Gastroesophageal Devascularization Research Articles

РЕЗУЛЬТАТЫ ПРИМЕНЕНИЯ МОДИФИЦИРОВАННОЙ ЛАПАРОСКОПИЧЕСКОЙ ЭЗОФАГОГАСТРАЛЬНОЙ ДЕВАСКУЛЯРИЗАЦИИ

Background. Transabdominal gastroesophageal devascularization is a technically feasible backup operation for most general surgeons in case of failure of endoscopic prophylaxis of bleeding from esophageal varices. There is an emerging trend in the development of laparoscopic technologies in the surgical correction of complications of portal hypertension. Purpose. Assessment of the clinical efficacy of laparoscopic esophagogastric devascularization in its own modification. Material and methods. In the period from 2009 to 2020, the results of treatment of 31 patients were studied. The patients were divided into 2 groups by the method of simple randomization. In the control group, surgery was performed in a standard way, in the main group - in the modification we proposed. Results. The use of our proposed technological methods when performing the stage of transection of the abdominal esophagus during laparoscopic esophagogastric devascularization in its own modification reduced the frequency of technical difficulties at this stage, which caused conversions, anastomotic leakage and other intra and postoperative complications. In the long-term period, there was a decrease in the degree of esophageal varices, a decrease in the frequency of recurrent bleeding and mortality, as well as an improvement in the quality of life in patients after a modified operation in comparison with the standard technique. Laparoscopic esophagogastric devascularization in our modification shows better results as a method of secondary prevention of bleeding from esophageal varices in cirrhosis of the liver in patients with a high risk of recurrence than the use of endoscopic sclerosis of esophageal varices, is characterized by a lower incidence of repeated episodes of bleeding from esophageal varices and less lethality. Conclusions. Based on the analysis of the immediate and long-term results of the use of laparoscopic esophagogastric devascularization in its own modification in the clinic, it should be noted the reproducibility of the surgical intervention, its effectiveness and safety.

Surgical Management of Portal Biliopathy – A Prospective Analysis.

Background: Portal biliopathy denotes intrahepatic and extra hepatic biliary ductal abnormalities in portal hypertension. It is usually associated with extra hepatic portal vein obstruction (EHPVO). These patients are also prone to develop obstructive jaundice as a result of strictures and/or choledocholithiasis. Surgical management of obstructive jaundice in such patients becomes difficult in the presence of these collaterals. The aim of the study is to prospectively analyze the approach to management of patients with Symptomatic portal biliopathy. Subjects and Methods: The study was conducted at Narayana Medical College & Hospital, Chintareddy Palem, Nellore, Andhra Pradesh on surgical management of the patients of EHPVO with portal biliopathy presenting to the surgical clinic of this tertiary referral center between November 2016 and October 2017. The data was analyzed for presentation, clinical features, imaging and results of surgical management. Results: During the study period, total of 44 patients of EHPVO were referred for surgical management. Of these 14 patients (9 males, mean age 34.6 years) were diagnosed to have portal biliopathy. Ten patients had prior history of variceal bleed which was managed endoscopically. Jaundice was the most common symptom followed by right upper quadrant pain and recurrent cholangitis. Four patients had prior unsuccessful endoscopic management. ERCP/ MRCP was used for delineation of the biliary tree, which showed irregularity (14 patients), dominant strictures (8 patients), filling defects (5 patients), and intrahepatic biliary dilatation (7 patients). Proximal splenorenal shunt (PSRS) was performed in 13 patients. While in 1 patient peroperatively liver was found to be grossly nodular, hence gastro-esophageal devascularization with simultaneous biliary drainage was done. Of the 13 patients who underwent PSRS, all patients were intensively followed for 4-6 weeks with history and liver function tests. After 6 weeks, five patients showed clinical as well as biochemical improvement and they are being followed up regularly. Eight patients had persistent symptoms and abnormal liver function tests. These were the patients with dominant stricture and choledocholithiasis. Of these, 6 patients underwent Roux-en-Y hepaticojejunostomy. The average blood transfusion requirement at second surgery was 1 unit. Postoperative complications were minimal with no mortality. One patient and was lost to follow up and the remaining one is awaiting second surgery (RYHJ). Over a follow up of 3-28 months the patients are asymptomatic and well. Conclusion: Portal biliopathy with symptomatic biliary obstruction needs intervention. Surgical decompressive shunt followed by biliary drainage is the best possible treatment. While for most of the early biliary changes shunt alone is effective, patients with dominant stricture will need a biliary diversion which can be safely performed following Porto systemic shunt without increase in morbidity or mortality.

P3.50: Portal hypertensive surgery for management of diffuse portomesenteric venous thrombosis - Surgical technique and long-term outcome

Introduction: Patients with diffuse portomesenteric venous thrombosis (PMVT) are often referred to the abdominal organ transplant centers particularly those with experience in gut transplantation. Despite the proven therapeutic efficacy of multivisceral transplantation (MVTx) for these complex patients, the forgotten different modalities of portal hypertensive surgery could be a better alternative particularly for those with compensated liver disease and gut varices in the milieu of a thrombophilic state. Methods: Between Aug2012 and Jan2019, a total of 28 patients referred to our center with diffuse PMVT underwent surgical intervention. Indication was history of variceal bleeding and occult varices in the setting of thrombophilia. All except 1 were adults with a mean age of 42±15 yrs. Precipitating causes of PMVT were thrombophilia (78%) and pancreatitis (18%). All patients had clinical, endoscopic and radiologic evidence of PMVT with stigmata of extra-hepatic portal hypertension. Variceal bleeding was reported in 36% patients. Type of shunt was determined intra-operative suitable visceral vascular anatomy and transplantation dictated by co-existence of advanced liver disease. Results: Portal hypertensive surgery was performed in 27 patients (96%) while MVTx was performed in one. The surgical modality was atypical non-selective portosystemic shunt in 14 patients (52%) and gastro-esophageal devascularization in the remaining 13 (48%). Partial gastric devascularization was commonly performed in patients with atypical shunt that may not completely decompress the left portal hypertensive compartment. Splenectomy was unavoidable in 4 patients. The utilization of autologous and synthetic vascular grafts are shown in Table 1. With a mean follow up of 40±26 months, overall shunt patency was radiologically documented in 78% patients. Recurrence of bleed occurred in only 1 patient (7%) despite shunt patency. Throughout the follow up period, surgical complications were minor (grade I & II) in 64% patients and major (grade III & IV) in 21% [Clavien grade]. With one mortality due to acute leukemia, all patients are currently alive with an overall survival rate of 96%. Conclusion: Portal hypertensive surgery is a viable alternative to MVTx for the management of diffuse PMVT and preserved hepatic function. Portal decompressive surgery should always be considered for thrombophilic patients with silent gut varices who are in need of life-long anticoagulation therapy.

УСПЕШНАЯ ЛАПАРОСКОПИЧЕСКАЯ ЭЗОФАГОГАСТРАЛЬНАЯ ДЕВАСКУЛЯРИЗАЦИЯ С АППАРАТНОЙ ТРАНССЕКЦИЕЙ ПИЩЕВОДА

Background. Bleeding from esophageal varices is one of the leading causes of death in patients with liver cirrhosis. Purpose. The analysis of laparoscopic gastroesophageal devascularization with stapler transsection of the esophagus. Material and methods. The first successful laparoscopic gastroesophageal devascularization with stapler transsection of the esophagus in the Republic of Belarus was performed in Grodno Regional Clinical Hospital in December, 2014, in a female patient with liver cirrhosis, portal hypertension and recurrent bleeding from esophageal varices. Results and conclusions. The operation contributed to the persistent lack of variceal bleeding recurrence in the postoperative period. This operation is highly effective and minimally invasive.

Diagnosis and treatment of portal vein thrombosis after splenectomy and gastroesophageal devascularization

Diagnosis and treatment of portal vein thrombosis after splenectomy and gastroesophageal devascularization

Gastroesophageal varices (bleeding) and splenomegaly: the initial manifestations of some pancreatic body and tail carcinoma.

Gastroesophageal varices (bleeding) and splenomegaly: the initial manifestations of some pancreatic body and tail carcinoma.

Single-incision laparoscopic splenectomy for massive splenomegaly combining gastroesophageal devascularization using conventional instruments.

Single-incision laparoscopic splenectomy has been reported and was proved to be feasible and safe. Yet reports on single-incision laparoscopic surgery (SILS) for massive splenomegaly is not seen, neither is SILS for gastroesophageal devascularization; another correlated procedure for patients complicated with bleeding esophageal varices. From February 2011 to March 2012, 6 male patients with a median age of 45.1 years (range, 25 to 65 y) who were diagnosed of liver cirrhosis, portal hypertension, splenomegaly, and hypersplenism underwent SILS by the same surgical team in our hospital. Of them, 4 patients who were indicated had combined gastroesophageal devascularization, except for 1 conversion to hand-assisted laparoscopic approach because of bleeding, the operations were performed uneventfully and the surgical outcomes were satisfactory. Preoperative diagnosis was hypersplenism secondary to liver cirrhosis, the surgical outcome was satisfactory. This video, Supplemental Digital Content 1 and 2, http://links.lww.com/SLE/A104 and http://links.lww.com/SLE/A105 illustrates the crucial steps regarding the SILS for massive splenomegaly combined with gastroesophageal devascularization. The preoperative diagnosis are, hepatitis B, the patient's liver function is Liver Child-Pugh grade A. The patient was placed in reverse Trendelenburg position, with the legs open. The surgeon was standing on the right side of the patient and an assistant standing in between the legs. One 20-mm incision was made under the umbilicus, a 10-mm Trocar (Johnson & Johnson Investment Co. Ltd., NJ) was introduced in the middle of the incision, and the abdominal cavity was explored with a 10-mm, 30-degree scope (Storz Co. Ltd., Germany). Then a 12-mm and a 5-mm trocar were introduced through the same incision, respectively, 45 degree to the 10-mm trocar at both sides to form a "∇" shape. The procedure started with the dissection of the splenocolic ligament at the lower pole of the spleen, followed by creating a window by dissecting the gastrocolic ligament. The secondary branches of splenic pedicle were dissected and divided. The dissection of splenogastric ligament was continued along the gastric greater curvature, and short gastric vessels were encountered and divided. The left gastric artery was clipped and secured, followed by gastroesophageal devascularization along the cardiac to the esophagus 5 cm away from the esophagocardia junction, with Ligasure device. The splenic artery was identified, clipped, and divided. The splenic vein was finally divided followed by intraoperative autologous blood transfusion technique by collecting the blood from the distal splenic vein. The spleen was removed from the umbilical incision in a sample bag after being sliced into pieces. A drainage was placed through the incision. The operation was successful and the patient recovered well postoperatively: the operation time was 265 minutes, and the intraoperative blood loss was 300 mL. The postoperative course was uneventful and the patient was discharged 13 days later. SILS combining gastroesophageal devascularization for massive splenomegaly is technically feasible in the hands of surgeons with experiences of laparoscopic splenectomy. Indeed, the relative large scale of operation field for laparoscopic splenectomy makes the conflicts of instruments less practically challenging; however, techniques and sequences of the laparoscopic procedures should be modified to facilitate it, given the unavoidable constriction of movements for each instrument.

Clinical analysis of splenectomy and selective devascularization based on intra-operative free portal pressure

Objective To investigate the short-term and long-term outcomes in patients with portal hypertension who underwent splenectomy and selective gastroesophageal devascularization based on intraoperative free portal pressure (FPP).Methods The clinical data of 304 patients from June 2003 to September 2013 were retrospectively analyzed.71 patients underwent splenectomy and selective gastroesophageal devascularzation (group A) and 233 patients received splenectomy and classical gastroesophageal devascularzation (group B).The alteration of FPP,liver function,operation time,volume of blood loss and postoperative complications were compared between the two groups.Results The overall 1-,3-,5-and 10-year accumulative survival rates in all the patients were 95％,92％,85％ and 77％ respectively.Median survival of the liver was 93 months.The Child-Pugh score (6.21 ± 1.04 vs 6.41 ± 1.26; P ＜ 0.05) significantly decreased postoperatively in two weeks in all the patients.The postoperative complications including rebleeding rate (5.6％ vs24.1％,P＜0.05),grade Ⅰ and Ⅱ portal vein thrombosis (19.7％ vs 33.9％,P＜0.05) and delayed gastric function (0 vs 5.6％,P ＜0.05) were significantly different between group A and group B.There were no significant difference between grade Ⅲ and Ⅳ portal vein thrombosis (2.8％ vs 3.4％,P ＞ 0.05).The FPP decreased significantly in both groups,but it decreased more in group A than group B [(10.06 ±4.34)cmH2O(1 cmH2O =0.098 kPa) vs (8.26 ±4.82)cmH2O,P ＜0.01].Moreover,the operation time and the volume of blood loss in group A were significantly less than those in group B.Conclusions Cirrhotic patients with portal hypertension benefited from splenectomy and gastroesophageal devascularization.Selective gastroesophageal devascularization was more safe and effective in patients with portal hypertension. Key words: Portal hypertension; Splenectomy; Devascularzation; Rebleeding rate

Anticoagulation therapy prevents portal-splenic vein thrombosis after splenectomy with gastroesophageal devascularization

To compare the incidence of early portal or splenic vein thrombosis (PSVT) in patients treated with irregular and regular anticoagulantion after splenectomy with gastroesophageal devascularization. We retrospectively analyzed 301 patients who underwent splenectomy with gastroesophageal devascularization for portal hypertension due to cirrhosis between April 2004 and July 2010. Patients were categorized into group A with irregular anticoagulation and group B with regular anticoagulation, respectively. Group A (153 patients) received anticoagulant monotherapy for an undesignated time period or with aspirin or warfarin without low-molecular-weight heparin (LMWH) irregularly. Group B (148 patients) received subcutaneous injection of LMWH routinely within the first 5 d after surgery, followed by oral warfarin and aspirin for one month regularly. The target prothrombin time/international normalized ratio (PT/INR) was 1.25-1.50. Platelet and PT/INR were monitored. Color Doppler imaging was performed to monitor PSVT as well as the effectiveness of thrombolytic therapy. The patients' data were collected and analyzed retrospectively. Among the patients, 94 developed early postoperative mural PSVT, including 63 patients in group A (63/153, 41.17%) and 31 patients in group B (31/148, 20.94%). There were 50 (32.67%) patients in group A and 27 (18.24%) in group B with mural PSVT in the main trunk of portal vein. After the administration of thrombolytic, anticoagulant and anti-aggregation therapy, complete or partial thrombus dissolution achieved in 50 (79.37%) in group A and 26 (83.87%) in group B. Regular anticoagulation therapy can reduce the incidence of PSVT in patients who undergo splenectomy with gastroesophageal devascularization, and regular anticoagulant therapy is safer and more effective than irregular anticoagulant therapy. Early and timely thrombolytic therapy is imperative and feasible for the prevention of PSVT.

Transabdominal gastroesophageal devascularization without transection for bleeding varices: Results and indicators of prognosis

Esophagogastric devascularization is an operation that can be performed for endoscopically uncontrolled variceal bleeding in hospitals having only basic surgical instruments and is therefore an appropriate procedure for small hospitals in developing countries. The aim of this study was to analyze one hospital's experience of this operation in consecutive patients with variceal bleeding. Between 1996 and 2003, 45 patients (30 male, 15 female) who had a mean age of 40 years (range 7-78 years) underwent devascularization procedures. Of the 45, 23 had cirrhosis and 22 had non-cirrhotic portal hypertension (11 extrahepatic portal venous obstruction, 11 non-cirrhotic portal fibrosis), and 18 patients had emergency procedures and 27 were elective. Mortality, morbidity, rebleeding rates and the prognostic factors for death were assessed. Elective and emergency mortality was one (3.7%) and 11 (61%) patients, respectively. There was no rebleeding in hospital. At follow up (mean 48 months, range 3-92 months) overall survival in patients with cirrhosis was 7 out of 20 and in patients with non-cirrhotic portal hypertension was 19 of 21. Five (17%) had recurrent variceal hemorrhage, of whom three, all cirrhotic patients, died. Preoperative prognostic indicators for death were emergency surgery, a Child-Pugh score >or=10, preoperative blood transfusion >or=20 units and renal failure. Gastroesophageal devascularization effectively controls variceal bleeding especially in non-cirrhotic patients with portal hypertension. In the elective situation it carries a low mortality and rebleed rate. In emergencies the prognosis is poor with advanced cirrhosis, following large quantities of blood transfusion and deranged renal function. It is suggested that this operation be offered especially to non-cirrhotic patients in hospitals in developing countries where facilities for more sophisticated procedures are not available.

Transabdominal Gastro‐esophageal Devascularization and Esophageal Transection for Bleeding Esophageal Varices after Failed Injection Sclerotherapy: Long‐Term Follow‐Up Report

Management of continued bleeding from esophageal varices despite adequate injection sclerotherapy remains one of the medical and surgical dilemmas. Transabdominal gastroesophageal devascularization and esophageal transection (TGDET) is considered an effective and safe procedure for such patients. This study aimed at presenting continued evaluation of TGDET. Various problems influencing the early outcome are discussed, and long-term outcome is analyzed. This was a prospective clinical descriptive study. Prospective data was collected on 142 consecutive patients managed by one group of surgeons over a 5 year-period and 15 years follow-up after failed injection sclerotherapy for variceal bleeding. Evaluation was made in terms of effectiveness in controlling the acute bleeding, postoperative morbidity and mortality, recurrent bleeding, encephalopathy, and long-term survival. There were 133 men and 9 women. Mean age was 41.8 years. Etiology of portal hypertension was bilharziasis in 54.9% and posthepatitic in 14.8%. Child-Pugh grading on admission was A: 47.2%, B: 28.8%, and C: 14%. Hemorrhage was controlled in all cases. Clinical leak was observed in 5.6%, portal vein thrombosis in 6.3%, and staple line erosion in 2.1% of cases. No patient developed encephalopathy. In-hospital mortality was 12.7%. Complete eradication of varices was observed in 70.6% patients. Recurrent variceal bleeding was noticed in 6.9% of cases. Actuarial 15-year survival for Child-Pugh A patients was 44%, B was 22.5%, and none for C. TGDET remains a safe and effective procedure after failure of sclerotherapy when other alternatives are either not indicated or not available.

Chirurgische Therapie der portalen Hypertension

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective and durable procedures to control variceal bleeding in patients with low operative risk and good liver function (Child A). In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) or a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergent endoscopic treatment or TIPS insertion fail to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) can be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.

Accessory Splenectomy with Gastroesophageal Devascularization for Recurrent Hypersplenism and Refractory Bleeding Varices in a Patient with Liver Cirrhosis: Report of a Case

We report a case of recurrent thrombocytopenia associated with symptomatic enlargement of an accessory spleen, 2 years after splenectomy, in a 36-year-old man with posthepatitic liver cirrhosis. The patient suffered three episodes of variceal bleeding, but the esophageal varices were not eradicated by two sessions of endoscopic injection sclerotherapy and endoscopic band ligation. Abdominal ultrasonography and computed tomography showed a giant accessory spleen (6 x 6 x 5 cm), gallbladder stones, and complete postsplenectomy splenomesoportal thrombosis. Subsequent 99mTc scintigraphy confirmed the presence of a functioning residual splenic nodule. Thus, we performed gastroesophageal devascularization (Hassab-Paquet procedure) with accessory splenectomy and cholecystectomy, after which the platelet count normalized and no further variceal bleeding occurred during 17 months of follow-up. To our knowledge, this is the first report in the English medical literature of accessory splenectomy for recurrent thrombocytopenia in a patient with liver cirrhosis.

Current state of portosystemic shunt surgery.

A switch to decompressive shunt procedures is mandatory if endoscopic therapy fails to control recurrent variceal hemorrhage. Surgical shunt procedures continue to be safe, highly effective, and durable procedures to treat variceal bleeding in patients with low operative risk and good liver function. In cirrhotics, elective operations using portal flow preserving techniques such as a selective distal splenorenal shunt (Warren) and a partial portocaval small diameter interposition shunt (Sarfeh) should be preferred. Rarely, end-to-side portocaval shunt may serve as a salvage procedure if emergency endoscopic treatment or transjugular intrahepatic portosystemic shunt insertion fails to stop bleeding. Until definitive results from randomized trials are available patients with good prognosis (Child-Pugh A and B) should be regarded as candidates for surgical shunts. For patients with noncirrhotic portal hypertension, in particular with extrahepatic portal vein thrombosis, portosystemic shunt surgery represents the only effective therapy which leads to freedom of recurrent bleeding and repeated endoscopies for many years, and improves hypersplenism without deteriorating liver function or encephalopathy. Gastroesophageal devascularization and other direct variceal ablative procedures should be restricted to treat endoscopic therapy failures without shuntable portal tributaries.

Current indication of a modified sugiura procedure in the management of variceal bleeding

Background: The role of gastroesophageal devascularization (Sugiura-type procedures) for the treatment of variceal bleeding remains controversial. Although Japanese series reported favorable longterm results, the technique has not been widely accepted in the Western Hemisphere because of a high postoperative morbidity and mortality. The reasons for the different outcomes are unclear. In a multidisciplinary team approach we developed a therapeutic algorithm for patients with recurrent variceal bleeding. Study design: The Sugiura procedure was offered only to patients with well-preserved liver function (Child A or Child B cirrhosis without chronic ascites) who were not candidates for distal splenorenal shunt, transhepatic porto-systemic shunt, or liver transplantation. Results: Fifteen patients with recurrent variceal bleeding underwent a modified Sugiura procedure between September 1994 and September 1997. All but one patient (operative mortality 7%) are alive after a median followup of 4 years. Recurrent variceal bleeding developed in one patient; esophageal strictures, which were successfully treated by endoscopic dilatation, developed in three patients; and one patient experienced mild encephalopathy. Major complications were noted only in patients with impaired liver function (Child B cirrhosis) or when the modified Sugiura was performed in an emergency setting. The presence of cirrhosis or the cause of portal hypertension had no significant impact on the complication rate. Conclusions: This series was performed during the last decade when all modern therapeutic options for variceal bleeding were available. Our results indicate that the modified Sugiura procedure is an effective rescue therapy in patients who are not candidates for selective shunts, transhepatic porto-systemic shunt, or transplantation. Emergency settings and decreased liver function are associated with an increased morbidity.

Left-upper-quadrant devascularization for 'unshuntable' portal hypertension.

No simple solution exists for the patient with bleeding due to diffuse splanchnic venous thrombosis (so-called unshuntable portal hypertension). Radical gastroesophageal devascularization or extended esophagogastrectomy has been considered obligatory in this setting. To examine the use of 1-stage, left-upper-quadrant devascularization for unshuntable portal hypertension. A retrospective call-back survey. A regional referral center. Eight consecutive patients with recurrent bleeding from esophagogastric varices due to diffuse splanchnic venous thrombosis. Splenectomy, staple transection of the esophagus, and proximal gastric devascularization. Operative complications, recurrent bleeding, survival, and quality of life. No operative deaths occurred, and 7 of 8 patients who were treated for unshuntable portal hypertension and who were followed-up for 1 to 15 years (mean, 4.7 years) are alive. No patient has had a recurrent variceal hemorrhage. A second endoscopy has demonstrated small varices in 4 patients. Early and late complications occurred in 3 and 1 of the patients, respectively. Left-upper-quadrant devascularization is a technically straightforward, safe, effective, and durable alternative to the Sugiura procedure or to radical esophagogastrectomy in patients with unshuntable portal hypertension.

HEPATOSPLENIC SCHISTOSOMIASIS: Pathophysiology and Treatment

HSS represents a special model of intrahepatic portal hypertension characterized by a presinusoidal portal block and a well-preserved liver parenchyma. Symmers' fibrosis appears in a small but significant proportion of patients with a high worm load. Its pathogenesis is not well established, although experimental and clinical studies point to egg granulomata as the main pathogenetic factor. The eggs carried continuously through the portal circulation produce inflammation and gross amputation of the intrahepatic veins, portal and periportal granulomas, and, eventually, a coarse perilobular fibrosis ("pipe-stem"). Portal hypertension, esophageal varices, and hepatosplenomegaly are the main consequences of these morphologic changes. Gastrointestinal bleeding is the most frequent cause of death. Unlike in cirrhosis, advanced liver failure is not seen except when HSS is associated with liver lesions from other causes such as virus and alcoholism. Helminthiasis treatment is based on chemotherapy with praziquantel or oxamniquine. Bleeding esophageal varices are managed by sclerotherapy or surgical procedures. Splenectomy with gastroesophageal devascularization seems to be the best choice.

Selective Shunt Versus Nonshunt Surgery for Management of Both Schistosomal and Nonschistosomal Variceal Bleeders

This clinical study included 219 (Child A/B) consecutive variceal bleeders. Electively 123 had distal splenorenal shunt (DSRS) and 96 had splenectomy with gastroesophageal devascularization (S&GD). Liver pathology was documented in 73% of patients, with schistosomal fibrosis in 41% and nonalcoholic cirrhosis or mixed pattern (fibrosis and cirrhosis) in 59%. The surgical groups were similar before operation, with a mean follow-up of 82 +/- 13 and 78 +/- 18 months, respectively (range, 60 to 120 months). The two pathologic populations were also similar before each and both procedures. The operative mortality rates were low, with incidences of 3.3% (DSRS) and 3.1% (S&GD). Rebleeding occurred significantly (p less than 0.05) more frequently after S&GD (27%) compared to DSRS (5.7%). Sclerotherapy salvaged 65% of S&GD rebleeders. Encephalopathy developed significantly (p less than 0.05) more after DSRS (18.7%) compared to S&GD (7.3%), with no significant difference among the current survivors. The difference in overall rebleeding and encephalopathy rates between both procedures was statistically related to patients with cirrhosis and mixed lesions (p less than 0.05). Distal splenorenal shunt significantly reduced the endoscopic variceal size more than S&GD (p less than 0.05). Prograde portal perfusion was documented in 94% of patients in each group, with a variable distinct pattern of portaprival collaterals in 91% (DSRS) and 65% (S&GD). The total population cumulative survival was similar with 80% for DSRS and 79% for S&GD (plus sclerosis in 23%), with hepatic cell failure the cause of death in 46% and 50%, respectively. However, in the schistosomal patients, survival was better improved after DSRS (90%) compared to S&GD (75%), with no difference among the cirrhotic and mixed group (DSRS 73%, S&GD 72%). In conclusion (1) both DSRS and S&GD have low operative mortality rates, (2) DSRS is superior to S&GD in the schistosomal patients, and (3) S&GD backed by endosclerosis for rebleeding is a good surgical alternative to selective shunt in the nonalcoholic cirrhotic and mixed population.