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Glowka TR, Kalff JC, Manekeller S. Update on Shunt Surgery. Visc Med 2020; 36:206-211. [PMID: 32775351 DOI: 10.1159/000507125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/11/2020] [Indexed: 12/13/2022] Open
Abstract
Background Bleeding from esophagogastric varices is a life-threatening complication from portal hypertension. It occurs in 15% of patients and has a mortality rate of 20-35%. Summary The primary therapy for variceal bleeding is medical. In cases of recurrent bleeding, a definitive therapy is required. In cases of parenchymal decompensation, liver transplantation is the causal therapy, but if liver function is preserved, portal decompression is the therapy of choice. The use of the transjugular intrahepatic portosystemic shunt (TIPS) has achieved widespread acceptance, although evidence for surgical shunts is comparable or better in patients with good hepatic reserve. The type of surgical shunt depends on the patent veins of the portomesenteric system. If total occlusion is present, a devascularization procedure might be indicated. Key Messages Therapy, taking into account liver function, morphology of the portovenous system, and imminent liver transplantation, should be performed by an interdisciplinary team of gastroenterologists, interventional radiologists, and gastrointestinal surgeons.
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Affiliation(s)
- Tim R Glowka
- Department of Surgery, University of Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of Surgery, University of Bonn, Bonn, Germany
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Abstract
Esophageal bleeding is one of the most common medical emergencies. It takes the 3rd place among all digestive hemorrhages, and accounts for 14–16 % among all gastrointestinal bleeding. The most common cause of esophageal hemorrhages is Mallory – Weiss esophageal tear (10–12 %), less often – varicose veins of the esophagus in portal hypertension syndrome (up to 4 %) and, in some cases, is esophagitis of various etiologies (up to 1.6 %). The problem of esophageal bleeding is characterized by high incidence, high mortality rate due to constant increase of portal hyper tension cases, recurrences, difficulties in diagnosis, anatomical and physiological features of the esophagus, low efficiency of the main methods of hemostasis. There are various surgical and conservative methods of hemostasis, which show a variety of opinions in the solution to the problem of stopping esophageal bleeding. In Mallory – Weiss syndrome, endoscopic hemostasis is considered to be the preferred method of treatment. Management of portal hypertension is the most difficult task; a wide range of operations is used from the minimally invasive operations to the liver transplantation, as well as endoscopic hemostasis (ligation, sclerotherapy). In esophageal bleeding, due to reflux esophagitis, mainly conservative treatment is suggested, operations are performed with recurrences or complications. Each kind of esophageal hemorrhage is considered as a separate problem.
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von Köckritz L, De Gottardi A, Trebicka J, Praktiknjo M. Portal vein thrombosis in patients with cirrhosis. Gastroenterol Rep (Oxf) 2017; 5:148-156. [PMID: 28533912 PMCID: PMC5421355 DOI: 10.1093/gastro/gox014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 03/17/2017] [Indexed: 12/15/2022] Open
Abstract
Portal vein thrombosis (PVT) is frequent in patients with liver cirrhosis and possible severe complications such as mesenteric ischemia are rare, but can be life-threatening. However, different aspects of clinical relevance, diagnosis and management of PVT are still areas of uncertainty and investigation in international guidelines. In this article, we elaborate on PVT classification, geographical differences in clinical presentation and standards of diagnosis, and briefly on the current pathophysiological understanding and risk factors. This review considers and highlights the pitfalls of the various treatment approaches and prophylactic treatments. Finally, we review the controversial issue of clinical impact of PVT on prognosis, especially considering liver transplantation and future perspectives.
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Affiliation(s)
- Leona von Köckritz
- Hepatology, Clinic of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Andrea De Gottardi
- Hepatology, Clinic of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland.,Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain
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Glowka TR, Kalff JC, Schäfer N. Clinical Management of Chronic Portal/Mesenteric Vein Thrombosis: The Surgeon's Point of View. VISZERALMEDIZIN 2015; 30:409-15. [PMID: 26288608 PMCID: PMC4513833 DOI: 10.1159/000369575] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bleeding from esophageal varices is a life-threatening complication of chronic portal hypertension (PH), occuring in 15% of patients with a mortality rate between 20 and 35%. METHODS Based on a literature review and personal experience in the therapy of PH, we recommend a therapy strategy for the secondary prophylaxis of variceal bleeding in PH. RESULTS The main causes for PH in western countries are alcoholic/viral liver cirrhosis and extrahepatic portal/mesenteric vein occlusion, mainly caused by myeloproliferative neoplasms or hypercoagulability syndromes. The primary therapy is medical; however, when recurrent bleeding occurs, a definitive therapy is required. In the case of parenchymal decompensation, liver transplantation is the causal therapy, but in case of good hepatic reserve or without underlying liver disease, a portal decompressive therapy is necessary. Transjugular intrahepatic portosystemic shunt has achieved a widespread acceptance, although evidence is comparable with or better for surgical shunting procedures in patients with good liver function. The type of surgical shunt should be chosen depending on the patent veins of the portovenous system and the personal expertise. CONCLUSION The therapy decision should be based on liver function, morphology of the portovenous system, and imminent liver transplantation and should be made by an interdisciplinary team of gastroenterologists, interventional radiologists, and visceral surgeons.
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Affiliation(s)
- Tim R Glowka
- Department of Surgery, University of Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of Surgery, University of Bonn, Bonn, Germany
| | - Nico Schäfer
- Department of Surgery, University of Bonn, Bonn, Germany
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Voros D, Polydorou A, Polymeneas G, Vassiliou I, Melemeni A, Chondrogiannis K, Arapoglou V, Fragulidis GP. Long-term results with the modified Sugiura procedure for the management of variceal bleeding: standing the test of time in the treatment of bleeding esophageal varices. World J Surg 2012; 36:659-66. [PMID: 22270986 PMCID: PMC7102180 DOI: 10.1007/s00268-011-1418-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The surgical approaches to the treatment of bleeding esophageal varices in cirrhotic patients have been reduced since the clinical development of endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation. However, when acute sclerotherapy fails, and in cases where no further treatment is accessible, emergency surgery may be life saving. In the present study we retrospectively analyzed the results of the modified Sugiura procedure, performed as emergency and semi-elective treatment in the patient with bleeding esophageal varices. Methods Ninety patients with cirrhosis and portal hypertension were managed in our department for variceal esophageal bleeding between January 1985 and December 1992. The modified Sugiura procedure was performed in 46 patients on an emergency (25 patients) or semi-elective (21 patients) basis. Liver cirrhosis stage according to Child classification was A in 4 patients, B in 16 patients, and C in 26 patients. Results Acute bleeding was controlled in all patients. Postoperative mortality was 23.9% (11 of 46 patients). The mortality rate was 34.6% in Child class C patients (9 of 26 patients), and 12.5% in Child class B patients (2 of 16 patients). Twenty-four patients had long-term follow-up extending from 14 months to 22 years (mean 83.1 months). Ten of 24 patients (41.6%) did not develop rebleeding for 5–22 years (mean 10.3 years). Overall 5-year survival in these 24 patients was 62.5%. Conclusions The modified Sugiura procedure remains an effective rescue therapy for patients with bleeding esophageal varices when alternative treatments fail or are not indicated. Moreover, it can be a life-saving procedure in patients with anatomy unsuitable for shunt surgery or for patients treated in nonspecialized centers where surgical expertise for a shunt operation is not available.
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Affiliation(s)
- D. Voros
- 2nd Department of Surgery, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis. Sophias Avenue, 11528 Athens, Greece
| | - A. Polydorou
- 2nd Department of Surgery, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis. Sophias Avenue, 11528 Athens, Greece
| | - G. Polymeneas
- 2nd Department of Surgery, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis. Sophias Avenue, 11528 Athens, Greece
| | - I. Vassiliou
- 2nd Department of Surgery, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis. Sophias Avenue, 11528 Athens, Greece
| | - A. Melemeni
- 1st Department of Anesthesia, Aretaieio Hospital, Medical School, University of Athens, 11528 Athens, Greece
| | - K. Chondrogiannis
- 1st Department of Anesthesia, Aretaieio Hospital, Medical School, University of Athens, 11528 Athens, Greece
| | - V. Arapoglou
- 2nd Department of Surgery, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis. Sophias Avenue, 11528 Athens, Greece
| | - G. P. Fragulidis
- 2nd Department of Surgery, Aretaieio Hospital, Medical School, University of Athens, 76 Vassilissis. Sophias Avenue, 11528 Athens, Greece
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Abstract
Portosystemic shunt surgery in addition to transjugular intrahepatic portosystemic shunt (TIPS) insertion must still be regarded as a current treatment option for portomesenteric decompression in patients with pharmacological and endoscopic treatment failure, where liver transplantation is not imminent. This applies to secondary prophylaxis of rebleeding from varices in patients with well preserved liver function, e.g. liver cirrhosis CHILD A or extrahepatic portal vein thrombosis. Even if emergency endoscopy represents the treatment of choice in the acute bleeding situation, latest data from San Diego on emergency portacaval shunt surgery are encouraging. Likewise, portacaval shunt procedures can be an attractive alternative to TIPS or liver transplantation for acute Budd-Chiari syndrome or veno-occlusive disease.This article is an update on the systematics and methodology of portacaval shunt surgery, emphasizing the significance of this treatment option based on latest studies.
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Clark W, Hernandez J, McKeon B, Villadolid D, Al-Saadi S, Mullinax J, Ross SB, Rosemurgy AS. Surgical Shunting versus Transjugular Intrahepatic Portasystemic Shunting for Bleeding Varices Resulting from Portal Hypertension and Cirrhosis: A Meta-Analysis. Am Surg 2010. [DOI: 10.1177/000313481007600831] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Surgical shunting was the mainstay in treating portal hypertension for years. Recently, trans-jugular intrahepatic portasystemic shunting (TIPS) has replaced surgical shunting, first as a “bridge” to transplantation and ultimately as first-line therapy for bleeding varices. This study was undertaken to examine evidence from trials comparing TIPS with surgical shunting to reassess the role of surgery in treating portal hypertension. The National Library of Medicine and the National Institutes of Health were searched for clinical trials comparing surgical shunting with TIPS. Meta-analysis using the fixed effects model was undertaken with end points of 30-day and 1- and 2-year survival and shunt failure (inability to complete shunt, irreversible shunt occlusion, major rehemorrhage, unanticipated liver transplantation, death). Three prospective randomized trials and one retrospective case-controlled study were identified. Analysis was limited to patients of Child Classes A or B. Significantly better 2-year survival (OR 2.5 [1.2-5.2]) and significantly less frequent shunt failure (OR 0.3 [0.1-0.9]) were seen in patients undergoing surgical shunting compared with TIPS. Meta-analysis promotes surgical shunting relative to TIPS because of improved survival and less frequent shunt failure. Surgical shunting should be accepted as first-line therapy for bleeding varices resulting from portal hypertension.
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Affiliation(s)
- Whalen Clark
- Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Jonathan Hernandez
- Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Brianne McKeon
- Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Desiree Villadolid
- Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Sam Al-Saadi
- Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - John Mullinax
- Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Sharona B. Ross
- Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
| | - Alexander S. Rosemurgy
- Digestive Disorders Center, Tampa General Hospital and the Department of Surgery, University of South Florida, Tampa, Florida
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Abstract
Portal hypertension, as a result of cirrhosis or other cause of liver dysfunction, is a life-threatening disease process. The risk of bleeding varices is high. Treatment options have much better outcomes when administered early on. The role of the PA in treating portal hypertension centers on recognizing the complications and understanding the medical management of those problems. Familiarity with the available treatment options can facilitate initiation of the most appropriate therapy for each patient. The best plan of action is to stabilize the patient and refer him or her to a tertiary center with clinicians who have experience in managing this uncommon problem.
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Rosemurgy A, Thometz D, Clark W, Villadolid D, Carey E, Pinkas D, Rakita S, Zervos E. Survival and variceal rehemorrhage after shunting support small-diameter prosthetic H-graft portacaval shunt. J Gastrointest Surg 2007; 11:325-32. [PMID: 17458606 DOI: 10.1007/s11605-006-0056-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This study was undertaken to report variceal rebleeding and survival after small-diameter prosthetic H-graft portacaval shunts (HGPCS) and to compare actual to predicted survival after shunting. Since 1987 we have prospectively followed patients after undergoing HGPCS to treat bleeding varices failing/not amenable to sclerotherapy/banding. One hundred and seventy patients underwent shunting. Cirrhosis was because of alcohol in 56%, hepatitis in 12%, both in 11%, and other causes in 21%. Child class was A for 10%, B for 28%, and C for 62%. Thirty-three patients died by 6 months, 54 by 24 months, 87 by 60 months, and 112 by 10 years, generally because of liver failure. Fifty-one patients are alive at a median of 48.3 months, 76 months +/- 57.8 (mean +/- SD). Variceal rehemorrhage was documented in 3 (2%) patients. By child class, 5-year/10-year survival rates were as follows: A 66.7/33.3%, B 48.6/15.6%, and C 29.2/7.0%. Actual survival was superior to predicted survival (Model for End-Stage Liver Disease [MELD]), (p < 0.001). Variceal rehemorrhage in patients undergoing small-diameter prosthetic H-graft portacaval shunting was very uncommon. Actual survival was superior to predicted survival (MELD). Long-term survival paralleled degree of hepatic function, although long-term survival was possible even with very advanced cirrhosis. Application of HGPCS is encouraged.
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Affiliation(s)
- Alexander Rosemurgy
- Department of Surgery, University of South Florida College of Medicine, Tampa, FL 33601, USA.
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