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Arabi M, Aldulaigan E, Almulhim A, Almasar K. Endovascular Distal Splenorenal Flow Diversion for Variceal Bleeding Control. J Vasc Interv Radiol 2023; 34:312-314. [PMID: 36309136 DOI: 10.1016/j.jvir.2022.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/11/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Mohammad Arabi
- Vascular Interventional Radiology, Medical Imaging Department, Ministry of National Guard Health Affairs, King Abdulaziz Medical City, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426, Saudi Arabia.
| | - Essam Aldulaigan
- Vascular Interventional Radiology, Medical Imaging Department, Ministry of National Guard Health Affairs, King Abdulaziz Medical City, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426, Saudi Arabia
| | - Abdulaziz Almulhim
- Vascular Interventional Radiology, Medical Imaging Department, Ministry of National Guard Health Affairs, King Abdulaziz Medical City, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426, Saudi Arabia; Vascular Interventional Radiology, Medical Imaging Department, Ministry of Health, Alahsa Health Cluster, Alhasa, Saudi Arabia
| | - Khalid Almasar
- Vascular Interventional Radiology, Medical Imaging Department, Ministry of National Guard Health Affairs, King Abdulaziz Medical City, National Guard Health Affairs, P.O. Box 22490, Riyadh, 11426, Saudi Arabia; Vascular Interventional Radiology, Medical Imaging Department, Prince Mohammad Medical City, Aljouf, Saudi Arabia
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Van Praet KM, Ceulemans LJ, Monbaliu D, Aerts R, Jochmans I, Pirenne J. An analysis on the use of Warren's distal splenorenal shunt surgery for the treatment of portal hypertension at the University Hospitals Leuven. Acta Chir Belg 2021; 121:254-260. [PMID: 32022643 DOI: 10.1080/00015458.2020.1726099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Extrahepatic portal vein thrombosis (PVT) is the most common cause of portal hypertension (PH), particularly in children. PH-related manifestations include refractory variceal bleeding, splenomegaly and ascites. Albeit more rarely performed, the distal splenorenal shunt (Warren's shunt) has proven to be effective in selectively decompressing the collateral circulation. The aim of our study was to describe our experience with the distal splenorenal shunt and to determine the long-term effect on PH-related side-effects. METHODS Distal splenorenal shunt operations performed at our institution between 2000 and 2014 were reviewed for: age, male/female ratio, children/adults ratio, body mass index, indications, grade of PVT (Yerdel classification), maximal shunt-flow velocity, shunt patency and thrombosis, re-intervention for variceal bleeding and survival. Complications of PH (esophageal variceal bleeding and ascites) were compared pre- versus post-operatively (last follow-up). Paired student t-test and fisher's exact were applied for pre- versus post-operative comparison. Results are reported as median [range]. RESULTS Fourteen patients with PVT and refractory complications of PH underwent distal splenorenal shunt surgery. Age was 15 years [4.5-66]. Male/female ratio was 7/7. PVT -grade was 2 [1-4]. Follow-up was 3 [0.5-14]. All shunts were patent (100%) with no shunt thrombosis (0%) at last follow-up. There was no re-intervention for variceal bleeding (0%) and survival at last follow-up was 100%. Occurrence of esophageal variceal bleeding was higher pre-operatively (57%) than postoperatively (0%) (p = .0032) and also the incidence of ascites was higher pre-operatively (79%) than postoperatively (0%) (p < .0001). CONCLUSIONS Based on our experience, the distal splenorenal shunt can be considered a valuable surgical technique for PVT-induced PH, with excellent post-operative prevention of complications of PH.
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Affiliation(s)
- Karel M. Van Praet
- Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Berlin, Germany
| | - Laurens J. Ceulemans
- Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
- Lung Transplantation Unit, University Hospitals Leuven, Leuven, Belgium
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Raymond Aerts
- Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
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A Thought-Provoking Case of Successfully Treated Carcinoma of the Head of the Pancreas with Metachronous Lung Metastasis: Impact of Distal Spleno-Renal Shunt for Regional Invasion on Long-Term Period after Pancreaticoduodenectomy. Case Rep Surg 2021; 2021:6689419. [PMID: 34136302 PMCID: PMC8179775 DOI: 10.1155/2021/6689419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 05/14/2021] [Indexed: 12/03/2022] Open
Abstract
When performing pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein, division of the splenic vein may cause sinistral portal hypertension resulting in gastrointestinal bleeding, splenic congestion, and hypersplenism. To prevent these adverse events, it is important to intentionally decompress the splenic vein. This report is of a 68-year-old woman with stage IA carcinoma of the head of the pancreas who survived for more than six years following tumor resection and pancreaticoduodenectomy and distal splenorenal shunt. A 68-year-old woman was diagnosed with carcinoma of the head of the pancreas that involved the confluence of the superior mesenteric vein, portal vein, and splenic vein. No unresectable cancer sites or distant metastases were detected. Pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein was performed. The superior mesenteric vein and portal vein were anastomosed in the end-to-end fashion, and the remnant splenic vein was anastomosed to the superior aspect of the left renal vein in the end-to-side fashion. At 22 months after the initial surgery, the patient underwent partial lung resection for a metachronous lung metastasis. For 6 years after the initial surgery, the venous reconstructions have maintained their patency without any obstruction of splenic venous flow, and the patient has remained in good health without further metastases or recurrences. This case has shown the importance of early diagnosis of carcinoma of the head of the pancreas, as appropriate and timely surgical management can result in good outcome. This patient responded well and remains alive six years following pancreaticoduodenectomy and preservation of the spleen with the use of a distal splenorenal shunt.
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Plaz Torres MC, Best LM, Freeman SC, Roberts D, Cooper NJ, Sutton AJ, Roccarina D, Benmassaoud A, Iogna Prat L, Williams NR, Csenar M, Fritche D, Begum T, Arunan S, Tapp M, Milne EJ, Pavlov CS, Davidson BR, Tsochatzis E, Gurusamy KS. Secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2021; 3:CD013122. [PMID: 33784794 PMCID: PMC8094621 DOI: 10.1002/14651858.cd013122.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years of diagnosis. Several different treatments are available, which include endoscopic sclerotherapy, variceal band ligation, beta-blockers, transjugular intrahepatic portosystemic shunt (TIPS), and surgical portocaval shunts, among others. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different initial treatments for secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for secondary prevention according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until December 2019 to identify randomised clinical trials in people with cirrhosis and a previous history of bleeding from oesophageal varices. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and previous history of bleeding from oesophageal varices. We excluded randomised clinical trials in which participants had no previous history of bleeding from oesophageal varices, previous history of bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those who had acute bleeding at the time of treatment, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included a total of 48 randomised clinical trials (3526 participants) in the review. Forty-six trials (3442 participants) were included in one or more comparisons. The trials that provided the information included people with cirrhosis due to varied aetiologies. The follow-up ranged from two months to 61 months. All the trials were at high risk of bias. A total of 12 interventions were compared in these trials (sclerotherapy, beta-blockers, variceal band ligation, beta-blockers plus sclerotherapy, no active intervention, TIPS (transjugular intrahepatic portosystemic shunt), beta-blockers plus nitrates, portocaval shunt, sclerotherapy plus variceal band ligation, beta-blockers plus nitrates plus variceal band ligation, beta-blockers plus variceal band ligation, sclerotherapy plus nitrates). Overall, 22.5% of the trial participants who received the reference treatment (chosen because this was the commonest treatment compared in the trials) of sclerotherapy died during the follow-up period ranging from two months to 61 months. There was considerable uncertainty in the effects of interventions on mortality. Accordingly, none of the interventions showed superiority over another. None of the trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation may result in fewer serious adverse events (number of people) than sclerotherapy (OR 0.19; 95% CrI 0.06 to 0.54; 1 trial; 100 participants). Based on low or very low-certainty evidence, the adverse events (number of participants) and adverse events (number of events) may be different across many comparisons; however, these differences are due to very small trials at high risk of bias showing large differences in some comparisons leading to many differences despite absence of direct evidence. Based on low-certainty evidence, TIPS may result in large decrease in symptomatic rebleed than variceal band ligation (HR 0.12; 95% CrI 0.03 to 0.41; 1 trial; 58 participants). Based on moderate-certainty evidence, any variceal rebleed was probably lower in sclerotherapy than in no active intervention (HR 0.62; 95% CrI 0.35 to 0.99, direct comparison HR 0.66; 95% CrI 0.11 to 3.13; 3 trials; 296 participants), beta-blockers plus sclerotherapy than sclerotherapy alone (HR 0.60; 95% CrI 0.37 to 0.95; direct comparison HR 0.50; 95% CrI 0.07 to 2.96; 4 trials; 231 participants); TIPS than sclerotherapy (HR 0.18; 95% CrI 0.08 to 0.38; direct comparison HR 0.22; 95% CrI 0.01 to 7.51; 2 trials; 109 participants), and in portocaval shunt than sclerotherapy (HR 0.21; 95% CrI 0.05 to 0.77; no direct comparison) groups. Based on low-certainty evidence, beta-blockers alone and TIPS might result in more, other compensation, events than sclerotherapy (rate ratio 2.37; 95% CrI 1.35 to 4.67; 1 trial; 65 participants and rate ratio 2.30; 95% CrI 1.20 to 4.65; 2 trials; 109 participants; low-certainty evidence). The evidence indicates considerable uncertainty about the effect of the interventions including those related to beta-blockers plus variceal band ligation in the remaining comparisons. AUTHORS' CONCLUSIONS The evidence indicates considerable uncertainty about the effect of the interventions on mortality. Variceal band ligation might result in fewer serious adverse events than sclerotherapy. TIPS might result in a large decrease in symptomatic rebleed than variceal band ligation. Sclerotherapy probably results in fewer 'any' variceal rebleeding than no active intervention. Beta-blockers plus sclerotherapy and TIPS probably result in fewer 'any' variceal rebleeding than sclerotherapy. Beta-blockers alone and TIPS might result in more other compensation events than sclerotherapy. The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. Accordingly, high-quality randomised comparative clinical trials are needed.
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Affiliation(s)
| | - Lawrence Mj Best
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Suzanne C Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicola J Cooper
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Davide Roccarina
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Amine Benmassaoud
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Laura Iogna Prat
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Norman R Williams
- Surgical & Interventional Trials Unit (SITU), UCL Division of Surgery & Interventional Science, London, UK
| | - Mario Csenar
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | | | - Sivapatham Arunan
- General and Colorectal Surgery, Ealing Hospital and Imperial College, London, Northwood, UK
| | | | | | - Chavdar S Pavlov
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Centre, Royal Free Hospital and the UCL Institute of Liver and Digestive Health, London, UK
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Simonetti RG, Perricone G, Robbins HL, Battula NR, Weickert MO, Sutton R, Khan S. Portosystemic shunts versus endoscopic intervention with or without medical treatment for prevention of rebleeding in people with cirrhosis. Cochrane Database Syst Rev 2020; 10:CD000553. [PMID: 33089892 PMCID: PMC8095029 DOI: 10.1002/14651858.cd000553.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND People with liver cirrhosis who have had one episode of variceal bleeding are at risk for repeated episodes of bleeding. Endoscopic intervention and portosystemic shunts are used to prevent further bleeding, but there is no consensus as to which approach is preferable. OBJECTIVES To compare the benefits and harms of shunts (surgical shunts (total shunt (TS), distal splenorenal shunt (DSRS), or transjugular intrahepatic portosystemic shunt (TIPS)) versus endoscopic intervention (endoscopic sclerotherapy or banding, or both) with or without medical treatment (non-selective beta blockers or nitrates, or both) for prevention of variceal rebleeding in people with liver cirrhosis. SEARCH METHODS We searched the CHBG Controlled Trials Register; CENTRAL, in the Cochrane Library; MEDLINE Ovid; Embase Ovid; LILACS (Bireme); Science Citation Index - Expanded (Web of Science); and Conference Proceedings Citation Index - Science (Web of Science); as well as conference proceedings and the references of trials identified until 22 June 2020. We contacted study investigators and industry researchers. SELECTION CRITERIA Randomised clinical trials comparing shunts versus endoscopic interventions with or without medical treatment in people with cirrhosis who had recovered from a variceal haemorrhage. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. When possible, we collected data to allow intention-to-treat analysis. For each outcome, we estimated a meta-analysed estimate of treatment effect across trials (risk ratio for binary outcomes). We used random-effects model meta-analysis as our main analysis and as a means of presenting results. We reported differences in means for continuous outcomes without a meta-analytic estimate due to high variability in their assessment among all trials. We assessed the certainty of evidence using GRADE. MAIN RESULTS We identified 27 randomised trials with 1828 participants. Three trials assessed TSs, five assessed DSRSs, and 19 trials assessed TIPSs. The endoscopic intervention was sclerotherapy in 16 trials, band ligation in eight trials, and a combination of band ligation and either sclerotherapy or glue injection in three trials. In eight trials, endoscopy was combined with beta blockers (in one trial plus isosorbide mononitrate). We judged all trials to be at high risk of bias. We assessed the certainty of evidence for all the outcome review results as very low (i.e. the true effects of the results are likely to be substantially different from the results of estimated effects). The very low evidence grading is due to the overall high risk of bias for all trials, and to imprecision and publication bias for some outcomes. Therefore, we are very uncertain whether portosystemic shunts versus endoscopy interventions with or without medical treatment have effects on all-cause mortality (RR 0.99, 95% CI 0.86 to 1.13; 1828 participants; 27 trials), on rebleeding (RR 0.40, 95% CI 0.33 to 0.50; 1769 participants; 26 trials), on mortality due to rebleeding (RR 0.51, 95% CI 0.34 to 0.76; 1779 participants; 26 trials), and on occurrence of hepatic encephalopathy, both acute (RR 1.60, 95% CI 1.33 to 1.92; 1649 participants; 24 trials) and chronic (RR 2.51, 95% CI 1.38 to 4.55; 956 participants; 13 trials). No data were available regarding health-related quality of life. Analysing each modality of portosystemic shunts individually (i.e. TS, DSRS, and TIPS) versus endoscopic interventions with or without medical treatment, we are very uncertain if each type of shunt has effect on all-cause mortality: TS, RR 0.46, 95% CI 0.19 to 1.13; 164 participants; 3 trials; DSRS, RR 0.93, 95% CI 0.65 to 1.33; 352 participants; 4 trials; and TIPS, RR 1.10, 95% CI 0.92 to 1.31; 1312 participants; 19 trial; on rebleeding: TS, RR 0.28, 95% CI 0.14 to 0.56; 127 participants; 2 trials; DSRS, RR 0.26, 95% CI 0.11 to 0.65; 330 participants; 5 trials; and TIPS, RR 0.44, 95% CI 0.36 to 0.55; 1312 participants; 19 trials; on mortality due to rebleeding: TS, RR 0.25, 95% CI 0.06 to 0.96; 164 participants; 3 trials; DSRS, RR 0.31, 95% CI 0.13 to 0.74; 352 participants; 5 trials; and TIPS, RR 0.65, 95% CI 0.40 to 1.04; 1263 participants; 18 trials; on acute hepatic encephalopathy: TS, RR 1.66, 95% CI 0.70 to 3.92; 115 participants; 2 trials; DSRS, RR 1.70, 95% CI 0.94 to 3.08; 287 participants; 4 trials, TIPS, RR 1.61, 95% CI 1.29 to 1.99; 1247 participants; 18 trials; and chronic hepatic encephalopathy: TS, Fisher's exact test P = 0.11; 69 participants; 1 trial; DSRS, RR 4.87, 95% CI 1.46 to 16.23; 170 participants; 2 trials; and TIPS, RR 1.88, 95% CI 0.93 to 3.80; 717 participants; 10 trials. The proportion of participants with shunt occlusion or dysfunction was overall 37% (95% CI 33% to 40%). It was 3% (95% CI 0.8% to 10%) following TS, 7% (95% CI 3% to 13%) following DSRS, and 47.1% (95% CI 43% to 51%) following TIPS. Shunt dysfunction in trials utilising polytetrafluoroethylene-covered stents was 17% (95% CI 11% to 24%). Length of inpatient hospital stay and cost were not comparable across trials. Funding was unclear in 16 trials; 11 trials were funded by government, local hospitals, or universities. AUTHORS' CONCLUSIONS Evidence on whether portosystemic shunts versus endoscopy interventions with or without medical treatment in people with cirrhosis and previous hypertensive portal bleeding have little or no effect on all-cause mortality is very uncertain. Evidence on whether portosystemic shunts may reduce bleeding and mortality due to bleeding while increasing hepatic encephalopathy is also very uncertain. We need properly conducted trials to assess effects of these interventions not only on assessed outcomes, but also on quality of life, costs, and length of hospital stay.
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Affiliation(s)
- Rosa G Simonetti
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Giovanni Perricone
- S.C. Epatologia e Gastroenterologia, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Helen L Robbins
- Department of Surgery, University Hospital Coventry and Warwickshire, Coventry, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Narendra R Battula
- Division of Hepatobiliary and Abdominal Transplant surgery, University of Florida, Gainesville, Florida, USA
| | - Martin O Weickert
- The ARDEN NET Centre, ENETS Centre of Excellence, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Robert Sutton
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Saboor Khan
- Surgery, University Hosptial Coventry and Warwickshire, Coventry, UK
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Richards WO. W. Dean Warren, MD, FACS, Father of Selective Shunts for Variceal Hemorrhage: Lessons Learned. Am Surg 2020; 86:1049-1055. [PMID: 33049164 DOI: 10.1177/0003134820942146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dr Dean Warren was born in 1924 and died prematurely from cancer in 1989. He was a man of uncommon intelligence, wit, collegiality, integrity, honesty, and a true leader in American surgery. In 1966, he and his colleagues (Drs Zeppa and Fomon) presented a new concept for surgical shunts to control variceal hemorrhage while maintaining portal perfusion or hepatopetal blood flow. He termed this new shunt the distal splenorenal shunt (DSRS), which was the first selective shunt invented. The DSRS selective shunt was a brilliant improvement over the total shunt concept proposed by Nicolai Eck and was practiced worldwide during the 1980s. In a space of 2 decades, Dr Warren's pioneering work would show that the selective DSRS was superior to total shunts for treatment of portal hypertension, but that endoscopic sclerotherapy was a better first-line treatment for variceal hemorrhage than his own creation. His absolute adherence to the principles he espoused in his presidential address to the Society for Surgery of the Alimentary Tract in 1973 were employed in his research and treatment of patients. This paper details Dr Warren's extraordinary research accomplishments and sets a lesson for us that well-designed clinical trials including randomization are essential in the advancement of the care of surgical patients.
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Affiliation(s)
- William O Richards
- Department of Surgery, University of South Alabama, College of Medicine, Mobile, AL, USA
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Oehme F, Distler M, Müssle B, Kahlert C, Weitz J, Welsch T. Results of portosystemic shunts during extended pancreatic resections. Langenbecks Arch Surg 2019; 404:959-966. [PMID: 31446472 DOI: 10.1007/s00423-019-01816-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Patients with borderline resectable pancreatic cancer are increasingly explored after neoadjuvant treatment protocols. A complete resection, then, frequently includes the resection of the mesentericoportal axis. Portosystemic shunting for advanced tumours with infiltration of the splenic vein or cavernous transformation of the portal vein can enable complete tumour resection and prevent portovenous congestion of the intestine. The aim of this study was to report the results of this technique for selected patients. METHODS Patients operated for pancreatic cancer at our department between September 2012 and December 2017 using intraoperative portosystemic shunting were included in this retrospective analysis. RESULTS Some 11 patients with pancreatectomy and simultaneous portosystemic shunting were included. The median age was 65.1 years. A distal splenorenal shunt and a temporary mesocaval shunt were accomplished in 5 and 4 cases, respectively. Two patients were operated using persistent mesocaval shunts (from the coronary, splenic or inferior mesenteric veins). The median operating time was 9.43 h. All but one patient were resected with tumour-negative resection margins; 5 patients had relevant complicated postoperative courses. There was one case of in-hospital mortality but no further 30- or 90-day mortality or graft-associated complications. Five patients were alive after a median follow-up of 24.6 months. The median postoperative survival was 12 months. CONCLUSION Portosystemic shunting at the time of extended pancreatectomy is technically challenging but feasible and enables complete tumour resection in cases in which standard vascular reconstruction is limited by cavernous transformation or to prevent sinistral portal hypertension with acceptable morbidity in selected cases. Considering the limited overall survival, the potential individual patient benefit needs to be weighed against the considerable morbidity of advanced tumour resections.
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Affiliation(s)
- Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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Polk HC, Levi D, Hutson DG. W Dean Warren, MD: Iron Hand and Principles of Steel. J Am Coll Surg 2019; 228:708-714. [PMID: 30677526 DOI: 10.1016/j.jamcollsurg.2018.12.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Hiram C Polk
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY.
| | - David Levi
- Department of Surgery, Carolinas Medical Center, Charlotte, NC
| | - Duane G Hutson
- Department of Surgery, University of Miami School of Medicine, Miami, FL
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Tian L, He Y, Li D, Zhang H. Surgical shunts compared with endoscopic sclerotherapy for the treatment of variceal bleeding in adults with portal hypertension: a systematic review and meta-analysis. Postgrad Med J 2017; 94:7-14. [PMID: 28756406 DOI: 10.1136/postgradmedj-2016-134750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 06/21/2017] [Accepted: 06/26/2017] [Indexed: 12/15/2022]
Abstract
AIM Portal hypertension is a common complication of chronic liver disease and can cause variceal bleeding which is associated with high mortality. Choices for the treatment of variceal bleeding include surgical shunts and endoscopic sclerotherapy. The aim of this study was to compare the efficacy of surgical shunts and endoscopic sclerotherapy in treating variceal bleeding due to portal hypertension. DESIGN Systematic review and meta-analysis. SETTING Medline, PubMed, Cochrane and Google Scholar databases were searched until 12 February 2015, for relevant randomised control trials. Twenty studies with a total of 1540 participants were included. PATIENTS Patients with variceal bleeding due to portal hypertension. INTERVENTIONS Surgical shunts compared to endoscopic sclerotherapy. MAIN OUTCOME MEASURES Rates of rebleeding, survival and hepatoencephalopathy, and length of hospital stay. RESULTS Pooled data for 17 studies showed that the rate of rebleeding was significantly more frequent with sclerotherapy compared with surgical shunt therapy (OR 3.99, 95% CI 2.98 to 5.33, p<0.001). The sclerotherapy patient group compared with the shunt group was less likely to develop hepatoencephalopathy (15 studies: pooled OR 0.53, 95% CI 0.31 to 0.91, p=0.021) and had shorter hospital stays (pooled mean difference-4.32, 95% CI- 7.97 to -0.66, p=0.021). No significant difference in the survival rate was observed between the two groups (seven studies: OR 1.01, 95% CI 0.63 to 1.62, p=0.964). CONCLUSION This analysis indicated that the two types of treatment have similar mortality rates but differed with respect to rebleeding rate, incidence of hepatoencephalopathy and length of hospital stay.
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Affiliation(s)
- Lu Tian
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yunjun He
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Levi DM, Levi JU. The Inseparable Histories of the Southern Surgical Association and Surgery for Portal Hypertension. J Am Coll Surg 2016; 222:712-6. [PMID: 26831365 DOI: 10.1016/j.jamcollsurg.2015.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 12/23/2015] [Indexed: 11/18/2022]
Affiliation(s)
- David M Levi
- Department of Surgery, Carolinas Medical Center, Charlotte, NC.
| | - Joe U Levi
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
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11
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Richter J, Bode JG, Blondin D, Kircheis G, Kubitz R, Holtfreter MC, Müller-Stöver I, Breuer M, Hüttig F, Antoch G, Häussinger D. Severe liver fibrosis caused by Schistosoma mansoni: management and treatment with a transjugular intrahepatic portosystemic shunt. THE LANCET. INFECTIOUS DISEASES 2015; 15:731-7. [PMID: 25769268 DOI: 10.1016/s1473-3099(15)70009-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Liver diseases are common in inhabitants and migrants of tropical countries, where the liver can be exposed not only to toxins but also to many viral, bacterial, fungal, and parasitic infections. Schistosomiasis--a common parasitic infection that affects at least 240 million people worldwide, mostly in Africa--is regarded as the most frequent cause of liver fibrosis worldwide. We present a case of a 19-year-old male refugee from Guinea with recurrent oesophageal variceal bleeding due to schistosomal liver fibrosis refractory to endoscopic therapy. This case was an indication for portosystemic surgery, which is a highly invasive non-reversible intervention. An alternative, less invasive, reversible radiological procedure, used in liver cirrhosis, is the placement of a transjugular intrahepatic portosystemic shunt (TIPS). After thorough considerations of all therapeutic options we placed a TIPS in our patient. In more than 3 years of observation, he is clinically well apart from one episode of hepatic encephalopathy related to an acute episode of viral gastroenteritis. Bleeding from oesophageal varices has not recurred. In this Grand Round, we review the diagnostic approaches and treatment options for portal hypertension due to schistosomal liver fibrosis.
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Affiliation(s)
- Joachim Richter
- Tropical Medicine Unit, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.
| | - Johannes G Bode
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Dirk Blondin
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Gerald Kircheis
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Ralf Kubitz
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Martha C Holtfreter
- Tropical Medicine Unit, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Irmela Müller-Stöver
- Tropical Medicine Unit, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Matthias Breuer
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Falk Hüttig
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
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12
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Gur I, Diggs BS, Orloff SL. Surgical portosystemic shunts in the era of TIPS and liver transplantation are still relevant. HPB (Oxford) 2014; 16:481-93. [PMID: 23961811 PMCID: PMC4008167 DOI: 10.1111/hpb.12163] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 06/10/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The surgical portosystemic shunts (PSS) are a time-proven modality for treating portal hypertension. Recently, in the era of liver transplantation and the transjugular intrahepatic portosystemic shunts (TIPS), use of the PSS has declined. OBJECTIVES This study was conducted to evaluate changes in practice, referral patterns, and short- and longterm outcomes of the use of the surgical PSS before and after the introduction of the Model for End-stage Liver Disease (MELD). METHODS A retrospective analysis of 47 patients undergoing PSS between 1996 and 2011 in a single university hospital was conducted. RESULTS Subgroups of patients with cirrhosis (53%), Budd-Chiari syndrome (13%), portal vein thrombosis (PVT) (26%), and other pathologies (9%) differed significantly with respect to shunt type, Child-Pugh class, MELD score and perioperative mortality. Perioperative mortality at 60 days was 15%. Five-year survival was 68% (median: 70 months); 5-year shunt patency was 97%. Survival was best in patients with PVT and worst in those with Budd-Chiari syndrome compared to other subgroups. Patency was better in the subgroups of patients with cirrhosis and other pathologies compared with the PVT subgroup. Substantial changes in referral patterns coincided with the adoption of the MELD in 2002, with decreases in the incidence of cirrhosis and variceal bleeding, and increases in non-cirrhotics and hypercoagulopathy. CONCLUSIONS Although the spectrum of diseases benefiting from surgical PSS has changed, surgical shunts continue to constitute an important addition to the surgical armamentarium. Selected subgroups with variceal bleeding in well-compensated cirrhosis and PVT benefit from the excellent longterm patency offered by the surgical PSS.
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Affiliation(s)
- Ilia Gur
- Division of Surgical Oncology, Oregon Health and Science UniversityPortland, OR, USA,Correspondence Ilia Gur, General Surgery, Sutter Gould Medical Foundation, 2545 W. Hammer Lane, STE 2200, Stockton, CA, 95209 USA. Tel: +209 941 0127. Fax: + 209 951 2438.
| | - Brian S Diggs
- Division of General Surgery, Oregon Health and Science UniversityPortland, OR, USA
| | - Susan L Orloff
- Division of Abdominal Organ Transplant, Oregon Health and Science UniversityPortland, OR, USA
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Tomikawa M, Akahoshi T, Sugimachi K, Ikeda Y, Korenaga D, Takenaka K, Hashizume M, Maehara Y. An assessment of surgery for portal hypertensive patients performed at a single community hospital. Surg Today 2010; 40:620-5. [PMID: 20582512 DOI: 10.1007/s00595-009-4123-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 04/27/2009] [Indexed: 01/07/2023]
Abstract
PURPOSE The outcomes of surgery for portal hypertensive patients at a single community hospital in the last two decades were retrospectively examined. METHODS From June 1989 to March 2008, 13 of 848 (1.5%) portal hypertensive patients admitted and treated at the community hospital underwent surgery. The types of surgery performed were a distal splenorenal shunt for 2 patients, gastric devascularization and splenectomy for 8, laparoscopic gastric devascularization and splenectomy for 1, distal gastrectomy for 1, and splenectomy alone for 1. This study reviewed the postoperative records of the endoscopic findings and additional treatments, and the perioperative records. RESULTS No patient had bleeding from esophagogastric varices during the 75-month mean follow-up period after surgery. Five patients had one or two series of endoscopic treatment for recurrent likely-to-bleed esophageal varices. One patient needed interventional radiology for recurrent gastric varices. No patients died due to upper gastrointestinal bleeding. The survival rates were 87.5% after 5 years and 46.9% after 10 years. CONCLUSIONS Surgery for portal hypertensive patients performed at a single community hospital is still safe and effective, and has been adequately incorporated into the late treatment strategy for portal hypertensive patients.
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Affiliation(s)
- Morimasa Tomikawa
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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14
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Affiliation(s)
- Rome JUTABHA
- Department of Medicine, Division of Digestive Diseases, UCLA Center for the Health Sciences, Center for Ulcer Research and Education : Digestive Diseases Research Center (CURE : DDRC); and the West Los Angeles Veterans Administration Medical Center, Los Angeles, California, USA
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15
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SHARMA N, TAKASE Y, SHIBUYA S, IWASAKI Y. Injection Sclerotherapy for Esophageal Varices Associated with Hepatocellular Carcinoma and Liver Cirrhosis. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1990.tb00072.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Niranjan SHARMA
- Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasuhiro TAKASE
- Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | - Susumu SHIBUYA
- Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yoji IWASAKI
- Department of Surgery, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
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16
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Aydin U, Yazici P, Kilic M. Porto-systemic shunt using adrenal vein as a conduit; an alternative procedure for spleno--renal shunt. BMC Surg 2007; 7:7. [PMID: 17555599 PMCID: PMC1905910 DOI: 10.1186/1471-2482-7-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2006] [Accepted: 06/07/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Currently, portal hypertension is still big problem for the patients with serious liver diseases. Variceal bleeding is one of the most important complications of portal hypertension. In case of failure of endoscopic and combined medical treatments, surgical decompressive shunts are required. We emphasized an alternative splenorenal shunt procedure using adrenal vein as a conduit. CASE PRESENTATION A 26-year-old male suffered from recurrent variceal bleeding was considered for surgical therapy. Although we planned to perform a distal splenorenal shunt procedure, it was observed to be difficult. Therefore left adrenal vein was used as a conduit between left renal vein and splenic vein after splenic artery was ligated. He did well and was discharged from the hospital on the postoperative day 6. In the follow up period for nine months, endoscopic and ultrasonographic examinations were normal. CONCLUSION We concluded that, in case of failure to perform distal splenorenal shunt due to technical problems, alternative porto-systemic shunt procedure using the adrenal vein as a vascular conduit can be safely employed.
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Affiliation(s)
- Unal Aydin
- Ege University School of Medicine, Department of Surgery, Izmir, Turkey
| | - Pinar Yazici
- Ege University School of Medicine, Department of Surgery, Izmir, Turkey
| | - Murat Kilic
- Ege University School of Medicine, Department of Surgery, Izmir, Turkey
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Krige JEJ, Kotze UK, Bornman PC, Shaw JM, Klipin M. Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices. Ann Surg 2006; 244:764-70. [PMID: 17060770 PMCID: PMC1856595 DOI: 10.1097/01.sla.0000231704.45005.4e] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis. SUMMARY BACKGROUND DATA Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy. METHODS Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24-87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565 upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded. RESULTS Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1-174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3-198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death. CONCLUSION Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients.
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Affiliation(s)
- Jake E J Krige
- Department of Surgery, University of Cape Town Health Sciences Faculty, Anzio Road, Observatory 7925, Cape Town, South Africa.
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Khan S, Tudur Smith C, Williamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database Syst Rev 2006; 2006:CD000553. [PMID: 17054131 PMCID: PMC7045742 DOI: 10.1002/14651858.cd000553.pub2] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Randomised clinical trials have compared portosystemic shunting procedures with endoscopic therapy for variceal haemorrhage, but there is no consensus as to which approach is preferable. OBJECTIVES To compare the effects of shunts (total surgical shunt (TS); distal spleno-renal shunts (DSRS) or transjugular intrahepatic porto-systemic shunts (TIPS) with endoscopic therapy (ET, sclerotherapy and/or banding) for prevention of variceal rebleeding in patients with cirrhosis. SEARCH STRATEGY The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Library, MEDLINE, EMBASE, conference proceedings, and the references of identified trials were searched (last search February 2004). Researchers in the field and in industry were contacted. SELECTION CRITERIA Randomised clinical trials comparing TS, DSRS or TIPS with ET in patients who had recovered from a variceal haemorrhage and were known to be cirrhotic. DATA COLLECTION AND ANALYSIS Data were collected to allow intention-to-treat analysis where possible. For each outcome, a pooled estimate of treatment effect (log hazard ratio for time to outcome, Peto odds ratio for binary outcomes, and differences in means for continuous outcomes) across trials was calculated. MAIN RESULTS Twenty-two trials evaluating 1409 patients were included. All trials had problems of method. Shunt therapy compared with ET demonstrated significantly less rebleeding (OR 0.24, 95% CI 0.18 to 0.30) at the cost of significantly increased acute hepatic encephalopathy (OR 2.07, 95% CI 1.59 to 2.69) and chronic encephalopathy (OR 2.09, 95% CI 1.20 to 3.62). There were no significant differences regarding mortality (hazard ratio 1.00, 95% CI 0.82 to 1.21) and duration of in-patient stay (weighed mean difference 0.78 day, 95% CI -1.48 to 3.05). The proportion of patients with shunt occlusion or dysfunction was 3.1% (95% CI 0.4 to 10.7%) following TS (two trials), 7.8% (95% CI 3.8 to 13.9%) following DSRS (four trials), and 59% (range 18% to 72%) following TIPS (14 trials). AUTHORS' CONCLUSIONS All shunts resulted in a significantly lower rebleeding rate at the expense of a higher incidence of encephalopathy. TIPS was complicated by a high incidence of shunt dysfunction. No survival advantage was demonstrated with any shunt.
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Affiliation(s)
- S Khan
- Queen Elizabeth Hospital, Liver Unit (Hepatobiliary Pancreatic and Liver Transplant), Metchley Lane, Edgbaston, Birmingham, West Midlands, UK.
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Khan S, Tudur Smith C, Williamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2006. [PMID: 17054131 DOI: 10.1002/14651858.cd000553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Randomised clinical trials have compared portosystemic shunting procedures with endoscopic therapy for variceal haemorrhage, but there is no consensus as to which approach is preferable. OBJECTIVES To compare the effects of shunts (total surgical shunt (TS); distal spleno-renal shunts (DSRS) or transjugular intrahepatic porto-systemic shunts (TIPS) with endoscopic therapy (ET, sclerotherapy and/or banding) for prevention of variceal rebleeding in patients with cirrhosis. SEARCH STRATEGY The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Library, MEDLINE, EMBASE, conference proceedings, and the references of identified trials were searched (last search February 2004). Researchers in the field and in industry were contacted. SELECTION CRITERIA Randomised clinical trials comparing TS, DSRS or TIPS with ET in patients who had recovered from a variceal haemorrhage and were known to be cirrhotic. DATA COLLECTION AND ANALYSIS Data were collected to allow intention-to-treat analysis where possible. For each outcome, a pooled estimate of treatment effect (log hazard ratio for time to outcome, Peto odds ratio for binary outcomes, and differences in means for continuous outcomes) across trials was calculated. MAIN RESULTS Twenty-two trials evaluating 1409 patients were included. All trials had problems of method. Shunt therapy compared with ET demonstrated significantly less rebleeding (OR 0.24, 95% CI 0.18 to 0.30) at the cost of significantly increased acute hepatic encephalopathy (OR 2.07, 95% CI 1.59 to 2.69) and chronic encephalopathy (OR 2.09, 95% CI 1.20 to 3.62). There were no significant differences regarding mortality (hazard ratio 1.00, 95% CI 0.82 to 1.21) and duration of in-patient stay (weighed mean difference 0.78 day, 95% CI -1.48 to 3.05). The proportion of patients with shunt occlusion or dysfunction was 3.1% (95% CI 0.4 to 10.7%) following TS (two trials), 7.8% (95% CI 3.8 to 13.9%) following DSRS (four trials), and 59% (range 18% to 72%) following TIPS (14 trials). AUTHORS' CONCLUSIONS All shunts resulted in a significantly lower rebleeding rate at the expense of a higher incidence of encephalopathy. TIPS was complicated by a high incidence of shunt dysfunction. No survival advantage was demonstrated with any shunt.
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Affiliation(s)
- S Khan
- Queen Elizabeth Hospital, Liver Unit (Hepatobiliary Pancreatic and Liver Transplant), Metchley Lane, Edgbaston, Birmingham, West Midlands, UK.
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Isaksson B, Thorell LH, Bengtsson F, Rosén I, Jeppsson B. Hepatic encephalopathy verified by psychometric testing and EEG in cirrhotic patients: effects of mesocaval interposition shunt or sclerotherapy. HPB (Oxford) 2005; 7:65-72. [PMID: 18333163 PMCID: PMC2023924 DOI: 10.1080/13651820410030853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this randomised prospective study was to evaluate hepatic encephalopathy after mesocaval interposition shunt operation and after repeated endoscopic sclerotherapy. METHODS Forty-five patients with bleeding oesophageal varices due to liver cirrhosis were randomised to the two treatment groups, 24 to the shunt group and 21 to the sclerotherapy group. The patients were evaluated preoperatively regarding blood tests, hepatic encephalopathy as measured by electroencephalogram with spectral analysis and by a battery of psychometric tests. The direction of portal flow in the shunt group was investigated by shunt phlebography and ultrasonography with Doppler. During follow-up the same investigations were performed twice at median 6.7 and 14.7 months after operation. RESULTS No statistically significant difference was found during follow-up regarding blood tests and electroencephalography with spectral analysis. Although the preoperative psychometric tests showed that the shunt group performed significantly better than the sclerotherapy group, the first follow-up showed that the shunt group performed statistically worse than the sclerotherapy group in seven of the tests: Synonyms (measuring verbal ability), Block Design Test (measuring visuo-spatial ability), Memory for Design Test, Error Score (measuring memory function), Revised Visual Retention Test, correct answers and the same test error answers (measuring visuo-spatial memory, ability and immediate memory), Digit Symbol Test (measuring perceptual ability) and Trial Making Test B (measuring cognitive motor abilities). CONCLUSIONS Patients treated by mesocaval interposition shunt showed a progressive general reduction in psychometric performance compared with patients treated with repeated sclerotherapy, in whom a general intellectual improvement was observed. This finding corresponds to the reverse direction of the preoperative portal flow to a hepatofugal pattern at first follow-up and at 12 months among two-thirds of the patients.
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Affiliation(s)
- B. Isaksson
- Department of Surgery, Lund University HospitalLund
| | - L.-H. Thorell
- Department of Neuroscience and Locomotion, Division of Psychiatry, Faculty of Health Sciences, Linköping UniversityLinköping
| | - F. Bengtsson
- Department of Neuroscience and Locomotion, Division of Psychiatry, Faculty of Health Sciences, Linköping UniversityLinköping,Department of Clinical Pharmacology, Lund University HospitalLundSweden
| | - I. Rosén
- Department of Clinical Neurophysiology, Lund University HospitalLundSweden
| | - B. Jeppsson
- Department of Surgery, Lund University HospitalLund
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Zargar SA, Yattoo GN, Javid G, Khan BA, Shah AH, Shah NA, Gulzar GM, Singh J, Shafi HM. Fifteen-year follow up of endoscopic injection sclerotherapy in children with extrahepatic portal venous obstruction. J Gastroenterol Hepatol 2004; 19:139-45. [PMID: 14731122 DOI: 10.1111/j.1440-1746.2004.03224.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Endoscopic sclerotherapy has emerged as an effective treatment for bleeding esophageal varices both in adults and children but the long-term outcome is poorly defined in children. The authors report a 15-year follow up of sclerotherapy in children with extrahepatic portal venous obstruction. METHODS Between June 1982 and February 1992, 69 children with bleeding esophageal varices underwent sclerotherapy; variceal eradication was achieved in 63 (91.3%) patients, with procedure-related morbidity of 28.9% and mortality of 1.4%. Fifty-nine patients with variceal eradication were followed for between 10.4 and 20.1 years (mean, 15.1 +/- 3.1 years). RESULTS After a median period of 3 years (range, 1.2-12.8 years), seven (11.9%) patients presented with recurrent bleeding (esophageal varices, four; gastric varices, two; and duodenal ulcer, one). Recurrent bleeding occurred in six of seven (85.7%) patients within the first 4 years of initial variceal eradication. Esophageal varices recurred in eight (13.6%) patients. Five of the seven patients with recurrent bleeding and all eight with recurrent varices were effectively treated with further sclerotherapy. Two patients with gastric variceal bleeding unresponsive to sclerotherapy underwent shunt surgery. Elective surgery was required in eight additional patients for reasons other than recurrent varices or bleeding. CONCLUSIONS The authors conclude that (i) sclerotherapy is the ideal, safe and effective treatment for bleeding esophageal varices, that it prevented bleeding in 88.1% patients after variceal eradication and hence, should be included in primary management strategies; (ii) follow-up endoscopy should be performed on a yearly basis for the first 4 years after variceal eradication; and (iii) surgery is required as a complementary technique for patients with uncontrolled bleeding, painful splenomegaly, growth retardation and symptomatic portal biliopathy.
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Affiliation(s)
- Showkat Ali Zargar
- Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
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Abstract
Portal hypertension is defined by an hepatic venous pressure gradient greater than 5mmHg. It is usually caused by an increase in resistance in the portal-hepatic vascular bed due to obstruction to flow. The severe forms of schistosomiasis usually evolve with portal hypertension, esophageal, intraabdominal, retroperitoneal and abdominal wall varices. Massive bleeding due to esophageal or gastric variceal rupture is the major complication of portal hypertension in schistosomiasis. In regard to treatment, clinical (propranolol, somatostain, octreotide), endoscopic (sclerotherapy, clips and ligature of varices), vascular (TIPS - transjugular intrahepatic portosystemic shunt) and surgical (portosystemic shunts and portovariceal disconnection) approaches have been tried to decrease portal hypertension and prevent bleeding. In the present review the author discusses the subject emphasizing the surgical procedures.
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Affiliation(s)
- Andy Petroianu
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.
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Abstract
Gastric varices and portal hypertensive gastropathy (PHG) are an important complication of both generalized and segmental portal hypertension. The natural history and risk factors for bleed from GV are not extensively studied as that for esophageal varices. Recently, effective therapy for gastric variceal bleed in form of tissue adhesives, balloon-occluded retrograde transvenous obliteration of gastric varices (BRTO) has been developed. Further advances are still needed regarding natural history, risk factors, bleeding, and mechanism of GV rupture.
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Affiliation(s)
- S K Sarin
- Department of Gastroenterology, G. B. Pant Hospital, New Delhi, India.
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Hemming A, Gallinger S. Liver. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Tomikawa M, Hashizume M, Saku M, Tanoue K, Ohta M, Sugimachi K. Effectiveness of gastric devascularization and splenectomy for patients with gastric varices. J Am Coll Surg 2000; 191:498-503. [PMID: 11085729 DOI: 10.1016/s1072-7515(00)00735-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bleeding from gastric varices is difficult to control and has a high mortality rate. Recently, newly developed treatments for this serious lesion have been used, but surgical intervention is still advocated by several studies. We report our experience with gastric devascularization and splenectomy and its effectiveness for patients with gastric varices. STUDY DESIGN Gastric devascularization and splenectomy was successfully performed to treat patients with isolated gastric varices (n = 42). The patients included 27 men and 15 women who ranged from 29 to 73 years of age (average 53.7 years). We analyzed the findings of gastric varices using endoscopy, the results of gastric devascularization and splenectomy, and survival after the operation. RESULTS No patient had tortuous varices (F1). Twenty-seven patients (64.3%) had nodular varices (F2) and 15 (35.7%) had tumorous varices (F3). Twenty-five patients (59.5%) had large varices that occupied two or more areas. Twenty-nine patients (69.0%) had varices with a positive red color sign. No major complications during or after the operation were observed, and peri-operative death did not occur. Gastric varices were eradicated in all 42 patients. Survival rates were 97.6% after 1 year, 88.1% after 3 years, 76.2% after 5 years (mean followup period, 46 months). CONCLUSIONS This study showed that gastric devascularization and splenectomy provides satisfactory results for patients with gastric varices that are likely to bleed and that it can be performed even on patients who have had other treatments.
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Affiliation(s)
- M Tomikawa
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Avgerinos A, Armonis A, Manolakopoulos S, Rekoumis G, Argirakis G, Viazis N, Vlachogiannakos J, Adamopoulos A, Kanaghinis T, Raptis SA. Endoscopic sclerotherapy plus propranolol versus propranolol alone in the primary prevention of bleeding in high risk cirrhotic patients with esophageal varices: a prospective multicenter randomized trial. Gastrointest Endosc 2000; 51:652-8. [PMID: 10840295 DOI: 10.1067/mge.2000.105983] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Analysis of primary prevention studies of the use of beta-blockers has shown clear reductions in variceal bleeding in cirrhotic patients with varices. In contrast, the usefulness of prophylactic endoscopic sclerotherapy, alone or in combination with propranolol, in the management of these patients is still under investigation. The present study compared the efficacy of combined sclerotherapy and propranolol versus propranolol alone in the primary prevention of hemorrhage in cirrhotic patients with varices and high (greater than 18 mm Hg) intraesophageal variceal pressure. METHODS Patients were randomly assigned to propranolol (42 patients) or to propranolol plus sclerotherapy (44 patients). The mean duration of follow-up was 26.8 +/- 7.7 and 24.6 +/- 9.8 months, respectively. RESULTS During this period 23% of the patients in the combination group experienced at least 1 episode of bleeding due to varices or congestive gastropathy as compared with 14% in the propranolol group (not significant). Twenty-three patients (52%) in the combination group developed complications as compared with 8 (19%) in the propranolol group (p = 0.002). The mortality rate was similar in both groups (14% and 18%, respectively). The only independent factor predictive of survival was the level of serum albumin. CONCLUSIONS Endoscopic sclerotherapy should not be used for the primary prevention of hemorrhage in cirrhotic patients at high risk of variceal bleeding who are undergoing treatment with propranolol.
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Affiliation(s)
- A Avgerinos
- 2nd Department of Gastroenterology and 2nd Department of Internal Medicine, Athens University, Evangelismos Hospital, Greece
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Gonçalves ME, Cardoso SR, Maksoud JG. Prophylactic sclerotherapy in children with esophageal varices: long-term results of a controlled prospective randomized trial. J Pediatr Surg 2000; 35:401-5. [PMID: 10726678 DOI: 10.1016/s0022-3468(00)90203-3] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND/PURPOSE Experience using endoscopic prophylactic sclerotherapy (PS) is restricted to adult patients and has led to conflicting results. There has not been a randomized, controlled study on the use of PS in children. The purpose of this study is to evaluate prospectively the value of PS to prevent the first hemorrhage from esophageal varices in children with portal hypertension and to assess the effect of PS on survival rate. METHODS In a controlled, prospective, computer-based randomized trial, the effectiveness of PS was analyzed in 100 consecutive children allocated to a group receiving sclerotherapy (n = 50) or to a control group (n = 50) subjected only to regular clinical and endoscopic examinations. Clinical characteristics in both groups were similar. The minimum follow-up period was at least 18 months after the cessation of the sessions of sclerotherapy. RESULTS After a median follow-up of 4.5 years, PS eliminated the esophageal varices in 47 of 50 (94%) patients but only 38 (76%) of them do not present upper digestive hemorrhage. Before complete obliteration of the varices, upper gastrointestinal bleeding occurred in 12 patients (24%). Six children (12%) had gastric varices, 3 of 6 of whom (50%) bled. Congestive hypertensive gastropathy was observed to occur in 8 (16%) patients, 4 of 8 of which (50%) had hemorrhagic episodes. Two patients bled from undetermined cause. In the control group, only 29 (58%) children remained free from esophageal variceal bleeding and 26 (52%) from any upper gastrointestinal bleeding (P<.05). During the follow-up period, the development of gastric varices was observed in 5 (10%) patients (P>.05) and of congestive hypertensive gastropathy in only 3 (6%) patients (P<.05), but none of them bled. PS does not improve survival rate. CONCLUSIONS In children with cirrhotic and noncirrhotic portal hypertension, PS reduces the overall incidence of bleeding from esophageal varices that were eradicated in 94% of cases. The source of bleeding has been different in each group, being predominantly from esophageal varices in the control group and from the stomach in the prophylaxis group. When applied with appropriate technique, PS is a safe procedure with a low incidence of minor complications. PS does not change the incidence of gastric varices but increases the development of congestive hypertensive gastropathy. PS increases the risk of bleeding from the naturally formed gastric varices and from congestive hypertensive gastropathy. PS does not affect survival rate.
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Affiliation(s)
- M E Gonçalves
- Department of Surgery, Instituto da Criança-Hospital das Clínicas, University of São Paulo Medical School, Brazil
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29
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Hepworth CC, Burnham WR, Swain CP. Development and application of endoloops for the treatment of bleeding esophageal varices. Gastrointest Endosc 1999; 50:677-84. [PMID: 10536327 DOI: 10.1016/s0016-5107(99)80020-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoloops are detachable nylon snares. The aims of this study were to develop an endoscopic method for repeated delivery of endoloops to arrest variceal bleeding, to compare efficacy of endoloop hemostasis with injection and band ligation in experimental models of bleeding, and to test the reliability and safety of endoloops in a pilot study in patients with varices. METHODS Technical modifications including ridged endcaps and alterations in angulation of endoloops were developed to speed delivery and improve efficacy. Hemostatic efficacy of endoloops was compared with sclerotherapy and band ligation in animal studies before studies in patients. RESULTS Modified endcap and endoloops allowed repeated applications without withdrawal of the endoscope. Right-angled endoloops ensnared more (p < 0.0001) gastric tissue and were more reliable (p < 0.05) than straight endoloops. Injection therapy and prestretched bands appeared ineffective, whereas band ligation was only effective on vessels up to 2 mm in diameter. Only endoloops achieved hemostasis on vessels of 3 to 5 mm (p < 0.05). No significant complications occurred using endoloops in animal (esophagus n = 20, stomach n = 20) or human (n = 11) studies. CONCLUSIONS Endcap and endoloop modifications simplified repeated application to varices. Endoloops were more effective than injection or band ligation in experimental hemostasis and appeared safe and effective in patients.
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Affiliation(s)
- C C Hepworth
- Oldchurch Gastroenterology Department, Romford, Essex, United Kingdom
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30
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Margarit C, Lázaro JL, Charco R, Hidalgo E, Revhaug A, Murio E. Liver transplantation in patients with splenorenal shunts: intraoperative flow measurements to indicate shunt occlusion. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1999; 5:35-9. [PMID: 9873090 DOI: 10.1002/lt.500050114] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Two patients with previous distal splenorenal shunts (DSRSs) performed 6 years earlier underwent liver transplantation (LT). A preoperative selective mesenteric artery angiogram showed collateral veins draining mesenteric venous flow into the shunt. Intraoperative flow measurements were performed to assess the steal of portal venous flow by the shunt and determine the need for shunt occlusion. Portal vein, hepatic artery, and shunt flows were measured by ultrasound transit-time flow probes in the native liver and after graft implantation with and without temporary shunt occlusion. Hemodynamic studies showed that long-standing DSRSs are high-flow shunts that steal portal flow. After graft implantation, DSRS flows remained high. Occlusion of the shunts produced an increase in portal vein flow at an amount similar to those of splenorenal shunt. Thus, the flow measurements showed persistent steal by the shunts after graft implantation and, therefore, the DSRSs were occluded but splenectomy was not performed. We conclude that the decision to occlude a DSRS should be based on the demonstration of steal of portal flow by the shunt and reversibility once the shunt is occluded. Splenectomy is not required when the DSRS is occluded.
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Affiliation(s)
- C Margarit
- Unidad de Trasplante Hepático, Hospital General Vall Hebrón, Spain
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31
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Hashizume M, Tanoue K, Morita M, Ohta M, Tomikawa M, Sugimachi K. Laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices with hypersplenism. J Am Coll Surg 1998; 187:263-70. [PMID: 9740183 DOI: 10.1016/s1072-7515(98)00181-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The combination of sclerotherapy with surgical salvage for sclerotherapy-resistant esophagogastric varices has recently received much attention, however, the longterm results after such an operation have yet to be reported. This is a preliminary report of a laparoscopic adaptation of a previously described surgical procedure for the treatment of refractory esophagogastric varices. STUDY DESIGN Laparoscopic gastric devascularization and splenectomy (Hassab's operation) was successfully performed to treat recurrent sclerotherapy-resistant giant esophageal varices (n=4) and recurrent rebleeding gastric varices (n=6). The patients included 8 men and 2 women who ranged in age from 35 to 67 years (average, 54.2 years). The procedure and clinical results were evaluated from various viewpoints. RESULTS The duration of the operation ranged from 200 to 400 minutes (mean+/-standard deviation; 287.5+/-66.0 minutes) and blood loss from 10 to 1,500 mL (average, 515.5+/-507.9 mL). The weight of the spleen ranged from 500 to 850 g (average 608.0+/-126.6 g). Conversion to minimal open operation with a gasless lifting method was done in 1 patient because of uncontrolled bleeding from the splenic vein. There were no other major complications either intraoperatively or postoperatively. All patients had hypersplenism; preoperative platelet counts ranged from 1.6 to 6.8 x 10(4)/microL (average, 4.5+/-2.7 x 10(4) microL) and the postoperative count was from 5.9 to 36.0 x 10(4)/microL (average, 21.7+/-11.5 x 10(4) microL). Postoperative endoscopy revealed that varices disappeared, and no patient had recurrence of the varices after operation during the mean followup period of 12.8+/-4.1 months (average, 8 to 20 months). CONCLUSIONS The combination of laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices is considered a feasible and relatively safe surgical method for patients with hypersplenism.
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Affiliation(s)
- M Hashizume
- Department of Surgery II, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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32
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Avgerinos A, Armonis A, Manolakopoulos S, Poulianos G, Rekoumis G, Sgourou A, Gouma P, Raptis S. Endoscopic sclerotherapy versus variceal ligation in the long-term management of patients with cirrhosis after variceal bleeding. A prospective randomized study. J Hepatol 1997; 26:1034-41. [PMID: 9186834 DOI: 10.1016/s0168-8278(97)80112-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS Long-term endoscopic injection sclerotherapy of oesophageal varices prevents rebleeding in patients with cirrhosis surviving an acute variceal bleeding episode. However, this treatment is associated with a substantial complication rate. Endoscopic band ligation is a newly developed technique in an attempt to provide a safer alternative. The aim of this study was to compare the efficacy and safety of injection sclerotherapy versus variceal ligation in the management of patients with cirrhosis after variceal haemorrhage. METHODS Seventy-seven patients with cirrhosis who proved to have oesophageal variceal bleeding were studied. After initial control of haemorrhage by sclerotherapy, 40 of the patients were randomly assigned to sclerotherapy and 37 to ligation. Both procedures were performed under midazolam sedation at intervals of 7-14 days until all varices in the distal oesophagus were eradicated or were too small to receive further treatment. RESULTS The eradication of varices required a lower mean number of sessions with ligation (3.7 +/- 1.9) than with sclerotherapy (5.8 +/- 2.7, p = 0.002). The mean duration of follow-up was similar in both groups (15.6 months +/- 7.3 and 15 +/- 7.4, respectively). The proportion of patients remaining free from recurrent bleeding against time was significantly higher in the ligation group as compared to the sclerotherapy group (chi 2 = 3.86, p = 0.05). Only 13 patients (35%) developed complications in the ligation group as compared to 24 (60%, p = 0.05) in the sclerotherapy group. The mortality rate was similar in both groups (20% and 21%, respectively). CONCLUSIONS Variceal ligation is better than sclerotherapy in the long-term management of patients with cirrhosis after variceal haemorrhage which was initially controlled with sclerotherapy.
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Affiliation(s)
- A Avgerinos
- 2nd Department of Gastroenterology, Evangelismas Hospital, Athens, Greece
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Rössle M, Deibert P, Haag K, Ochs A, Olschewski M, Siegerstetter V, Hauenstein KH, Geiger R, Stiepak C, Keller W, Blum HE. Randomised trial of transjugular-intrahepatic-portosystemic shunt versus endoscopy plus propranolol for prevention of variceal rebleeding. Lancet 1997; 349:1043-9. [PMID: 9107241 DOI: 10.1016/s0140-6736(96)08189-5] [Citation(s) in RCA: 165] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The transjugular-intrahepatic-portosystemic shunt is a new interventional treatment for portal hypertension. The aim of our study was to compare the transjugular shunt with endoscopic treatment for the prophylaxis of recurrent variceal bleeding. METHODS Between March, 1993, and March, 1996, 126 patients with variceal bleeding were randomly assigned either transjugular shunt (n = 61) or endoscopic treatment (n = 65). Patients were followed up for a median of 14 (IQR 8-25) months and 13 (8-25) months, respectively. In 31 (51%) of the shunted patients, simultaneous transjugular-variceal embolisation was done at the time of shunt placement. Endoscopic treatment consisted of sclerotherapy and/or banding ligation and was combined with propranolol medication. FINDINGS Technical success was achieved in all patients assigned to the shunt group. During follow-up, the cumulative 1-year variceal rebleeding rates in the shunted and endoscopically treated patients were 15% and 41% and the 2-year rates were 21% and 52% (p = 0.001), respectively. In nine (12%) patients from the endoscopic group treatment failed and the patients received the transjugular-shunt treatment. A total of 19 bleeding episodes from any source occurred in 15 patients in the shunt group compared with 100 episodes in 33 patients in the endoscopic group. There was no difference in survival with estimated 1-year survival rates for shunted and endoscopically treated patients of 90% and 89%, and 2-year survival rates of 79% and 82%, respectively. The incidence of clinically significant hepatic encephalopathy after 1 year was higher in the shunt group (36% vs 18%, p = 0.011). INTERPRETATION These results suggest, that the transjugular shunt is more effective than endoscopic treatment in prevention of variceal rebleeding but has a considerable risk of hepatic encephalopathy. Survival is similar in the two groups.
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Affiliation(s)
- M Rössle
- Department of Gastroenterology and Hepatology, University Hospital, University of Frelburg, Germany
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Hashizume M, Sugimachi K. Sclerotherapy resistant oesophageal varices: what are their clinical significance in prophylactic sclerotherapy? J Gastroenterol Hepatol 1996; 11:1105-9. [PMID: 9034927 DOI: 10.1111/j.1440-1746.1996.tb01836.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Caldwell SH, de Lange EE, Gaffey MJ, Sue M, Boyd JC, Dickson RC, Driscoll C, Stevenson WC, Ishitani MB, McCullough C, Pruett TL. Accuracy and significance of pretransplant liver volume measured by magnetic resonance imaging. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1996; 2:438-42. [PMID: 9346690 DOI: 10.1002/lt.500020606] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Measurement of liver volume in patients with advanced liver disease is used to gauge the appropriate size of donor organs and may have prognostic value. We sought to determine the accuracy of magnetic resonance imaging (MRI) in measuring liver volume in 19 adult patients under consideration for liver transplantation. We also correlated the liver volume determination to the clinical severity of disease. Liver volume was measured at MRI by averaging the calculated volumes from coronal and transverse breath-hold T1-weighted images. These results were compared to the explanted liver volume measured by fluid displacement and the explant mass. The correlation coefficient for MRI liver volume and the explant displacement volume was 0.90. The mean liver volume for Child-Pugh class AB by MRI was 1986 +/- 568 mL (1002-2470 mL) compared to 1433 +/- 379 mL (540-1889 mL) in Child-Pugh class C patients (p = .02). We conclude that MRI offers an anatomically accurate means of determining adult liver volume in vivo. Lower mean liver volumes were observed in Child-Pugh class C patients. In addition to its ability to provide tumor screening and vascular assessment, MRI is able to provide accurate determinations of liver volume in patients undergoing liver transplant evaluations.
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Affiliation(s)
- S H Caldwell
- University of Virginia Health Sciences Center, Department of Internal Medicine, Charlottesville 22908, USA
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Jutabha R, Jensen DM. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Med Clin North Am 1996; 80:1035-68. [PMID: 8804374 DOI: 10.1016/s0025-7125(05)70479-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article reviews the management of severe upper gastrointestinal bleeding in the patient with chronic liver diseases. The initial assessment, diagnostic work-up, and treatment options for variceal and nonvariceal bleeding are discussed. The role of diagnostic and therapeutic endoscopy for esophagogastric varices is reviewed with special emphasis on new endoscopic techniques including variceal band ligation and cyanoacrylate injection. Various pharmacologic, surgical, and radiologic treatment options for variceal bleeding also are discussed. In addition, nonvariceal causes of severe upper gastrointestinal bleeding are reviewed including peptic ulcer diseases, Mallory-Weiss tear, portal hypertensive gastropathy, and gastric antral vascular ectasia.
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Affiliation(s)
- R Jutabha
- Department of Medicine, University of California, Los Angeles School of Medicine 90095-1684, USA
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Jalan R, Redhead DN, Hayes PC. Transjugular intrahepatic portasystemic stent-shunt in the treatment of variceal haemorrhage. Br J Surg 1995; 82:1158-64. [PMID: 7551988 DOI: 10.1002/bjs.1800820905] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The transjugular intrahepatic portasystemic stent-shunt (TIPSS) is a side-to-side portocaval shunt, performed by interventional radiological methods, linking the hepatic and portal veins through the liver parenchyma with an expandable metal stent. The technique can be performed successfully in over 90 per cent of patients. The procedure-related mortality rate is about 1 per cent, mainly from intraperitoneal bleeding. The main indications for TIPSS insertion are control of acute variceal bleeding in patients with cirrhosis that is refractory to sclerotherapy and recurrent variceal haemorrhage despite sclerotherapy or band ligation. TIPSS insertion is followed by variceal rebleeding in about 10-20 per cent of cases, encephalopathy in 10-20 per cent, transient deterioration of liver function in 25-35 per cent and subsequent shunt dysfunction over a 6-12-month period in 15-60 per cent. The final place of TIPSS insertion in the management of portal hypertension is being evaluated in controlled studies, but its use in the treatment of uncontrolled variceal haemorrhage seems assured.
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Affiliation(s)
- R Jalan
- Department of Medicine, Royal Infirmary, Edinburgh, UK
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38
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Jalan R, Elton RA, Redhead DN, Finlayson ND, Hayes PC. Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage. J Hepatol 1995; 23:123-8. [PMID: 7499782 DOI: 10.1016/0168-8278(95)80325-4] [Citation(s) in RCA: 124] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND/AIMS The aim of this study was to analyse prognostic variables predicting mortality, shunt insufficiency, variceal rebleeding and encephalopathy following transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage. METHODS Sixty-eight patients with cirrhosis who successfully underwent transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage were studied. Mean age was 54.8 years (s.e. 1.5); 41 were males and 27 were females. Mean Child score was 8.3 (s.e. 0.3). Cirrhosis was alcohol related in 47. The patients have been followed up for a mean of 10.8 (s.e. 1.1) months. The univariate association between 30 prognostic variables and post-treatment encephalopathy was tested by the Chi-squared or Wilcoxon rank-sum tests and multiple logistic regression was used to test the significance of factors adjusted for one another. Cox's proportional hazard regression was used to test the univariate and multivariate significance of the other three outcomes. RESULTS Transjugular intrahepatic portosystemic stent-shunt was performed successfully in 89.5% of patients. Twenty-two patients have died and eight have been transplanted. Fourteen patients died within 30 days of transjugular intrahepatic portosystemic stent-shunt and death was predicted independently by hyponatraemia (p < 0.001) and by severe liver disease (Child C, p < 0.001). Eight patients died during follow up and survival in the long term was predicted independently by the presence of encephalopathy (p < 0.001) prior to transjugular intrahepatic portosystemic stent-shunt (p < 0.001). Shunt insufficiency was predicted by an initial portal pressure gradient of greater than 18 mmHg (p < 0.01). None of the variables analysed predicted variceal rebleeding. Encephalopathy following transjugular intrahepatic portosystemic stent-shunt was only predicted indepedently by its presence prior to transjugular intrahepatic portosystemic stent-shunt (p < 0.001). CONCLUSIONS The results of this study suggest that patients with severe liver disease and hyponatraemia are liable to die early, and the presence of encephalopathy prior to transjugular intrahepatic portosystemic stent-shunt independently determines long-term survival. Patients in these groups should be considered high risk and worked up for orthotopic liver transplantation early. Shunt function in patients with an initial portal pressure gradient of > 18 mmHg requires close supervision. Encephalopathic patients should have smaller shunts and prophylactic measures to prevent worsening encephalopathy.
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Affiliation(s)
- R Jalan
- Department of Medicine, Royal Infirmary of Edinburgh, Scotland, UK
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39
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Evans TR, Mansi JL. Oesophageal varices: a potentially fatal complication of liver metastases. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1995; 21:204-5. [PMID: 7720899 DOI: 10.1016/s0748-7983(95)90633-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Haemorrhage from oesophageal varices is a common and potentially life-threatening complication of portal hypertension, which is usually due to cirrhosis of the liver. Although liver metastases and hepatic dysfunction frequently occur in malignant disease, reports of oesophageal varices arising as a consequence of metastatic liver disease are sporadic, suggesting that this complication is unusual. Indeed, one review of the literature identified only 23 cases, although a few others have subsequently been reported. The management of such patients bleeding from oesophageal varices is clearly very different from bleeding due to other causes such as peptic ulceration. We report three cases and review the literature. All of our cases presented to us within a period of one year, suggesting that this complication of metastatic liver disease is more common than originally considered to be the case.
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Affiliation(s)
- T R Evans
- Department of Medical Oncology, St George's Hospital Medical School, London, UK
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40
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Maddern G, Meunier B, Launois B. Surgical management of portal hypertension. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1994; 64:818-22. [PMID: 7980253 DOI: 10.1111/j.1445-2197.1994.tb04555.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The surgical management of portal hypertension depends on the location of the obstruction. Suprahepatic obstruction is usually optimally treated by a surgical portacaval shunt. In extrahepatic obstruction the treatment should be sclerotherapy. For intrahepatic obstruction in emergency situations, sclerotherapy is the first choice, with portacaval systemic shunts or transjugular intrahepatic portal systemic stent shunt the second option. Liver transplantation in other situations should, if possible, be considered ahead of a portal diversion.
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Affiliation(s)
- G Maddern
- Department of Digestive Surgery and Transplantation, Pontchaillou University Hospital, Rennes, France
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41
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Berger H, Bugnon F, Goffette P, Steiner W, Strobelt M, Flemmer A, de Ville de Goyet J, Clapuyt P, Otte JB, Buts JP. Percutaneous transjugular intrahepatic stent shunt for treatment of intractable varicose bleeding in paediatric patients. Eur J Pediatr 1994; 153:721-5. [PMID: 7813528 DOI: 10.1007/bf01954487] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
UNLABELLED Two 10-year and 11-year-old children with oesophageal and gastric varicose haemorrhage unresponsive to medical treatment and repeated endoscopic sclerotherapy underwent percutaneous transjugular intrahepatic portosystemic shunting (TIPSS). A newly developed introducing system was used. The procedure was performed to avoid the increased risk of emergency liver transplantation in children with hepatic failure. Immediately after the procedure bleeding stopped and the patient's condition improved. Ascites disappeared and liver function improved. The stent shunt was shown to be patent by angiography and Doppler ultrasound for a follow up period of more than 1 year. CONCLUSION TIPSS may be of benefit in children with severe portal hypertension. It allows control of intractable bleeding, and stabilizes the patients preparing them for subsequent elective orthotopic liver transplantation.
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Affiliation(s)
- H Berger
- Ludwig-Maximilians Universität München, Klinikum Grosshadern, Institut für Radiologische Diagnostik, München, Germany
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42
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Affiliation(s)
- P C Bornman
- Groote Schuur Hospital, Observatory, South Africa
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43
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Terblanche J, Stiegmann GV, Krige JE, Bornman PC. Long-term management of variceal bleeding: the place of varix injection and ligation. World J Surg 1994; 18:185-92. [PMID: 8042321 DOI: 10.1007/bf00294399] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Injection sclerotherapy remains the most widely used long-term management for patients after an esophageal variceal bleed. Sclerotherapy treatments should be repeated weekly until the varices are eradicated. Follow-up endoscopy every 6 to 12 months is required for life. Whenever varices recur, further weekly injection treatments are administered until re-eradication is achieved. Failure of sclerotherapy must be diagnosed early and an alternative salvage procedure performed. We currently recommend the distal splenorenal shunt. Although the complications of sclerotherapy are not great, they are cumulative with time. Unlike most surgical procedures for portal hypertension, the technique of performing sclerotherapy is not standardized, making the comparison of controlled trials difficult. The current status of controlled trials comparing sclerotherapy with other treatments is evaluated. We conclude that repeated injection sclerotherapy is at present the initial treatment of choice for patients after an esophageal variceal bleed. The technique of the new procedure of esophageal variceal ligation is described. As with sclerotherapy, weekly treatment sessions are recommended until the esophageal varices are eradicated, followed by long-term endoscopic surveillance and repeat ligation treatment when varices recur. The four controlled trials that have compared variceal ligation with sclerotherapy favor ligation. Ligation eradicated esophageal varices with fewer treatment sessions and a lower complication rate. One trial demonstrated improved survival. Complications due to the overtube are being increasingly reported but were not a problem in the controlled trials. Although esophageal variceal ligation or ligation plus sclerotherapy may ultimately prove to be superior to sclerotherapy alone, more data are required before a final conclusion can be reached.
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Affiliation(s)
- J Terblanche
- Department of Digestive Surgery, Regional Hospital, Pontchaillou, France
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44
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Barsoum MS, Boulos FI, Aly AM, Saad M, Soliman MA, Doss WH, Zakaria S, Thakeb F. Acute variceal hemorrhage: the persistent bleeder. A plea for management. World J Surg 1994; 18:273-8; discussion 278. [PMID: 8042334 DOI: 10.1007/bf00294413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A group of 1910 patients with acutely bleeding esophagogastric varices were managed in the Kasr El Aini sclerotherapy project; 458 of the patients (24%) were lost to follow-up. The remaining patients were studied in five groups: group I (294/401 patients), rigid versus flexible sclerotherapy; group II (254/336 patients), intravariceal versus paravariceal sclerotherapy; group III (174/227 patients), timing of initial sclerotherapy and the optimum frequency of sclerotherapy sessions; group IV (80/99 patients), splenectomy devascularization operation alone versus combined surgery with sclerotherapy; group V (650/847 patients), management of failures of and recurrences after sclerotherapy. The mean period of follow-up was 72 months. Rigid sclerotherapy was significantly superior to flexible sclerotherapy for emergency control of acute bleeding but was associated with significantly more morbidity. Paravariceal injection achieved insignificantly better initial control of bleeding and had more morbidity than intravariceal injection, which obliterated the varices in a significantly larger proportion of patients. Emergency injection of the acute bleeder should be carried out soon after admission, with sclerotherapy sessions repeated every 2 weeks. Combined sclerotherapy with splenectomy and devascularization was significantly more effective for controlling bleeding than surgery alone. Surgery should be done without delay for continued bleeding after the second attempt of sclerotherapy and in patients who rebleed after their third sclerotherapy session. Survival, however, was not significantly improved by the different modalities of sclerotherapy.
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Affiliation(s)
- M S Barsoum
- Department of Surgery, Kasr El Aini School of Medicine, Cairo University, Egypt
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45
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Henderson JM. Role of distal splenorenal shunt for long-term management of variceal bleeding. World J Surg 1994; 18:205-10. [PMID: 8042324 DOI: 10.1007/bf00294402] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Distal splenorenal shunt (DSRS) has been studied extensively over the past 25 years to define its role in management of variceal bleeding. The operative technique of the shunt has not changed, but more aggressive attempts at portal-azygos disconnection have been studied for their effect on maintenance of portal perfusion. Control of variceal bleeding is achieved in about 90% of patients. Portal flow to the liver is maintained in > 90% of patients with nonalcoholic etiology of portal hypertension and in 50% to 84% of patients with alcoholic cirrhosis depending on the degree of portal-azygos disconnection. Encephalopathy and liver failure do not seem to be accelerated by DSRS but depend on the severity of the underlying liver disease. Reported survival likewise depends on the etiology of portal hypertension and the severity of liver disease: > 90% survival can be achieved in portal vein thrombosis and patients with cirrhosis and normal liver function, but 50% to 60% 3- to 5-year survivals are reported for patients with more advanced disease. DSRS offers one treatment modality for management of variceal bleeding that must fit into an overall strategy for these patients. Full evaluation is the key to allow selection of patients for pharmacotherapy, sclerotherapy, variceal decompression, or liver transplantation.
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Affiliation(s)
- J M Henderson
- Department of General Surgery, Cleveland Clinic Foundation, Ohio 44195
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46
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Early and late changes in fasting and absorptive plasma amino acids and ammonia after distal splenorenal shunt in cirrhosis. Hepatology 1994. [DOI: 10.1002/hep.1840190210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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47
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Rössle M, Haag K, Ochs A, Sellinger M, Nöldge G, Perarnau JM, Berger E, Blum U, Gabelmann A, Hauenstein K. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med 1994; 330:165-71. [PMID: 8264738 DOI: 10.1056/nejm199401203300303] [Citation(s) in RCA: 524] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Transjugular placement of an intrahepatic stent is a new technique to establish a portosystemic shunt for treatment of portal hypertension. A puncture needle is advanced in a catheter through the inferior vena cava into a hepatic vein; then an intrahepatic branch of the portal vein is punctured and an expandable stent of metallic mesh is implanted to establish the shunt. METHODS We attempted the stent-shunt procedure in 100 of 112 consecutive patients with variceal bleeding due to cirrhosis, who were then followed for a mean (+/- SD) of 12 +/- 6 months. Of the 100 patients, 22 had Child-Pugh class C cirrhosis, 10 were treated on an emergency basis, and 68 had alcoholic cirrhosis. The shunt was established with use of Palmaz stents expanded to 8 to 12 mm in diameter. RESULTS Technical success was achieved in 93 percent of the patients. The mean (+/- SD) time for the procedure was 1.2 +/- 0.3 hours. The shunt reduced the portal venous pressure gradient by 57 percent. Major complications were hemorrhage (intraabdominal bleeding in six patients, biliary bleeding in four, and bleeding in the liver capsule in three) and migration of the stent into the pulmonary artery (in two patients). At follow-up, stenosis of the shunt was evident in 21 patients and occlusion in 10 patients; 10 of these 31 patients had variceal rebleeding. Stenoses and occlusions of the shunt were all treated successfully by redilation, thrombolysis, or implantation of an additional stent. Hepatic encephalopathy (stages I to III) developed in 25 percent of the patients. The proportion of patients with shunts who remained free of variceal rebleeding was 92 percent at six months and 82 percent at one year. The 30-day mortality was 3 percent. The cumulative one-year survival was 85 percent. CONCLUSIONS These results suggest that the transjugular placement of an intrahepatic portosystemic stent is an effective and safe treatment for variceal hemorrhage in patients with portal hypertension due to cirrhosis.
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Affiliation(s)
- M Rössle
- Medizinische Universitätsklinik, Freiburg, Germany
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48
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Abstract
Injection sclerotherapy is the mainstay of treatment for acute variceal bleeding and for long-term management after a variceal bleed. In those few patients in whom sclerotherapy fails to control acute bleeding, either a surgical shunt or a simple esophageal transection is recommended. A surgical shunt or a more extensive esophagogastric devascularization and transection operation is advocated for the failures of long-term sclerotherapy management. The role of pharmacological agents in acute variceal bleed management remains in question, and the use of propranolol in long-term management, either as an alternative to sclerotherapy or in combination with sclerotherapy, is controversial. The definitive roles of the newly described variceal banding and transjugular intrahepatic porto-systemic shunts (TIPS) procedures have yet to be established. All patients presenting with end-stage liver disease and esophageal variceal bleeding should be evaluated for a liver transplant, although few will qualify. A possible future transplant should be kept in mind when emergency treatment is planned. Any form of prophylactic therapy for patients with esophageal varices that have not yet bled will remain unjustified until those patients at high risk of a first variceal bleed can be identified. The gastric mucosal lesion, portal hypertensive gastropathy, has been underdiagnosed in the past. Although bleeding does occur, it is seldom a major clinical problem. When necessary, bleeding can be controlled by propranolol or a surgical shunt.
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Affiliation(s)
- J Terblanche
- Department of Surgery, University of Cape Town, South Africa
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49
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Terés J, Bosch J, Bordas JM, Garcia Pagán JC, Feu F, Cirera I, Rodés J. Propranolol versus sclerotherapy in preventing variceal rebleeding: a randomized controlled trial. Gastroenterology 1993; 105:1508-14. [PMID: 8224655 DOI: 10.1016/0016-5085(93)90158-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Sclerotherapy has been widely recommended as initial treatment for prevention of variceal rebleeding. The present study was aimed at comparing the efficacy of endoscopic sclerotherapy and long-term administration of propranolol in the prevention of rebleeding and long-term survival in patients who had bled from varices. METHODS One hundred sixteen consecutive cirrhotic patients admitted because of variceal bleeding were randomly allocated to either continuous administration of propranolol to reduce the resting heart rate by 25% (58 patients) or weekly intravariceal sclerotherapy sessions using 5% ethanolamide oleate until varices disappeared (58 patients). Results were analyzed on an intention-to-treat basis. RESULTS Rebleeding occurred in 37 patients of the propranolol group and in 26 patients of the sclerotherapy group (RR = 1.45; 95% CI, 1.03-2.03). The actuarial probability of rebleeding was lower in the sclerotherapy group (P = 0.02). No differences were found in rebleeding index, hospitalization requirements, survival, and causes of death. Complications were significantly more frequent and severe in the sclerotherapy group. CONCLUSIONS Despite the higher efficacy of sclerotherapy decreasing the probability of rebleeding when compared with propranolol, no beneficial effects were observed on other parameters also reflecting the efficacy of therapy. Moreover, complications of sclerotherapy were more frequent and severe than those of propranolol, which probably shall restrict the use of long-term elective sclerotherapy.
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Affiliation(s)
- J Terés
- Gastroenterology Unit, Hospital Clinic i Provincial Medical School, Barcelona, Spain
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50
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Avgerinos A, Rekoumis G, Klonis C, Papadimitriou N, Gouma P, Pournaras S, Raptis S. Propranolol in the prevention of recurrent upper gastrointestinal bleeding in patients with cirrhosis undergoing endoscopic sclerotherapy. A randomized controlled trial. J Hepatol 1993; 19:301-11. [PMID: 8301065 DOI: 10.1016/s0168-8278(05)80586-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The purpose of this study was to investigate the possible value of continuous administration of propranolol in the prevention of recurrent upper gastrointestinal bleeding in patients with cirrhosis undergoing chronic endoscopic sclerotherapy. Among 239 patients admitted for acute variceal bleeding, 85 with cirrhosis were randomized to receive sclerotherapy either alone (40) or in combination with propranolol (45). Sclerotherapy was carried out with an intravariceal injection of 5% ethanolamine oleate through a fiberoptic endoscope. The procedure was performed every week, until the esophageal varices at the gastroesophageal junction were too small for any further injections. Varices were reinjected if they recurred. Propranolol was given orally twice a day until heart rate was reduced by 25% in the resting position. The mean follow-up period was 23.2 and 24.2 months for sclerotherapy and the sclerotherapy plus propranolol groups, respectively. During this period a significant (P = 0.001) reduction in the recurrence of esophageal varices was observed in patients treated with the combination of sclerotherapy plus propranolol compared with those treated with sclerotherapy alone. However, the time of rebleeding from any source or from esophageal varices did not differ significantly between the two groups. In the sclerotherapy group 21 patients rebled (35 bleeding episodes) compared with 14 (22 episodes) in the combination therapy group. Patients in the sclerotherapy group were more prone to bleed from gastric varices and congestive gastropathy than patients treated with the combination of sclerotherapy plus propranolol (P = 0.012). Twenty-five patients in the endoscopic sclerotherapy group developed complications attributed to sclerotherapy compared with 23 patients in the sclerotherapy plus propranolol group. Complications directly attributable to propranolol were observed in 11 patients. Three of these patients stopped taking the drug due to heart failure (1) and flapping tremor (2). Eight patients (17.8%) died in the latter group while the corresponding figure in the sclerotherapy group was nine (22.5%). It is concluded that the continuous administration of propranolol may reduce incidences of recurrent upper gastrointestinal hemorrhage from gastric sources in patients with cirrhosis undergoing chronic sclerotherapy.
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Affiliation(s)
- A Avgerinos
- 2nd Department of Gastroenterology, Evangelismos Hospital, Athens, Greece
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