Improved results with selective distal splenorenal shunt in a highly selected patient population. A prospective study

In a 5-year period 299 patients were admitted to the Heinz-Kalk Hospital with bleeding esophageal varices. Patients with acute bleeding were treated with endoscopic sclerotherapy. Sessions were performed as many times as needed for each individual case. One hundred seventy-eight patients in Child-Pugh class C were excluded from surgical treatment; the remaining 121 patients (Child AB) were selected using the following criteria: liver volume (ultrasound) between 1000 to 2500 ml, portal perfusion (sequential scintigraphy) more than 30%, no activity or progression of liver disease proved by biopsy, no stenosis of the hepatic arteries, and suitable anatomy to perform the Warren shunt. Only 32 patients fulfilled these criteria. In seven of these cases the shunt was technically impossible to perform. Operative mortality rate was 8% and the late mortality rate was 12%. No history of rebleeding, encephalopathy, and/or shunt thrombosis was recorded. Five-year survival rate, according to the method of Kaplan-Meier was 75%. We conclude that the Warren shunt is the treatment of choice for elective management of bleeding esophageal varices. The postoperative results can be improved with strict selection using the above criteria. The preoperative use of sclerotherapy has a positive influence. Prophylactic management to prevent encephalopathy is also recommended.     

Management of Variceal Hemorrhage in Children with Extrahepatic Portal Venous Obstruction-Shunt Surgery Versus Endoscopic Sclerotherapy

Extrahepatic portal venous obstruction (EHPVO) is a common cause of portal hypertention in children. Esophageal variceal hemorrhage is a major cause of morbidity and mortality in these patients. For many decades, portal systemic shunts were considered as the most effective treatment of variceal hemorrhage. Endoscopic injection sclerotherapy (EIS) was first introduced for emergency management of bleeding varices and subsequently as definitive treatment to prevent recurrent hemorrhage. The purpose of the study was to compare the safety and efficacy of shunt surgery and endoscopic sclerotherapy for patients with proven esophageal variceal bleeding due to EHPVO. The study was a prospective randomized study of 61 children with bleeding esophageal varices due to EHPVO carried out jointly by the department of General Surgery and Gastroenterology at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, between March 2001 and September 2003. Thirty patients received surgery and other 31 patients received EIS. Overall incidence of rebleeding was 22.6% in sclerotherapy group and 3.3% in shunt surgery group. Treatment failure occurred in 19.4% patients in sclerotherapy group and 6.7% in shunt surgery group. The rebleeding rate of sclerotherapy is significantly higher than that of shunt surgery. However, the therapy failure rate of sclerotherapy is not significantly different from that of shunt surgery.     

A new therapeutic concept for the selection of liver cirrhotics with recurrent bleeding esophageal varices for selective shunt]

Analysis was made of almost 600 patients who received shunt operations between January 1, 1952 and January 1, 1975 because of liver cirrhosis and repeated bleeding from gastroesophageal varices. The emergency portosystemic shunt was abandoned owing to its 50% lethality; the portocaval shunt was also discontinued, because of an encephalopathy rate of 25%. The splenorenal shunt (Linton) and coronary-caval shunt (Gütgemann) gave comparatively satisfactory results. A more recent introduction was the mesocaval interposition shunt (Drapanas). We also developed new criteria of indication for a shunt operation: elective shunt, liver volume 1000--2500 ml, portal vein perfusion 15%--40%, avoidance of celiac trunk and hepatic artery stenosis. Using only the types of shunt operation and criteria of indication here recommended, lethality among 65 patients operated on between January 1, 1975 and July 1, 1978 was only 6%, delayed lethality only 3%. The rate of encephalopathy was reduced to 5%. The 5-year life expectancy should increase to more than 70%. Thus, support is provided for the proposed therapy concept and criteria for shunt indication.     

The interposition mesocaval shunt

The interposition mesocaval C-shunt is an excellent alternative for the management of bleeding esophageal varices. The comparable operative mortality, long-term survival, and minimal operative time and blood loss make it the emergency shunt of choice. The C-shunt modification has improved long-term patency and ease of operation. The interposition mesocaval shunt also is increasing in importance as the best portosystemic shunt in those patients who may eventually require liver transplantation.     

Mesocaval shunt for bleeding oesophageal varices

A total of 43 patients underwent end to side mesocaval (25 patients) or interposition shunts (18 patients) for bleeding oesophageal varices in 1970-1985. Alcoholic cirrhosis was the aetiology in 30 patients. The operation was elective in 26 and urgent or as emergencies in 17 instances. Operative mortality in elective operations was 19%. In emergency operations the bleeding was controlled in all but one patient, but the mortality was 56%. In Child's group C the mortality was also high, about 50%. During the follow-up of 18 months to 16 years there were five episodes of gastrointestinal bleeding, two of which might have been variceal. Out of the 43 patients 22 survived at least 2 years. Most of the late deaths were caused by hepatic coma; no patient died of recurrent variceal bleeding. - The two types of shunt were equally effective in lowering portal venous pressure. Two venous leg ulcers occurred after an end to side shunt. During the period under study the end to side mesocaval shunt was abandoned and from 1980 only interposition shunts have been performed in our clinic.     

Surgical procedures for bleeding esophagogastric varices when sclerotherapy fails: a prospective study

In a 7-year period, 692 patients were admitted to the Heinz-Kalk Hospital with bleeding esophageal varices. All patients were first treated with endoscopic sclerotherapy (ES). Fourteen patients exsanguinated during the first 2 hours of admission or refused treatment. Long-term injection sclerotherapy was performed in 311 Child-Pugh C patients. Among the remaining 367 patients, 182 were in class A and 185, class B. In 194 patients, ES was successful. In 173 patients with at least two rebleeding episodes despite long-term sclerotherapy, specific selection criteria were used to assess suitability for a shunt. Eighty-eight patients received a shunt: 54, a narrow-lumen mesocaval (NLMS) shunt; 32, a distal splenorenal shunt; 1, a portacaval shunt; and 1, a proximal splenorenal Linton shunt. There was no significant difference in mortality at 30 days; however, late mortality in the ES group was 36% and in the shunt group, 17%. This difference was statistically significant in favor of the shunt operation (p less than 0.01). Thus, using specific selection criteria, shunt procedures performed in Child-Pugh class A and B patients are the best form of treatment for bleeding esophagogastric varices resistant to long-term ES. Furthermore, the narrow-lumen mesocaval shunt is a good alternative to the distal splenorenal shunt if the latter is technically impossible to perform or hemodynamically not advisable.     

Small-Diameter PTFE Portosystemic Shunts: Portocaval vs Mesocaval

Fifty-seven patients with failed sclerotherapy received a mesocaval interposition shunt with an externally supported, ringed polytetrafluoroethylene prosthesis of either 10 or 12 mm diameter. Thirty-one patients had Child-Pugh gradeA disease and 26 grade B; all had a liver volume of 1000– 2500 ml. Follow-up ranged from 16 months to 6 years 3 months. Three patients (5 per cent) died in the postoperative period. There were two postoperative recurrences of variceal haemorrhage and one recurrent bleed in the second year after surgery. The cumulative shunt patency rate was 95 per cent and the incidence of encephalopathy 9 per cent; the latter was successfully managed by protein restriction and/or lactulose therapy. The actuarial survival rate for the whole group at 6 years was 78 per cent, for those with Child-Pugh grade A 88 per cent and for grade B 67 per cent. Small-lumen mesocaval interposition shunting achieves portal decompression, preserves hepatopetal flow, has a low incidence of shunt thrombosis, prevents recurrent variceal bleeding and is not associated with significant postoperative encephalopathy.     

Combined therapy for esophageal varices: sclerotherapy, embolization, and splenopneumopexy

A new approach consisting of sclerotherapy, embolization, and splenopneumopexy was designed to treat esophageal varices, which were caused by cirrhosis of the liver in 13 patients and by idiopathic portal hypertension in three. No serious complications occurred. Fifteen of the patients were well and without recurrent bleeding or encephalopathy during the 29-month follow-up period. One patient died of hepatic failure 4 months postoperatively. The varices either disappeared or were significantly improved. Placement of a portopulmonary shunt by splenopneumopexy is a safe, simple, and effective procedure for the resolution of varices that recur following sclerotherapy.     

Portal hypertension and bleeding esophageal varices

Summary Bleeding from esophageal varices exacts a high mortality and extraordinary societal costs. Prophylaxis—medication, sclerotherapy, or shunt surgery to prevent an initial bleeding episode—is ineffective. In patients who have bled from varices, endoscopic injection sclerotherapy can control acute bleeding in more than 90% of patients. Because recurrent bleeding frequently occurs and survival without definitive therapy is dismal, selection of a permanently effective treatment is mandatory once variceal bleeding has been controlled.Long-term injection sclerotherapy can be performed in compliant patients; it is relatively safe but is associated with a 30–50% rebleeding rate. Betablockers significantly reduce portal pressure and recurrent bleeding but have not been shown to diminish mortality from BEV. Portal decompressive surgery permanently halts bleeding in more than 90% of patients; the risk of operative mortality is high in decompensated cirrhotics, and long-term complications of encephalopathy and accelerated liver failure may limit indications for shunt surgery to good-risk cirrhotics who are not liver transplant candidates. Devascularization procedures have a low operative mortality and encephalopathy rate but unacceptably high rates of recurrent bleeding.Liver transplantation is curative therapy for bleeding esophageal varices and the associated underlying hepatic dysfunction; cost and availability of donor organs generally limit its use in this setting to variceal bleeders with end-stagè liver disease not associated with active alcoholism.     

Interposition mesocaval H shunt associated with a left inferior vena cava.

Variations in the anatomy of the inferior vena cava are important in abdominal surgery. A patient with recurrent bleeding from esophageal varices was noted to have a single left inferior vena cava at the time of panangiography. An interposition mesocaval H shunt subsequently was performed successfully. This represents the first reported case in which a mesocaval H shunt has been performed in a patient with a single left inferior vena cava.     

Experience with interposition mesocaval shunt for management of variceal bleeding.

We present an experience with 20 patients undergoing interposition mesocaval shunts for decompression of esophageal varices. There were 14 men and six women, ranging in age from 32 to 80 years. Two patients were classified as good risks, nine as moderate risks, and nine as poor risks. There were ten elective operations, seven urgent operations, and three emergency procedures. An operative mortality of 10% was noted in the entire group, with one late death due to shunt occlusion. All deaths occured in the emergency group. A shunt patency of 88% and minimal problems with postoperative hepatic encephalopathy were noted. The interposition mesocaval shunt is judged to be a safe, technically easy procedure that is currently a satisfactory solution to the problem of hemorrhage from esophageal varices.     

Sugiura procedure in portal hypertensive children

Bleeding from esophageal varices is an important cause of morbidity and mortality in children with portal hypertension. The treatment protocol is planned according to the etiologic factors underlying the portal hypertension, which may be either intrahepatic or extrahepatic. Although portasystemic venous shunt operations were common previously, they are now regarded as nonphysiologic and are rarely used because of their unexpected results and complications. Today, in many centers, endoscopic procedures have become the first-step treatment modality in bleeding esophageal varices. More complicated surgical procedures, such as devascularization procedures in extrahepatic portal hypertension, and liver transplantation in patients with failing liver, should be performed when conservative measures fail. We followed up 69 patients with portal hypertension with endoscopic sclerotherapy in our department. Here we present a retrospective evaluation of the effect of the Sugiura operation on the prognosis of 12 children (6 with extrahepatic and 6 with intrahepatic portal hypertension) who were not responsive to the sclerotherapy program. No rebleeding was seen in 9 of the 12 (75%) patients after the procedure, and the mortality rate in this series was 1 of 12 (8.3%); this patient died of hepatic failure. Received: November 7, 2000 / Accepted: January 25, 2001     

Comparative study of portacaval and mesocaval interposition shunts

Portacaval and mesocaval interposition shunts using vascular prosthetic grafts were compared in 37 cirrhotic patients without portal vein thrombosis who were operated on for previous or active variceal hemorrhage. Operative indications and severity of liver disease were similar in the two groups of patients having one or the other procedure. The major difference in results was that none of the 23 patients with portacaval H-graft shunts had rebleeding, while 4 of 14 had rebleeding from varices after mesocaval interposition shunting. This contributed to the higher operative mortality associated with the latter procedure. The index of operative difficulty, as judged by blood loss and length of operation, and postshunt encephalopathy rates were similar for both procedures. Thus, while the mesocaval interposition shunt offers none of the reported theoretical advantages over portacaval H-graft shunt, it does place patients at greater risk of postoperative variceal rehemorrhage. It is concluded that the portacaval interposition shunt, because of its effectiveness and technical expediency, may be the operation of choice in cirrhotic patients with bleeding varices who are not otherwise candidates for other procedures which reduce portal flow less drastically.     

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??Diagnosis and treatment of idiopathic portal hypertension: a report of 28 cases MA Xiu-xian, XUE Ming-hui, SUN Yu-ling, et al. Department of General Surgery, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China Corresonding author: SUN Yu-ling, E-mail: ylsun@zzu.edu.cn Abstract Objective To investigate the clinical features, diagnosis and treatment of idiopathic portal hypertension. Methods The clinical data of 28 patients with idiopathic portal hypertension treated between 1987 and 2008 at the First Affiliated Hospital of Zhengzhou University were analyzed retrospectively. Results The operations included splenectomy and disconnection (14patients), the shunt from splenic vein to inferior vena cave and severed around cardiac blood vessels (8 patients), splenorenal shunt and gastric coronary vein suture (4 patients), splenectomy and the shunt from superior mesenteric vein to inferior vena cave by C-bridge ( 1 patient ), severed lower esophageal and around cardiac blood vessels ( 1 patient ) . Twenty-seven patients were followed up for six months to 17 years, who were in good condition. Hypersplenism, significant ascites, further bleeding and liver encephalopathy were disappeared. All liver function were normal. Esophageal varices was disappeared in 16 patients. Esophageal varices marked improvement in 9 patients. Esophageal varices did not change in 3 patients. Conclusion Cureing bleeding and prevention of recurrence of IPH are the key issue. The patients have no liver failure preferred surgical treatment which might be portal azygous disconnection or portosystemic shunt. The patients who can not tolerate surgery or were variceal bleeding after operation might be used endoscopic injection sclerotherapy or endoscopic ligation treatment.     

Endoscopic sclerotherapy in the management of esophageal varices in 61 children with biliary atresia

Sixty-one children who have survived 2.5 years or more after corrective surgery for biliary atresia were prospectively followed by endoscopy. Esophageal varices were detected in 41 patients (67%), 17 of whom (28%) had experienced episodes of variceal hemorrhage. Control of variceal bleeding was achieved by endoscopic injection sclerotherapy in all but one child who died from hemorrhage before the completion of treatment. Complications of the technique comprised episodes of bleeding before variceal obliteration (7), esophageal ulceration (5), and stricture (3). These resolved with conservative management and without long-term sequelae. During a mean follow-up period of 2.8 years after variceal obliteration, rebleeding from recurrent esophageal varices developed in only one child and responded to further sclerotherapy. These results are better than those following surgical procedures for portal hypertension in biliary atresia, and therefore endoscopic sclerotherapy is recommended as the treatment of choice.     

Treatment of esophageal varices by sclerotherapy in children

Bleeding from esophageal varices may be a serious or lethal complication of portal hypertension in children. The standard therapy over the past 30 years has been to create a portosystemic shunt. In children physiologic complications leading to high rates of perioperative morbidity and early and late thrombosis with recurrence and encephalopathy have been common. Over a 42 month period, we treated six patients aged 5 to 18 years, with endoscopic injection of 3 percent sodium tetradecyl sulfate into the varix. Five patients required only injection, whereas one underwent direct oversewing of gastric varices followed by endoscopic sclerosis of the esophageal varices which remained. A total of 38 endoscopic procedures were performed. There has been complete cessation of bleeding in two patients, minimal subsequent bleeding in two others, and anemia requiring transfusion in the last two treated. These last two patients, although still requiring occasional transfusions, have been free from hypotensive or exsanguinating hemorrhage since beginning sclerotherapy. No deaths or serious complications were encountered in this series. Follow-up has ranged from 18 to 42 months (mean 26 months). The results of this trial suggest that repeated endoscopic sclerotherapy of varices, combined with operative oversewing of gastric varices when necessary, offered a viable alternative therapy for patients with esophageal varices.     

Management of esophageal varices in the Western world--the state of the art

The treatment by Western countries of bleeding from esophageal varices was reviewed from three definite viewpoints: prevention of first bleeding or prophylactic treatment, control of acute bleeding or emergency treatment, and prevention of rebleeding or elective treatment. Even though prophylactic surgery has been abandoned on the basis of several randomized studies, some authors still perform esophageal transection and report encouraging results. In emergency situations, the role of surgery has been limited by the prohibitive hospital mortality and by the introduction of vasoactive drugs and endoscopic sclerotherapy. Nevertheless, good immediate and long term results have been obtained in specialized centers in which bleeding patients undergo surgery no later than 8 hours after their admission. As regards the prevention of rebleeding, non selective portal decompression gives adequate protection against rebleeding, however, hepatoencephalopathy follows in considerable incidence. In order to avoid this complication, direct operations on varices have been performed, largely with good results. The Warren shunt offers results showing advantage over the non-selective shunt in the first postoperative period but later on, it behaves hemodynamically as a total shunt and the advantage is then cancelled. We report herein a review of the literature and also describe our personal experience with treating bleeding esophageal varices.     

Results of portacaval shunt after failure of sclerotherapy in patients with cirrhosis]

Therapy of variceal bleeding is currently based on endoscopic sclerotherapy. However, the treatment of bleeding recurrences after sclerotherapy has not yet been established, but consists of the choice between continuation of sclerotherapy or a surgical procedure. We report herein the results of portocaval shunt performed in 26 cirrhotic patients among the 175 cirrhotic patients (15%) admitted between 1985 and 1990 to our Intensive Care Unit for variceal bleeding. These 26 patients were operated because of failure of sclerotherapy as defined by haemostasis failure (n = 1), the persistence of unchanged oesophageal varices after six sessions of sclerotherapy (n = 1), and the occurrence of at least one severe episode of rebleeding (n = 24). Emergency and elective portocaval shunts were performed in 12 and 14 cases respectively. The time delay between admission and surgical procedure was equal to 21 +/- 8 hours and 12 +/- 4 days in the two groups respectively. The operative mortality (30 days) was equal to 23% and was observed in emergency shunts only. Actuarial survival rates were significantly different between the two groups (p < 0.01). Predictive factors of mortality as assessed by univariate analysis were the emergency nature of the procedure, serum aminotransferases and urea levels at the time of the index bleeding, and the number of bleeding episodes related to portal hypertension before the index bleeding. The prognosis at one year was not influenced by the number of bleeding recurrences between the index bleeding and the bleeding episode justifying the shunt.(ABSTRACT TRUNCATED AT 250 WORDS)     

The current role of devascularization and transection procedures in portal hypertension]

It is not clear which theory should be used in patients with bleeding esophageal varices that are not controlled by emergency endoscopic sclerotherapy. Definitive hemostasis is the key to successful therapy of variceal bleeding. Recurrence of haemorrhage in patients with portal hypertension is the most feared life threatening complication. Based on our management of 658 patients with esophageal varices and the availability of treatment options at our institution, the strategy of management of uncontrollable variceal haemorrhage by endoscopic sclerotherapy has evolved. Bleeding was controlled in 64 liver cirrhosis (100%) by devascularization and transection procedures and 50 patients (78%) survived to leave the hospital including 43 of 64 patients (67%) with Child grade C liver cirrhosis. Cumulative rebleeding rate at 10 years following emergency surgery was 3% (2/64). It is associated with a lower morbidity and mortality as well as a lower incidence of subsequent encephalopathy. We suggest that emergency transection and devascularization is an effective salvage treatment for the endoscopic sclerotherapy failed group.     

Partial portacaval shunt: renaissance of an old concept.

BACKGROUND. Partial diversion of the portal system aims to reduce portal pressure sufficiently to prevent variceal hemorrhage but still maintain adequate hepatic portal flow. METHODS. Partial portacaval shunts were performed in 25 patients with cirrhosis with portal hypertension and esophageal varices, either as a primary procedure (n = 16) or for failure of endoscopic sclerotherapy (n = 9), with ringed polytetrafluoroethylene prostheses (8, 10, or 12 mm). RESULTS. All patients have now been followed up for at least 1 year. The operative mortality rate (2 months) was 4%. In 24 patients who survived beyond the initial perioperative period, there was no recurrence of variceal bleeding. Cumulative shunt patency (up to 4 years) is 96%. Acute encephalopathy was detected in two patients (8%), but no patients had signs of chronic encephalopathy. Intraoperative pressure measurements revealed a significant correlation between decreasing diameter of the graft and the percentage reduction of the portacaval pressure gradient. Selective angiography, performed 1 year after surgery, revealed that hepatopetal flow was maintained in 70% of patients with a 10 mm shunt. CONCLUSIONS. It is possible to achieve a partial portacaval shunt, related to the diameter of the prosthesis, that preserves hepatopetal flow in the majority of patients and is associated with a very low incidence of shunt thrombosis. This effectively prevents recurrent variceal bleeding and significant postoperative encephalopathy. The performance of subsequent orthotopic liver transplantation is not compromised. The technique is recommended, either as a primary procedure or when sclerotherapy has failed, in patients with good liver function who are unlikely to require early liver transplantation (grade A and some grade B cirrhosis).