Clinical Aspects of the Therapy of Esophageal Bleeding

Abstract

Based on 246 experiences of portal hypertension patient, clinical and pathological features as well as surgical therapy for esophageal bleeding were discussed.(1) Incidence of esophageal bleeding was varying according to the kinds of original disease: 11% in Banti's syndrome, 25% in cirrhosis of the liver and schistosomiasis japonica respectively, and 61% in prehepatic portal block. It was also found that patients with liver cirrhosis is prone to make massive hematemesis in bleeding episode.(2) Autopsy examination of the cirrhotics revealed that the varices with irregularity thickened wall ruptured often, while those with simple dilatation with no thickening scarecely ruptured. This finding may suggest that the mechanical weakness of the varices is the major factor leading to the rupture.(3) Here varying incidence in the the type of cirrhosis of Japanese and western patients should be mentioned. Portal cirrhosis, which responds well to medical treatment, is the most common type found in American patients. In Japanese patients, on the other hand, postnecrotic and Laennec cirrhosis are the types of highest incidence. Then, if the direct portacaval shunt is performed on cirrhotic patients with such poor liver function, portal blood avoids hepatic circulation and a hepatic anoxia may be more frequently encountered. Taking into account such a special circumstance of the Japanese patients, the most elective therapy has been worked out as follows.In emergent cases, as a rule, shunt operation is contraindicated, and the transperitoneal proximal gastrectomy is recommendable. It is not seldom that the site of bleeding is not in the esophagus, but in the stomach. It should also be noticed that the stomach ulcer appears more often in the cirrhotic patients as compared in the controlled group.Concerning the interval operation, referring to our experiences involving splenectomy alone, splenectomy with dissection of the gastric coronary vein, and shunt operations, it was concluded that the most reliable method for eliminating esophageal bleeding is to make a shunt between the portal and systemic circulation. And, I have pointed out to introduce a concept“Controlled Shunting”which materially implies a shunt that is so constructed that it does not impair hepatic circulation and at the same time achieves adequate decompression to prevent esophageal bleeding. In this sense, direct portacaval shunt does not meet the purpose. For realizing this concept, a new method of splenorenal anastomosis has been devised. The principle of the new technique is that the juncture angle between splenic vein and renal vein is made acute by utilizing an autogenous vein graft taken up from an anatomic bifurcation of the iliac vein. It has been proved that patency of the anastomosis was nearly 90%, and operative as well as follow-up mortality is very low, and satisfactory results for esophageal bleeding were obtained. It should be emphasized that difficulties of curing esophageal bleeding in Japanese has, to a major degree, been overcome by our new operative method of splenorenal anastomosis.