameter, into: normotest (over 70% of control plasma), correctable (responsive to the administration of 5mg of vitamin K for three days to normal limits); and non-correctable or not responsive to vitamin K.

Gastro-esophageal endoscopy was also done before surgery and every six months during post-operative follow-up.

The results of the albumin and billirubin serum concentrations, and plasma prothrombin levels were expressed by their means and standard deviations. The paired Student "t" test was used for measuring the differences between different means. The Chi square test was used for assessing the differences among different frequencies. P < 0.05 was used to reject the null hypothesis.

RESULTS

Although there was a slight increase in the frequency of patients with grade A (good risk) of the Child’s criteria for assessment of hepatic reserve after surgical treatment, the difference was not significant.(Table I)

There was no change in the mean serum albumin concentration before and after surgery (3.16 g/dl ± 0.63 g/dl Vs 3.25 g/dl -± 0.50 g/dl - P > 0.05).

Only one child presented with billirubin concentration slight over 2 mg/dl. Similarly, only one patient has been presenting with post-operative serum billirubin concentration just over 2 mg/dl.

Before surgery two patients presented with ascites which was controlled with infusion of albumin and administration of furosemide. Two other patients developed transient ascites in the immediate post-operative period. None of the patient presented with ascites in the last follow-up.

There was a significant improvement in the plasma prothrombin levels when compared the first evaluation on the admission in hospital and the last evaluation in the out patient department.(Table II)

DISCUSSION

The patients from this series showed improvement of the endoscopic pattern of the esophageal varices², however, four children (10%) have had recurrent hemorrhage, three of them were controlled by endoscopic sclerotherapy of esophageal varices. One patient (2.5%) died from a severe hemathemesis without medical assistance.

The five patients who had hypersplenism before surgery are cured.

There was no increase in the rate of infections and so far none of the patients included in this protocol has developed an overwhelming infection.

Similarly to the patients with cirrhosis the morbidity and mortality of the patients with hepatosplenic schistosomiasis mansoni are related, among other factors, to the hepatic functional reserve^16,17. Differently from the cirrhotic patients, the patients with schistosomiais mansoni preserve their hepatic functional reserve, unless hepatitis and/or cirrhosis have been associated with the underlying disease. In the present series, laboratory investigation revealed four patients (10%) with hepatitis B antigenemia. This association has been reported in approximately 15% of the adult patients with the same disease, in north eastern - Brazil, and it has been proved that this association worsens the hepatic functional reserve¹². In agreement with this assumption, in our series three of the four children with schistosomiais mansoni and hepatitis revealed some degree of hepatic cirrhosis with proliferation of the biliary ducts resembling sclerosing cholangitis. These three patients have had their serum albumin concentrations lower than 3 g/dl and developed ascites before or just after surgery. One of them have had his billirubin concentration slight over 2 mg/dl. As regard to the protime, two of them has been included in the correctable group and one did not respond, pre-operatively and after surgery, to the administration of vitamin K.

It has been reported that selective distal splenorenal shunts for intractable variceal bleeding in pediatric portal hypertension are followed by a variable degree of decrease in the portal hepatic blood flow with subsequent deterioration of the hepatic function and, in some cases, even with portosystemic encephalopathy because progressive hepatic failure^8,4. The observation that splenectomy, at least temporarily, decreases the portal hypertension in approximately 40%, and reduces the portal blood flow could predispose to a deterioration of the hepatic functional reserve^1,2,3. The findings of the present investigation do not support this possibility and shows that there is an improvement in the plasma prothrombin levels. The ligature of the left gastric vein, included in the surgical protocol of this series, obstructing, partially, the hepatofugal blood flow frequently found in these patients, could make a contribution for the hepatopedal blood flow, helping to preserve the liver function.

Overall there has been a significant increase in weight and height, and also developmental improvement of these patients. Some of the patients have even changed (increased) their channel of development³. Before treatment there was a general deficit of the BMD in these patients varying from 1% to 65% (mean 20% +/- 19%), it was more significant among the females. The mean of bone mineral density before treatment was 0.638 g/cm²± 0.128. g/cm² After treatment there was a slight, although not significant, improvement of the BMD (0.672 g/cm²± 0.046. g/cm²) ⁶. It has been recognized that patients with chronic liver disease have reduced muscle mass, poor nutritional status particularly affecting calcium and vitamin D, hormonal disturbances especially hypogonadism; all these factors are deleterious to bone, promoting osteopenia (low mineral density)⁷. The maintenance of the BMD in the follow up of these patients adds a further evidence that there was no deterioration of the hepatic functional reserve of the children in this series.

The Child’s criteria and the plasma prothrombin levels used in this investigation for assessment of the hepatic functional reserve were considered satisfactory, however, there were two patients with ascites and serum albumin concentration lower than 3g/dl without encephalopathy where classification (moderate risk B) was, in some way, not precise. Measurements of plasma abnormal prothrombin levels¹⁴, or serum trace elements¹³ and other parameters such as quantitative metabolic markers, especially isozyme-specific markers⁵ have been used in other liver diseases and seem to improve the evaluation of the hepatic functional reserve. However, the clinically used classifications and the routine laboratory investigations appear to be reliable indicators of the degree of hepatic function of chronic liver disease⁵.

BRANDT, C.T.; MACIEL, D.S.T.; CANECA, O.A.F. - Esplenectomia associada a ligadura da veia gástrica esquerda em crianças com esquistosomíase: análise da reserva funcional hepática. Acta Circ. Bras., 12(3):150-3, 1997.

RESUMO: Foram submetidas 40 crianças, portadoras de esquistosomíase mansônica hepatoesplemica e sangramento de varizes esofágica, à esplenectomia e ligadura da veia gástrica esquerda. Foram acompanhadas durante 48 meses de pós-operatório, determinando-se a reserva funcional hepática durante esse período. Antes do tratamento cirúrgico, 13 crianças classificadas como grau A de Child's e 27 como grau B. A concentração média da albumina sérica era 3.16g/dl ± 0.62g/dl. Apenas em 1 paciente a concentração de bilirrubina sérica era pouco maior do que 2mg/dl. Após intervenção operatória, 15 pacientes foram diagnosticados como grau A de Child's e 25 como grau B. A concentração média de albumina sérica foi 3.25g/dl ± 0.50g/dl. Um paciente apresentava ainda na evolução pós-operatória concentração de bilirrubina sérica maior que 2mg/dl. Houve melhora significante após operação dos níveis de protrombina plásmica. Concluiu-se que não houve deteriorização da reserva funcional hepática nos pacientes operados.

DESCRITORES: Esquistosomíase mansoni. Hipertensão portal. Esplenectomia. Reserva funcional hepática.

Address reprint request:

Carlos Teixeira Brandt

R. 19 de abril, 30/602

52071-332 Recife - PE

Accepted for publication on may, 1997

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1

. Paper from Pediatric Surgical Service of the University Hospital,Pernambuco - Brazil.

2. Head Professor of Pedriatric Surgery - Federal University of Pernambuco - Brazil.

3. Assistant Professor of Pedriatric Surgery - Federal University of Pernambuco - Brazil.

Publication Dates

• Publication in this collection
  08 June 2001
• Date of issue
  Sept 1997

History

• Accepted
  May 1997