Proximal gastric resection in the treatment of bleeding gastro-oesophageal varices in patients with portal hypertension due to extrahepatic obstruction

Radical esophagogastrectomy for unshuntable extrahepatic portal hypertension with bleeding varices: report of a case

A 29-year-old woman with idiopathic portal hypertension was referred to our department for the surgical management of repetitive bleeding from esophageal and gastric varices. At the age of 16 years she had undergone a splenectomy with esophageal transection followed by endoscopic sclerotherapy which had been performed a total of 24 times. Although vericeal hemorrhage was prevented for several months, bleeding from gastric varices and portal hypertensive gastropathy was not able to be controlled readily by endoscopic sclerotherapy from when she was 26 years old. On admission, angiographic studies showed a complete obstruction of the portal vein; however, a portosystemic shunt operation was not able to be performed due to her previous splenectomy. To control her repetitive bleeding, we decided to perform a total gastrectomy and distal esophagectomy with reconstruction by a Roux-en-Y esophagojejunostomy. Her postoperative course was uneventful, and no episodes of recurrent bleeding or other complications have developed, indicating that her quality of life has dramatically improved. Thus, we conclude that distal esophagectomy and total gastrectomy constitute an effective surgical treatment for unshuntable extrahepatic portal hypertension.

Experience with radical esophagogastric devascularization procedures (Sugiura) for variceal bleeding outside Japan

The Sugiura operation has been reported to have low operative mortality, rebleeding, and encephalopathy rates when carried out in a predominantly nonalcoholic Japanese population with good liver function. A literature review of reports of the Sugiura procedure outside Japan reveals a high complication and mortality rate when it is used as an emergency procedure in patients with advanced liver disease, especially in those with alcoholic cirrhosis. Uncontrolled studies report results that differ little from the Japanese series when the operation is confined to good-risk patients in the elective situation. Our experience with the Sugiura operation supports its role in these circumstances, especially in patients with portal vein thrombosis and normal liver function. The only good prospective controlled trial has been carried out in patients with schistosomiasis and suggests that the Sugiura operation is far superior to total shunt and may have a slight advantage over the Warren shunt because of its low incidence of postoperative encephalopathy. More controlled trials are required to establish its role in good- to moderate-risk patients with alcoholic cirrhosis.

Long-term results of radical esophagogastrectomy for bleeding varices due to unshuntable extrahepatic portal hypertension

This report describes the long-term results of one-stage total gastrectomy and distal two-thirds esophagectomy, with reconstruction by esophagojejunostomy (16 Roux-en-Y; 2 interposition), in 18 adult patients with recurrent variceal hemorrhage due to unshuntable extrahepatic portal hypertension (EHPH) from occlusion of all major tributaries of the portal venous system. The etiology of portal venous occlusion was unknown in 11 patients, abdominal trauma in 3, peritonitis in 3, and thrombotic coagulopathy in 1. Almost half of the patients had their first episode of bleeding in childhood, and 83% experienced bleeding before 40 years of age. The severity of the problem was reflected by frequent previous bleeding episodes (mean: 12.8, range: 4 to 21), a large cumulative requirement for blood transfusions (mean: 129 units, range: 28 to 247 units), repeated, costly hospital admissions (mean: 15, range: 4 to 24), and numerous previous unsuccessful operations (mean: 4.4, range: 1 to 14). Blood transfusions transmitted serum hepatitis to three patients and AIDS to one, for an incidence of 22%. Bleeding recurred after repetitive endoscopic sclerotherapy in 10 patients and after various operations in 16 (failed portal-systemic shunts in 9, splenectomy in 16, devascularization procedures in 13). All patients had large esophageal and gastric varices on endoscopy, normal liver function, and widespread portal venous occlusion on visceral angiography. Radical esophagogastrectomy was usually a long and arduous operation because of dense adhesions, extensive collateral veins, and a scarred, contracted bowel mesentery due to previous operations. All patients survived the operation and are currently alive. No patient has had recurrent bleeding during 1 to 26 years of follow-up (mean: 13.9 years, 7 or more years in 14 patients). Quality of life has been good. It is concluded that radical esophagogastrectomy is the only effective treatment of unshuntable EHPH and that the operation should be performed promptly when this disease, which is associated with high mortality, high morbidity, and high costs, is diagnosed.

Long-term results of surgical treatment for bleeding oesophageal varices in children with portal hypertension

The long-term results of surgical treatment for bleeding oesophageal varices in children with portal hypertension are reviewed. Twenty-four children below the age of 13 years who presented with gastrointestinal bleeding over a 20-year period form the basis of this study. The importance of the aetiology of portal hypertension on the long-term follow-up has been studied. The results of surgical treatment in controlling haemorrhage are assessed.

Though extrahepatic obstruction is considered to be associated with a better long-term prognosis than intrahepatic disease the results of treatment in both groups were similar, with a 7-year survival rate of 75 per cent. Shunt surgery as a definitive procedure is advised in both groups, though the type of shunt used will depend on the age of the child and the site of obstruction.

The results obtained with emergency surgery in the treatment of persistent haemorrhage from gastro-oesophageal varices in the cirrhotic patient

The management of the cirrhotic patient with bleeding gastro-oesophageal varices is discussed with particular reference to the role of emergency surgery. An analysis is made of the results obtained in 77 patients with emergency surgery to control recurrent haemorrhage.

The deleterious effect of failing to control haemorrhage immediately and effectively in these cases is emphasized. If haemorrhage recurs in spite of conservative measures, including tamponade, surgery is considered mandatory. Only 8 cases have had an emergency portacaval anastomosis, with 4 survivors, all good-risk cases. More patients might benefit from this operation but only if haemorrhage is rapidly and effectively brought under control in the first instance. The poor-risk case has a 30 per cent chance of survival with a Boerema-Crile operation. However, this is not a definitive operation and patients who survive this procedure should have a portacaval anastomosis as soon as their liver function has sufficiently recovered.