Portasystemic shunt--our twenty years experience

OBJECTIVE: It was the aim of this study to demonstrate our experiences over twenty years with portasystemic shunt surgery in patients with chronic liver disease and variceal bleeding. PATIENTS AND METHODS: From January 1 st, 1980 to December 31 st, 2000 we performed 90 portasystemic shunt operations (PSO). The patients were divided in two groups. The patients of the first group were operated upon between 1980-1988 (n = 58), patients of the second group (n = 32) between 1988-1998. Both groups did not differ in age, gender and cause of hepatic disease. In the first group the most performed type of shunt was the portacaval shunt, in group II the splenorenal shunt. RESULTS: We observed an improved early and late mortality rate, encephalopathy rate and reduction of recurrent variceal bleeding in the second group: the early mortality rate decreased from 16 to 9 % (p < 0.01), the late mortality rate from 35 to 6 % (p < 0.05), the encephalopathy rate from 43 to 12 % and the variceal rebleeding rate from 10 to 6 %. CONCLUSION: Selective shunts, such as the distal splenorenal shunt are significantly superior to the standard (end-to-side or side-to-side) portasystemic shunt. In countries where acute treatment of recurrent variceal hemorrhage with sclerotherapy is not available in remote areas or in countries where transplantation procedures are in the very beginning and where TIPPS operations are too expensive, portasystemic shunt operations are the only possibility to save the patients life when sclerotherapy fails.     

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.     

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.     

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.     

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 selective role of endoscopic sclerotherapy in the management of bleeding esophageal varices

Twenty-one patients (62% Child's C) underwent endoscopic sclerotherapy (ES) to control hemorrhage from esophageal varices. Four patients exsanguinated; bleeding was controlled in the remaining 17 patients (81%). Of this latter group, 14 patients were discharged from the hospital and three patients died from causes other than hemorrhage. A protocol of continued ES was offered to those patients with estimated poor hepatic reserve and to those with excellent reserve who refused portasystemic shunt procedures. During a mean 13 month follow-up of the six patients in this group, rebleeding occurred in two patients (one of whom died). All three patients with excellent hepatic reserve who underwent elective portacaval shunt have suffered neither morbidity nor further hemorrhagic episodes. No significant morbidity related to ES was encountered. ES is recommended in the acute phase of managing all patients with unremittent variceal hemorrhage, and on a continued basis for those with poor hepatic reserve. Patients with excellent reserve should be offered elective portasystemic shunt, accepting the risk of surgical intervention as fair trade-off for its superiority over ES in controlling hemorrhage.     

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.     

Transjugular intrahepatic portasystemic shunt vs surgical shunt in good-risk cirrhotic patients: a case-control comparison

HYPOTHESIS: In good-risk patients with variceal bleeding undergoing portal decompression, surgical shunt is more effective, more durable, and less costly than angiographic shunt (transjugular intrahepatic portasystemic shunt [TIPS]). DESIGN: Retrospective case-control study. SETTING: Academic referral center for liver disease. PATIENTS: Patients with Child-Pugh class A or B cirrhosis with at least 1 prior episode of bleeding from portal hypertension (gastroesophageal varices, portal hypertensive gastropathy). INTERVENTION: Portal decompression by angiographic (TIPS) or surgical (portacaval, distal splenorenal) shunt. MAIN OUTCOME MEASURES: Thirty-day and long-term mortality, postintervention diagnostic procedures (endoscopic, ultrasonographic, and angiographic studies), hospital readmissions, variceal rebleeding episodes, blood transfusions, shunt revisions, and hospital and professional charges. RESULTS: Patients with Child-Pugh class A or B cirrhosis undergoing TIPS (n = 20) or surgical shunt (n = 20) were followed up for 385 and 456 patient-months, respectively. Thirty-day mortality was greater following TIPS compared with surgical shunt (20% vs 0%; P =.20); long-term mortality did not differ. Significantly more rebleeding episodes (P<.001); rehospitalizations (P<.05); diagnostic studies of all types (P<.001); shunt revisions (P<.001); and hospital (P<.005), professional (P<.05), and total (P<. 005) charges occurred following TIPS compared with surgical shunt. CONCLUSIONS: Operative portal decompression is more effective, more durable, and less costly than TIPS in Child-Pugh class A and B cirrhotic patients with variceal bleeding. Good-risk patients with portal hypertensive bleeding should be referred for surgical shunt.     

Duodenal varices as a cause of massive upper gastrointestinal bleeding

Duodenal varices are an uncommon but serious manifestation of portal hypertension. Our management of three patients with massive bleeding due to duodenal varices stimulated a review of this subject. Thirteen cases of this condition were previously reported. Endoscopic examination of the entire duodenal mucosa is essential to document bleeding from duodenal varices. Medical therapies, including vasopressin and endoscopic sclerotherapy, have had limited success in controlling active duodenal variceal bleeding. Duodenal varix suture ligation or resection also resulted in a high rate of rebleeding. End-to-side portocaval shunt was the most effective procedure in stopping acute and subsequent bleeding in patients with duodenal varices. Despite therapy with or without portosystemic shunt, mortality risk is high in Child's class C patients and in patients with emergency duodenal variceal bleeding.     

肝硬化伴食管静脉曲张破裂出血行脾切除加断流治疗与内镜治疗的疗效对比分析

目的探讨外科手术治疗(脾切除+门奇静脉断流术)与内镜下治疗(内镜下套扎和硬化剂治疗)对肝硬化所致食管静脉曲张破裂出血的疗效,并寻找导致术后再出血的危险因素。方法回顾性分析陆军军医大学大坪医院2012年1月至2017年11月收治的肝硬化伴食管静脉曲张破裂出血病人的资料。将行脾切除、门奇静脉断流术者纳入外科手术治疗组(54例);将内镜下行套扎、硬化剂治疗者纳入内镜治疗组(63例)。根据搜集所得资料及电话随访结果,统计病人治疗后的再出血率、治疗后再出血的平均间隔时间等。数据采用SPSS(23.0版)软件进行处理。结果手术治疗组术后1、3、5年再出血率分别为9.3%、20.5%、23.1%,内镜治疗组术后1、3、5年再出血率分别为39.7%、73.0%、74.8%,手术治疗组再出血率明显低于内镜治疗组(P<0.001)。COX多因素分析显示:内镜治疗术后再出血的风险是手术治疗的7.2倍(P<0.001)。曲张的食管静脉距门齿的距离、脾脏的大小、脾功能亢进的程度与术后再出血与否无统计学相关性。结论外科手术治疗相比内镜治疗可更好地控制曲张食管静脉的破裂出血,其1、3、5年再出血率明显小于内镜治疗组。治疗方式是病人术后再次出血的危险因素。     

Emergency and elective sclerotherapy of oesophageal varices.

Endoscopic injection sclerotherapy of oesophageal varices was performed in 71 patients: 50 with intrahepatic and 21 with extrahepatic block. In summary 330 procedures were done: 220 under general anaesthesia using the Negus rigid oesophagoscope and 110 with diazepam as premedication using a flexible, fibreoptic endoscope. Definitive control of variceal haemorrhage was achieved in 30 of 34 emergency admissions (88%). The hospital mortality in acute variceal bleeding was 26.5%. Elective, repeated sclerotherapy was performed in 60 patients. In 43 patients complete obliteration of varices or their marked reduction were observed. Rebleeding occurred in 23% and major complications in 17% of patients. The overall one year survival rate was 82%. We consider sclerotherapy as a method of choice in bleeding oesophageal varices uncontrollable by vasopressin and balloon tamponade. It also represents a valuable method of preventing rebleeding particularly in patients with a high operative risk.     

Digestive hemorrhage caused by rupture of esophageal varices. Analysis of 47 emergency surgeries

Between 1 January 1984 and 31 December 1986, 47 patients out of a total of 228 patients admitted to hospital with endoscopy-proven bleeding esophageal varices, underwent an emergency operation. The indications were massive hemorrhage in 29 patients, and rebleeding early after a first serious episode in 18 patients. Four patients underwent early reoperation for recurrent variceal bleeding. Thirty-seven porto-caval shunts, 10 esophageal transections, 3 proximal gastric resections and 1 exploratory laparotomy were performed. The early results were satisfactory in 53.2% of the patients; operative morbidity and mortality were 19.1% and 27.7% respectively. Four patients died from gastric variceal bleeding soon after esophageal transection. Operative mortality was greater when the patient was Child C or operated for massive hemorrhage. Survivors were followed for at least 12 months. Two patients died from shunt occlusion and recurrent variceal bleeding. No severe encephalopathy was reported. Analysis of the results suggest that porto-caval shunt is indicated in Child A or B patients, particularly with recurrent variceal bleeding soon after a first episode controlled medically.     

Management of variceal bleeding in patients with noncirrhotic portal vein thrombosis.

Since 1971, 70 patients have been seen at Emory University Hospital with gastroesophageal varices secondary to extrahepatic portal vein thrombosis (PVT). Thirty-seven of these patients had had prior major operative therapy. In only three patients (8%) was shunt surgery successful, and there was a high incidence of rebleeding, other morbidity, and mortality. Of especial note are the serious consequences of simple splenectomy; splenomegaly and thrombycytopenia should rarely, if ever, be used as indication for splenectomy in portal hypertension. In 1977, the use of selective distal splenorenal shunt (DSRS) was begun at Emory in this population and a selective shunt has been possible in 24 of 29 patients (83%) who had had no prior operative therapy. Results have been excellent with a greater than 90% patency rate, long-term portal perfusion in all, no encephalopathy, and late rebleeding in one patient. Quantitative studies at 3-6 years show stability of liver function, significant decrease in spleen size, and rise in platelet count. However, long-term follow-up (greater than 15 years) is required in PVT patients before definitive assessment can be obtained. A specific problem of the PVT patient is late shunt stenosis which requires close observation; dilatation of the shunt was performed in six of the 24 patients with a patent shunt. Poor results with non-shunt operative procedures in PVT were again documented. The proper role of endoscopic variceal sclerotherapy is not yet clear, but appears to be an excellent addition to the therapeutic options. In conclusion, for patients with a patent splenic vein, initial therapy should be a selective shunt; for patients without a patent splenic venous system, endoscopic sclerotherapy is the procedure of choice.     

Shunts for portal hypertension

Eighty-nine patients underwent 95 portasystemic shunts for portal hypertension at our institutions between June 1963 and March 1981. Ninety-three shunts were performed for bleeding varices. Procedures that were performed included 11 Warren shunts, 29 Linton shunts, 28 interposition mesocaval shunts, 26 classic portacaval shunts, and one umbilical to saphenous vein shunt. Thirty-six shunts were performed in Child class A patients (5.5% operative mortality), 37 in Child class B (16.2% operative mortality), and 22 in Child class c patients (36.3% operative mortality). Five-year survival for Child A patients was 74 per cent, 17.4 per cent for Child B patients and 26.3 per cent for Child C patients. Twelve of 14 patients (15.7%) who had recurrent postoperative upper gastrointestinal bleeding were found to have occluded shunts (two Warren, six Linton, one mesocaval, and three portacaval). Of 21 patients who became encephalopathic postoperatively, 17 had alcoholic liver disease. In 15 of these alcoholic patients who survived the immediate postoperative period, encephalopathy correlated directly with continued alcohol consumption. Several conclusions can be drawn from our data: portasystemic shunts can be performed with acceptable morbidity and mortality; rebleeding generally indicates shunt occlusion; encephalopathy can be correlated with continued alcohol consumption after shunting; there appears to be little difference in survival and rebleeding in the various shunt procedures; the poor survival figures for Child B and C patients must make one seriously consider alternative procedures in these poor-risk candidates.     

Emergency portacaval shunt for variceal hemorrhage. A prospective study.

Emergency portacaval shunt for variceal bleeding is associated with a high operative mortality, particularly if used as a last resort. Because of this, a strong case has been made against emergency shunt. This report describes an experience with emergency portacaval shunt for the treatment of variceal bleeding when used systematically after hemodynamic stabilization and control of the bleeding episode with balloon tamponade, if necessary, in patients with mild or moderate liver disease. The population studied comprised 62 consecutive patients who rebled from varices while participating in a controlled trial of propranolol for the prevention of rebleeding. Of the 62 patients, nine died of massive hemorrhage and 53 survived the hemorrhage. Of the 53 survivors, 11 had severe liver disease and were not considered for shunt surgery. Of the remaining 42 patients with mild or moderate liver disease, 36 had emergency central portacaval shunt. The interval between endoscopic diagnosis of variceal bleeding and surgery averaged 19 +/- 3 hours (mean +/- SE). The operative mortality rate, defined as in-hospital mortality, was 19%. One- and 2-year survival rates were 78% and 71%, respectively. The incidence of postoperative hepatic encephalopathy was 36%; all patients responded favorably to protein restriction and lactulose. Thus, under specific conditions, emergency portacaval shunt results in an acceptable long-term survival rate. In patients with mild or moderate liver disease, emergency portacaval shunt should be considered when other forms of treatment for the prevention of variceal rebleeding have failed.     

Sugiura procedure outside Japan. The Mexican experience

In the last 10 years, we operated on 231 patients with hemorrhagic portal hypertension. Most of these patients had some form of liver disease. We performed various surgical procedures: 47 conventional shunts with H grafts and terminolateral portacaval shunts with arterialization of the portal stump, 139 selective Warren shunts, and in those patients in whom a selective portasystemic shunt could not be performed for technical reasons, esophagogastric devascularization in the form of the Sugiura procedure. Forty-five patients were treated with the Sugiura procedure as a one stage or two stage procedure. A total of 68 emergency and elective operations were performed. The operative mortality rate for the emergency thoracic operation was 41 percent and for the abdominal operation, 42 percent. The overall operative mortality rate in the emergency group was 41 percent. The incidence of recurrent variceal bleeding and encephalopathy was 0 in the surviving patients. The survival rate at 3 year follow-up was 40 percent. The elective group was made up of 24 patients. Eighteen patients had a two stage procedure and 6 patients had a one stage procedure. The operative mortality rate for the abdominal operation was 11 percent, whereas that for the thoracic operation was 7 percent. The operative mortality rate for the one stage procedure was 16 percent. The overall operative mortality rate in the elective group was 10.8 percent. None of these patients had recurrent variceal bleeding and encephalopathy developed in only one (5 percent). The encephalopathy was easily controlled with medical treatment. The 3 year survival rate was 83 percent. We conclude that the Sugiura procedure is an effective procedure to treat hemorrhagic portal hypertension when a selective shunt cannot be performed.     

Prospective study of a planned approach to the surgical management of bleeding oesophageal varices.

A policy of joint management of patients with acute variceal bleeding was constructed and applied prospectively to 37 consecutive patients. According to the protocol, every patient underwent an initial joint assessment by a physician and a surgeon soon after admission and resuscitation, which included age, previous history, physical examination and biochemical profile. Pugh's modification of Child's scoring system was used to assess the severity of the underlying hepatic disorder. Patients in groups A and B who were less than 70 years of age were treated by shunt surgery carried out during the same admission. Patients outwith this category were managed conservatively and a blood transfusion limit (10 units) imposed unless the clinical picture subsequently improved or the liver function was good but the patient was not eligible for surgery because of age. Twenty seven patients underwent shunt surgery, the most frequent procedure being a Warren shunt (n = 21). The average hospital stay in the surgically treated group was 18 days. The 30 day operative mortality was 15%. Two further deaths in the shunted group occurred during the follow-up period (mean = 30 months, range = 6-97 months). Seventeen patients in the shunted group remain well but three have required further therapy because of rebleeding episodes (two with sclerotherapy, one by surgery). Two patients who went abroad after recovery from their shunt surgery have been lost to follow up. The survival in the conservatively treated group was short and recurrent bleeding common.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Long term follow-up of 100 patients with portal hypertension treated by a modified splenorenal shunt

One hundred consecutive Child's A or B patients with portal hypertension who survived the index episode of variceal bleeding were electively treated by a distal splenorenal shunt modified by a retroperitoneal approach. The operative mortality of the whole series was 11 per cent, but fell from 16 per cent in the first 50 patients to 6 per cent in the second half of the series. The median survival probability (68 months) and the 5 year survival rate (52 per cent) of Child's A patients differed significantly from those of Child's B patients (8 months and 15 per cent respectively; P less than 0.001). The probabilities of freedom from rebleeding and hepatic encephalopathy at 5 years were also significantly greater in Child's A patients (70 per cent and 70 per cent respectively) than Child's B patients (25 per cent and 30 per cent respectively). These results suggest that the modified distal splenorenal shunt is an effective and relatively safe procedure for the elective treatment of variceal bleeding in Child-Campbell 'A' patients but that patients in group B should be considered for other forms of therapy.     

Transabdominal modified devascularization procedure with or without esophageal stapler transection--an operation adequate for effective control of a variceal bleed. Is esophageal stapler transection necessary?

BACKGROUND: In Japan, the original Sugiura procedure reported favorable results in non-cirrhotic patients but in the West, the modified Sugiura procedure is not widely accepted because of high rebleeding, morbidity, and mortality in cirrhotics. We retrospectively analyzed the efficacy of our modified Sugiura procedure i.e., devascularization with/without esophageal transection combined with salvage endotherapy and pharmacotherapy for control of a variceal bleed. MATERIALS AND METHODS: Between January 1999 and December 2004, 912 patients with variceal bleeding were treated. Of these, 66 (7.2%) patients were subjected to surgery after failed endotherapy/propranolol. Among these 66 patients, 52 had transabdominal devascularization (16 emergency, 36 elective); 14 patients underwent devascularization with esophageal stapler transection (group I), and 38 patients had devascularization without esophageal stapler transection (group II). Another 14 patients underwent elective end-to-side proximal splenorenal shunt surgery. RESULTS: Postoperative mortality was 7.1% in group I, 10.5% in group II (P>0.05). Mortality for emergency surgery was 31.2% (5/16) but there were no deaths in the elective surgery group. Overall morbidity was 57.1% in group I and 21.0% in group II (P<0.05). The rates of variceal rebleeding were 7.1% and 7.8%; residual varices were 30.7% and 32.3%; recurrent varices were 7.6% and 5.8% following the group I and group II procedures, respectively, over a mean follow-up period of 39.9 (7-2) months. Esophageal transection-related morbidity (leak, stricture, and bleeding) was 21.4% (3/14) in group I. CONCLUSIONS: Devascularization without esophageal stapler transection is a safe and effective procedure for adequate (urgent and long-term) control of variceal bleeding with similar results and less morbidity when compared to devascularization with esophageal transection in cirrhotic patients, as well as non-cirrhotic patients.