A randomized trial for the study of the elective surgical treatment of portal hypertension in mansonic schistosomiasis

Portal vein thrombosis in patients with hepatosplenic schistosomiasis who underwent oesophagogastric devascularization combined with splenectomy

BACKGROUND

Portal vein thrombosis (PVT) has been described in nearly 50% of patients who underwent oesophagogastric devascularization combined with splenectomy (EGDS), but no previous study has compared its occurrence in surgical and non-surgical groups. This study aimed to investigate PVT in hepatosplenic schistosomiasis (HSS) and its association with EGDS and upper variceal bleeding (UVB).

METHODS

Retrospectively, 104 HSS individuals were enrolled. Following EGDS, the occurrence of PVT, mesenteric vein thrombosis (MVT), hospital admissions and UVB were recorded.

RESULTS

EGDS was performed in 27 (26%) patients. PVT and MVT were detected in 30 (33%) and 8 (9.8%) patients, respectively. Patients who underwent EGDS were at greater risk of PVT (63% vs 19.7%; odds ratio [OR] 6.12 [95% confidence interval {CI} 2.3 to 16.1], p<0.001) when compared with a non-surgical approach. There was no significant difference in UVB occurrence and β-blocker usage. PVT was associated with more hospital admissions (p=0.030) and higher alkaline phosphatase levels (p=0.008). UVB occurrence in patients with and without thrombosis was similar. In multivariate analysis, after adjustment, PVT was associated with the surgical approach (OR 4.56 [95% CI 1.55 to 13.38], p=0.006) and age at HSS diagnosis (OR 0.94 [95% CI 0.90 to 0.99], p=0.021).

CONCLUSIONS

EGDS was not associated with a decreased frequency of UVB when compared with the non-surgical approach but was an independent risk factor for PVT.

Left Ventricular Dilation and Pulmonary Vasodilatation after Surgical Shunt for Treatment of Pre-Sinusoidal Portal Hypertension

Objective

The aim of this study was to prospectively investigate the long-term cardiovascular and pulmonary hemodynamic effects of surgical shunt for treatment of portal hypertension (PH) due to Schistosomiasis mansoni.

Location

The University of São Paulo Medical School, Brazil; Public Practice.

Methods

Hemodynamic evaluation was performed with transesophageal Doppler and contrast-enhanced echocardiography (ECHO) on twenty-eight participants with schistosomal portal hypertension. Participants were divided into two groups according to the surgical procedure used to treat their schistosomal portal hypertension within the last two years: group 1—distal splenorenal shunt (DSRS, n = 13) and group 2—esophagogastric devascularization and splenectomy (EGDS, n = 15).

Results

The cardiac output (5.08 ± 0.91 L/min) and systolic volume (60.1 ± 5.6 ml) were increased (p = 0.001) in the DSRS group. DSRS participants had a significant increase (p < 0.0001) in their left ventricular end-systolic and end-diastolic diameters as well as in their left ventricular end-diastolic and end-systolic volumes (p < 0.001) compared with the preoperative period. No statistically significant difference was found in the patients who underwent EGDS. ECHO revealed intrapulmonary vasodilatation (IPV) in 18 participants (64%), 9 DSRS and 9 EGDS (p > 0.05).

Conclusions

The late increase in the cardiac output, stroke volume and left ventricular diameters demonstrated left ventricular dilatation after a distal splenorenal shunt. ECHO revealed a greater prevalence for IPV in patients with schistosomiasis than has previously been described in patients with PH from liver cirrhosis.

Angiografic and pressoric changes determined by splenectomy with left gastric vein ligature in mansoni schistosomiasis

BACKGROUND

In hepatosplenic schistosomiasis occurs diffuse hepatic fibrosis associated with venous congestion of the portal system resulting in hepatosplenomegaly. It can produce digestive hemorrhage caused by rupture of esophageal and stomach varices or peptic gastroduodenal mucosal lesions.

AIM

To study the effects of splenectomy and ligature of the left gastric vein on portohepatic hemodynamics.

METHOD

Twenty-three patients with hepatosplenic schistosomiasis mansoni were studied before and about two weeks after operation through angiographic diameter of the common and proper hepatic artery, splenic artery, superior mesenteric artery, portal vein, superior mesenteric vein and left gastric vein. The pressures of the inferior vena cava and central venous pressure, free hepatic vein, the hepatic sinusoidal and occluded vein were measured.

RESULTS

The splenectomy and ligature of the left gastric vein determined low morbidity and null mortality. It determined significant addition to the following variables: diameters of the common and proper hepatic artery; diameter of the superior mesenteric vein. It determined non significant increase on the following measurements: right atrial pressure and diameter of the superior mesenteric artery. It determined non significant decrease to the following variables: inferior vena cava pressure; free hepatic vein pressure; occluded hepatic vein pressure; sinusoidal pressure, diameter of the portal vein.

CONCLUSION

Splenectomy and ligature of the left gastric vein do not determine portal hemodynamic changes capable of breaking the functional hemodinamic balance that characterizes the hepatosplenic mansoni schistosomiasis.

Trashepatic left gastric vein embolization in the treatment of recurrent hemorrhaging in patients with schistosomiasis previously submitted to non-derivative surgery

CONTEXT

Non-derivative surgical techniques are the treatment of choice for the control of upper digestive tract hemorrhages after schistosomotic portal hypertension. However, recurrent hemorrhaging due to gastroesophagic varices is frequent.

OBJECTIVE

To evaluate the outcome of treatment based on embolization of the left gastric vein to control the reoccurrence of hemorrhages caused by gastroesophagic varices in patients with schistosomiasis previously submitted to non-derivative surgery.

METHODS

Rates of reoccurrence of hemorrhages and the qualitative and quantitative reduction of gastroesophagic varices in patients undergoing transhepatic embolization of the left gastric vein between December 1999 and January 2009 were studied based on medical charts and follow-up reports.

RESULTS

Seven patients with a mean age of 39.3 years underwent percutaneous transhepatic embolization of the left gastric vein. The mean time between azigoportal disconnections employed in combination with splenectomy and the percutaneous approach was 8.4 ± 7.3 years, and the number of episodes of digestive hemorrhaging ranged from 1 to 7 years. No episodes of reoccurrence of hemorrhaging were found during a follow-up period which ranged from 6 months to 7 years. Endoscopic postembolization studies revealed reductions in gastroesophagic varices in all patients compared to preembolization endoscopy.

CONCLUSIONS

Percutaneous transhepatic embolization of the left gastric vein in patients with schistosomiasis previously submitted to surgery resulted in a decrease in gastroesophagic varices and was shown to be effective in controlling hemorrhage reoccurrence.

A modified Hassab's operation for portal hypertension: experience with 562 cases

BACKGROUND

Many patients with portal hypertension require surgical treatment each year, and Hassab's operation, or esophagogastric devascularization and splenectomy, is an elective procedure. However, it is difficult to devascularize all the vessels of the upper half of the stomach and distal esophagus when hyperblastosis, edema, extensive vein conglobation, and conglutination are present during the operation. These increase the postoperative risk of repeat bleeding.

PATIENTS AND METHODS

We modified Hassab's operation to address the difficulties associated with devascularization in these cases. All consecutive Chinese patients with liver cirrhosis and portal hypertension who underwent the modified Hassab operation in the Second Affiliated Hospital of Xi'an Jiaotong University from September 1995 to December 2010 were included in the present retrospective study.

RESULTS

A total of 562 modified Hassab's operations were performed, and all the emergency operations performed because of bleeding obtained hemostasis. Although the pressure and blood flow of the portal vein decreased slightly after surgery, it was still maintained at a high level. Overall, 21.8% of the patients had complications, and 4.6% of these patients died during the hospitalization period. Within the 12-month follow-up period, the overall improvement rate of varices was 98.5% and the variceal bleeding rate was 1%. The 5-year bleeding rate was 9.7%.

CONCLUSIONS

The modified Hassab operation is an effective procedure for the treatment of portal hypertension. Few early or late complications were observed among the patients.

The surgical treatment for portal hypertension: a systematic review and meta-analysis

Aim. To compare the effectiveness of surgical procedures (selective or nonselective shunt, devascularization, and combined shunt and devascularization) in preventing recurrent variceal bleeding and other complications in patients with portal hypertension. Methods. A systematic literature search of the Medline and Cochrane Library databases was carried out, and a meta-analysis was conducted according to the guidelines of the Quality of Reporting Meta-Analyses (QUOROM) statement. Results. There were a significantly higher reduction in rebleeding, yet a significantly more common encephalopathy (P = 0.05) in patients who underwent the shunt procedure compared with patients who had only a devascularization procedure. Further, there were no significant differences in rebleeding, late mortality, and encephalopathy between selective versus non-selective shunt. Next, the decrease of portal vein pressure, portal vein diameter, and free portal pressure in patients who underwent combined treatment with shunt and devascularization was more pronounced compared with patients who were treated with devascularization alone (P < 0.05). Conclusions. This meta-analysis shows clinical advantages of combined shunt and devascularization over devascularization in the prevention of recurrent variceal bleeding and other complications in patients with portal hypertension.

Esplenectomia e ligadura da veia gástrica esquerda na esquistossomose mansônica: efeitos sobre pressão das varizes do esôfago e indicadores endoscópicos de risco de sangramento por varizes esofagogástricas

RACIONAL: Expressivo contingente de pacientes esquistossomóticos com a forma hepatoesplênica e hipertensão portal apresentam hemorragia causada pela ruptura de varizes esofagogástricas, principal causa de alta morbidade e mortalidade da doença. OBJETIVO: Investigar os efeitos da esplenectomia e ligadura da veia gástrica esquerda sobre fatores de risco de sangramento por varizes esofagogástricas em portadores de esquistossomose mansônica, forma hepatoesplênica, com antecedente de hemorragia digestiva alta. MÉTODO: Estudaram-se, de forma prospectiva, 34 pacientes, com idade entre 1 e 74 anos (média 44,14), sendo 18 (53%) mulheres. Analisaram-se: 1) pressão das varizes do esôfago, aferida pela técnica endoscópica do balão pneumático; 2) tamanho, local, cor e sinais de cor vermelha nas varizes do esôfago; 3) varizes gástricas e gastropatia da hipertensão portal. Realizaram-se avaliações no pré-operatório, no pós-operatório imediato e no sexto mês após a ligadura da veia gástrica esquerda. RESULTADOS: A pressão das varizes do esôfago diminuiu de 22,3+/-2,6 mmHg, antes da operação, para 16,0+/-3,0 mmHg no pós-operatório imediato (p<0,001), caindo para 13,3+/-2,6 mmHg no pós-operatório do sexto mês (p<0,001). A proporção de varizes de grosso calibre, varizes no esôfago superior, varizes de cor azul, varizes com sinais de cor vermelha e de gastropatia da hipertensão portal decresceu de forma significante apenas no sexto mês de pós-operatório. CONCLUSÃO: A ligadura da veia gástrica esquerda, em esquistossomóticos hepatoesplênicos, com antecedente de hemorragia digestiva alta, revelou-se eficaz em diminuir alguns dos principais fatores de risco de hemorragia por varizes esofagogástricas, indicando boa perspectiva no controle definitivo do sangramento.

Noncirrhotic portal hypertension

Portal hypertension is characterized by an increase in portal pressure (> 10 mmHg) and could be a result of cirrhosis of the liver or of noncirrhotic diseases. When portal hypertension occurs in the absence of liver cirrhosis, noncirrhotic portal hypertension (NCPH) must be considered. The prognosis of this disease is much better than that of cirrhosis. Noncirrhotic diseases are the common cause of portal hypertension in developing countries, especially in Asia. NCPH is a heterogeneous group of diseases that is due to intrahepatic or extrahepatic etiologies. In general, the lesions in NCPH are vascular in nature and can be classified based on the site of resistance to blood flow. In most cases, these disorders can be explained by endothelial cell lesions, intimal thickening, thrombotic obliterations, or scarring of the intrahepatic portal or hepatic venous circulation. Many different conditions can determine NCPH through the association of these various lesions in various degrees. Many clinical manifestations of NCPH result from the secondary effects of portal hypertension. Patients with NCPH present with upper gastrointestinal bleeding, splenomegaly, ascites after gastrointestinal bleeding, features of hypersplenism, growth retardation, and jaundice due to portal hypertensive biliopathy. Other sequelae include hyperdynamic circulation, pulmonary complications, and other effects of portosystemic collateral circulation like portosystemic encephalopathy. At present, pharmacologic and endoscopic treatments are the treatments of choice for portal hypertension. The therapy of all disorders causing NCPH involves the reduction of portal pressure by pharmacotherapy or portosystemic shunting, apart from prevention and treatment of complications of portal hypertension.

Effect of esophagogastric devascularization with splenectomy on schistossomal portal hypertension patients' immunity

BACKGROUND: Surgical treatment of hemorrhagic complication in schistosomal portal hypertension in our hospital is an esophagogastric devascularization procedure with splenectomy. Infectious risks and immunological alterations imputed to splenectomy may have significant importance. To minimize the consequences of spleen absence, the use of subtotal splenectomy and spleen auto-transplantation were stimulated. AIM: To verify the immunologic alterations imposed by this procedure in our patients. METHOD: Twenty-eight patients with schistosomal portal hypertension and previous history of upper digestive bleeding due to esophagogastric varices rupture underwent elective esophagogastric devascularization and splenectomy. They were prospectively studied before esophagogastric devascularization procedure with splenectomy, 15 and 30 days, 3 and 6 months after the procedure. T and B-lymphocytes, CD4 and CD8 subpopulations were determinated by monoclonal antibodies. Immunoglobulins A, M, G and C3, C4 components of the complement were determinated by radial immunodiffusion. RESULTS: We observed important reduction of all immune cells, increase of IgG and normal levels of IgM, IgA, C3 and C4 at preoperative. CD4/CD8 relation was normal. Six months after esophagogastric devascularization procedure with splenectomy, significant increase in T-lymphocytes, CD4, CD8 and B-lymphocytes were observed. CD4/CD8 relation remained normal. We noted significant increase in C3. IgA, IgM, IgG and C4 had increased, but without significant difference. CONCLUSION: Esophagogastric devascularization procedure with splenectomy determines an increase in T and B-lymphocytes, CD4 and CD8 subpopulations without compromising immunoglobulins and components of complement levels.

507 Warren-Zeppa distal splenorenal shunts: a 34-year experience

OBJECTIVE

To define the long-term characteristics, prognostic factors, and outcomes of patients undergoing selective splenorenal shunting procedures for portal hypertension-induced recurrent upper gastrointestinal bleeding.

MATERIALS AND METHODS

A retrospective evaluation of a prospectively collected data set.

RESULTS

From June 1971 through May 2005, 507 Warren-Zeppa shunts were performed at a single institution. Indications included: alcoholic cirrhosis, 52.6%; viral cirrhosis, 21.8%; cryptogenic cirrhosis, 8.4%; autoimmune cirrhosis, 5.8%; and other causes, 6.3%. Median survival was 81 months (5-year survival, 58.9%; 10-year survival, 34.4%; 20-year survival, 12.5%). patients with portal vein thrombosis and biliary cirrhosis demonstrated better survival than others (P = 0.03), while patients with alcoholic cirrhosis trended toward worse survival than those with nonalcoholic causes (P = 0.11). Multivariate analysis of preoperative risk factors found body hair loss (hazard ratio, 17.3; P > 0.005), preoperative encephalopathy (hazard ratio, 1.93; P > 0.003), diuretic use (hazard ratio, 1.43; P > 0.003), and age (hazard ratio, 1.02 per year of age; P > 0.051) were independent predictors of poor long-term survival. Multivariate analysis of operative factors demonstrated blood loss <500 mL was predictive of up to a 4-fold improved long-term survival (hazard ratio, 3.95; P < 0.013). Postoperative complications included: recurrent bleeding, 12%; ascites, 17.5%; and encephalopathy, 13.9%. Multivariate analysis of postoperative factors prospectively collected in 130 patients found that alcoholic recidivism (hazard ratio, 2.66; P > 0.001) was the only independent predictor of poor prognosis.

CONCLUSIONS

The Warren-Zeppa shunt provides long-term survival and control of bleeding in most patients with portal hypertension. Excellent long-term survival can be obtained in properly selected patients with portal hypertension and relatively spared hepatic function.

Current management of portal hypertension

Portal hypertension can lead to life-threatening hemorrhage, ascites, and encephalopathy. This paper reviews the pathophysiology and multidisciplinary management of portal hypertension and its complications, including the indications for and techniques of the various surgical shunts. Variceal bleeding is the most dreaded complication of portal hypertension. It may occur once the portal-systemic gradient increases above 12 mm Hg, occurs in 30% of patients with cirrhosis, and carries a 30-day mortality of 20%. Treatment of acute variceal bleeding includes resuscitation followed by upper endoscopy for sclerosis or band ligation of varices, which can control bleeding in up to 85% of patients. Medical therapies such as vasopressin and somatostatin can also be useful adjuncts. Shunt therapy, preferably the placement of a TIPS, is indicated for refractory acute variceal bleeding. Recurrent variceal bleeding is common and is associated with a high mortality. Therapies to prevent recurrent variceal bleeding include chronic endoscopic therapy, nonselective beta-blockade, operative or nonoperative (TIPS) shunts, devascularization operations, and liver transplantation. Recommendations and a treatment algorithm are provided, taking into account both the etiology and the manifestations of portal hypertension.

Schistosomiasis mansoni -- clinical features

In the present review, we will discuss the Schistosoma mansoni form, which is the most widely distributed schistosome in humans and is found both in the Old and New Worlds. The main features of the natural history of mansonic schistosomiasis are reviewed, with emphasis on the clinical forms of the disease, their diagnosis and treatment.

[Surgical treatment of portal hypertension in schistosomiasis mansoni]

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.

Evolution of schistosomiasis-induced pathology after therapy and interruption of exposure to schistosomes: a review of ultrasonographic studies

Ultrasonography (US) is suitable for diagnosing schistosomiasis-related organic pathology and is particularly useful to assess its evolution after therapy and/or interruption of exposure to the Schistosoma parasites. Evolution of pathology after treatment: Regression of hepatic abnormalities in Schistosma mansoni-infected children and adolescents has been observed already from 7 months post-therapy on. This does, however, not occur in all cases: individual differences are great ranging from spontaneous regression of pathology without treatment to persistence of pathology lasting for years after therapy even without re-infection. Intensity and duration of exposure, different parasite strains, patients' age and genetic background all influence the evolution of pathology. In communities at continuous exposure to S. mansoni infection, repeated re-treatment is required to control hepatosplenic morbidity. In Schistosoma japonicum infection, changes around the portal tree may regress, but characteristic diffuse abnormalities described as 'network pattern' abnormalities do not resolve. In Schistosoma haematobium infection bladder abnormalities and urinary tract obstruction frequently resolve after treatment. Clinically relevant pathology may resurge from 1 year after therapy on if exposure continues. Subjects with more advanced pathology before therapy, appear to be at higher risk of pathology re-appearance. Evolution of pathology after interruption of exposure to schistosomiasis: Knowledge on the evolution of pathology induced by S. mansoni is limited to some reports in emigrants and to the experience of ultrasonographists working in areas, where transmission has been partially interrupted. Due to the longevity of the parasite, infection may last for many years. Even after elimination of the parasites severe pathology may persist for long. In S. haematobium infection spontaneous healing after interruption of re-exposure may occur, but cases have been reported where urogenital lesions led to complications many years after exposure. Contrary to hepatosplenic and urinary pathology, knowlegde on the evolution of other organic abnormalities is very limited: studies on the evolution of biliary abnormalities or intestinal pathology have not been published. Genital pathology may be induced by all Schistosoma spp. Post-therapy evolution of genital schistosomiasis is largely ignored. In some European travellers partial regression of prostatic fibrosis has been described. Schistosomal adnexitis leading to infertility and/or ectopic pregnancy has been reported occurring many years after interruption of exposure. Ultrasonography (US) has never been used to study the influence of schistosomiasis on pregnancy. Concluding, current knowlegde on the evolution of pathology after treatment and/or interruption of exposure is still fragmentary. Frequently, fibrosis reverses after therapy, but advanced pathology may persist for long. Therefore, the possibility of severe clinical complications has to be taken into account, even if the infection is inactive since many years. In interventions aimed at controlling schistosomiasis-related morbidity, evolution of pathology must be monitored by US in representative patient cohorts. Further systematic US-studies are needed not only on the evolution of hepatosplenic and urinary pathology but also on that of intestinal, biliary and genital pathology induced by schistosomiasis, as well as on the influence of schistosomiasis on the outcome of pregnancy.

The changing spectrum of treatment for variceal bleeding

OBJECTIVE

The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage.

SUMMARY BACKGROUND DATA

Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures.

METHODS

Two hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout all four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS.

RESULTS

The risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). In all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization.

CONCLUSIONS

The sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.

Recidiva hemorrágica em pacientes esquistossomóticos operados

Foram estudados, no período de 1987 a 1991, trinta doentes esquistossomóticos submetidos anteriormente a operações não descompressivas para tratamento da hemorragia digestiva alta, e que apresentaram recidiva hemorrágica. Através de endoscopia digestiva alta, ultra-sonografia abdominal e estudo angiográfico, procurou-se determinar o local do novo sangramento e quais os possíveis fatores de recidiva hemorrágica presentes. Procurou-se também determinar a influência da cirurgia anterior no intervalo de tempo decorrido entre esta e o primeiro episódio de recidiva hemorrágica. Os autores concluem que as varizes esofágicas foram significativamente o local mais freqüente do sangramento nas recidivas hemorrágicas (86,7%); que a úlcera péptica gástrica (13,3%), a não desvascularização gastroesofágica (30%), a desvascularização incompleta (16,7%) ou a trombose da veia porta (26,7%) estão presentes na maioria dos casos de recidiva hemorrágica; e que a associação da desvascularização gastroesofágica à esplenectomia não alterou o intervalo médio de tempo decorrido entre a cirurgia anterior e o primeiro episódio de recidiva do sangramento.

Transabdominal esophagogastric devascularization as treatment for variceal hemorrhage

BACKGROUND

During the past 18 years we have used a selective operative approach for variceal bleeders in whom endoscopic sclerotherapy failed or sclerotherapy was not indicated. Esophagogastric devascularization with splenectomy has been reserved for unshuntable patients and for those in whom a shunt was deemed inadvisable. The purposes of this study are to describe the surgical procedure technique and indications for esophagogastric devascularization and to report its long-term results.

METHODS

Thirty-two patients who underwent either a limited (n = 9) or extensive (n = 23) esophagogastric devascularization procedure without esophageal transection for variceal bleeding were retrospectively reviewed. Common indications were thrombosis of all splanchnic veins (n = 12), distal splenorenal shunt thrombosis (n = 7), generalized portal hypertension with isolated splenic vein thrombosis (n = 5), and symptomatic splenomegaly or severe hypersplenism (n = 6). Eighteen patients (56%) had cirrhosis, eleven (34%) received an emergency operation, and eighteen (56%) bled from gastric varices.

RESULTS

Three patients with Child's class C disease undergoing emergency surgery died during the early postoperative interval. Rebleeding occurred in nine surviving patients (31%) and was the cause of death in three. Rebleeding rates for the limited and extensive devascularization procedures were 50% and 24%, respectively. Only one of 11 patients with diffuse splanchnic venous thrombosis without liver disease has died. The 5-year survival rate of patients with liver disease was 51%. Only two patients experienced postoperative encephalopathy.

CONCLUSIONS

When used in selected patients, esophagogastric devascularization without esophageal transection is a reasonably effective alternative to shunt surgery.

Comparison of a modified Sugiura procedure with portal systemic shunt for prevention of recurrent variceal bleeding in cirrhosis

BACKGROUND

There is no agreement on the management of patients with cirrhosis and recurrent variceal bleeding after failure of medical or endoscopic treatments or both. Portal systemic shunts are highly effective in preventing rebleeding but are associated with a high incidence of chronic encephalopathy. This study compared the results of a slightly modified Sugiura procedure (esophageal transection plus esophagogastric devascularization plus splenectomy) with those of nonselective portal systemic shunts in patients with previous variceal bleeding.

METHODS

Fifty-four patients were included in this randomized controlled study between January 1984 and April 1989. The major end point was chronic encephalopathy. Secondary end points were recurrent variceal bleeding, survival, ascites, and hepatocellular carcinoma.

RESULTS

Twenty-seven patients were assigned to each group. The rate of chronic encephalopathy was significantly (p = 0.002) lower after modified Sugiura procedure than after portal systemic shunt. Recurrent variceal bleeding was more frequent after modified Sugiura procedure than after portal systemic shunt, but the difference is not significant. One-, two-, and three-year survival rates were 93%, 81%, and 67%, respectively, in the modified Sugiura group and 78%, 66%, and 39%, respectively, in the portal systemic shunt group (p = 0.044).

CONCLUSIONS

These results suggest that the modified Sugiura procedure is better overall than the nonselective portal systemic shunt in the management of patients with cirrhosis and recurrent variceal bleeding. Although the rebleeding rate is higher after the modified Sugiura procedure, this does not seem to affect mortality in these patients.

Outcome of portal-systemic shunt surgery for portal hypertension associated with intrahepatic obstruction in patients with agnogenic myeloid metaplasia

Life-threatening portal hypertension (PHN) in patients with chronic myeloproliferative disorders may result from increased portal flow caused by marked splenomegaly or an increased resistance to portal flow from either a large vein thrombosis or an intrahepatic obstruction usually associated with agnogenic myeloid metaplasia (AMM). The former cause is correctable by splenectomy alone, whereas the latter requires portal-systemic shunt surgery. Few data exist regarding the outcome of portal-systemic shunt surgery in patients with AMM and intrahepatic obstruction. During the past 25 years, 13 patients with chronic myeloproliferative disorders underwent portal-systemic shunt surgery at our institution. The cause of PHN was intrahepatic obstruction in ten patients and hepatic vein thrombosis in three. Ten of the thirteen patients had AMM as initial diagnosis. Only one patient had intraoperative complications, and four patients had either sepsis or thrombosis during the postoperative period. Twelve patients survived the postoperative period and had a median postsurgical survival of 3 years (range, 0.25 to 19 years). The long-term complications of the operation were very few and included hepatic encephalopathy (one patient), portal vein thrombosis (one patient), and shunt occlusion (one patient). The procedure was successful in alleviating complications of PHN in all but one patient. Deterioration of hepatic function and subsequent hepatomegaly were unusual. Portal-systemic shunt surgery seems to be a useful option in patients with AMM and life-threatening PHN from intrahepatic obstruction.

Portal hypertension in schistosomiasis: a long-term follow-up of a randomized trial comparing three types of surgery

The long-term follow-up of patients with the severe form of Manson's schistosomiasis who had had elective surgical treatment for portal hypertension, in a randomized trial, was clinically evaluated. Of 94 patients, proximal splenorenal shunting was performed in 32, esophagogastric devascularization with splenectomy in 32 and distal splenorenal shunting in 30. Patients were observed during a mean of 85.7 +/- 33.1 mo, excluding nine patients (9.6%) who were lost to follow-up. Recurrence of upper gastrointestinal tract bleeding occurred in 24.1% of the patients, without statistical differences among the three groups, but rebleeding because of varices was more frequent after esophagogastric devascularization with splenectomy. Hepatic encephalopathy was significantly higher after proximal splenorenal shunting (39.3%) when compared with distal splenorenal shunting (14.8%) and with esophagogastric devascularization with splenectomy (0%). Lethality was also significantly higher after proximal splenorenal shunting (42.9%) when compared with distal splenorenal shunting (14.8%) and with esophagogastric devascularization with splenectomy (7.1%). Indirect hyperbilirubinemia was absent after esophagogastric devascularization with splenectomy and more frequent after distal splenorenal shunting (52%) although also present after proximal splenorenal shunting (29.6%). Esophagogastric devascularization with splenectomy was demonstrated to be the best option because of the absence of encephalopathy and because of low mortality rates. Hepatic encephalopathy occurred after distal splenorenal shunting but in a lesser percentage than after proximal splenorenal shunting. The higher incidence of encephalopathy and lethality proscribes proximal splenorenal shunting in Manson'schistosomiasis.

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

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

Role of distal splenorenal shunt for long-term management of variceal bleeding

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.

Surgical emergencies in liver disease

In this chapter the surgical management of bleeding oesophageal varices, ruptured hepatocellular carcinoma and fulminant liver failure have been discussed. Bleeding oesophageal varices can usually be successfully treated with vasopressin, balloon tamponade and injection sclerotherapy. Emergency surgery should be considered if two courses of injection sclerotherapy have failed to achieve haemostasis. Stapled oesophageal transection and portosystemic shunting are currently the two most popular procedures. The former is associated with a lower morbidity and mortality as well as a lower incidence of subsequent encephalopathy. Ruptured hepatocellular carcinomas are usually associated with liver cirrhosis and impaired liver function. Selective coeliac axis cannulation followed by embolization of the hepatic artery branches supplying the tumour is an effective method of achieving haemostasis and is associated with a lower morbidity and mortality than emergency hepatic artery ligation or liver resection. If haemostasis is achieved by embolization the patient may subsequently be assessed for an elective resection of the tumour. Fulminant liver failure may be managed by supportive medical therapy or orthotopic liver transplantation. Patients whose liver failure is graded as mild (grade I) should be treated by medical therapy, whereas those with severe liver damage (grades III and IV) should be assessed for transplantation. Accurate monitoring of the patient's clinical progress and prognostic indicators are vital in deciding whether conservative treatment should be continued or liver transplantation performed.

Should both schistosomal and nonschistosomal variceal bleeders be disconnected?

Splenopancreatic disconnection (SPD) was conceived and implemented as a technical addition to distal splenorenal shunt (DSRS) to maintain its selectivity and preserve portal perfusion. The proposed hemodynamic and metabolic stability of hepatocytes after DSRS-SPD should improve survival. In this nonrandomized study, 145 consecutive (Child A/B) variceal bleeders were electively subjected to selective shunt with DSRS in 93 and DSRS-SPD in 52 patients. The 2 groups were similar before surgery with a mean follow up of 24 +/- 12 (DSRS) and 27 +/- 14 (DSRS-SPD) months. DSRS-SPD had an operative mortality of 3.8%. Postoperative pancreatitis occurred in 7.7% after DSRS-SPD and 3.2% after DSRS alone, with schistosomal hepatic fibrosis representing 86% of morbid cases. Shunt patency was high and recurrent variceal hemorrhage was low in both groups. Clinical encephalopathy was significantly reduced after DSRS-SPD (p less than 0.05). The addition of SPD significantly reduced both the incidence of chronic hyperbilirubinemia in the schistosomal patients (p less than 0.05) and the difference between the changes in total serum bilirubin in all patients (p = 0.001). Portal perfusion was preserved after DSRS-SPD in all of the angiographically-studied patients. The overall survival was 84% after DSRS and 88% after DSRS-SPD. The schistosomal patients showed an incidence of 95% and 96% survival after DSRS and DSRS-SPD, respectively. DSRS-SPD was able to improve survival (92%) better than DSRS (77%) among well-matched nonschistosomal patients. These data show: (1) DSRS-SPD still has low operative mortality and a high patency rate with a low incidence of recurrent variceal hemorrhage, (2) DSRS-SPD maintains portal perfusion, achieves better survival, and reduces the incidence of encephalopathy, especially in patients with nonalcoholic cirrhosis and mixed liver disease, (3) in the schistosomal population, DSRS-SPD reduces the incidence of chronic hyperbilirubinemia but increases the risk of postoperative pancreatitis.

Portal hypertension in mansonic schistosomiasis

Mansonic schistosomiasis is an endemic disease in Brazil, with an estimated 10-12 million people infested. Among its clinical manifestations, the hepatosplenic form causes portal hypertension which, in turn, brings about severe digestive hemorrhage, the most serious complication of the disease. Normally, the patients are young, and have hepatosplenomegaly, hypersplenism without clinical manifestations, and slightly reduced hepatic function. The angiographic findings are characteristic, differing from those of hepatic cirrhosis. In Brazil, the definitive treatment for gastrointestinal hemorrhage is surgery, which should be done under elective conditions whenever possible. During a short period of time, known as the "risk period" (the time between the hemorrhagic episode and the surgery), propranolol has been used to prevent further bleeding. Surgical treatment is indicated only after the first episode, and never on a prophylactic basis. In 1977, a prospective, randomized trial was begun in order to assess the delayed results of the 3 surgical operations most widely used in this country. The study was interrupted after 94 patients had been operated on due to the high incidence of encephalopathy in the group who underwent classical splenorenal shunt. After a follow-up of at least 60 months and, at most, 130 months, the results showed that classical splenorenal shunt caused encephalopathy in 39.3% of the cases and distal splenorenal shunt in 14.8%. None of those submitted to esophagogastric devascularization with splenectomy developed encephalopathy. The 3 procedures showed similar rates of hemorrhagic recurrence.

Selective shunt versus nonshunt surgery for management of both schistosomal and nonschistosomal variceal bleeders

This clinical study included 219 (Child A/B) consecutive variceal bleeders. Electively 123 had distal splenorenal shunt (DSRS) and 96 had splenectomy with gastroesophageal devascularization (S&GD). Liver pathology was documented in 73% of patients, with schistosomal fibrosis in 41% and nonalcoholic cirrhosis or mixed pattern (fibrosis and cirrhosis) in 59%. The surgical groups were similar before operation, with a mean follow-up of 82 +/- 13 and 78 +/- 18 months, respectively (range, 60 to 120 months). The two pathologic populations were also similar before each and both procedures. The operative mortality rates were low, with incidences of 3.3% (DSRS) and 3.1% (S&GD). Rebleeding occurred significantly (p less than 0.05) more frequently after S&GD (27%) compared to DSRS (5.7%). Sclerotherapy salvaged 65% of S&GD rebleeders. Encephalopathy developed significantly (p less than 0.05) more after DSRS (18.7%) compared to S&GD (7.3%), with no significant difference among the current survivors. The difference in overall rebleeding and encephalopathy rates between both procedures was statistically related to patients with cirrhosis and mixed lesions (p less than 0.05). Distal splenorenal shunt significantly reduced the endoscopic variceal size more than S&GD (p less than 0.05). Prograde portal perfusion was documented in 94% of patients in each group, with a variable distinct pattern of portaprival collaterals in 91% (DSRS) and 65% (S&GD). The total population cumulative survival was similar with 80% for DSRS and 79% for S&GD (plus sclerosis in 23%), with hepatic cell failure the cause of death in 46% and 50%, respectively. However, in the schistosomal patients, survival was better improved after DSRS (90%) compared to S&GD (75%), with no difference among the cirrhotic and mixed group (DSRS 73%, S&GD 72%). In conclusion (1) both DSRS and S&GD have low operative mortality rates, (2) DSRS is superior to S&GD in the schistosomal patients, and (3) S&GD backed by endosclerosis for rebleeding is a good surgical alternative to selective shunt in the nonalcoholic cirrhotic and mixed population.

Definitive therapy for variceal bleeding: a personal view

Definitive therapy for variceal hemorrhage has evolved during the past half century. Only completely decompressing shunts (nonselective shunts) were available before 1967. Additional options now include selective shunts, devascularization procedures, endoscopic sclerotherapy, pharmacotherapy, and hepatic transplantation. Although drug treatment is experimental at the present time, the remaining therapeutic options are applicable to various subgroups of patients and in certain clinical settings. At the University of Nebraska, patients with variceal bleeding are first grouped based on their candidacy for transplantation. Transplantation candidates with advanced (Child's class C) or symptomatic liver disease undergo transplantation as soon as possible. Future transplantation candidates with stable, asymptomatic liver disease undergo either long-term sclerotherapy or a distal splenorenal shunt if sclerotherapy fails or if they have poor access to tertiary medical care. These patients are carefully monitored so that they can undergo transplantation before they become high-operative risks. Patients who are not candidates for transplantation receive chronic variceal sclerotherapy as initial therapy so long as shunt surgery is readily available if sclerotherapy fails. When surgery is indicated, the distal splenorenal shunt is preferred to nonselective shunts because several controlled and uncontrolled series have demonstrated a lower frequency of encephalopathy after selective variceal decompression.

Selective or total shunts for variceal bleeding

Shunt surgery remains an important therapeutic option in the management of variceal bleeding, and both total and selective shunts have a role to play. The distal shunt is associated with a lower long-term encephalopathy rate and may yield better survival in the nonalcoholic patient; it is, therefore, the preferred shunt in the elective situation. The total shunt is technically easier to perform and more widely available; it is, therefore, preferred in the emergency situation. Ordinarily, the side-to-side and end-to-side shunts have similar outcomes; however, in patients with hepatic venous outflow obstruction and patients with intractable ascites, the side-to-side shunt should be used.

The portacaval shunt. Is it still indicated?

This article has attempted to question whether the more recently introduced methods of treating the patient with variceal hemorrhage have resulted in higher salvage rates and a better quality of life. Data concerning other types of central shunts, selective shunting, nonshunt operations, hepatic transplantation, sclerotherapy, and pharmacologic manipulation have all been critically reviewed. It seems clear that, although some of these modalities are roughly equivalent to portacaval shunting, others are inappropriate. This is especially so in the majority of patients with portal hypertension in the United States whose cirrhotic etiology is based on alcohol addiction. Additionally, a large, one-institution series of side-to-side portacaval shunts has been presented that yielded good results. It is hoped that this presentation has succeeded, at a minimum, in causing the reader to question the basis of treatment for variceal hemorrhage and, at a maximum, in convincing him or her to retain the portacaval shunt as a mainstay in treating the hemorrhagic complications of portal hypertension.

Endoscopic sclerotherapy

Various sclerotherapy techniques have proved successful in the management of acute variceal bleeding and in long-term control of patients after a variceal bleed. We prefer either an intravariceal or a combined intravariceal and paravariceal technique using ethanolamine oleate, but we advocate that individual units utilize the technique with which they have the most experience. The use of an unmodified flexible endoscope has been almost universally accepted. Once active variceal bleeding is diagnosed on emergency endoscopy, immediate emergency sclerotherapy should be performed. When this is not possible, bleeding should be controlled by balloon-tube tamponade with subsequent delayed emergency sclerotherapy after resuscitation. Patients with variceal bleeding that has stopped at the time of the diagnostic endoscopy can either be treated by immediate sclerotherapy or be observed initially and subsequently treated using the long-term management policy of the unit concerned. Over 90% of actively bleeding patients should be controlled using emergency sclerotherapy. Failures are defined as patients who have more than two acute variceal bleeds during a single hospital admission. Such patients should be identified early and treated either by simple staple-gun transection or by an emergency portosystemic shunt. Repeated injection sclerotherapy using a flexible endoscope and the technique with which the group concerned has the most experience is recommended as the primary form of treatment for the majority of patients after a proven esophageal variceal bleed. Repeat injection treatments should probably be performed at weekly intervals until the esophageal varices are eradicated, with follow-up at 6-month or yearly intervals thereafter. Recurrent varices should be treated similarly. Failures of sclerotherapy are defined as patients who have either recurrent bleeds or in whom varices are difficult to eradicate. They require either a portosystemic shunt or a devascularization and transection operation. All patients presenting with cirrhosis and variceal bleeding should be evaluated for liver transplantation; unfortunately, however, few variceal bleeders are candidates for transplantation. Prophylactic sclerotherapy in patients with esophageal varices that have not bled remains unjustified outside of controlled trials. Available trials have produced conflicting data.

The distal splenorenal shunt

Distal splenorenal shunt (DSRS) provides selective decompression of gastroesophageal varices, with maintenance of portal hypertension and prograde portal flow to the cirrhotic liver. Accurate patient evaluation is essential to select appropriate patients for DSRS. Variceal bleeding control is greater than 85% and is as effective as total portosystemic shunts. Maintenance of prograde portal flow is greater than 90% in nonalcoholic disease, but only 50% in alcoholic cirrhosis; the latter is improved by total splenopancreatic disconnection. Hepatic function is better maintained when portal flow is maintained. Encephalopathy is lower after DSRS than after total shunts. Survival is not significantly improved after DSRS in patients with alcoholic cirrhosis compared to outcome after total shunts. The survival in patients with nonalcoholic disease is significantly improved over that of alcoholics.

Transabdominal gastro-oesophageal devascularization and oesophageal transection for bleeding oesophageal varices

Fifty consecutive unselected patients presenting with acute haematemesis and melaena from endoscopically confirmed bleeding oesophageal varices were treated by one-stage transabdominal oesophageal transection with gastro-oesophageal devascularization and splenectomy. According to Child's classification, 15 were Grade A, 29 Grade B and six Grade C. The mortality rate was 10 per cent. Postoperative complications included gastric fundal leak (4 per cent), pleural effusion (4 per cent), subphrenic abscess (2 per cent), atelectasis (2 per cent) and pneumothorax (2 per cent). Although five patients (10 per cent) complained of transient dysphagia during follow-up, only one (2 per cent) presented evidence of stricture at the site of oesophageal transection. Clinical encephalopathy was not present in the surviving patients in the postoperative period. No recurrence of bleeding has been recorded in the surviving patients over a follow-up period of 2-3 years.

The surgeon's role in the management of portal hypertension

Patients with portal hypertension are referred to surgeons for several reasons. These include the management of continued active variceal bleeding; therapy after a variceal bleed to prevent further recurrent bleeds; consideration for prophylactic surgical therapy to prevent the first variceal bleed; or, rarely, an unusual cause of portal hypertension which may require some specific surgical therapy. Injection sclerotherapy is the most widely used treatment for both acute variceal bleeding and long-term management after a variceal bleed. Unfortunately it has probably been overused in the past. The need to identify the failures of sclerotherapy early and to treat them by other forms of major surgery is emphasized. The selective distal splenorenal shunt is the most widely used portosystemic shunt today, particularly in nonalcoholic cirrhotic patients. The standard portacaval shunt is still used for the management of acute variceal bleeding as well as for long-term management, particularly in alcoholic cirrhotic patients. For acute variceal bleeding the surgical alternative to sclerotherapy or shunting is simple staple-gun esophageal transection, whereas in long-term management the main alternative is an extensive devascularization and transection operation. Liver transplantation is the only therapy that cures both the portal hypertension and the underlying liver disease. All patients with cirrhosis and portal hypertension should be assessed as potential liver transplant recipients. If they are candidates for transplantation, sclerotherapy should be used to treat bleeding varices whenever possible, as this will interfere least with a subsequent liver transplant.

Schistosomal versus nonschistosomal variceal bleeders. Do they respond differently to selective shunt (DSRS)?

The distal splenorenal shunt (DSRS) was performed in 125 consecutive variceal bleeders. To date, no patients have been lost to follow-up (mean of 79 +/- 20 months). Liver pathology was documented in 85 patients: 45 patients had schistosomal hepatic fibrosis, 17 had nonalcoholic cirrhosis, and 23 had mixed pattern (hepatic fibrosis and cirrhosis). The preoperative data base for these three groups was matched (p greater than 0.05), with a mean follow-up of 79 +/- 20, 70 +/- 14, and 77 +/- 22 months for each population, respectively. The results showed low operative mortality (4.8%), high cumulative patency rate (94.8%) and low recurrent variceal hemorrhage (5.6%). The biochemical data showed significant increase in serum bilirubin (p less than 0.001) and aspartate transaminase (AST) (p less than 0.05) in the nonschistosomal patients. Chronic hyperbilirubinemia was found in 33% of the schistosomal group. Prograde portal perfusion was detected in 94% of the patients, with development of collaterals in 91%. The angiographic pattern of these collaterals was 50% pancreatic, 45% gastric, and 26% colosplenic. Patients with mixed liver disease had a high incidence of Grade III portal perfusion (57%) and more common pancreatic and gastric collaterals (71%). The cumulative survival for all patients was 74.1%, with hepatic cell failure being the leading cause of death (13 patients, 50% of all deaths). The schistosomal patients had a 91.6% incidence, whereas the cirrhotic and mixed groups had survival rates of 75.6% and 65.2%, respectively. Also, of a 15% total incidence of encephalopathy, 4.4% was related to the schistosomal patients, 23.5% to the cirrhotics, and 21.7% to the mixed population. Statistically, the survival rate was significantly better (p less than 0.05) and encephalopathy was significantly lower (p less than 0.05) in the schistosomal population. In conclusion, this data shows that: 1) DSRS has a high patency rate and a low variceal hemorrhage recurrence rate; 2) it maintains some degree of portal perfusion in patients with different nonalcoholic liver diseases, despite development of collaterals; and 3) the schistosomal patients have a better survival rate, with a low incidence of encephalopathy after DSRS, compared with the cirrhotic and mixed populations.

Improved quality of life after distal splenorenal shunt. A prospective comparison with side-to-side portacaval shunt

The distal splenorenal shunt (DSRS) was compared with the side-to-side portacaval shunt (PCS) in 93 prospectively matched patients with portal hypertension. After 38 months mean follow-up the two shunts had a different incidence of acute encephalopathy (22% in PCS group and 33% in DSRS group) and chronic encephalopathy (35% in PCS group and 17% in DSRS group), but the difference was not statistically significant. However, the only cases of severe and disabling chronic encephalopathy arose after PCS (p = 0.049). Actuarial curves of chronic encephalopathy showed that the maximum rate of encephalopathy (18%) in the DSRS group was reached 27 months after shunt surgery, whereas this value was reached and passed in PCS group only 4 months after shunt. Chronic encephalopathy occurred for a total duration of 20.1 months after PCS and only 11.1 months afer DSRS (p = 0.003) and occupied 46.3% of the follow-p of PCS patients, as contrasted to 18.7% of the follow-up of DSRS patients (p = 0.0001). DSRS is associated with a lower global incidence of chronic HE without severe forms and provides a better quality of life than does a nonselective shunt.

Bleeding esophageal varices

No single treatment for bleeding esophageal varices is appropriate for all patients and situations. An algorithm for management of the patient with acute bleeding is presented in this article. The options for long-term, definitive therapy and the criteria for selection of each are discussed.