Transection of the oesophagus for bleeding oesophageal varices

Reductions in portal pressure by selective beta 2-adrenoceptor blockade in patients with cirrhosis and portal hypertension

In order to elucidate the mechanisms by which beta-adrenoceptor blockade leads to a reduction in portal pressure, we have measured portal pressure, heart rate and cardiac index in 17 patients with cirrhosis and portal hypertension following the oral administration of the selective beta 2-adrenoceptor blocking agent, ICI 118551, in the two dosage ranges 10-20 mg and 50-100 mg. There was a fall in portal pressure in 14 of the 17 patients from a median of 17 mm Hg to a median of 15 mm Hg, P less than 0.01, that occurred only at 60 min following administration of the drug. Although there were early systemic haemodynamic changes, with a significant fall in heart rate and cardiac index from before to 30 min after the ingestion of ICI 118551 (median heart rates 86 and 80 beats/min respectively, P less than 0.01, median cardiac indices 3.5 and 3.31 min-1 m-2, P less than 0.05), these occurred before the fall in portal pressure and were unrelated to changes in portal pressure. This reduction in portal pressure independent of systemic haemodynamic changes is consistent with beta 2-adrenoceptor blockade within the splanchnic and hepatic arterial circulations; subsequent increases in splanchnic and hepatic arterial resistances with a concomitant fall in portal blood flow and hepatic portal resistance may lead to the reduction in portal pressure.

Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis

Celiotomy in cirrhotic patients is reported to bear a high risk of operative morbidity and mortality. We reviewed 100 consecutive, cirrhotic patients who underwent nonshunt celiotomy. Thirty patients died and major complications occurred in another 30 patients. Hospital mortality rate was 21% in 39 biliary operations, 35% in 26 procedures for peptic ulcer disease, and 55% in nine colectomies . Fifty-two variables were compared between survivors without complication, survivors with complications, and nonsurvivors. A computer-generated, multivariant discriminant analysis yielded an equation predictive of survival. Utilizing coagulation parameters, presence of active infection, and serum albumin, the equation predicted survival with 89% accuracy. In a similar fashion, amount of operative transfusions, absence of postoperative ascites, pulmonary failure, gastrointestinal bleeding, and culture-positive urine predicted survival with 100% accuracy. We conclude that celiotomy in the cirrhotic patient is truly associated with very high morbidity and mortality, and preoperative assessment can predict survival with 89% accuracy.

Injection sclerotherapy for oesophageal varices: a prospective randomised trial of different treatment schedules

A prospective randomised study to compare the efficacy and complications of injection sclerotherapy carried out at intervals of one week and three weeks up to the time obliteration of varices was achieved, was undertaken in 55 patients (48 cirrhosis, six portal vein thrombosis, one nodular regenerative hyperplasia). The number of courses of injection required for obliteration of the varices was not different in the two groups and despite a shorter time scale for obliteration in the weekly treated patients the frequency with which further episodes of bleeding occurred before that was not significantly less. Mucosal ulceration during the period required for obliteration was observed at endoscopy more frequently in the weekly treated patients but was not associated with a greater frequency of postinjection pain, dysphagia or of long term stricture formation.

Selective and non-selective beta receptor blockade in the reduction of portal pressure in patients with cirrhosis and portal hypertension

To elucidate the mechanisms by which beta receptor blockade leads to a reduction of portal pressure, 18 patients with cirrhosis and portal hypertension were given comparable doses of propranolol or metoprolol. The fall in portal pressure was more marked with propranolol together with a significant reduction in hepatic blood flow, which was not seen with metoprolol. No correlation between the reduction in cardiac output and the decrease in portal pressure or changes in hepatic blood flow could be elicited in each group, but there was a direct relationship between the decrease in hepatic blood flow and fall in portal pressure in the propranolol treated patients. The difference observed may be related to blockade of beta 2 vasodilator receptors in the splanchnic circulation which will occur only with propranolol and lead to a greater fall in splanchnic blood flow than will be produced by a reduction in cardiac output alone. Metoprolol, by maintaining effective hepatic blood flow, may be preferable to propranolol in patients with severely impaired liver function.

Controlled trial of propranolol for the prevention of recurrent variceal hemorrhage in patients with cirrhosis

We conducted a prospective randomized trial of propranolol for the prevention of recurrent variceal bleeding in 48 patients with cirrhosis of the liver. During a follow-up period of up to 21 months, 12 of 26 patients in the propranolol group and 11 of 22 in the control group had rebleeding from esophageal varices. There was no significant difference in rebleeding between the two groups. This contrasts with a previous report of the efficacy of propranolol in preventing recurrent gastrointestinal bleeding in alcoholic cirrhosis. The difference in results may be due to the inclusion in our study of patients with other causes of cirrhosis and more severe liver disease. Propranolol may not be indicated for the prophylaxis of variceal rebleeding in such patients, and we advocate that its use be limited at present to controlled clinical trials.

Factors affecting successful endoscopic sclerotherapy for oesophageal varices

Forty patients with bleeding oesophageal varices were studied during treatment by endoscopic sclerotherapy to discover what factors determine successful outcome. Large varices required more injections than small varices for obliteration, and rebleeding during treatment occurred only in patients with large varices. Radiological studies with sclerosant contrast mixture showed that in two groups of varices of comparable size, intravenous sclerosant was significantly more effective, leading to thrombosis in 8/10 as opposed to only 3/10 after paravasal injection (p less than 0.05). Intravenous contrast was rapidly cleared upwards, whereas paravasal contrast formed a rounded opacity alongside the vein that persisted for approximately 90 minutes, responsible for the complications of oesophageal ulceration and stenosis.

A prospective randomized study of two sclerotherapy techniques for esophageal varices

In a study designed to compare the efficacy and safety of two techniques of injection sclerotherapy, 40 patients (30 with cirrhosis and 10 with portal vein block) were randomly allocated to the sheath or free-hand technique. Although the former was associated with significantly less bleeding within the first 24 hr of injection (p less than 0.05) but more postinjection pain (p less than 0.05) and esophageal stricture, there was a trend toward earlier obliteration of varices. This was most marked over the first three courses of injection, and although frequency of rebleeding was not significantly less, none of the 11 episodes in the sheath group were fatal, compared to 5 of 15 bleeds in those injected by the free-hand technique (p less than 0.05).

Esophageal procedures to control bleeding from varices

Portal-systemic shunting of all types has failed to improve long-term survival in patients with bleeding esophageal varices and carries a high morbidity and prohibitive mortality in the emergency setting. Direct esophageal approaches are receiving renewed attention. Sclerotherapy promises to be the simplest, safest, and most effective treatment for acute bleeding. Rebleeding is frequent with this technique unless all the varices are subsequently obliterated. Even then, rebleeding may be a recurring hazard, albeit with reduced frequency and increasing interval. For the nonalcoholic patient with a significant life expectancy or in the young patient with cirrhosis, this can be a significant factor. Simple esophageal resection-transection using stapling devices is a rapidly accomplished, simple, and effective operative approach if combined with coronary vein ligation. This procedure deserves a trial earlier in such patients and in those who are failures of repeated sclerotherapy. Extensive esophagogastric devascularization preserving the paraesophageal veins--the Sugiura procedure--is a more extensive undertaking that is probably unnecessary for most and too dangerous for some. At present, it should be reserved for failures of other techniques. It shows promise of long-term effectiveness if performed safely on only certain patients.

The management of acute variceal haemorrhage

Sixty-two patients presented on 81 occasions with acute-oesophageal variceal haemorrhage. Bleeding required tamponade on or during that admission on 87 occasions and was successful in arresting haemorrhage in 93%. Employing a policy of management in which injection sclerotherapy was the main therapeutic option, control of haemorrhage was achieved on 89% of admissions with an admission mortality of 30%. These results are compared with other reported series.

Randomised, controlled study of transhepatic obliteration of varices and oesophageal stapling transection in uncontrolled variceal haemorrhage

Percutaneous transhepatic obliteration and surgical stapling transection of the oesophagus with the EEA gun were compared prospectively in the treatment of uncontrolled oesophageal variceal haemorrhage unresponsive to conservative measures. Twenty patients with cirrhosis, with a patient portal vein and who were considered suitable for general anaesthesia and surgery, were randomised to two treatment groups (10 patients each). Immediate arrest of haemorrhage was achieved in 17 patients (nine surgery, eight obliteration). In one other patient, stapling transection succeeded where attempted transhepatic obliteration failed, and in another patient obliteration succeeded where attempted transection had failed. One patient continued to bleed and died following attempts at both procedures. Two other patients also died in hospital, without rebleeding following surgery. Variceal rebleeding during the same hospital admission occurred in two patients in the obliteration group and in none after surgery. Oesophageal stapling transection compares very favourably with a non-surgical technique such as transhepatic obliteration of varices in the emergency treatment of uncontrolled variceal haemorrhage in patients with moderate liver failure.

Emergency endoscopic sclerotherapy for bleeding esophageal varices: a prospective study in patients not responding to balloon tamponade

To assess the efficacy of endoscopic paravariceal sclerotherapy (EPS) compared to balloon tamponade, 25 patients with massive hemorrhage from esophageal varices not responding to Sengstaken or Linton tube tamponade were treated by emergency EPS. None of the patients had received vasopressin. Immediate control of hemorrhage was achieved in 92%. Recurrent bleeding occurred in 17.4% of patients during their primary admission. Minor complications resulting from EPS were observed in three patients (12%): esophageal ulcer, esophageal stenosis, and pleural effusion. Ten patients (40%) died in the hospital, seven of them despite arrested hemorrhage. Fifteen patients were discharged and followed at 3-month intervals for a mean of 21.3 months (range, 8.8 to 29.7). During this period one death due to liver failure without recurrent hemorrhage and three rebleeding events in two patients were observed (rebleeding risk per patient month, 9.4 x 10(-3). We conclude that EPS is very effective in controlling acute bleeding from esophageal varices, even in poor risk patients with ineffective balloon tamponade.

Randomized controlled trial of injection sclerotherapy for bleeding oesophageal varices--an interim report

Oesophageal varices are the commonest cause of acute upper gastrointestinal bleeding in Egypt, due to the prevalence not only of schistosomiasis but also chronic hepatitis. Poor results of conventional treatment and shunt surgery led us to evaluate injection sclerotherapy, using fibreoptic endoscopy. In a controlled trial, 108 patients were randomly allocated to injection sclerotherapy or to conventional treatment (medical measures, with modified splenectomy and oesophagogastric devascularization in selected cases). We report the results in the first 108 patients, with a follow-up of 1-35 months. Fifty-three patients received injection sclerotherapy; 5 died (2 of recurrent bleeding) and 5 others had recurrent bleeding but were controlled by further injections. Thirty-six of the 55 control patients underwent surgery; 5 died (2 of recurrent bleeding) and 2 others developed recurrent bleeding. Further bleeding occurred in 12 of the 19 patients who were managed by medical measures alone, with 7 dying. These early results indicate that injection sclerotherapy can be effective in urgent and elective situations and that it appears to have advantages over conventional medical and surgical treatments.

Controlled trial of terlipressin ('Glypressin') versus vasopressin in the early treatment of oesophageal varices

In a randomised controlled trial the effect of intermittent bolus injection of triglycyl lysine vasopressin (terlipressin 'Glypressin') (2 mg that 6-hourly), an analogue of vasopressin, was compared with that of a constant peripheral intravenous infusion of vasopressin (0.4 units/Min) in the initial management of bleeding oesophageal varices in nineteen patients. Failure of vasopressin therapy was defined as continued bleeding of sufficient severity to necessitate the passage of a Sengstaken tube. Bleeding was controlled in 70% of patients treated with glypressin but in only 9% of patients given vasopressin. The glypressin group required significantly less blood after randomisation than the vasopressin group. Because of its efficacy, lack of side-effects, and ease of administration, glypressin appears to be valuable in the management of bleeding varices.

Does multiple injection sclerotherapy have a role in the long-term management of oesophageal varices?

Sixty-nine cirrhotic patients were treated by injection sclerotherapy for bleeding oesophageal varices, with an emergency hospital mortality, from all causes, of 29%. The treatment of 35 of these continued with elective, long-term injections alone: 9 have so far survived more than 3 years, the longest being 5 years 4 months. The risk factor for rebleeding per patient month was 0·03 and, with its minimal complications, long-term sclerotherapy can be recommended as an alternative to portasystemic shunts for all grades of liver disease.

A new posterior exposure of the splenic vein for an H-graft splenorenal shunt

A preliminary report is presented of a posterior exposure of the splenic vein allowing H-graft splenorenal shunt to be carried out without removing the spleen. The operation was successfully performed in 14 patients with portal hypertension due to schistosomal hepatic fibrosis, and this was associated with post-hepatitic cirrhosis in 5 of them. Dacron grafts were inserted in 8 patients and autologous internal jugular vein grafts in 6 patients. The long term follow-up of the patients (maximum 45 months) showed that recurrence of bleeding developed in 2 patients due to shunt thrombosis and one died. Complications occurred in 3 patients, including one patient who developed first grade encephalopathy. Shunt patency was demonstrated in 12 patients, including all the vein grafts.

Tamponade and injection sclerotherapy in the management of bleeding oesophageal varices

One hundred patients with bleeding oesophageal varices were randomized into two treatment groups after resuscitation. One group was managed by tamponade only (group 1); the other group (group 2) was treated by endoscopic injection of oesophageal varices. The patients in group 2 were further subdivided into 25 patients (group 2a), who had tamponade applied immediately after sclerotherapy, and 25 patients (group 2b), who had sclerotherapy without subsequent tamponade. Injection of varices controlled the acute bleeding episode more effectively than tamponade (74 per cent in group 2 v. 42 per cent in group 1). There was no significant difference in the overall mortality rate of the two groups, but group 2 had a significantly higher proportion of Child's grade C patients (38/50 v. 29/50 = 76 v. 58 per cent). If only Child's grade C patients are considered, 16 out of 29 (55 per cent) died in group 1, whereas only 12 out of 38 (32 per cent) died in group 2 (P less than 0.05). Tamponade applied after sclerotherapy had no demonstrable effect on the outcome of sclerotherapy. The long term follow-up of patients (maximum 4 years) showed that recurrence of bleeding was less in the sclerotherapy group (8.1 per cent) than in the tamponade only group (27.6 per cent; P less than 0.05).

Increased long-term survival in variceal haemorrhage using injection sclerotherapy. Results of a controlled trial

Analysis of 107 patients with cirrhosis and recent variceal haemorrhage included in a prospective randomised trial of endoscopic injection sclerotherapy showed that in the sclerotherapy group 22 (43%) of the 51 patients had episodes of haemorrhage during the period of treatment, but in only 4 did bleeding occur after the varices had been obliterated. This contrasts with episodes of bleeding in 42 (75%) of the 56 patients receiving standard medical management-a highly significant difference. The overall risk of bleeding per patient-month of follow-up was reduced threefold with sclerotherapy. Of 22 patients followed up for at least one year after obliteration of varices, 14 had no evidence of reappearance of varices within this period and, by means of cumulative life-analysis tables, survival was shown to be significantly improved in the sclerotherapy group.

Transhepatic embolization in patients with acute variceal hemorrhage

Control of acute variceal bleeding by transhepatic embolization was investigated in 14 patients with alcoholic liver disease. In these patients hemorrhage was unresponsive to general supportive measures, intravenous vasopressin and balloon tamponade. Embolization was performed using Gelfoam and a synthetic polymer, bucrylate. Acute hemorrhage was arrested in 86 percent of patients. Rebleeding after transhepatic embolization occurred in 35 percent of patients. There were three deaths from intraabdominal hemorrhage related directly to transhepatic embolization (21 percent). Six patients (43 percent) left the hospital alive. In a group of cirrhotic patients in whom transhepatic embolization was employed after traditional modes of therapy had failed to control variceal hemorrhage, mortality and rebleeding rates were high.

The acute treatment of haemorrhage from oesophageal varices: a comparison of oesophageal transection and staple gun anastomosis with mesocaval shunt

Two matched groups of 20 patients with bleeding oesophageal varices were treated by the same surgical team by either oesophagogastric transection and anastomosis using a mechanical stapling instrument or by mesocaval portosystemic shunt operation. Five of the patients treated by transection died postoperatively, 2 of the survivors developed portosystemic encephalopathy (PSE). 2 died later and 5 rebled. Seven of the patients who had a mesocaval shunt died postoperatively, 8 developed PSE, 3 died later and 4 rebled. It is concluded that oesophagogastric transection and anastomosis using a mechanical instrument is preferable to portal decompression for managing bleeding oesophageal varices in the urgent situation.

'Currents and clots'--an approach to the problem of acute variceal bleeding

The Sengstaken-Blakemore tube will frequently control haemorrhage from oesophageal varices but a large proportion of patients rebleed soon after removing the tube and the hospital mortality in these patients is high. It has been demonstrated that the passage of an electric current across a blood vessel wall will precipitate a thrombus on the positively charged electrode, leading to complete occlusion of the vessel. A direct current of 3.2 mA/cm2 of electrode passed for 1 h produced complete occlusion of the femoral vein in the dog, without arterial occlusion or adjacent tissue damage. A system of longitudinal flexible gold-plated strip electrodes was placed around the oesophageal component of a Sengstaken tube. The technique has been applied in 8 poor risk patients with active variceal bleeding; haemorrhage was arrested in 7 of these on removal of the tube.

Long term follow-up of interposition mesocaval shunting in portal hypertension

The long term results of 28 interposition mesocaval shunts performed between 1971 and 1975 are analysed over a follow-up period of 5-9 years. There were 6 emergency operations and 22 elective operations, with an overall operative mortality of 14.3 per cent and a 5-year survival for the complete series of 31.5 per cent (class A patients 55.5 per cent, class B 33 per cent and class C 0 per cent). Shunt patency at 7 months was 95 per cent but by 5 years this had fallen to 53 per cent. Further variceal bleeding occurred in 6 patients (31.5 per cent) in 4 of whom shunt occlusion was confirmed.

Endoscopic sclerotherapy in acute variceal hemorrhage

Acute variceal hemorrhage in patients with alcoholic cirrhosis and poor liver function is associated with a high mortality. A nonoperative treatment, endoscopic sclerotherapy, was employed in 22 patients with cirrhosis and poor liver function who had 24 episodes of acute variceal hemorrhage over a 20 month period. Portal hypertension was secondary to alcoholic cirrhosis in 21 patients and cystic fibrosis in 1 patient. Of the 24 patient admissions, 21 were of patients in Child's class C and 3 were class B. Endoscopic sclerotherapy was performed under endotracheal general anesthesia using a modified Negus rigid esophagoscope. The sclerosant (5 percent sodium morrhuate) was injected into all visible varices near the gastroesophageal junction using a MacBeth needle. Definitive control of variceal hemorrhage for the entire hospitalization was achieved in 19 of 24 admissions (79 percent). The in-hospital mortality for acute variceal bleeding was 29 percent; 81 percent of the patients were discharged after control of hemorrhage. There were two major and five minor complications related to sclerotherapy. Based on this preliminary experience it is concluded that injection sclerotherapy controls bleeding and reduces mortality associated with acute variceal hemorrhage in patients with poor liver function.

Prospective controlled trial of injection sclerotherapy in patient with cirrhosis and recent variceal haemorrhage

64 patients with cirrhosis and recent variceal haemorrhage were studied in a prospective randomised trial of injection sclerotherapy by means of a flexible oesophageal sheath. 12 (33%) of the 36 patients in the sclerotherapy group, suffered further bleeds from varices compared with 19 (68%) of the 28 patients receiving standard medical treatment. The risk of bleeding per patient-month of follow up decreased more than threefold with sclerotherapy and the number of patients rebleeding after 2, 6, and 12 months was significantly reduced (p < 0.05). 1-year survival without further bleeding improved significantly with sclerotherapy (46% compared with 6%, p < 0.02), although the difference in overall survival assessed by cumulative life-table analysis was not statistically significant. The main complication of the technique was the development of oesophageal ulcers in some patients.

Prospective comparison of two Sengstaken tubes in the management of patients with variceal haemorrhage

To compare the efficacy of two oesophageal tamponade tubes, 28 patients with endoscopically proven actively bleeding varices were randomly allocated to be intubated with either a newly available 4-lumen tube incorporating an extra lumen for oesophageal suction, or the modified 3-lumen Sengstaken tube. The patients and the nursing staff preferred using the 4-lumen tube and both aspiration pneumonias and balloon dysfunction occurred less frequently. Variceal haemorrhage was successfully controlled for the first 12 hours in most patients in the two treatment groups, although the incidence of re-bleeding at 48 hours after the tube had been deflated was high.

Clinical experience with silicone rubber grafts as shunts in portal hypertension

We report the use of a woven silicone rubber graft as an alternative prosthesis for a shunt in 8 patients with portal hypertension. Four patients were operated on as emergencies and 4 electively. In 4 cases the graft was used as a standard mesocaval H graft, in 2 as a portocaval H graft and in 2 cases it was used to simplify the Warren selective distal splenorenal shunt. The material has properties which make it a superior graft to existing prostheses and autogenous vein. Our results confirm the experience of others, that the poor risk patients do badly whatever form of shunt is performed, and of those who survive, the total portal shunt carries the risk of postoperative encephalopathy.

Fibreoptic endoscopy and the use of the Sengstaken tube in acute gastrointestinal haemorrhage in patients with portal hypertension and varices

The value of emergency upper gastrointestinal fibre-endoscopy, followed where required by the use of a modified Sengstaken tube, was studied during 84 episodes of acute bleeding in 75 patients who had evidence of portal hypertension with varices. The portal hypertension was due to alcoholic cirrhosis in 80% and to cryptogenic cirrhosis in 9% of the patients. By definition, varices were present in all patients, but in only 66% of episodes were the varices the cause of the bleed. The correct diagnosis of the source of bleeding was made at endoscopy in 89%. A Boyce modification of the Sengstaken-Blakemore tube was passed in 73% of the episodes of variceal bleeding. It effectively stopped the bleeding primarily in 85% of patients but was successful as a final definitive measure only in 46%. Furthermore, only 40% of the patients in whom the tube was passed, survived. Mortality rate could be related to the severity of the bleed and to hepatocellular dysfunction. Survival increased from 23% in those patients with jaundice, ascites, and encephalopathy on admission to 92% in those without these manifestations. The in-hospital survival rate was 52% in patients bleeding from varices and 64% in those bleeding from other causes, with an overall survival rate of 56%, indicating the poor prognosis in cirrhotic patients with gastrointestinal bleeding, irrespective of the cause.

Early experience with the Boerema button for bleeding oesophageal varices

Early experience with the use of the Boerema button for bleeding oesophageal varices is reported. A simplified technique for its insertion is described, and of the 6 patients so treated, only 1 died. No patient has re-bled in the short follow-up period available, and oesophageal appearances suggest that prolonged relief from bleeding can be anticipated. Further exploration of the button ligation transection technique is suggested not only for control of acute bleeding, but also for patients unsuitable for shunt surgery.

Interposition grafting for portal hypertension

During the past six years, thirty-seven patients underwent interposition graft shunting for thirty-three instances of bleeding from varices and five instances of intractable ascites, either electively (twenty-seven instances) or as an emergency (eleven instances). Autogenous jugular vein was used in twenty-five instances, homologous vena cava in nine, and Dacron in four. Portacaval and mesocaval anastomoses were done in equal numbers (nineteen). Using Childs' method of clinical evaluation, thirty-three patients were Class C and four Class B. There were five (13.2 per cent) early deaths with one (3.5 per cent) in the elective and four (36 per cent) in the emergency group. Twelve grafts were open at autopsy, fifteen at splenoportography, and seven assumed patent because patients were asymptomatic. Two Dacron grafts and two homografts thrombosed. There were ten late deaths, only one related to graft failure. Apparently, the operation controls ascites, with autogenous jugular vein being the ideal material. Interposition grafting is a simple, safe procedure that can be used for portal decompression in patients with bleeding varices.

Modified oesophagoscope for injecting oesophageal varices

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