Selective and nonselective shunts for variceal bleeding. A prospective study of 103 patients

Based on the experience reported herein, the following conclusions have been made: (1) Although nonoperative means, including sclerotherapy, have an important role in the management of bleeding varices, they are not definitive means of treating recurrent variceal hemorrhage. (2) Because of the maintenance of hepatopetal flow and splanchnic venous hypertension, a selective shunt is associated with a lower incidence of encephalopathy and provides a better quality of life than does a nonselective shunt. Thus, an elective distal splenorenal shunt is the elective operation of choice for recurrent variceal hemorrhage. (3) Nonselective shunts can be performed with similar expectation of patient survival as selective shunts, but because of increased encephalopathy, should be reserved for emergency operations, in cases of unsuitable venous anatomy, and in those patients with intractable ascites. (4) A well-conceived elective shunt procedure can be performed with low operative mortality and long-term patency, results in significant survival, and is still considered the "gold standard" for treatment of variceal bleeding.     

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.

     

Selective operative approach for variceal hemorrhage

Since 1978, the operation chosen for patients with variceal hemorrhage has been based on preoperative hemodynamic and clinical factors. One hundred sixteen consecutive patients were managed with the following operations: distal splenorenal shunt (75 patients), nonselective shunts (33 patients), and nonshunting operation (8 patients). Emergency surgery was required in 19 percent of patients. The selection criteria used resulted in the majority of high risk patients receiving nonselective shunts. This selective operative approach resulted in an overall operative mortality of 12 percent, a median survival of 3 years, and postoperative encephalopathy, ascites, and recurrent variceal hemorrhage in 20, 23, and 11 percent of patients, respectively. Operative mortality for the total group was closely related to Child's class. Whereas encephalopathy was most frequent after nonselective shunts, ascites was more common after the distal splenorenal shunt. Recurrent hemorrhage rarely occurred after a shunting procedure, but was a frequent complication of nonshunting operations. Neither the type of procedure selected nor the cause of liver disease influenced long-term survival.     

Outcome of total splenectomy with portosystemic shunt for massive splenomegaly and variceal bleeding in cystic fibrosis

Multilobular biliary cirrhosis and portal hypertension are frequent complications of cystic fibrosis liver disease, leading to esophageal varices and splenomegaly. Therapy is focused on variceal bleeding control; however, reduction of spleen volume is also important to restore gastric volume and resolve invalidating abdominal discomfort. We report long-term follow up (median duration, 5.5 years; range, 14 months-21.5 years) of 6 patients with cystic fibrosis (4 men, 2 women; median age, 14 years; range, 8-18 years) who underwent splenectomy with a splenorenal shunt operation. Three patients received elective surgery for massive splenomegaly with important abdominal discomfort, recurrent variceal bleeding, and hypersplenism. Three were urgently treated to control variceal bleeding after several sessions of sclerotherapy. All but 2 received antipneumococcal vaccination before surgery. Four patients had a weight gain of 10% within 3 months of surgery, and 3 developed spontaneous puberty. Lung function remained stable, and there was an overall reduction of respiratory tract infections. The youngest patient, however, died of overwhelming septicemia during treatment with steroids. Although total splenectomy has important risks, in well-selected cases, it can have benefits. Immuno- and chemoprophylaxis, combined with patient awareness of supplementary risk of infections is indispensable to minimize septic complications.     

Mesogonadal shunts for extrahepatic portal vein thrombosis and variceal hemorrhage.

Extrahepatic portal vein thrombosis (EHPVT) may occur in children or adults and usually comes to clinical attention due to complications of portal hypertension such as variceal hemorrhage. A variety of standard surgical techniques exist to manage these patients, but when these fail surgical options are limited. We describe two novel portosystemic shunts that utilize the gonadal vein as an autologous conduit. Four patients were evaluated for EHPVT with variceal bleeding. None of the patients were candidates for a standard splenorenal shunt due to prior surgical procedures. The first patient underwent a left mesogonadal shunt and the remaining 3 patients underwent a right mesogonadal shunt. Postoperative ultrasound or computed tomography (CT) scan confirmed early patency of the shunt in each patient. There have been no further episodes of variceal hemorrhage with follow-up of 3.5 years in the child who underwent the left mesogonadal shunt, and 17, 19, and 20 months in the patients who underwent the right mesogonadal shunt. Three of the 4 shunts remain patent. One shunt thrombosis occurred in a patient homozygous for the Factor V Leiden mutation despite anticoagulation with coumadin. This is the first report of the successful use of the gonadal vein as an in situ conduit for constructing a portosystemic shunt. In conclusion, the right and left mesogonadal shunts may be useful as salvage operations for patients with EHPVT who have failed standard surgical shunt procedures.     

三联手术治疗门静脉高压症食管静脉曲张破裂出血

目的　评价三联手术(人造血管肠腔静脉C型架桥、冠状静脉结扎、脾动脉结扎)治疗门静脉高压症(PHT)上消化道出血的效果。方法　对采用三联手术治疗的58例门静脉高压症上消化道出血患者的临床资料进行回顾性分析。结果　手术前胃网膜静脉压为27～45cmH2O,术后为25～43cmH2O,平均下降8cmH2O。术后因脑血管意外死亡1例。2例有轻度肝性脑病,经对症治疗后好转;3例发生乳糜瘘,分别在手术后5,10d和3个月后自行消失。随访1个月～6年的共41例,无再出血病例,无肝性脑病发生。所有病人脾机能亢进消失。腹水消失20例,明显减少10例,无1例增加。肝功能好转10例,下降3例,28例变化不明显。B超或彩色多普勒检查,40例人造血管均通畅。结论　本手术主要适应于以下原因引起的门静脉高压:①单纯化肝静脉闭塞(布加综合征的一种病理类型);②门静脉主干血栓形成成海绵样变性引起的肝前性门静脉高压;③肝内型门静脉高压行断流术后再发出血或未行手术,肝功能为ChildA和B级者。     

精准断流术治疗门静脉高压症上消化道出血疗效分析

目的探讨精准断流术治疗门静脉高压症上消化道出血的疗效。方法回顾性分析2005~2012年期间施行精准断流术治疗门静脉高压症上消化道出血病人43例,观察该组病人手术前后血象、肝功能、并发症等指标,术后对病人进行长期随访,观察再出血率和生存情况。结果手术止血率为100%,围手术期无再出血及死亡病例。围手术期术后脾功能亢进得到有效治疗(P0.05);术后发生胃潴留2例(3.7%),手术创面渗血2例(3.7%),均经保守治疗后痊愈;术后门静脉超声检查均未发现门静脉血栓形成。43例病人全部顺利出院,术后住院时间为7~34 d,平均(11.2±5.7)d。43例中有40例获得随访,随访率为93.0%,随访时间为8~73个月,平均(49.2±10.5)月。其中1年再出血率为2.5%(1/40),1年死亡率为5.0%(2/40)。总体再出血率为17.5%(7/40),总体死亡率为22.5%(9/40),死亡原因为上消化道出血2例、肝衰竭7例,其中合并肝细胞肝癌2例。结论精准断流术是治疗门静脉高压症上消化道出血的一种有效术式。     

Status of sclerotherapy for variceal bleeding in 1990

The enthusiasm for injection sclerotherapy over the last decade has almost certainly surpassed what was justified on the basis of objective evidence. This was most clearly emphasized by the widespread adoption of prophylactic sclerotherapy after the report of the first two trials, even though enough was known of the natural history of variceal hemorrhage in patients with cirrhosis to warrant caution. The use of sclerotherapy for an episode of variceal hemorrhage represents the role most supported by the available data. Diagnostic endoscopy, as an integral part of management, provides the optimum time to intervene with sclerotherapy. Sclerotherapy can then provide hemostasis in patients who are actively bleeding and prevent early rebleeding in those in whom bleeding has stopped spontaneously. The progression to long-term injection sclerotherapy is of proven benefit; however, doubts exist concerning the need for the intensive regimens currently in use. The continued use of long-term injection sclerotherapy is dependent not only on additional investigations, but also on the accumulating evidence arising from comparative studies encompassing other available therapy.     

Surgical shunts and TIPS for variceal decompression in the 1990s

BACKGROUND: In the 1990s, liver transplantations and transjugular intrahepatic portosystemic shunts (TIPS) have become the most common methods to decompress portal hypertension. This center has continued to use surgical shunts for variceal bleeding in good-risk patients who continue to bleed through endoscopic and pharmacologic treatment. This article reports this center's experience with surgical shunts and TIPS shunts from 1992 through 1999. METHODS: Sixty-three patients (Child A, 43 patients; Child B, 20 patients) received surgical shunts: distal splenorenal, 54 patients; splenocaval, 4 patients; coronary caval, 1 patient; and mesocaval, 4 patients. Sixty-two patients had refractory variceal bleeding, and 1 patient had ascites with Budd-Chiari syndrome. Two hundred patients (Child A, 24 patients; Child B, 62 patients; Child C, 114 patients) received TIPS shunts. One hundred forty-nine patients had refractory variceal bleeding, and 51 patients had ascites, hydrothorax, or hepatorenal syndrome. Data were collected by prospective databases, protocol follow-up, and phone contact. RESULTS: The 30-day mortality rate was 0% for surgical shunts and 26% for TIPS shunts; the overall survival rate was 86% (median follow-up, 36 months) for surgical shunts and 53% (median follow-up, 40 months) for TIPS shunts. For surgical shunts, the portal hypertensive rebleeding rate was 6.3%; the overall rebleeding rate was 14.3%. For TIPS shunts, the overall rebleeding rate was 25.5% (30-day, 9.4%; late, 22.4%). There were 4 reinterventions for surgical shunts (6.3%); the reintervention rate for TIPS shunts in the bleeding group was 33%, and the reintervention rate in the ascites group was 9.5%. Encephalopathy was severe in 3.1% of the shunt group and mild in 17.5%; this was not systematically evaluated in the TIPS shunts patients. CONCLUSIONS: Surgical shunts still have a role for patients whose condition was classified as Child A and B with refractory bleeding, who achieve excellent outcomes with low morbidity and mortality rates. TIPS shunts have been used in high-risk patients with significant early and late mortality rates and have been useful in the control of refractory bleeding and as a bridge to transplantation. The comparative role of TIPS shunts versus surgical shunt in patients whose condition was classified as Child A and B is under study in a randomized controlled trial.     

Repeated endoscopic sclerotherapy for active variceal bleeding.

Emergency endoscopic sclerotherapy (EEST) during continued moderate to severe bleeding was carried out using a flexible endoscope and absolute alcohol as a sclerosant in 38 patients with variceal bleeding. Portal hypertension was due to cirrhosis in 27, noncirrhotic portal fibrosis in eight, extrahepatic obstruction in two, and Budd-Chiari Syndrome in one patient. A technically adequate EEST could be carried out in 36 (95%) patients, with successful control of variceal bleeding in 35 (92%). Thirty-one episodes of rebleeding occurred in 12 (31.6%) patients. Twenty-nine (93.5%) of these episodes could be controlled with repeated EEST, giving an overall success of 87%. The new approach of repeating sclerotherapy on every rebleeding episode up to a maximum of three course within 24 hours, use of a wide bore injector, and certain other technical innovations were found safe and effective. The mean (+/- SD) amount of alcohol injected per patient was 9.23 +/- 3.3 ml and the mean (+/- SD) number of injections needed per patient were 6.0 +/- 3.07. Complications were minor, transient, and similar to conventional sclerotherapy. There were three deaths, two due to massive rebleeding and one due to hepatic encephalopathy. It can be concluded that EEST is technically feasible during active variceal bleeding and is an effective and relatively safe procedure. It can serve as the first line treatment in this group of patients.     

Selective shunt in the management of variceal bleeding in the era of liver transplantation.

This study reports the Emory experience with 147 distal splenorenal shunts (DSRS) and 110 orthotopic liver transplants (OLT) between January 1987 and December 1991. The purpose was to clarify which patients with variceal bleeding should be treated by DSRS versus OLT. Distal splenorenal shunts were selected for patients with adequate or good liver function. Orthotopic liver transplant was offered to patients with end-stage liver disease who fulfilled other selection criteria. The DSRS group comprised 71 Child's A, 70 Child's B, and 6 Child's C patients. The mean galactose elimination capacity for all DSRS patients was 330 +/- 98 mg/minute, which was significantly (p less than 0.01) above the galactose elimination capacity of 237 +/- 82 mg/minute in the OLT group. Survival analysis for the DSRS group showed 91% 1-year and 77% 3-year survival, which was better than the 74% 1-year and 60% 3-year survivals in the OLT group. Variceal bleeding as a major component of end-stage disease leading to OLT had significantly (p less than 0.05) poorer survival (50%) at 1 year compared with patients without variceal bleeding (80%). Hepatic function was maintained after DSRS, as measured by serum albumin and prothrombin time, but galactose elimination capacity decreased significantly (p less than 0.05) to 298 +/- 97 mg/minute. Quality of life, measured by a self-assessment questionnaire, was not significantly different in the DSRS and OLT groups. Hospital charges were significantly higher for OLT (median, $113,733) compared with DSRS ($32,674). These data support a role for selective shunt in the management of patients with variceal bleeding who require surgery and have good hepatic function. Transplantation should be reserved for patients with end-stage liver disease. A thorough evaluation, including tests of liver function, help in selection of the most appropriate therapeutic approach.     

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.      

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.     

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.     

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.

     

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.