Esophageal Transection Research Articles

Treatment of bleeding oesophageal varices by infusion of vasopressin into the superior mesenteric artery.

Seventeen patients bleeding from oesophageal varices were treated by continuous infusion of vasopressin through a catheter inserted percutaneously and positioned in the superior mesenteric artery and in two other patients catheterization proved technically impossible. Bleeding was completely controlled on only four out of 18 occasions in the 17 patients treated. In seven patients, bleeding was controlled for two or more days but then recurred although the infusion was continued with an increased dose of vasopressin. There was a high incidence of complications, including bleeding from the site of catheter insertion in the groin and septicaemias. Sengstaken balloon tamponade and oesophageal transection had to be used to control bleeding in some patients but only six out of 17 survived to leave hospital.

Follow-up Result of Esophageal Transection for Esophageal Varices

Follow-up Result of Esophageal Transection for Esophageal Varices

Transthoracic esophageal transection in patients of the esophageal varices associated with river cirrohsis

Transthoracic esophageal transection in patients of the esophageal varices associated with river cirrohsis

Transthoracic, transgastric interruption of bleeding esophageal varices.

Portasystemic shunt operations provide effective and prolonged control of bleeding from gastroesophageal varices accompanying portal hypertension. In patients who are not candidates for emergency portal decompression because of extrahepatic portal vein obstruction, small size of vein, or other reasons, direct surgical interruption of bleeding esophageal varices may be employed. Transesophageal suture of varices, as advocated by Boerema, 1 Crile, 2 and Linton and Warren 3 controls bleeding immediately but is followed by a high incidence of rebleeding and the risk of leakage from an esophageal suture line. More extensive operations such as gastroesophageal resection 4,5 gastric or esophageal transection, 6 and portaazygos disconnection, 7 reduce the likelihood of recurrent bleeding but require an esophageal anastomosis and may cause gastroesophageal reflux and esophagitis postoperatively. To reduce these hazards, a technique has been devised for transthoracic, transgastric suture of bleeding varices with devascularization and reconstruction of the cardia. This method interrupts submucosal

Treatment of bleeding esophageal varices in portal-systemic shunt failures.

In some patients with massive hemorrhage from esophageal varices, and particularly in extrahepatic portal obstruction, shunting procedures fail to prevent further significant bleeding or are technically impossible. For this relatively small group of patients with portal hypertension, a variety of approaches have been proposed, including varix ligation,¹hepatic or splenic arterial ligation,²injection of sclerosing agents,³omentopexy,⁴mediastinal packing,⁵gastric and esophageal transection and resuture,^6-8and gastric and esophageal resection. These latter operations have been designed either to excise the acid-secreting portions of the stomach and thereby prevent acidpeptic erosion of the mucosal covering of the varices, or to excise the varix tissue itself. The introduction of procedures involving excision of the stomach and esophagus occurred during the same years that the potral-systemic shunt procedures were first clinically introduced on a broad scale (Table 1).^9-14However, the number of patients subjected to such

Rationale for Transthoracic Esophageal Transection for Bleeding Varices

Rationale for transthoracic esophageal transection has been clarified in animal experimentation, and the results of clinical transthoracic esophageal transection for bleeding varices in 15 patients were reported. Esophageal transection extirpated all the collaterals to the esophageal varices and the regeneration of the collaterals in the esophageal region was much less than expected, probably because of the sufficient compensation with other collaterals and because of the tight scar tissue at the site of esophageal reconstruction. Fourteen of the 15 patients survived the operation and had no further bleeding from esophageal varices throughout the follow-up period up to 22 months.

The effect of esophagectomy on absorption in man: clinical and metabolic observations

Summary In seven patients (six with carcinoma of the esophagus) with prior normal absorption, distal or near total esophagectomy resulted in malabsorption of fat, decreased appetite, gastric stasis, post-prandial discomfort, and loose and frequent bowel movements. Tumor per se, mediastinal radiation, transection of the cervical esophagus, or esophageal bypass by colon transplant had no significant effect on absorption. These conclusions are supported by the finding of fat malabsorption in five of seven additional patients studied after esophagectomy who gave no clinical history of altered bowel function prior to this procedure. Fecal nitrogen and potassium losses following esophagectomy were often increased but the changes were usually small; fecal sodium was usually normal as were xylose and vitamin B 12 absorption. Roentgenological studies following esophagectomy revealed marked gastric stasis (despite a drainage procedure) and small bowel changes of mild to moderate degree, characterized mainly by delayed transit time and ileal stasis. Follow-up studies indicated that the steatorrhea, anorexia, gastric stasis, and small bowel changes tended to persist for many months or years in the majority of the subjects who were followed. Patients with postesophagectomy steatorrhea were then studied in an effort to elucidate the etiology of this malabsorption. Histological examination of small bowel mucosa from seven cases revealed the presence of villi with normal epithelial cells. A gluten-free diet was without effect in two affected individuals. Administration of pancreatic and bile extracts or various antibiotics to a number of subjects did not consistently improve the steatorrhea. The evidence suggests that the malabsorption is not the result of impaired secretion of digestive juices, a blind loop syndrome, villous atrophy, or lymphatic obstruction. Medium chain triglycerides improved the steatorrhea and decreased the frequency of bowel movements in all patients tested. The etiology of the malabsorption remains uncertain although it is probably related to some unknown effect of the bilateral thoracic vagotomy accompanying esophagectomy.

The Croonian Lectures on the Influence of the Circulation upon the Nervous System

Injection sclerotherapy is now the accepted first line treatment for bleeding oesophageal varices, although it is associated with an impressive list of rare complications. The main problem concerns the strategy for uncontrollable or recurrent bleeding. Patients with uncontrolled bleeding may be referred for surgery after considerable blood loss and are then extremely difficult to assess. The effects of blood loss on liver function can lead to an unduly pessimistic assessment of liver status. An effective choice of emergency surgical procedure may require considerable surgical expertise. Oesophageal transection and devascularisation are satisfactory for many patients with oesophageal varices secondary to cirrhosis and should nearly always control bleeding. Difficulties arise in patients who are grossly obese and in those who have undergone extensive surgery in the upper abdomen. Problems may also be encountered in those treated by repeated sclerotherapy, which may have caused severe inflammatory change and thickening around the lower oesophagus and upper stomach. We believe that an emergency mesocaval shunt using either a vein graft or a synthetic material such as polytetrafluoroethylene is the procedure of choice for this difficult group of very sick patients. The surgical exposure is satisfactory and not unduly prolonged in even the largest patients and the technique does not interfere with any subsequent transplant operation. There is a greater choice in the management of the patient with less urgent bleeding from recurrent varices after sclerotherapy. Repeat sclerotherapy may be effective for small oesophageal varices while liver transplantation may be indicated in the patient with deteriorating liver function. A selective distal splenorenal shunt should be considered for patients with intact splenic and left renal veins and a mesocaval vein graft for the remainder. We would therefore suggest that surgery should still be considered for the management of portal hypertension, particularly in the following circumstances: (1) Uncontrollable bleeding during the initial course of sclerotherapy; (2) Life threatening haemorrhage from recurrent varices; (3) Bleeding from ectopic varices not accessible to sclerotherapy; (4) Uncontrollable bleeding from oesophageal ulceration secondary to injection sclerotherapy; (5) Severe, symptomatic hypersplenism; (6) For patients who live in communities remote from blood transfusion facilities and adequate medical care. The management of the complications of portal hypertension continues to pose problems. We believe that the best results should come from a combined management approach using injection sclerotherapy as primary treatment and surgery for complications and for haemorrhage from unusual anatomical sites.