Mesocaval shunts for the control of bleeding esophageal varices.

Results in 44 patients with esophageal bleeding who underwent a mesocaval shunt utilizing a prosthetic graft are presented. Portal hypertension was secondary to alcoholic cirrhosis in 30 patients, to chronic active hepatitis in eight, to primary biliary cirrhosis in four, to cirrhosis secondary to inflammatory bowel disease in one, and to portal vein thrombosis following splenectomy in one. Thirty-six shunts were performed during the emergent or semiemergent time period, and only eight were performed electively. Sixteen of the patients were Child's class A, 16 were class B, and 12 were class C. There were no hospital deaths in the emergency shunt group (of eight patients); there was a 12% mortality rate for patients undergoing semiemergency shunts (two of 17 patients) and a 42% mortality rate for patients who had emergency shunts (eight of 19 patients). Death was related more closely to hepatic reserve, however, than to timing of the shunt. Among the 32 class A and B patients, there were only three deaths in hospital (9%), as compared with seven deaths among the 12 class C patients (58%). Portal-systemic encephalopathy was high in the period immediately after operation (13 of 34 patients, 38%), but it was a chronic problem following discharge from the hospital in only three of 34 patients (9%). The mesocaval shunt is a safe, effective procedure for the control of variceal bleeding in class A and class B patients in any time period, but it carries a high operative mortality risk in the class C patient when it is performed as an emergency operation.     

Lysis of a superior mesenteric artery embolus following local infusion of streptokinase and heparin.

The successful lysis of a superior mesenteric artery embolus with streptokinase and heparin infused locally through catheter selectively placed in the superior mesenteric artery is described. There was minimal morbidity, and the hazards of surgical embolectomy were avoided.     

EEA esophageal stapling for control of bleeding esophageal varices

Esophageal transection with the EEA stapler was performed in five patients with bleeding esophageal varices. Bleeding from varices has not recurred in surviving patients during follow-up of up to 27 months. One death occurred during the postoperative period. Esophageal transection with the EEA stapler is an effective means of preventing recurrent variceal hemorrhage. This technique is best suited for patients requiring emergency operation to prevent exsanguination and for those in whom a major shunting procedure is contraindicated because of the severity of hepatic disease or other medical illness.     

Initial control of bleeding from esophageal varices with the Sengstaken-Blakemore tube. Experience in 82 patients

The records of 82 patients treated with the Sengstaken-Blakemore tube for massive bleeding from esophageal varices have been reviewed. Initial control of hemorrhage was obtained in 78 patients (95 percent). Six patients suffered major nonfatal complications, including bronchial aspiration (five patients) and esophageal rupture (one patient). Twenty-one patients rebled after balloon deflation and underwent emergency portal disconnection of the esophagus with a clip. The other patients underwent elective operation. Long-term survival rates were 49 percent at 1 year, 35 percent at 5 years, and 14 percent at 10 years. Ninety-four percent of the patients were free of recurrent variceal bleeding, as proved by endoscopy, at 1 year, 90 percent at 5 years, and 77 percent at 10 years. This study shows that temporary use of the Sengstaken-Blakemore tube for the initial control of acutely bleeding esophageal varices is effective and relatively safe. In our experience, methods for the prevention of complications were early endotracheal intubation in patients under anesthesia, avoidance of traction on the tube, and a period of tamponade not exceeding 24 hours.     

Massive bleeding from a ruptured superior mesenteric artery aneurysm duodenum.

A traumatic false aneurysm of the superior mesenteric artery resulting from a gunshot wound five years previously, caused massive hemorrhage into the second portion of the duodenum. Dissection, resection, and end-to-end anastomosis was successful in controlling bleeding into the gastrointestinal tract, but immediate postoperative angiography showed a reappearance of the aneurysm, and three months later, it bled into the retroperitoneum. The patient underwent further resection and two subsequent reconstructions of the superior mesenteric artery, the first with a Dacron graft, which clotted, and the second with autologous saphenous vein, which was successful. Three years later, the patient is well. The case shows that adequate reconstruction of an arterial injury is best performed immediately after it is diagnosed.     

Outcome in cirrhotic patients with acute alcoholic hepatitis after emergency portacaval shunt for bleeding esophageal varices

Operative liver biopsy findings were reviewed in 164 consecutive, unselected patients with alcoholic cirrhosis who had bleeding from esophageal varices and underwent emergency portacaval shunt. The survival rate up to 10 years in 49 patients with acute alcoholic hepatitis and alcoholic cirrhosis was not significantly different from that of patients with alcoholic cirrhosis alone. The two groups of patients were compared with respect to 35 other preoperative clinical and laboratory variables, and no other difference between the groups was found that obscured an adverse effect of acute alcoholic hepatitis on survival. We have concluded that acute alcoholic hepatitis and the presence of Mallory bodies in the liver are not a contraindication to portacaval shunt and that there is currently no demonstrated role for preoperative liver biopsy in the evaluation of patients with alcoholic cirrhosis and bleeding esophageal varices.     

Traumatic injury to the superior mesenteric artery.

BACKGROUND: Superior mesenteric artery (SMA) injuries are rare and devastating injuries incurring very high mortality rates. It is the purpose of this study to review our experience with these injuries, to analyze Fullen's classification based on anatomical zone and injury grade for its predictive value, and to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality. METHODS: Retrospective study was made over a 65-month period of all patients sustaining SMA injuries in an urban level I trauma center. RESULTS: Thirty-five patients, mean age 31, had a mean Revised Trauma Score of 5.86 and a mean Injurity Severity Score of 23. Mechanisms of injury were penetrating 27 (77%) and blunt 8 (23%). Mean admission systolic blood pressure was 85 mm Hg. Mean estimated blood loss was 8,500 mL and mean total fluid replacement 17,000 mL. Operating room findings were retroperitoneal hematoma in 34 (97%) and "black bowel" in 2 (6%). Number of associated injuries was nonvascular, mean 4.2, and vascular, mean 1.5. Surgical management consisted of ligation in 18 (51%), primary repair in 14 (40%), and interposition graft in 2 (6%). Overall mortality was 19 of 35 (54%). Mortality versus Fullen's zones was zone I, 100%, zone II, 43%, and zones III and IV, 25%. Mortality versus Fullen's ischemia grade was grade 1, 89%, grade 2, 58%, grade 3, 100%, and grade 4, 19%. Mortality versus AAST-OIS: was grade 1, 0%, grade II, 20%, grade III, 0%, grade IV, 59%, and grade V, 88%. CONCLUSIONS: SMA injuries are highly lethal. Most deaths are due to exsanguination. A higher number of associated vascular injuries increases mortality. "Black bowel" is an uncommon finding. Both Fullen's anatomical zones and the AAST-OIS for abdominal vascular injuries correlate with mortality. Fullen's ischemia grade does not.     

Revascularization of the superior mesenteric artery.

From 1965 to 1973, 7 patients with severe chronic mesenteric vascular insufficiency have been successfully operated upon. Abdominal pain, weight loss and epigastric murmur were the most significant symptoms and signs in these diffusely atheromatous patients. Aortography with exposure in the lateral projection was essential for diagnosis and operative planning. Although two and often all three main splanchnic arteries were involved, revasculariztion of only the superior mesenteric artery restored normal hemodynamics. There was no operative mortality. Weight gain was dramatic and post-prandial pain disappeared in all patients. One patient diedone year and one half after the operation from an acute cerebro-vascular accidnet. Our surgical experience in this field, although small, is very gratifying and rewarding.     

Severe bleeding from esophageal varices resistant to endoscopic treatment in a non cirrhotic patient with portal hypertension

A non cirrhotic patient with esophageal varices and portal vein thrombosis had recurrent variceal bleeding unsuccessfully controlled by endoscopy and esophageal transection. Emergency transhepatic portography confirmed the thrombosed right branch of the portal vein, while the left branch appeared angulated, shifted and stenotic. A stent was successfully implanted into the left branch and the collateral vessels along the epatoduodenal ligament disappeared. In patients with esophageal variceal hemorrhage and portal thrombosis if endoscopy fails, emergency esophageal transection or nonselective portocaval shunting are indicated. The rare patients with only partial portal thrombosis can be treated directly with stenting through an angioradiologic approach.     

Sugiura procedure in the treatment of bleeding esophageal varices.

AIM OF THE STUDY: The aim of this study was to report our results and to make an attempt to define the possible role of Sugiura procedure in the treatment of variceal bleeding. MATERIAL AND METHODS: From January 1979 to December 1997, 39 patients with portal hypertension and acute variceal bleeding (17 patients) or previous variceal bleeding (22 patients) underwent Sugiura procedure. Operations were performed in two stages. When performed in an emergency situation (17 patients) thoracic operation was performed first. In elective cases abdominal operation was usually preferred. Complete two-stage operation was performed in 16 patients. Twenty-three patients did not undergo the second stage because of early postoperative death, deterioration of condition or refusal. There were 17 men and 22 women, aged 41.7 +/- 18.3 years (range 8-71 years). According to the Child--Turcotte classification of hepatic function there were 23 Child class A, 13 Child class B and 3 Child class C patients. SUMMARY OF RESULTS: Overall operative mortality was 10.3% (4 deaths per 39 patients with 54 operations), mortality in an emergency situation was 17.6% (3 deaths per 17 patients) and in elective cases 4.3% (1 death per 22 patients with 37 operations). Variceal rebleeding occurred in 4 survivors (11.4%) at an average follow-up of 6.1 +/- 4.3 years. Survival rate was 84.6% at 1 year, 71.8% at 5 years and 64.1% at 10 years. CONCLUSIONS: Sugiura operation carries low operative risk in an elective situation and results in an effective prevention of recurrent variceal bleeding.     

Transthoracic ligation of bleeding esophageal varices in patients with intraheptic portal obstruction.

Patency rates were unrelated to severity of ischemia, to runoff, to presence of diabetes, and to diameter of vein in 156 femoropopliteal bypass grafts with saphenous vein followed from 9 to 106 months.