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.     

Emergency portasystemic shunt for bleeding varices.

Sixty-eight patients with bleeding oesophageal varices due to cirrhosis of the liver who have had an emergency portasystemic shunt are reviewed. The reasons for the emergency shunt surgery and the results are described and discussed. The low postoperative mortality is attributed to careful case selection. Apart from clinical and serological factors, the importance of the bromsulphthalein excretion test is stressed. Emergency shunts are now undertaken by the author in patients whose serum bilirubin is less than 2-5/100 ml and bromsulphthalein retention less than 10 per cent in 30 minutes. This is in marked contrast to the author's previous series in which there was a 30 per cent mortality. The poor results in patients treated conservatively and the disparity between the author's results and those of other reported series are reviewed and discussed.     

经颈静脉肝内门体分流术联合胃冠状静脉栓塞治疗食管胃底静脉曲张破裂出血

目的探讨经颈静脉肝内门体分流术(TIPS)联合胃冠状静脉栓塞治疗食管胃底静脉曲张破裂出血的疗效。方法回顾性分析70例接受TIPS治疗食管胃底静脉曲张破裂出血患者的临床资料,其中15例患者单独接受TIPS治疗(非栓塞组),55例患者接受TIPS联合胃冠状静脉栓塞术治疗(栓塞组),比较两组治疗方法的临床疗效。结果所有TIPS手术操作均成功完成。栓塞组和非栓塞组患者术后12个月累积无消化道再出血率分别为77.33%和86.67%(P=0.30),分流道累积通畅率分别为74.10%和83.33%(P=0.30);栓塞组患者术后12、24个月累积生存率分别为90.38%和82.85%,而非栓塞组分别为93.33%和82.96%,两组比较差异无统计学意义(P=0.62)。栓塞组和非栓塞组患者术后肝性脑病发生率分别为18.18%(10/55)和40.00%(6/15),差异无统计学意义(P=0.15)。结论与单独TIPS相比,TIPS联合胃冠状静脉栓塞并未提高食管胃底静脉曲张破裂出血的疗效。     

Esophageal procedures to control bleeding from varices

Portal-systemic shunting of all types has failed to improve long-term survival in patients with bleeding esophageal varices and carries a high morbidity and prohibitive mortality in the emergency setting. Direct esophageal approaches are receiving renewed attention. Sclerotherapy promises to be the simplest, safest, and most effective treatment for acute bleeding. Rebleeding is frequent with this technique unless all the varices are subsequently obliterated. Even then, rebleeding may be a recurring hazard, albeit with reduced frequency and increasing interval. For the nonalcoholic patient with a significant life expectancy or in the young patient with cirrhosis, this can be a significant factor. Simple esophageal resection-transection using stapling devices is a rapidly accomplished, simple, and effective operative approach if combined with coronary vein ligation. This procedure deserves a trial earlier in such patients and in those who are failures of repeated sclerotherapy. Extensive esophagogastric devascularization preserving the paraesophageal veins--the Sugiura procedure--is a more extensive undertaking that is probably unnecessary for most and too dangerous for some. At present, it should be reserved for failures of other techniques. It shows promise of long-term effectiveness if performed safely on only certain patients.     

TIPS治疗食管胃底静脉曲张出血预后影响因素分析

目的分析影响TIPS治疗食管胃底静脉曲张出血(EGVB)预后的因素。方法回顾性分析68例接受TIPS治疗的EGVB患者的资料。采用Kaplan-Meier方法计算术后累积生存率,不同患者间生存率比较采用log-rank检验。以Cox回归模型分析影响预后的因素,并以ROC曲线确定其预测经TIPS治疗后EGVB患者预后的最佳截点。结果 TIPS术后患者1、2、3年累积生存率分别为90.7%、82.2%和77.9%。患者年龄、术前血清白蛋白为影响TIPS治疗EGVB的预后因素。ROC曲线分析显示,以患者年龄、术前血清白蛋白评估EGVB患者TIPS术后1年生存预后的AUC分别为0.923(P=0.001)和0.183(P=0.011),年龄67.5岁为最佳截点。年龄≤67.5岁患者术后1年累积生存率明显高于年龄67.5岁者(96.4%vs 64.3%,χ~2=10.785,P=0.001)。结论年龄及术前血清白蛋白是预测TIPS治疗EGVB患者生存情况的独立因素;年龄67.5岁患者预后较差。     

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.     

Intermittent bleeding from anorectal varices

A patient with anorectal varices is reported. Anorectal varices are a rare cause of rectal bleeding and are often erroneously diagnosed as bleeding hemorrhoids. However, the subcutaneous extension of the varices should alert the clinician. Although local treatment such as ligation of the varices has been advocated, in the presence of portal hypertension a more radical operation is recommended. A portosystemic shunt, preferably between the inferior mesenteric vein and the vena cava or renal vein, is then the treatment of choice.     

经皮经肝穿刺门静脉行胃底食管曲张静脉栓塞术治疗上消化道出血

目的　评价经皮经肝穿刺门静脉行胃底食管曲张静脉栓塞治疗肝硬化门静脉高压症上消化道大出血的疗效。方法　对37例肝硬化门静脉高压症急性上消化道大出血患者行经皮经肝穿刺门静脉栓塞胃冠状静脉,至造影复查曲张静脉完全消失为止。结果　37例患者在栓塞术后出血均迅速停止,无1例技术方面的并发症出现。随访37例1～38个月,栓塞3个月后再出血2例,1例术后3周死于心脏功能衰竭,5例6个月后死于肝癌。结论　经皮经肝穿刺门静脉胃底食管曲张静脉栓塞术治疗肝硬化门静脉高压症急性上消化道大出血是安全有效的方法     

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.     

A ten year prospective experience with semi-elective shunt in selected patients for bleeding oesophageal varices

In a prospective study from 1972 to 1982, 38 patients with bleeding oesophageal varices and relatively good liver function were treated by semi-elective or emergent shunt 2-4 weeks after admission. There were no deaths within 3 months of surgery. This constituted 30% of the total 125 patients admitted with bleeding varices during that period. No referred case for treatment of portal hypertension was included in this study. The procedures performed were end-to-side portacaval shunt in 30 cases, lieno renal shunt in seven cases and interposition mesenterico-caval shunt in one case. All patients were admitted to a special unit with a two stage policy of management. Immediate endoscopic diagnosis and balloon tamponade in those with continued bleeding was followed by shunt in selected cases. Follow-up of the 38 patients showed a cumulative survival at 1 year of 89%, at 3 years of 75% and 5 years of 65%. In four cases (13%) a clinical diagnosis of portal systemic encephalopathy was made, all were controlled by medical management. In four of ten follow-up deaths, liver failure was the cause, in none of these cases was encephalopathy a problem. It is concluded that with a policy of early diagnosis and control of haemorrhage, 30% of a typical series of prospectively studied patients admitted with bleeding varices can be treated without mortality by definitive surgery. There was low incidence of encephalopathy and no cases of incapacitating mental confusion. Centralization of treatment and prospective study is essential for the implementation of such a policy of management.