Long-term management of variceal bleeding: The place of varix injection and ligation

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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Resumen La escleroterapia sigue siendo el método de mayor utilización en el manejo de los pacientes que han sufrido un episodio de hemorragia por várices esofágicas. La escleroterapia debe ser repetida semanalmente hasta cuando las várices sean erradicadas, y se requiere luego un seguimiento semestral o anual de por vida. En el momento en que se detecte recurrencia de las várices, se debe emprender de nuevo el régimen de inyecciones semanales hasta lograr su erradicación. La falla de la escleroterapia debe ser diagnosticada precozmente, para emprender una alternativa terapéutica de salvamento; nuestro grupo actualmente recomienda un shunt espleno-renal distal. Aunque las complicaciones de la escleroterapia no son mayores, sí son acumulativas. A diferencia de lo que ocurre con los procedimientos quirúrgicos, la técnica de la escleroterapia no ha sido estandarizada, lo cual hace difícil la comparación entre los diferentes ensayos clínicos controlados.En el presente artículo se hace una evaluación del estado actual de los ensayos clínicos controlados, que comparan la escleroterapia con otras modalidades terapéuticas. Nuestra conclusión es que la escleroterapia, mediante inyecciones repetidas, es en el momento actual el tratamiento de elección para pacientes que han presentado hemorragia varicosa.También se describe la técnica del nuevo procedimineto de ligadura endoscópica de las várices esofágicas. Al igual que con la escleroterapia, se recomiendan sesiones semanales hasta la erradicación de las várices, seguidas de vigilancia endoscópica a largo plazo, con repetición de la ligadura si hay recurrencia de las várices. Los cuatro ensayos clínicos controlados que comparan la ligadura con la escleroterapia, favorecen todos la ligadura.La ligadura logró la erradicación de las várices con un número menor de sesiones y con inferior tasa de complicaciones, y uno de ellos demostró mejor supervivencia. A diferencia de la escleroterapia, la técnica de la ligadura sí está estandarizada. Se han venido informando complicaciones por el uso del tubo secundario, pero éstas no representaron problema en los ensayos clínicos controlados. Aunque la ligadura de las várices combinada con escleroterapia puede llegar a demostrar superioridad sobre la escleroterapia sola, todavía se requiere investigación adicional antes de llegar a conclusiones finales.

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Résumé La sclérothérapie reste le traitement de base pour les patients ayant saigné par rupture de varices oesophagiennes. Les injections de sclérothérapie doit être répétées chaque semaine jusqu'à ce que les varices soient éradiquées. Un suivi par endoscopie est nécessaire au moins une fois par an et à vie. Lorsque les varices réapparaissent, la sclérothérapie doit être recommencée jusqu'à obtenir de nouveau l'éadication. En cas d'échec, un procédé alternatif, le plus souvent une anastomose splénorénale distale, doit être choisi. Bien que le taux de complications de la sclérothérapie ne soit pas très élevé, celles-ci s'accumulent avec le temps. Au contraire des interventions chirurgicales, la technique de sclérothérapie n'est pas standardisée, ce qui rend la comparaison des essais contrôlés difficile. Les essais publiés jusqu'à présent comparant la sclérothérapie à d'autres modalités de traitement sont discutés. Nous concluons que la sclérothérapie répétée est le traitement initial de choix pour le patient ayant saigné de varices oesophagiennes. La technique de ligature des varices oesophagiennes est également décrite. Tout comme la sclérothérapie, les séances hebdomadaires sont nécessaires jusqu'à l'éradication des varices, suivies d'une surveillance endoscopique et éventuellement d'autres séances de ligature à la demande. Les quatre essais contrôlés comparant la ligature à la sclérothérapie sont tous en faveur de la ligature. De même, dans un des essais, la survie après ligature est améliorée. Les complications en rapport avec la gaine nécessaire à la ligature commencent à être publiées mais elles n'avaient pas été mentionnées auparavant dans les essais contrôlés. Il se peut que la ligature des varices ou la ligature combinée à la sclérothérapie soient supérieures à la sclérothérapie seule, mais il faut attendre les résultats d'autres études avant de pouvoir conclure formellement.

     

Narrow-diameter portacaval shunts for management of variceal bleeding

Over the past decade, we have developed and refined a method for partial portosystemic shunting for the control of bleeding esophageal varices in alcoholic cirrhotic patients. The narrow-diameter interposition portacaval H-graft using 8 mm polytetraffuoroethylene has been performed in 32 patients at our institution with low operativ mortality (16.3%) and nearly complete cessation of variceal bleeding (96.7%) over a mean follow-up period of 43 months. In comparison with total shunts, diminished rates of postshunt encephalopathy (13% versus 40%) have been observed. Prograde portal blood flow has been preserved in 90% of 30 patients studied by perioperative portography. Shunt patency with continued prograde flow has been demonstrated at up to 9 years of follow-up. Investigators at three other centers have studied partial shunting using substantially similar techniques, with similar findings. Based on these results, we conclude that narrow-diameter shunts provide effective, long-lasting treatment for variceal hemorrhage due to portal hypertension in the alcoholic.

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Resumen En el curso del último decenio hemos desarrollado y refinado un método de derivación portasistémica parcial para el control del sangrado por várices esofágicas en pacientes con cirrosis alcohólica. La interposición portacava en H por medio de un injerto de politetrafluoroetileno de diámetro delgado, 8mm, ha sido utilizada en 32 pacientes en nuestra institución, con baja mortalidad operatoria (6.3%) y el logro casi total del cese del sangrado varicoso (96.7%) en el curso de un seguimiento promedio de 43 meses. Al comparar con los shunts totales, se observan menores tasas de encefalopatía (13% versus 40%). Se ha logrado preservar el flujo portal prógrado en un 90% de 30 pacientes estudiados mediante portografía perioperatoria. La permeabilidad del shunt con flujo prógrado confirmado ha sido demostrada hasta en 9 años de seguimiento. Investigadores en otros tres centros han estudiado la derivación parcial utilizando una técnica similar, registrando resultados similares. Con base en estos resultados, llegamos a la conclusión de que los shunts de diámetro delgado representan una modalidad terapéutica efectiva y de larga duración en el manejo de la hemorragia por hipertensión portal causada por cirrosis.

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Résumé Pendant ces 10 dernières années, nous avons conçu et perfectionné une méthode d'anastomose porto-cave partielle pour contrôler l'hémorragie par rupture des varices oesophagiennes chez le cirrhotique d'origine alcoolique. Nous réalisons une anastomose par interposition portocave avec une prothèse de 8 mm en polytétrafluoroéthylène (PTFE). Ceci a été effectué chez 32 patients avec une mortalité faible (6.3%) en obtenant un arrêt de saignement chez 96.7% des patients avec un suivi de 43 mois. En comparaison avec d'autres types d'anastomose, la fréquence d'encéphalopathie est amoindrie (23% vs 48%). Le flux portal antérograde a été conservé chez 90% des 30 patients étudiés par portographie périopératoire. La perméabilité de l'anastomose avec une conservation de flux antérograde a été retrouvé jusqu'à 9 ans après l'intervention initiale. Les investigateurs de trois autres centres ont étudié cette anastomose partielle avec une technique similaire et des résultats tout à fait comparables. En nous appuyant sur ces résultats, nous concluons que l'anastomose par prothèse interposée de petit calibre peut donner un résultat efficace et durable dans le traitement de la rupture de varices oesophagiennes en rapport avec l'hypertension portale chez le cirrhotique d'origine alcoolique.

     

Recent advances in the management of variceal bleeding

A prospective randomized trial of selective distal splenorenal shunt (DSRS)versus H-graft interposition total shunt at Emory Hospital in 1971 showed DSRS to be superior to a total shunt in shunt patency, prevention of variceal bleeding, preserving hepatic cell function, preserving the quality of life and patient survival. These results were particularly evident in the non-alcoholic patients. In the alcoholic patients, there was a greater loss of hepatic portal perfusion. In a later phase of the study, it was found that pancreatic veins formed a pathway of collaterals to the shunt, that is a socalled pancreatic siphon. In order to prevent loss of portal and pancreatic flow through the siphon, a total spleno-pancreatic disconnection was developed, whereby the hormone diversion is expected to be diminished. This report is the gist of a paper read by W. D. W. at the 85th Annual Meeting of the Japanese Surgical Society, Sendai, Japan, 1985     

Recent advances in the management of variceal bleeding

A prospective randomized trial of selective distal splenorenal shunt (DSRS) versus H-graft interposition total shunt at Emory Hospital in 1971 showed DSRS to be superior to a total shunt in shunt patency, prevention of variceal bleeding, preserving hepatic cell function, preserving the quality of life and patient survival. These results were particularly evident in the non-alcoholic patients. In the alcoholic patients, there was a greater loss of hepatic portal perfusion. In a later phase of the study, it was found that pancreatic veins formed a pathway of collaterals to the shunt, that is a so-called pancreatic siphon. In order to prevent loss of portal and pancreatic flow through the siphon, a total spleno-pancreatic disconnection was developed, whereby the hormone diversion is expected to be diminished.     

Sugiura procedure for management of variceal bleeding in Japan

During the last three decades the Sugiura procedure and other nonshunting operations have been widely performed as the operations of choice for bleeding esophageal varices in Japan. The Sugiura procedure (University of Tokyo method), a transthoracoabdominal esophageal transection, consists in paraesophageal devascularization, esophageal transection and reanastomosis, splenectomy, and pyloroplasty. The results have been satisfactory with low operative mortality and low rebleeding rate. The prognosis of the patients after this operation depended on the liver function at the time of operation but not on whether operation was done as an emergency, elective, or prophylactic measure. Although the Sugiura procedure has recently been performed in more selected cases with an advance in endoscopic injection sclerotherapy, this procedure remains the ultimate direct operation for portal hypertension in Japan.

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Resumen En los últimos tres decenios, el procedimiento de Sugiura y otras operaciones no derivativas han sido extensamente practicadas como el tipo de operación de preferencia para várices esofágicas sangrantes en el Japón. El procedimiento de Sugiura (o método de la Universidad de Tokyo) es una transección esofágica transtoracoabdominal, que consiste en desvascularización paraesofágica, transección esofágica y reanastomosis, esplenectomía y píloroplastia. Los resultados han sido satisfactorios con baja mortalidad operatoria y baja tasa de hemorragia recurrente.El pronóstico luego de esta operación depende del estado de la función hepática en el momento de la cirugía, pero nó de si la operación es realizada como medida de emergencia, electiva o profiláctica. Aunque el procedimiento de Sugiura ha sido recientemente practicado en casos más seleccionados, sigue siendo la operación directa definitiva para el tratamiento de la hipertensión portal en el Japón.

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Résumé Depuis les trois dernières décades, au Japon, on préfère pratiquer l'opération de Suguira et d'autres procédés non anastomotiques pour rupture de varices oesophagiennes. L'opération de Suguira (ou la méthode de l'Université de Tokyo) est une transsection oesophagienne transthoracoabdominale suivie d'anastomose associée une dévascularisation paraoesophagienne, une splénectomie et une pyloroplastie. Les résultats ont été satisfaisants avec une mortalité et un taux de récidive bas. Le pronostic des patients après cette opération dépend de la fonction hépatique au moment de l'intervention, mais pas du caractère urgent de l'intervention. Bien que cette intervention ait été pratiquée récemment dans quelques cas sélectionnés après sclérothérapie, l'opération de Suguira reste l'intervention directe ultime pour l'hypertension portale au Japon.

     

Portoenterostomy for biliary atresia: Long-term survival and prognosis after esophageal variceal bleeding

Background/purpose

Portoenterostomy is the procedure of choice in patients with biliary atresia. The authors analyzed the long-term survival rate and complications of the procedure in children operated on at The University of Hong Kong Medical Centre between 1979 and 2000.

Methods

Seventy-seven consecutive patients were analyzed by retrospective chart review. The patients were divided into groups according to postoperative bile flow, decade of operation, and age at operation. The data were analyzed statistically.

Results

The overall actuarial transplant-free survival rate was 68% at 10 years after operation. For patients with poor, partial, and good postoperative bile flow, transplant-free survival rate was 0%, 22%, and 96%, respectively (P < .001). Age and decade of operation were not significant risk factors. Esophageal variceal bleeding occurred in 13 patients and was a prognostic indicator for end-stage liver failure (P = .044); the poor prognosis of patients with variceal bleeding, however, was related to poor or partial initial bile drainage.

Conclusions

The postoperative serum bilirubin level is the most important predictor of long-term survival in patients with portoenterostomy for biliary atresia. Esophageal hemorrhage is not an absolute indication for urgent liver transplantation in patients with good bile drainage.     

Long-term management after variceal bleed--the current role of sclerotherapy

While injection sclerotherapy has been accepted as the treatment of choice for acute variceal bleeding, its role as a definitive long-term treatment modality has not yet been clearly defined. This paper will critically analyse the current status of this technique, now widely used, and a comparison will be made with conventional medical management. The review will be based on the 10 years' Cape Town experience and the published series on this subject. A long-term management strategy will also be discussed.     

Long-term results with the modified Sugiura procedure for the management of variceal bleeding: standing the test of time in the treatment of bleeding esophageal varices

Background  

The surgical approaches to the treatment of bleeding esophageal varices in cirrhotic patients have been reduced since the clinical development of endoscopic sclerotherapy, transjugular intrahepatic portosystemic shunt (TIPS), and liver transplantation. However, when acute sclerotherapy fails, and in cases where no further treatment is accessible, emergency surgery may be life saving. In the present study we retrospectively analyzed the results of the modified Sugiura procedure, performed as emergency and semi-elective treatment in the patient with bleeding esophageal varices.     

急诊内镜治疗食管胃底静脉曲张破裂出血的护理风险管理

目的探讨急诊内镜治疗食管胃底静脉曲张破裂出血护理风险管理方法及应用效果。方法将201例食管胃底静脉曲张破裂出血患者按照时间顺序分组,2015年1~12月的93例设为实施前组,实施常规护理。2016年1~12月108例设为实施后组,应用医疗失效模式与效应分析(HFMEA)方法,分析急诊内镜治疗食管胃底静脉曲张破裂出血失效模式和潜在风险原因,计算优先风险数(RPN),对需要优先解决的问题进行干预,并对实施HFMEA前后的效果进行评价。结果实施HFMEA管理后,患者护理安全不良事件发生率显著低于实施前(均P<0.05),RPN下降。结论应用HFMEA能改进急诊内镜治疗食管胃底静脉曲张破裂出血的流程,降低围手术期患者护理安全不良事件风险率,保证患者安全。     

The selective shunt for variceal bleeding: a personal perspective

It has been proved that selective decompression of esophageal varices can occur by way of the left gastric venous route or the transsplenic route. The left gastric venacaval shunt functions well over a long postoperative period, if the shunt is technically satisfactory; however, the distal splenorenal shunt (DSRS) can be problematic. Unless the proximal and distal portions of the splenic vein are both entirely isolated from the pancreas, blood flow will be diverted from the portal vein to the distal splenic vein, where the pressure has been lowered by the shunt. This portal malcirculation may lead to portal thrombosis or stenosis on occasion. To prevent this adverse effect, complete isolation of the splenic vein (splenopancreatic disconnection) is necessary. Extensive gastric disconnection is irrelevant in this regard. Although the conventional DSRS has been viewed with disfavor, we must realize that splenopancreatic disconnection makes the DSRS a satisfactory technique. The clinical evidence and theoretic basis of the selective shunt for esophageal varices are described herein.     

Control of variceal bleeding: Reassessment of rationale

The selective shunt concept has been validated both physiologically and clinically for the nonemergent patient with variceal bleeding. The patency rate of the shunt has been good and long-term control of gastroesophageal bleeding excellent. Furthermore, the transsplenic decompression of the upper stomach and lower esophagus has effectively prevented the problems related to gastritis and gastric varices seen with nonshunt procedures. Continued portal perfusion of the liver has been sustained for more than 9 years in some patients, and 9 of 11 patients have portal perfusion exceeding 7 years. The metabolic problems of the portaprival syndrome have been greatly ameliorated, and long-term survival with clinical well-being has been achieved. For the actively bleeding patient, acute renal vein hypertension needs to be prevented to provide effective control of hemorrhage. Selective splenocaval shunts have been successful in this regard in a small number of patients.     

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目的 探讨应用吻合器经腹行食管下段部分切除再吻合治疗门静脉高压食管胃底静脉曲张出血的疗效。方法 回顾分析了自1995年10月至2001年11月行贲门周围血管离断术加用吻合器作食管下段部分切除再吻合48例(切除组)的疗效，并与20例同期仅行周围血管离断术(单纯组)的疗效进行比较，分别观察食管曲张的消除率、再出血率、手术死亡率、吻合口狭窄以及吻合口瘘的发生率。结果平均随访20个月。单纯组再出血率为25％(5／20)，切除组无再发出血。食管静脉曲张的治愈率切除组为100％，而单纯组为50．0％(10／20)。吻合狭窄发生率切除组为4．1％(2／48)，单纯组为0。两组均未发生吻合口瘘。结论 应用吻合器行食管下段切除再吻合术是安全的，可使断离更为彻底，降低复发，从而进一步提高周围血管离断术的疗效。     

Current indication of a modified Sugiura procedure in the management of variceal bleeding

BACKGROUND: The role of gastroesophageal devascularization (Sugiura-rype procedures) for the treatment of variceal bleeding remains controversial. Although Japanese series reported favorable longterm results, the technique has nor been widely accepted in the Western Hemisphere because of a high postoperative morbidity and mortality. The reasons for the different outcomes are unclear. In a multidisciplinary team approach we developed a therapeutic algorithm for patients with recurrent variceal bleeding. STUDY DESIGN: The Sugiura procedure was offered only to patients with well-preserved liver function (Child A or Child B cirrhosis without chronic ascites) who were not candidates for distal splenorenal shunt, transhepatic porto-systemic shunt, or liver transplantation. RESULTS: Fifteen patients with recurrent variceal bleeding underwent a modified Sugiura procedure between September 1994 and September 1997. All but one patient (operative mortality 7%) are alive after a median followup of 4 years. Recurrent variceal bleeding developed in one patient; esophageal strictures, which were successfully treated by endoscopic dilatation, developed in three patients; and one patient experienced mild encephalopathy. Major complications were noted only in patients with impaired liver function (Child B cirrhosis) or when the modified Sugiura was performed in an emergency setting. The presence of cirrhosis or the cause of portal hypertension had no significant impact on the complication rate. CONCLUSIONS: This series was performed during the last decade when all modern therapeutic options for variceal bleeding were available. Our results indicate that the modified Sugiura procedure is an effective rescue therapy in patients who are not candidates for selective shunts, transhepatic porto-systemic shunt, or transplantation. Emergency settings and decreased liver function are associated with an increased morbidity.     

A hepatologist's view of variceal bleeding

Patients with cirrhosis and esophagogastric varices have a 25% to 33% risk of initial variceal bleeding, a risk of up to 70% for recurrent variceal bleeding, and an associated mortality of up to 50%. Based on a review of prospective randomized trials, control of acute variceal bleeding should involve vasopressin plus nitroglycerin as indicated for minor bleeding episodes, sclerotherapy for more severe bleeding episodes, and staple transection of the esophagus for patients who do not respond to these initial measures. Emergency portasystemic shunt surgery cannot be recommended at this time. For prevention of recurrent variceal hemorrhage, the data support the use of nonselective beta-adrenergic blockers (propranolol or nadolol) for patients with good liver function (Child's class A and B) and the use of chronic sclerotherapy to obliterate esophageal varices for patients with decompensated cirrhosis (Child's class C). Surgical procedures should be reserved for failures of medical management. The use of beta-adrenergic blockers offers the most promise for prevention of initial variceal bleeding.     

经腹应用吻合器不同吻合方式治疗食道胃底静脉出血疗效分析

目的总结近4年来在贲门周围血管离断术基础上应用吻合器进行食道横断治疗门静脉高压症的经验．比较不同食道横断吻合方法的疗效。方法回顾分析2000年1月至2003年6月在我院因为门静脉高压症行贲门周围血管离断术加食道横断吻合术的病人98例，比较不同吻合方法的优缺点。结果在两种不同的食道横断吻合方法中，应用食道食道再吻合组32例，围手术期死亡1例(3．13％)，食道胃底瘘2例(6．25％)，无近期内再出血病例发生；应用食道胃底再吻合组66例，围手术期死亡1例(1．52％)．无食道胃底瘘和近期内再出血病例发生。两组病人的术后随访率分别为90．63％(29／32)和95．45%(63／66)，随访时间3个月至3年6个月。在手术半年后的胃镜或食道吞钡检查中．食道食道再吻合组，食道胃底曲张静脉消失者23例(79．31％)，显著改善者6例(20．69％)；食道胃底再吻合组，食道胃底曲张静脉消失者60(95．24％)，显著改善者3例(4．?6％)。结论贲门周围血管离断术同时加用食道横断吻合术治疗肝硬化性门静脉高压症的疗效优良．其曲张静脉消失率很高，围手术期死亡率很低，并发症少，手术操作相对简单，是一种值得推广的门静脉高压症手术方法。两者中以食道横断、食道胃底吻合术疗效更为显著。     

Colonic variceal bleeding in a child

A 5-year-old girl with biliary atresia is described who developed lower gastrointestinal bleeding from colonic varices. Vasopressin infusions temporarily controlled the bleeding. Following a right hemicolectomy the bleeding has not recurred.     

Oesophagogastric variceal bleeding in portal hypertension

This article reviews substantial progress made in the past decade in the management of patients with portal hypertension who present with major upper gastrointestinal bleeding. Variceal and portal pressure measurements and endoscopy facilitate a reasoned approach to management, and several treatment options are available to gain control of ongoing or recurrent haemorrhage. These encompass endoscopic therapy (sclerotherapy, endoscopic variceal ligation), radiological intervention with transjugular intrahepatic systemic shunt (TIPS) procedures, and a variety of surgical procedures for devascularization or shunting from the high‐pressure portal system to low‐pressure systemic venous connections. In most prospective randomized trials endoscopic variceal ligation has proved superior to sclerotherapy, and TIPS has found a role in the salvage of patients with further haemorrhage, sparing them surgical intervention. Advances in pharmacotherapy for the control of initial bleeding and secondary prophylaxis hold promise. Liver transplantation has become an option for selected patients with end‐stage liver disease.      

Role of the distal splenorenal shunt in management of variceal bleeding in Latin America

In the early 1970s, we began to perform selective shunts on a regular basis for the treatment of portal hypertension. In a 15-year period, 177 patients (155 with liver cirrhosis) were treated with 3 kinds of selective shunts: the Warren shunt (128 patients) the end-to-end splenorenal shunt (29 patients), and the splenocaval shunt (20 patients). One hundred sixty-seven of the procedures were elective. Operative mortality was 14%, and survival for the Child's class A group was 75% at 1 year, 69% at 5 years, and 65% at 15 years. Incapacitating encephalopathy was observed in 7% of the patients, rebleeding in 6%, and shunt thrombosis in 6%. Postoperative portal vein alterations included reduced venous diameter (13%) and thrombosis (21%). Experience with the Warren shunt in schistosomiasis, a disease in which normal liver function is the rule in Latin American countries, is discussed. We believe that, when feasible, the selective shunts are the treatment of choice for portal hypertension in Latin American countries.