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have led to various therapeutic approaches, including vasodilator therapy, portal-caval shunting procedures, and splenic transposition or splenopneumopexy to encourage development of additional portasystemic collaterals. Nonshunt procedures are discussed later in this chapter. NATURAL HISTORY OF CIRRHOSIS AND VARICEAL BLEEDING

Esophageal varices are asymptomatic until they bleed. Hemorrhage from varices is painless, sudden, and in many cases catastrophic. Until recently, the natural history of cirrhosis and that of variceal bleeding were uncertain. We now know that about 12% of cirrhotic patients develop varices that are demonstrable with conventional imaging and endoscopic techniques. Of these patients, one third experience an episode of

bleeding at some time with an associated mortality rate that is almost 60%. Those who survive the initial bleed have about a 30 to 50% risk of rebleeding within 6 weeks if no further therapy is given.1 ' The risk of dying appears to be the same with each episode of variceal bleeding. The relationships are shown in Figure 28-2 . If a patient survives an episode of variceal bleeding and the ensuing high-risk period (6 to 8 weeks), the subsequent risk of late rebleeding is similar to that reported for unselected cirrhotic patients or for cirrhotic patients with demonstrated varices. It is clear that if we hope to alter the natural history of cirrhosis and variceal bleeding, we must concentrate

Figure 28-2 Natural history of cirrhosis and bleeding esophageal varices. (From Voorhees, A.B.: Portal hypertension as I see it. In Child, C.G., III [ed.]: Portal Hypertension. Philadelphia, W.B. Saunders, 1974, p. 63, with permission.)

Blakemore Tube Placement

Figure 28-3 Diagrammatic placement of the Sengstaken-Blakemore tube. (From Hermann, R.E., and Traul, D.: Experience with the Sengstaken-Blakemore tube for bleeding esophageal varices. Surg. Gynecol. Obstet, 130:879, 1970, by permission of Surgery, Gynecology and Obstetrics.)

Figure 28-4 Transparent view of the endoscopic ligating device and distal gastroscope. The prototype device was built with threaded ends to attach directly to the endoscope. Note the tripwire (arrow), which runs retrograde through the biopsy channel and exits the biopsy channel entry port. The elastic O ring is positioned at the far end of the inner cylinder. (From Van Stiegmann, G., and Goff, S.F.: Endoscopic esophageal varixligation: Preliminary clinical experience. Gastrointest. Endosc., 34:113, 1988, with permission.)

Figure 28-5 A, The endoscopist approaches the target varix and obtains 360-degree tissue contact between the target and the end of the inner cylinder. Endoscopic suction is activated at this point. B, Endoscopic suction has drawn the target varix fully inside the inner (ligating) cylinder. Once endoscopic "red-out" has occurred, the tripwire is pulled, moving the inner cylinder toward the endoscope and releasing the elastic O ring around the neck of the varix. C, The ligated varix is discharged from the cylinder by withdrawing the endoscope 2 to 3 cm and insufflating air. The endoscope and device are withdrawn and reloaded and further ligations are performed. This sequence is facilitated by use of an endoscopic overtube. (From Van Stiegmann, G., and Goff, S.F.: Endoscopic esophageal varix ligation: Preliminary clinical experience. GastrointesL Endosc., 34:113, 1988, with permission.)

Figure 28-5 A, The endoscopist approaches the target varix and obtains 360-degree tissue contact between the target and the end of the inner cylinder. Endoscopic suction is activated at this point. B, Endoscopic suction has drawn the target varix fully inside the inner (ligating) cylinder. Once endoscopic "red-out" has occurred, the tripwire is pulled, moving the inner cylinder toward the endoscope and releasing the elastic O ring around the neck of the varix. C, The ligated varix is discharged from the cylinder by withdrawing the endoscope 2 to 3 cm and insufflating air. The endoscope and device are withdrawn and reloaded and further ligations are performed. This sequence is facilitated by use of an endoscopic overtube. (From Van Stiegmann, G., and Goff, S.F.: Endoscopic esophageal varix ligation: Preliminary clinical experience. GastrointesL Endosc., 34:113, 1988, with permission.)

Figure 28-6 A, Modified Ross needle is advanced from a hepatic to a portal vein via a transjugular approach (arrows indicate hepatofugal flow in an enlarged coronary vein). B, Guidewire is advanced through the needle into the superior mesenteric vein. C, An 8-mm angioplasty balloon is advanced over the guidewire and expanded across hepatic parenchymal tract. D, Palmaz stent, mounted on an 8-mm angioplasty balloon, is expanded to bridge hepatic and portal veins. E, Final appearance of stent resulting in an intrahepatic shunt from portal to hepatic vein. Coronary vein is smaller and demonstrates return to hepatopetal flow. (From Zemel, G., Katzen, B.T., Becker, G.J., et al.: Percutaneous transjugular portosystemic shunt. JAMA, 266:390, 1991, with permission.)

Rectum Transposition

Figure 28-7 Selective transplenic decompression of gastroesophageal varices via (A) distal splenorenal shunt or (B) splenic transposition. Analogy between the two techniques is illustrated by the schematic drawings. (From Hastbacka, J.: Thoracic transposition of the spleen in portal hypertension. Ann. Chir. Gynaecol., 60:54, 1971, with permission.)

Figure 28-7 Selective transplenic decompression of gastroesophageal varices via (A) distal splenorenal shunt or (B) splenic transposition. Analogy between the two techniques is illustrated by the schematic drawings. (From Hastbacka, J.: Thoracic transposition of the spleen in portal hypertension. Ann. Chir. Gynaecol., 60:54, 1971, with permission.)

Figure 28-8 The technique of splenopneumopexy establishes splenothoracic collaterals in patients with portal hypertension and gastroesophageal varices. A, A 10-cm circular segment of diaphragm is excised, exposing the superior pole of the spleen. The spleen is sutured circumferentially to the diaphragm to decrease ascites leak or herniation of intra-abdominal contents into the thoracic cavity. Band C, Multiple longitudinal furrows are created by excising the splenic capsule and overlying peritoneum. Strips of retained capsule help to secure the sutures placed between the splenic parenchyma and lung. D, A rim of lung tissue is sutured to the posterior aspect of a previously created defect in the diaphragm. The lung is abraded with a bone rasp to produce moderate bleeding and air leakage. E, Ten to 12 deep, absorbable sutures are placed between the lung tissue and the splenic parenchyma to ensure close apposition of these surfaces, thus encouraging the formation of collaterals. F, The anterior and lateral lung edges are secured to the cut edge of the corresponding section of diaphragm.

Spleen Devascularization
Figure 28-9 Normal anatomy of the upper abdomen and gastroesophageal area before devascularization.
Spleen Devascularization

Figure 28-10 The anatomy of the upper abdomen after extensive paraesophagogastric devascularization and splenectomy. The entire abdominal esophagus and 6 to 8 cm of thoracic esophagus are devascularized by dividing the "shunting" veins and by preserving the major portal azygous collaterals. The stomach is devascularized distally to the level of the crow's foot along the lesser curvature and to the midpoint of the greater curvature. Splenectomy Is performed routinely with this particular technique.

Esophageal Transection Varices

Figure 28-11 The technique of esophageal transection and reanastomosis. An EEA stapling instrument is inserted through a proximal gastrotomy incision. The esophagus is transected approximately 2 cm above the gastroesophageal junction. The excised rings of tissue should be inspected carefully for completeness. The gastrotomy incision is closed in layers.

References Pathogenesis

1. Conn, H.O.: The volcano varix connection (Editorial). Gastroenterology, 79:1333, 1980.

2. Lebrec, D., De Fleurry, P., Reuff, B., et al.: Portal hypertension, size of esophageal varices, and the risk of gastrointestinal bleeding in alcoholic cirrhosis. Gastroenterology, 79:1139, 1980.

3. Leevy, C.M., Zinke, M., Baber, J., et al.: Observations on the influence of medical therapy on portal hypertension in hepatic cirrhosis. Ann. Intern. Med., 49:837, 1958.

4. Vianna, A., Hayes, P.C., Moscosco, G., et al.: Normal venous circulation of the gastroesophageal junction. A route to understanding varices. Gastroenterology, 98:876, 1987.

Etiology

5. Cameron, J.L., and Maddrey, W.: Meso-atrial shunt: A new treatment for Budd-Chiari syndrome. Ann. Surg., 187:402, 1978.

6. Huet, P.M., Villineuve, J.P., and Pomier-Layrargues, G.: Hepatic circulation in cirrhosis. Clin. Gastroenterol., 14:155, 1985.

7. Leevy, C.M.: Fatty liver: A study of 270 patients with biopsy-proven fatty liver and a review of the literature. Medicine, 41:249, 1982.

8. Nadell, J., and Kosek, J.: Peliosis hepatis: Twelve cases associated with oral androgen therapy. Arch. Pathol. Lab. Med., 101:405, 1977.

9. Orloff, M., and Johansen, K.: Treatment of Budd-Chiari syndrome by side-to-side portacaval shunt: Experimental and clinical results. Ann. Surg., 188:494, 1978.

Pathophysiology: Implications for Treatment

10. Siegel, J.H., Giovannini, I., Coleman, B., et al.: Death after portal decompressive surgery: Physiologic state, metabolic adequacy and the sequence of development of the physiologic determinants of survival. Arch. Surg., 116:1330, 1981.

11. Zimmon, D.S., and Kessler, R.E.: Effect of portal venous blood flow diversion on portal pressure. J. Clin. Invest., 65:1388, 1980.

Natural History of Cirrhosis and Variceal Bleeding

12. Graham, D.Y., and Smith, J.L.: The course of patients after variceal hemorrhage. Gastroenterology, 80:800, 1981.

Diagnosis

13. Gill, R.A., Goddman, M.W., Golfus, G.R., et al.: Aminopyrine breath test predicts surgical risk for patients with liver disease. Ann. Surg., 198:701, 1983.

14. Henderson, J.M., Kutner, M.H., and Bain, R.P.: First order clearance of plasma galactose: The effect of liver disease. Gastroenterology, 83:1090, 1982.

15. McLeod, M.K., Eckhauser, F.E., and Turcotte, J.G.: Significance of corrected sinusoidal pressure (CSP) in patients with cirrhosis and portal hypertension. Ann. Surg., 194:562, 1981.

16. Moriyasu, F., Nishida, O., Ban, N., et al.: Measurement of portal vascular resistance in patients with portal hypertension. Gastroenterology, 90:710, 1986.

17. Sarfeh, I.J., Juler, G.L., Stemmler, E.A., et al.: Results of surgical management of hemorrhagic gastritis in patients with gastroesophageal varices. Surg. Gynecol. Obstet., 155:167, 1982.

Pharmacologic Therapy

18. Aronse, K.F., and Nylander, G.: The mechanism of vasopressin hemostasis in bleeding esophageal varices: An angiographic study in the dog. Acta Chir. Scand., 131:443, 1966.

19. Barbare, J.C., Poupon, R., Jaillon, P., et al.: The influence of vasoactive agents on the metabolic activity of the liver in cirrhosis: A study of the effects of posterior pituitary extract, vasopressin and somatostatin. Hepatology, 4:59, 1984.

20. Bosch, J., Kravetz, D., and Rodes, J.: Effects of somatostatin on hepatic hemodynamics in patients with cirrhosis of the liver: Comparison with vasopressin. Gastroenterology, #0:518, 1981.

21. Chojkier, M., Groszmann, R., Atterbury, C., et al.: A controlled comparison of continuous intra-arterial and intravenous infusion of vasopressin in hemorrhages from esophageal varices. Gastroenterology, 77:540, 1979.

22. Groszmann, R.J., Kravetz, D., Bosch, J., et al.: Nitroglycerin improves the hemodynamic response to vasopressin in portal hypertension. Hepatology, 2:562, 1982.

23. Johnson, W., Widrich, W., Ansell, J., et al.: Control of bleeding varices by vasopressin: A prospective, randomized study. Ann. Surg., 180:369, 1977.

24. Kehne, J., Hughes, F., and Gompertz, M.: The use of pituitrin in the control of esophageal varix bleeding: An experimental study and report of two cases. Surgery, 39:917, 1956.

25. Valenzuela, J.E., Schubert, T., Fogel, M.R., et al.: A multicenter randomized double blind trial of somatostatin in the management of acute hemorrhage from esophageal varices. Hepatology, 10:958, 1989.

26. D'Amico, G., Pugliaro, L., and Bosch, J.: The treatment of portal hypertension: A meta-analytic review. Hepatology, 22:332, 1995.

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