Small-diameter mesocaval shunts: a 10-year evaluation

The use of small-diameter portosystemic shunts for the treatment of bleeding esophageal varices caused by portal hypertension has emerged as an outgrowth of the development of polytetrafluoroethylene vascular grafts, which allow the use of a narrow lumen. We report our experience with this type of graft over a 10-year period. Thirty-three patients with good liver function (Child-Pugh class A) were electively operated. The average age of these patients was 45 years (range 17 to 71 years). Twenty-nine patients had liver cirrhosis, one had portal fibrosis, and three had idiopathic portal hypertension. Operative mortality was 3%, and the rebleeding rate was 15%. Postoperative encephalopathy was observed in 14 patients (11%), three of whom had grade III to IV encephalopathy. The remaining 11 patients, had mild encephalopathy that was easily controlled. Postoperative angiography showed shunt patency in 81% of the patients, reduction in portal vein diameter in 33% of the patients, and portal vein thrombosis in 6%. Good postoperative quality of life was observed in 63% of the patients. Survival according to the Kaplan-Meier actuarial method was 81% at 12 months, 56% at 60 months, and 36% at 10 years. These shunts are a good alternative for patients being considered for surgery in whom other portal blood flow preserving procedures (i.e., elective shunts, devascularization with esophageal transection) are not feasible.

A comparative study of the elective treatment of variceal hemorrhage with beta-blockers, transendoscopic sclerotherapy, and surgery: a prospective, controlled, and randomized trial during 10 years

OBJECTIVE

To compare three options for the elective treatment of portal hypertension during a 10-year period.

METHODS

Patients included in the trial were 18 to 76 years old, had a history of bleeding portal hypertension, and had undergone no prior treatment. Treatment options were beta-blockers (propranolol), sclerotherapy, and portal blood flow-preserving procedures (selective shunts and the Sugiura-Futagawa operation).

RESULTS

A total of 119 patients were included: 40 in the pharmacology group, 46 in the sclerotherapy group,and 33 in the surgical group. The three groups showed no differences in terms of age, Child-Pugh classification, and cause of liver disease. The rebleeding rate was significantly lower in the surgical group than in the other two groups. The rebleeding rate was only 5% in the Child A surgical group, compared with 71% and 68% for the sclerotherapy and pharmacotherapy groups, respectively. Survival was better for the low-risk patients (Child A) in the three groups, but when the three options were compared, no significant difference was found.

CONCLUSIONS

Portal blood flow-preserving procedures offer the lowest rebleeding rate in low-risk patients undergoing elective surgery.

Biliary duct injury: partial segment IV resection for intrahepatic reconstruction of biliary lesions

A technique for intrahepatic reconstruction of the biliary tree after complex high injuries is described. The fundament of the procedure is the removal of a wedge of segment IV at the level of the hilar plate. When the hilar plate is reached and no adequate exposure of the ducts can be obtained, removing a 1 x 1-in wedge of segment IV between the gallbladder bed and the round ligament exposes the left and right ducts. An anteroposterior view of the plate is obtained instead of a caudocephalic dissection, exposing healthy, nonscarred ducts for reconstruction. We have used this approach in 22 patients, and adequate exposure of the ducts has been obtained, with a high success rate of patency of the anastomosis at a mean follow-up of 3 years. Twenty patients have a patent anastomosis, with a good quality of life and no restenosis.