Abstract
The management of esophageal variceal hemorrhage ranges from conservative to surgical modalities. Before introduction of liver transplantation as a potentially curative therapy of the underlying etiology, decompressive portosystemic shunt operations have been the mainstay of mostly palliative procedures Our own experience with surgery for advanced hepatic disease and portal hypertension over 20 years includes 803 liver transplantations and 201 portosystemic shunts, emphasizing our primary objective of treatment. The results after shunt surgery were favorable in Child class A candidates when performed electively and with selective decompression. After liver replacement the clinical status of the patient, including hepatic function and extrahepatic complications, had a strong influence on postoperative outcome, with the chance of excellent long-term survival. The additional risk of previous shunt surgery for subsequent transplantation could be reduced over time. Based on this experience and reports from others there are enough reasonable arguments for shunt and transplantation. Instead of the choice being controversial, the two forms of therapy should supplement each other and be available in the same center that specializes in the treatment of patients with diseases that eventually lead to liver failure and portal hypertension Selection of either approach must depend on etiology, stage of the disease, and proper timing. Shunt procedures may be indicated in stable patients with the risk of bleeding after sclerotherapy failure, in those with contraindications to transplantation, or as a bridge to transplantation. The role of liver transplantation has been clearly established in patients with progressive or endstage (otherwise intractable) hepatobiliary disease.
Résumé
La gamme thérapeutique de l'hémorragie par rupture de varices oesophagiennes comprend des mesures les unes conservatrices et les autres chirurgicales. Avant d'envisager la transplantation comme un moyen potentiellement curateur de l'étiologie sousjacente, les interventions visant la décompression du système portocave restent l'essentiel de l'arsenal thérapeutique palliatif. Notre expérience dans le traitement des maladies hépatiques avancées et de l'hypertension portale sur ces 20 dernières années comporte 803 transplantations hépatiques et 201 anastomoses portocaves, mettant l'accent sur nos objectifs de traitement primaire des maladies hépatiques Les résultats des anastomoses sont favorables lorsqui'il s'agit d'anastomose de décompression sélective, réalisée électivement, chez les patients du stade Child A. Après transplantation, hépatique, l'état clinique du patient, sa fonction hépatique, et la survenue de complications extrahépatiques ont fortement influencé l'évolution à court et à long terme. Avec l'expérience le risque supplémentaire encouru par une chirurgie de décompression antérieure est réduite. D'après notre expérience et la littérature, il existe des arguments en faveur des deux formes de traitement, qui, en fait, sont complémentaires. Les deux modalités devraient être idéalement disponibles dans le même centre traitant des patients ayant une maladie susceptible d'évoluer soit vers une insuffisance hépatique ou une hypertension portale. La sélection d'un ou de l'autre des procédés dépend de l'étiologie, du stade de la maladie, et du moment évolutif où la thérapeutique se discute. Les anastomoses portocaves sont indiquées plutôt chez le patient stable ayant un risque d'hémorragie après sclérothérapie, en cas de contreindication ou en attendant la transplantation. Le rôle de la transplantation est bien établi chez le patient ayant une maladie hépatique évolutive ou terminale, autrement incurable.
Resumen
El manejo de la hemorragia por várices esofágicas va desde una modalidad conservadora hasta la intervención quirúrgica. Antes de la introducción del trasplante de hígado como una forma de terapia potencialmente curativa de la causa etiológica primaria, las operaciones de descompresión porta-sistémicas eran la modalidad de preferencia entre los procedimientos quirúrgicos fundamentalmente paliativos.
Nuestra propia experiencia con la cirugía en pacientes con enfermedad hepática avanzada e hipertensión portal en más de 20 años, incluye 803 trasplantes hepáticos y 201 “shunts’ porta-sistémicos. Los resultados de los “shunts” fueron favorables en pacientes Child A, cuando fueron realizados en forma electiva y fueron del tipo de la descompresión selectiva. Luego de trasplante hepático, el estado clínico, del paciente, incluyendo la función hepática y las complicaciones extrahepáticas, demostró tener una fuerte influencia sobre el resultado postoperatorio, con excelente posibilidad de sobrevida a largo plazo. Se ha logrado reducir el riesgo adicional que representa un “shunt” realizado con anterioridad al trasplante.
Nuestra experiencia y los informes de otros autores constituyen suficiente y razonable argumentación en favor de la cirugía derivativa (“shunts”) y trasplante. En vez de plantear controversia, se considera que estas dos modalidades terapéuticas son complementarias.
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Ringe, B., Lang, H., Tusch, G. et al. Role of liver transplantation in management of esophageal variceal hemorrhage. World J. Surg. 18, 233–239 (1994). https://doi.org/10.1007/BF00294407
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DOI: https://doi.org/10.1007/BF00294407