Urgent transjugular retrograde obliteration for prophylaxis of rebleeding from gastric varices in patients with a spontaneous portosplenorenal shunt

BACKGROUND: Bleeding isolated gastric varices with a spontaneous portosplenorenal shunt are difficult to control. The urgent use of transjugular retrograde obliteration (TJO) to prevent early rebleeding and to improve early mortality has not yet been demonstrated. We report our experience with this technique in patients with isolated gastric varices after treatment of acute bleeding. METHODS: We reviewed our experience of 6 patients with isolated gastric varices with a spontaneous portosplenoral shunt treated with TJO after treatment of acute bleeding. We basically applied endoscopic glue embolization using cyanoacrylate monomer for treatment of acute bleeding. TJO was a method using an occlusive balloon catheter to control a spontaneous portosplenorenal shunt flow while injecting sclerosant retrograde into the gastric varices. RESULTS: Treatment of acute bleeding was achieved immediately by endoscopic glue embolization, endoscopic variceal ligation, and ligating the varices with sutures following anterior gastrotomy in 4, 1 and 1 patients, respectively, and then TJO was performed. Permanent hemostasis and variceal eradication was achieved in these 6, and they all survived. They were alive for 6-66 months without gastric variceal recurrence. CONCLUSIONS: We conclude that urgent TJO is effective in the prophylaxis of early and late rebleeding from isolated gastric varices in patients with a spontaneous portosplenorenal shunt.     

The use of sclerotherapy for the management of oesophageal varices in portal hypertension

Summary Although sclerotherapy is currently the most widely used treatment for the management of both acute variceal bleeding and the long-term management of patients with varices, its definitive role in the treatment of these patients has yet to be finally proven. Sclerotherapy appears to be the most effective treatment for the majority of patients with acute variceal bleeding. Failures require either a shunt or a transection and/or devascularisation procedure. Current evidence favours simple staple gun transection or a shunt (either a portacaval shunt or a side-to-side narrow diameter polytetrafluoroethylene graft between the portal vein and vena cava). In long-term management of patients after a variceal bleed the currently favoured treatment is repeated sclerotherapy. However, failures should be identified early. We define failures as patients who present with varices that are either difficult to eradicate by sclerotherapy or who have repeated life-threatening variceal bleeds during the course of repeated injection sclerotherapy. Such patients should have either a portal-to-systemic shunt or a transection and devascularisation operation. Further controlled trials are required to define the specific indications for the individual forms of therapy. Prophylactic treatment for varices that have not yet bled is unjustified at present. Based on a presentation to the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

Endoscopic sclerotherapy

Various sclerotherapy techniques have proved successful in the management of acute variceal bleeding and in long-term control of patients after a variceal bleed. We prefer either an intravariceal or a combined intravariceal and paravariceal technique using ethanolamine oleate, but we advocate that individual units utilize the technique with which they have the most experience. The use of an unmodified flexible endoscope has been almost universally accepted. Once active variceal bleeding is diagnosed on emergency endoscopy, immediate emergency sclerotherapy should be performed. When this is not possible, bleeding should be controlled by balloon-tube tamponade with subsequent delayed emergency sclerotherapy after resuscitation. Patients with variceal bleeding that has stopped at the time of the diagnostic endoscopy can either be treated by immediate sclerotherapy or be observed initially and subsequently treated using the long-term management policy of the unit concerned. Over 90% of actively bleeding patients should be controlled using emergency sclerotherapy. Failures are defined as patients who have more than two acute variceal bleeds during a single hospital admission. Such patients should be identified early and treated either by simple staple-gun transection or by an emergency portosystemic shunt. Repeated injection sclerotherapy using a flexible endoscope and the technique with which the group concerned has the most experience is recommended as the primary form of treatment for the majority of patients after a proven esophageal variceal bleed. Repeat injection treatments should probably be performed at weekly intervals until the esophageal varices are eradicated, with follow-up at 6-month or yearly intervals thereafter. Recurrent varices should be treated similarly. Failures of sclerotherapy are defined as patients who have either recurrent bleeds or in whom varices are difficult to eradicate. They require either a portosystemic shunt or a devascularization and transection operation. All patients presenting with cirrhosis and variceal bleeding should be evaluated for liver transplantation; unfortunately, however, few variceal bleeders are candidates for transplantation. Prophylactic sclerotherapy in patients with esophageal varices that have not bled remains unjustified outside of controlled trials. Available trials have produced conflicting data.     

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.     

Portal hypertension management

Summary Injection sclerotherapy is the mainstay of treatment for acute variceal bleeding and for long-term management after a variceal bleed. In those few patients in whom sclerotherapy fails to control acute bleeding, either a surgical shunt or a simple esophageal transection is recommended. A surgical shunt or a more extensive esophagogastric evascularization and transection operation is advocated for the failures of long-term sclerotherapy management. The role of pharmacological agents in acute variceal bleed management remains in question, and the use of propranolol in long-term management, either as an alternative to sclerotherapy or in combination with sclerotherapy, is controversial. The definitive roles of the newly described variceal banding and transjugular intrahepatic portosystemic shunts (TIPS) procedures have yet to be established. All patients presenting with end-stage liver disease and esophageal variceal bleeding should be evaluated for a liver transplant, although few will qualify. A possible future transplant should be kept in mind when emergency treatment is planned. Any form of prophylactic therapy for patients with esophageal varices that have not yet bled will remain unjustified until those patients at high risk of a first variceal bleed can be identified. The gastric mucosal lesion, portal hypertensive gastropathy, has been underdiagnosed in the past. Although bleeding does occur, it is seldom a major clinical problem. When necessary, bleeding can be controlled by propranolol or a surgical shunt.     

Duodenal varices.

Upper gastrointestinal bleeding from isolated duodenal varices is a rare occurrence. We report the case of a patient with idiopathic duodenal varices in whom the diagnosis was established preoperatively by endoscopy. The patient did not have esophageal varices or portal hypertension, and he was treated by exicising the varix with a full thickness of duodenal wall. Bleeding has not recurred. Duodenal varices as well as duodenal ulcer and gastritis must be considered in evaluating a patient with cirrhosis and upper gastrointestinal bleeding.     

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.     

Duodenal dearterialization and stapling for severe hemorrhage from duodenal varices with portal vein thrombosis

BACKGROUND: Hemorrhage from duodenal varices is a rare but frequently fatal cause of gastrointestinal bleeding. Portal vein thrombosis may worsen the bleeding and prevent access for reduction of variceal pressure. METHODS: A technique to control bleeding and reduce inflow pressure to the varices is described. It includes ligation of the gastroduodenal and splenic arteries, splenectomy, stapling of the duodenum, and gastroenterostomy. RESULTS: Three patients, hemodynamically unstable from duodenal hemorrhage, underwent the procedure. No further bleeding was encountered. One patient died of fungal sepsis and liver failure, but 2 are alive without further problems 21 and 24 months later. CONCLUSIONS: Reduction in arterial inflow, direct variceal ligation, reversal of hypersplenism, and food stream diversion are elements of this procedure that may have contributed the control of severe hemorrhage from duodenal varices associated with portal vein thrombosis.     

Concurrent treatment of hepatocellular carcinoma and esophageal varices by hepatic resection and distal splenorenal shunt

Ten patients with both hepatocellular carcinoma (HCC) and esophageal or esophagogastric varices were concurrently treated by partial hepatic resection and distal splenorenal shunt. All the patients were men aged from 45 to 71 years. Four patients had had recent episodes of variceal bleeding. Six patients were considered to be at high risk for bleeding, as their varices were large and had "red color signs" endoscopically. Liver cirrhosis was associated with all cases. The grade of hepatic dysfunction was Child A in seven and Child B in three patients. As the HCCs were relatively small, partial wedge hepatectomy was carried out in all patients. Five patients underwent the original Warren shunt, but the remaining five had modified shunts with expanded polytetrafluoroethylene (Gore-Tex) interposition. There was no operative mortality within one month. Nine patients with patent shunts had no variceal bleeding despite the fact that three of them had tumor recurrence in the liver. Hepatic encephalopathy occurred transiently in only one instance. Six patients were alive at the time this report was written, eight to 49 months after operation. Five were free of cancer and one had tumor recurrence. This result may indicate that relatively small HCCs and esophageal varices can be simultaneously treated by limited hepatic resection and distal splenorenal shunt in patients with Child A or B liver disease.     

Duodenal varices: a novel treatment and literature review

Hemorrhage associated with duodenal varices is an uncommon but often fatal manifestation of portal hypertension. We report a case of duodenal varices, review the literature, and present a new treatment modality. A 63-year-old man presented with hematemesis and hematochezia. An upper gastrointestinal endoscopy revealed hemorrhage from the duodenal varices that was initially controlled with injections of epinephrine. However, this was only partially successful, as the patient had repeated episodes of bleeding that was not amenable to injection sclerotherapy. The patient was taken emergently to the operating room after endoscopy failed to control the hemorrhage. The bleeding was controlled with simple oversewing of the duodenal varices through a duodenotomy. Three years later the patient remains symptom free. We propose that simple oversewing of duodenal variceal veins combined with a beta-blocker is an effective treatment for duodenal variceal hemorrhage.     

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.     

The surgeon''s role in the management of portal hypertension.

Patients with portal hypertension are referred to surgeons for several reasons. These include the management of continued active variceal bleeding; therapy after a variceal bleed to prevent further recurrent bleeds; consideration for prophylactic surgical therapy to prevent the first variceal bleed; or, rarely, an unusual cause of portal hypertension which may require some specific surgical therapy. Injection sclerotherapy is the most widely used treatment for both acute variceal bleeding and long-term management after a variceal bleed. Unfortunately it has probably been overused in the past. The need to identify the failures of sclerotherapy early and to treat them by other forms of major surgery is emphasized. The selective distal splenorenal shunt is the most widely used portosystemic shunt today, particularly in nonalcoholic cirrhotic patients. The standard portacaval shunt is still used for the management of acute variceal bleeding as well as for long-term management, particularly in alcoholic cirrhotic patients. For acute variceal bleeding the surgical alternative to sclerotherapy or shunting is simple staple-gun esophageal transection, whereas in long-term management the main alternative is an extensive devascularization and transection operation. Liver transplantation is the only therapy that cures both the portal hypertension and the underlying liver disease. All patients with cirrhosis and portal hypertension should be assessed as potential liver transplant recipients. If they are candidates for transplantation, sclerotherapy should be used to treat bleeding varices whenever possible, as this will interfere least with a subsequent liver transplant.     

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.     

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 hemorrhage in the potential liver transplant candidate

The increased utilization of liver transplantation raises new issues regarding the management of bleeding esophageal varices in patients who are or may become transplant candidates. Since December 1982, 53 patients were referred from a university hospital to distant liver transplant centers for transplantation. Transplants were performed in 37 patients; at last follow-up, 6 died before transplantation, 7 were awaiting transplantation, and 3 were declined. Of the 53 patients referred for transplantation, 22 (42 percent) had a history of variceal hemorrhage. Sclerotherapy was required in nine patients and portosystemic shunt in four patients. Variceal hemorrhage contributed to the deaths of three of the six patients who died before transplantation could be performed. Endoscopic sclerotherapy has become the mainstay of invasive therapy in most patients with bleeding esophageal varices. If sclerotherapy is unsuccessful in the arrest or control of variceal hemorrhage, the decision must be made whether to proceed with urgent liver transplantation or portosystemic shunt. Factors which influence this choice include the ability to stabilize an acutely bleeding patient, the hepatic reserve and general clinical stature of a patient, and the availability of a liver transplant center.     

Transabdominal Extensive Esophagogastric Devascularization with Gastroesophageal Stapling for Management of Noncirrhotic Portal Hypertension: Long-term Results

Outside Japan portosystemic shunts have been favored as the surgical procedure of choice for the management of portal hypertension of noncirrhotic etiology. Devascularization procedures have resulted in high rebleed rates probably owing to a limited extent of devascularization. We performed this study to assess the efficacy of our modification of Sugiura's procedure for long-term control of variceal bleeding in patients with noncirrhotic portal hypertension. Forty-six patients with extrahepatic portal venous obstruction (EHPVO) and 22 with noncirrhotic portal fibrosis (NCPF) were subjected to transabdominal extensive esophagogastric devascularization with esophageal or gastric stapled transection (modified Sugiura's procedure), 38 in an emergency situation and 30 electively. Follow-up endoscopies were performed every 6 months. Operative mortality, morbidity, variceal status, and causes of recurrent bleeding were evaluated. The postoperative mortality was 4%. Early procedure-related complications were seen in 6%, and esophageal strictures formed in 7 of 45 survivors undergoing esophageal transection (15%). Over a mean ± SD follow-up of 53 ± 34 months, 95% of patients were free of varices. Seven survivors (11%) had a rebleed, but only 5% were due to varices (two esophageal, one gastric). Six (9%) patients developed gastropathy. The 5-year survival was 88%. The modified Sugiura's procedure is safe and effective for long-term control of variceal bleeding especially in the emergency setting and in patients with anatomy unsuitable for shunt surgery or if surgical expertise for a shunt operation is not available.     

Evaluation of selective transsplenic decompression of gastroesophageal varices

A distal splenorenal shunt and selective gastric devascularization have been utilized in the management of gastroesophageal variceal bleeding in sixteen patients with portal hypertension. There was a single operative death in a patient with severe hepatic decompensation and uncontrollable bleeding. The three late deaths were not related to the operation or to liver failure. Neither variceal bleeding nor encephalopathy has occurred postoperatively. The data suggest that the concept that selective transsplenic decompression of gastroesophageal varices preserves hepatic portal flow and hepatic function is sound. The low morbidity and mortality suggest that further clinical use of this operative procedure is indicated.     

When endoscopic therapy or pharmacotherapy fails to control variceal bleeding: what should be done?

BACKGROUND: Acute variceal bleeding is the major cause of death in patients with chronic liver disease. This justifies the search for a more effective therapy to achieve rapid and definitive hemostasis in every patient. At present, the recommended standard treatment for acute variceal bleeding consists of immediate drug treatment with terlipressin or octreotide together with early endoscopic band ligation or sclerotherapy. In the case of ectopic varices terlipressin and cyanoacrylate embolization (if varices can be reached by endoscope) are in use. FOCUS: The treatment is considered to have failed when bleeding continues or significant bleeding recurs within 48 h. This indicates the need for emergency transjugular intrahepatic portosystemic shunting (TIPS) which has been regarded as rescue treatment of choice when standard treatment fails. Although randomized studies against supportive treatment are lacking, the high efficacy and relatively low mortality after TIPS implantation are convincing. It is reasonable that smaller shunts should be preferred (probably 8 mm in diameter) since most patients have an increased risk of liver failure. To increase the effect of the shunt with respect to acute hemostasis it should be combined with transjugular embolization of the varices. CONCLUSION: Only strict adherence to the definition of failure of standard treatment and a generous indication to the TIPS implantation before multiorgan failure occurs may decrease the high mortality of acute variceal bleeding.     

Prophylactic distal splenorenal shunt for child's class A and B patients at high risk of bleeding

During recent 17 years, prophylactic distal splenorenal shunt was carried out on 29 patients. Patients were composed of 18 males and 11 females. Age ranged from 34 to 66 years with an average of 52.4. All patients had risky esophagogastric varices; varices larger than 5 mm in diameter and or varices with red color signs such as cherry red spots endoscopically. Underlying liver disease were cirrhosis of the liver in 27, chronic hepatitis in one, and idiopathic portal hypertension in one. Twenty-three patients were in Child's class A and six were in class B. Thirteen patients underwent the original Warren shunt but the remaining 16 had modified distal splenorenal shunts with expanded polytetrafluoroethylene interposition. Portal-azygos disconnection was routinely performed. One patients (3.4%) died of hepatic failure on the 6th postoperative day. Four patients (14.3%) developed hepatic encephalopathy of mild to moderate degree but no patients have suffered from variceal bleeding until now. The 5-, 10-, and 15-year survival rates were all 85.5 per cent. It is concluded that distal splenorenal shunt is a safe and reliable method to prevent variceal bleeding in a selected group of patients.     

Association of transjugular intrahepatic portosystemic shunt with embolization in the treatment of bleeding duodenal varix refractory to sclerotherapy

BACKGROUND: Bleeding from duodenal varices are often severe (mortality as high as 40%), and more difficult to sclerose than esophageal varices. We report a patient with a bleeding duodenal varix, refractory to sclerotherapy, successfully treated by the association of portosystemic shunt placement and varix embolization, via the same transjugular intrahepatic route. METHODS: A 40-year-old Black male underwent emergency TIPS and duodenal varix embolization after failure of endoscopic sclerotherapy. The portosystemic pressure gradient droped from 16 to 9 mm Hg following TIPS. At 5 months from TIPS, the patient is well, with a patent shunt at Doppler ultrasound. CONCLUSION: The present report of successful control of duodenal varix, actively bleeding and refractory to sclerotherapy, by means of combined TIPS and embolization, supports the role of TIPS and suggests that its association to embolization can be valuably considered in the difficult setting of portal hypertension with bleeding duodenal varices.