Management of Variceal Bleeding in Patients with Noncirrhotic Portal Vein Thrombosis (original) (raw)
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Journal of the American College of Surgeons, 2002
BACKGROUND: This article discusses the largest and longest experience reported to date of the use of portalsystemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT). STUDY DESIGN: Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93%); 166 were eligible for and received 10 or more years of regular followup (83%). RESULTS: The etiology of PVT was unknown in 65% of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15%), umbilical vein catheterization in 14 patients (7%), and peritonitis in 14 patients (7%). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76%), the portal vein and adjacent superior mesenteric vein in 10 patients (5%), and the portal and splenic veins in 56 patients (28%). Postoperative survival to leave the hospital was 100%. Actuarial 5-year, 10-year, and 15-year survival rates were 99%, 97%, and 95%, respectively. Five patients (2.5%), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97% of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected.
Gastroenterology, 2006
Variceal bleeding refractory to medical treatment with -blockers and endoscopic therapy can be managed by variceal decompression with either surgical shunts or transjugular intrahepatic portal systemic shunts (TIPS). This prospective randomized trial tested the hypothesis that patients receiving distal splenorenal shunts (DSRS) would have significantly lower rebleeding and encephalopathy rates than TIPS in management of refractory variceal bleeding. Methods: A prospective randomized controlled clinical trial at 5 centers was conducted. One hundred forty patients with Child-Pugh class A and B cirrhosis and refractory variceal bleeding were randomized to DSRS or TIPS. Protocol and event follow-up for 2-8 years (mean, 46 ؎ 26 months) for primary end points of variceal bleeding and encephalopathy and secondary end points of death, ascites, thrombosis and stenosis, liver function, need for transplant, quality of life, and cost were evaluated. Results: There was no significant difference in rebleeding (DSRS, 5.5%; TIPS, 10.5%; P ؍ .29) or first encephalopathy event (DSRS, 50%; TIPS, 50%). Survival at 2 and 5 years (DSRS, 81% and 62%; TIPS, 88% and 61%, respectively) were not significantly different (P ؍ .87). Thrombosis, stenosis, and reintervention rates (DSRS, 11%; TIPS, 82%) were significantly (P < .001) higher in the TIPS group. Ascites, need for transplant, quality of life, and costs were not significantly different. Conclusions: DSRS and TIPS are similarly efficacious in the control of refractory variceal bleeding in Child-Pugh class A and B patients. Reintervention is significantly greater for TIPS compared with DSRS. Because both procedures have equivalent outcomes, the choice is dependent on available expertise and ability to monitor the shunt and reintervene when needed.
Objective : Surgical portosystemic shunts are effective for treating rebleeding from esophageal and gastric varices and improvement in the thrombocytopenia and leukopenia in patients with portal hypertension with well preserved liver function. Materials and methods : 8 patients (4 male and 4 female) who received splenorenal shunts for the indication of varices bleeding and hypersplenism from September 2015 to November 2017. Their etiology of portal hypertension, associated treatments and clinical outcomes were reviewed. Results : All patients received PSRS, were examined for median follow-up of 7-24 months. No postoperative encephalopathy or major complications. Late rebleeding which occurs in esophageal varices, occurred in one patient who was managed by using endoscopic treatment.
The Changing Spectrum of Treatment for Variceal Bleeding
Annals of Surgery, 1998
The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage. Summary Background Data Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures.
Portal vein thrombosis in cirrhosis with variceal hemorrhage
Journal of Gastrointestinal Surgery, 1997
Organized thrombus in the main tnmk of the portal vein was encountered in 85 (6.5%) of 1300 patients with cirrhosis and variceal hemorrhage who underwent direct portacaval shunt (PCS). The thrombus was successfully removed with restoration of portal blood flow in all patients by phlebothrombectomy and balloon catheter extraction. Of the 85 patients, 65 were among 400 unselected patients who underwent emergency PCS (16%), and 20 were among 900 selected patients who underwent elective PCS (2%). All patients were closely followed for at least 5 years. Patients with portal vein thrombosis (PVT) had more advanced liver disease than those without PVT, reflected preoperatively in significantly higher (P <0.01) incidences of ascites (75%), severe muscle wasting (52 %), varices of very large size (94%), the hyperdynamic state (94%), severe hypersplenism with a platelet count of less than 50,000/mm 3 (92%), and placement in Child's class C (52%). Side-to-side PCS reduced the portal vein-inferior vena cava pressure gradient to a mean of 23 mm saline solution in patients with PVT, similar to the marked pressure reduction obtained in patients without PVT. PCS promptly stopped variceal bleeding in all patients in the emergency PCS group. Permanent prevention of recurrent variceal bleeding was successful in 95% of patients with PVT and more than 99% of patients without PVT. Survival rates were similar in patients with and without PV-E In patients with PVT, survival rates at 30 days and 1, 5, 10, and 15 years following emergency PCS were 69%, 66%, 65%, 55 %, and 51%, respectively, and following elective PCS were 95%, 90%, 70%, 65%, and 60%, respectively. Quality of life was similar in patients with and without PVT. Long-term PCS patency was demonstrated yearly in 93% of patients in the group with PVT and in 99.7% of patients without PVT. Other similarities after 5 years between patients with and without PVT, respectively, were the incidences of recurrent encephalopathy (9% vs. 8%), alcohol abstinence (61% vs. 64%), improved liver function (68% vs. 62% to 75%), and return to work (52% vs. 56% to 64%). It was concluded that in patients with cirrhosis and variceal hemorrhage it is almost always possible to remove portal vein thrombus by means of phlebothrombectomy and then perform a direct PCS with results similar to those achieved in the absence of PVT.
Evaluation of Splenic Embolization in Patients with Portal Hypertension and Hypersplenism
Annals of Surgery, 1982
Twenty-five patients with hypersplenism caused by portal hypertension were treated by repeated partial splenic embolization. Fourteen surviving patients were followed for up to six years showing a good response on peripheral blood count and bleeding tendency. Three patients died in connection with the treatment and another eight died within half a year because of the underlying liver disease. The discomfort and complications of fever, pain, pleural effusion, and abscess formation and the possibility to avoid these by repeated partial embolization under antibiotic cover are discussed. The results are compared with reports in the reviewed actual literature and the splenic embolization is given a place among the means of a successful selective symptomatic treatment of partial hypertension. nORTAL HYPERTENSION has four well-known complircations: bleeding esophageal varices, ascites, encephalopathy, and hypersplenism. In the past most of the interest has been focused on the bleeding varices and its prevention; the other complications have been more or less neglected. Today there is a tendancy to a more conservative-noninvasive-approach to portal hypertension in general. This has led surgeons and physicians including the authors to give more attention to the other complications and their treatment, selective symptomatic treatment (SST).3 A consequence of this is the new view on ascites, which in most cases can be managed by intensive diuretic treatment,'1 and if failure occurs, by peritoneal-venous shunting.28 Another consequence is the newly awaked interest in the transoesophageal sclerotherapy that has provided an outstanding tool for treatment ofbleeding oesophageal varices' '6; also in line with this is that alternative techniques for treatment of splenomegaly and hypersplenism are discussed.34 It has not been long since splenectomy was a hazardous procedure especially in patients with advanced portal hypertension and in patients with hematologic dis-