Nonshunting Operations for Variceal Hemorrhage

Abstract

To evaluate the various nonshunting treatment modalities currently being used, it is difficult to make comparative assessments by reviewing the literature. There is varied composition in the groups studied; numerous major modifications, but more often subtle but poorly described differences in surgical techniques; and lack of uniform definitions and methods of reporting even the most basic of results, be it recurrent hemorrhage, encephalopathy, or survival. Series often lump together patients with cirrhosis, both alcoholic and nonalcoholic, noncirrhotic intrahepatic block, and extrahepatic block, each of which has a different natural history, prognosis, and physiologic and hemodynamic response to interventions. Classification of severity of cirrhosis, although commonly referred to as Child's class A, B, or C, may be based on time of assessment, worst criteria present, or a point scoring system. The operations are described as "emergency," "urgent," "emergent," or "elective," and the definition of each varies with investigator. Clearly, the ability of the patient to stop bleeding and survive the hazards and high mortality of the early hours of the acute event places him in a better risk group irrespective of whether the surgical intervention is performed "urgently" within 24 hours or electively in 24 days. Expressions of long-term survival frequently do not always take into account the operative deaths or the mean follow-up time. However, some general remarks can be made. The Sugiura procedure can be performed with an extremely low mortality in selected elective patients, particularly the nonalcoholic, with virtually no postoperative encephalopathy and negligible variceal rebleeding. Postoperative major hepatic decompensation does not appear to occur with time, and long-term survival would appear superior to DSR shunt. In the class A or B alcoholic cirrhotic, results are certainly as good as and perhaps better than DSR shunt, and it is a reasonable alternative, particularly when technical and other considerations make the performance of such a shunt difficult. Surgeons who routinely perform the Warren shunt should have this operation available in their repertoire as an alternative. Attempts to compromise and reduce the extent of devascularization utilizing only a thoracic or abdominal venue or to violate Sugiura's principle of leaving intact the coronary-periesophageal-azygos venous pathway generally result in a progressively higher incidence of recurrent hemorrhage with time. The early success reported by Perecchia, Abouna, and Franco, with a transabdominal approach and lesser thoracic devascularization, which avoids "entry" into the chest, is noted with interest for the future and suggests such an approach for the more critically bleeding patients rather than the initial thoracic approach of others.(ABSTRACT TRUNCATED AT 400 WORDS)