Prevention of recurrent variceal bleeding - is surgical rescue the answer?

Article Abstract:

Liver cirrhosis and portal hypertension, where there is increased pressure in the portal vein that brings blood to the liver, can lead to bleeding from enlarged veins in the lower esophagus. These swollen veins are called esophageal varices. An episode of bleeding from esophageal varices has a 50 percent chance of being fatal, because it typically involves massive hemorrhage. Because of the high mortality, therapies that will prevent variceal bleeding and improve survival have been sought. There are three major therapeutic options: shunt surgery, where the blood flow is redirected; sclerotherapy, where an irritant is applied which results in fibrosis or hardening of tissues; and treatment with drugs. A slightly higher survival rate was shown after shunt surgery in three of four clinical trials, and all four trials showed that shunt surgery prevented recurrent bleeding. There have been seven studies of sclerotherapy, which all showed that sclerotherapy reduced the frequency and severity of variceal bleeding. Only two trials showed an increase survival rate. Out of seven drug trials with propranolol or nadolol, four showed a reduction in recurrent bleeding, but no increase in survival. Five trials have compared the use of sclerotherapy with propranolol, with two trials showing sclerotherapy to be better than propranolol in preventing recurrent bleeding and the other three trials showing the two therapies to be equally effective. Another study was conducted to compare sclerotherapy with distal splenorenal shunt for preventing recurrent bleeding. The survival rate was better in patients who received sclerotherapy. However, this was due to the fact that 35 percent of those receiving sclerotherapy developed recurrent variceal bleeding and were further treated with surgery. The combination of sclerotherapy and surgical shunt resulted in greater chances of survival for patients with liver cirrhosis due to alcoholism but not with patients with non-alcoholic liver disease. However, the prevention of recurrent bleeding was better in the patients who received splenorenal shunt therapy compared with those who were treated with sclerotherapy. Three other studies comparing sclerotherapy with distal splenorenal shunt also showed less recurrent bleeding with surgical shunt. It appears that the treatment which yields better survival rates from recurrent variceal hemorrhage in liver cirrhosis due to alcoholism is sclerotherapy with surgical rescue, but trials using larger numbers of patients are needed to test this combination therapy further. (Consumer Summary produced by Reliance Medical Information, Inc.)

Health aspects, Adrenergic beta blockers, Adrenergic beta-antagonists, editorial

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Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis

Article Abstract:

Liver cirrhosis and portal hypertension, where there is increased pressure in the portal vein bringing blood to the liver, can cause esophageal varices. These enlarged and fragile veins can burst, causing massive hemorrhage that has a one in two chance of being fatal. There are three main therapeutic options for esophageal varices: shunt surgery, where the blood flow is redirected; sclerotherapy, where an irritant is applied which causes fibrosis or hardening of tissues; and treatment with drugs. A study of 72 patients was conducted to compare sclerotherapy with distal splenorenal shunt in terms of enhancing the chances of survival and preventing recurrent bleeding. The survival rate was better in patients who received sclerotherapy. However, this may be due to the fact that 13 of 37 patients who received sclerotherapy developed recurrent variceal bleeding and were further treated with surgery, which is referred to as surgical rescue. The combination of sclerotherapy and surgical shunt resulted in greater chances of survival for patients with liver cirrhosis due to alcoholism, but for patients with non-alcoholic liver disease, there was no difference between combined therapy and shunt alone. The prevention of recurrent bleeding was better in the patients who received splenorenal shunt therapy than in those who were treated with sclerotherapy. It appears that the best treatment to enhance survival from recurrent variceal hemorrhage in liver cirrhosis due to alcoholism is sclerotherapy with surgical rescue, but trials using greater numbers of patients are necessary to test this combination therapy further. (Consumer Summary produced by Reliance Medical Information, Inc.)

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The Emory perspective of the distal splenorenal shunt in 1990

Article Abstract:

Esophageal varices (enlarged, swollen and tortuous veins at the lower end of the esophagus) result from portal hypertension (increased pressure in the portal vein of the liver) caused by blood flow obstruction within the liver, usually due to cirrhosis. Distal splenorenal shunt (DSRS), a procedure that selectively decompresses varices while maintaining portal vein pressure and flow, may be used to control bleeding varices. Making a decisions regarding method of treatment of variceal bleeding requires weighing the risk of further bleeding against the risk of liver failure. Deciding if DSRS is a suitable treatment depends on the status of the patient's liver, which may be evaluated by angiography, X-ray examination of the blood vessels following injection of radio-opaque contrast dye. Studies at Emory University have shown DSRS to be successful in controlling bleeding in 88 to 97 percent of patients; in other studies success rates have ranged from 73 to 95 percent. Currently DSRS is the main treatment for variceal bleeding in patients who have portal vein thrombosis (abnormal condition in which clotting elements and cell debris accumulate and attach to a point on the interior wall of the vein) and patients with nonalcoholic cirrhosis who are good risks. DSRS should be the shunt procedure of choice for patients whose bleeding is not able to be controlled by sclerotherapy. The choice between DSRS and liver transplant must be based on careful evaluation of the patient. (Consumer Summary produced by Reliance Medical Information, Inc.)

Usage, Injuries, Surgery, Splenic vein

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