Presented at the 51st Annual Meeting of the Society for Surgery of the Alimentary Tract during Digestive Disease Week, New Orleans, Louisiana, May 1–5, 2010.
Emergency treatment of bleeding esophageal varices in cirrhosis is of singular importance because of the high mortality rate. Emergency portacaval shunt is rarely used today because of the belief, unsubstantiated by long-term randomized trials, that it causes frequent portal-systemic encephalopathy and liver failure. Consequently, portacaval shunt has been relegated solely to salvage therapy when endoscopic and pharmacologic therapies have failed. Question: Is the regimen of endoscopic sclerotherapy with rescue portacaval shunt for failure to control bleeding varices superior to emergency portacaval shunt? A unique opportunity to answer this question was provided by a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt conducted from 1988 to 2005.
Unselected consecutive cirrhotic patients with acute bleeding esophageal varices were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup was completed and treatment was initiated within 8 h. Failure of endoscopic sclerotherapy was defined by strict criteria and treated by rescue portacaval shunt (n = 50) whenever possible. Ninety-six percent of patients had more than 10 years of follow-up or until death.
Comparison of emergency portacaval shunt and endoscopic sclerotherapy followed by rescue portacaval shunt showed the following differences in measurements of outcomes: (1) survival after 5 years (72% versus 22%), 10 years (46% versus 16%), and 15 years (46% versus 0%); (2) median post-shunt survival (6.18 versus 1.99 years); (3) mean requirements of packed red blood cell units (17.85 versus 27.80); (4) incidence of recurrent portal-systemic encephalopathy (15% versus 43%); (5) 5-year change in Child’s class showing improvement (59% versus 19%) or worsening (8% versus 44%); (6) mean quality of life points in which lower is better (13.89 versus 27.89); and (7) mean cost of care per year ($39,200 versus $216,700). These differences were highly significant in favor of emergency portacaval shunt (all p < 0.001).
Emergency portacaval shunt was strikingly superior to endoscopic sclerotherapy as well as to the combination of endoscopic sclerotherapy and rescue portacaval shunt in regard to all outcome measures, specifically bleeding control, survival, incidence of portal-systemic encephalopathy, improvement in liver function, quality of life, and cost of care. These results strongly support the use of emergency portacaval shunt as the first line of emergency treatment of bleeding esophageal varices in cirrhosis.
Graham DY, Smith H. The course of patients after variceal hemorrhage. Gastroenterology 1981; 80:800–809. PubMed
Smith JL, Graham DY. Variceal hemorrhage: a critical evaluation of survival analysis. Gastroenterology 1982; 82:968–973. PubMed
Burroughs AK, Mezzanotte G, Phillips A, McCormick PA, McIntyre N. Cirrhotics with variceal hemorrhage: the importance of the time interval between admission and the start of analysis for survival and rebleeding rates. Hepatology 1969; 9:801–807. CrossRef
Bornman PC, Krige JE, Terblanche J. Management of esophageal varices. Lancet 1994; 353:1079–1084. CrossRef
Khan S, Tudur Smith C, Williamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No. CD000553. doi: 10.1002/14651858. CD000553. Pub 2.
Mikkelsen WP. Therapeutic portacaval shunt. Preliminary data on controlled trial and morbid effects of acute hyaline necrosis. Arch Surg 1974; 108:302–305. PubMed
D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology 1995; 22:332–354. PubMed
Krige JE, Shaw JM, Bornman PC. The evolving role of endoscopic treatment of esophageal varices. Wld J Surg 2005; 29:966–973. CrossRef
Garcia N Jr, Sanyal AJ. Portal hypertension. Clin Liver Dis. 2001; 5:1–26. CrossRef
Grace ND. Diagnosis and treatment of gastrointestinal bleeding secondary to portal hypertension. Am J Gastroenterol. 1997; 92:1081–1091. PubMed
Khan S, Tudur Smith C, Williamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database Syst Rev. 2006:CD000553.
Pagliaro L, Burroughs AK, Sorensen TI, Lebrec D, Morabito A, D’Amico G, Tine F. Therapeutic controversies and randomized controlled trials (RCTs): prevention of bleeding and rebleeding in cirrhosis. Gastroenterology International 1989; 2:71–84.
Rikkers LF, Jin G. Emergency shunt. Role in the present management of variceal bleeding. Arch Surg. 1995; 130:472–477. PubMed
Orloff MJ, Isenberg JI, Wheeler HO, Haynes KS, Jinich-Brook H, Rapier R, Vaida F, Hye RJ. Portal-systemic encephalopathy in a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt treatment of acutely bleeding esophageal varices in cirrhosis. Ann Surg 2009; 250:598–610.
Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, Gotzsche PC, Lang T. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med 2001; 134:663–694. PubMed
Orloff MJ, Orloff MS, Orloff SL, Rambotti M, Girard B. Three decades of experience with emergency portacaval shunt for acutely bleeding esophageal varices in 400 unselected patients with cirrhosis of the liver. J Am Coll Surg 1995; 180:257–272. PubMed
Child III, CG, Turcotte JG. Surgery and portal hypertension. In: The Liver and Portal Hypertension. Edited by CG Child III. W.B. Saunders, Philadelphia, pp. 1–85, 1964.
Orloff MJ, Orloff SL, Orloff MS. Portacaval shunts: side-to-side and end-to-side. In: Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery. P-A Clavien, MG Saar, Y Fong, eds. Springer-Verlag, Berlin Heidelberg, 2007, pp. 687–702. CrossRef
Eck NV. Kvoprosu o pbrevyazkie vorotnois veni. Prdvaritblmoye soobshtshjdmye. Voen Med Zh 1877; 130:1–2.
Hahn M, Massen O, Nencki M, Pavlov J. Die Eck’sche Fistel zwischen der untern Hohlvene und der Pfortader und ihre Folgen fuer den Organismus. Arch Exp Pathol Pharmacol 1893; 32:161–210. CrossRef
Ferguson JD. Hemodynamics in surgery for portal hypertension. Ann Surg 1963; 158:383–386. PubMed
Price JB, Voorhees AB Jr, Britton RC. Operative hemodynamic studies in portal hypertension. Arch Surg 1967; 95:843–852. PubMed
Burchell AR, Moreno AH, Panke WF, Nealon TF. Hemodynamic variables and prognosis following portacaval shunt. Surg Gynecol Obstet 1974; 138:359–369. PubMed
Price JB Jr, Britton RC, Voorhees AB Jr. The significance and limitations of operative hemodynamics in portal hypertension. Arch Surg 1967; 95:843–852. PubMed
Steegmuller KW, Marklin H-M, Hollis HW Jr. Intraoperative hemodynamic investigations during portacaval shunt. Arch Surg 1984; 119:269–273. PubMed
- Emergency Portacaval Shunt Versus Rescue Portacaval Shunt in a Randomized Controlled Trial of Emergency Treatment of Acutely Bleeding Esophageal Varices in Cirrhosis—Part 3
Marshall J. Orloff
Jon I. Isenberg
Henry O. Wheeler
Kevin S. Haynes
Robert J. Hye
Neu im Fachgebiet Chirurgie
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