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Emergency and Elective Operations for Bleeding Esophageal Varices
Symposium on Gastrointestinal Surgery
Emergency and Elective Operations for Bleeding Esophageal Varices Ronald A. Malt, M.D. *
The source of hematemesis in adult patients with portal hypertension is often something other than varices - something like gastritis, peptic ulceration, or an esophageal tear. 30 Although fashion has decreed that these other sources predominate, the fashion is doubtless too extreme. It is based on the frequency with which gastritis is found by endoscopy in patients with portal hypertension who were expected to have had bleeding varices. But since gastritis may occur within a few minutes after a gastric tube is inserted for aspiration'or lavage, and since massive bleeding from varices selects against a patient's undergoing instant endoscopic examination, estimates of non variceal sites of bleeding are likely to have been exaggerated. Whether the margin of error is small or large is impossible to state.
EMERGENCY PROCEDURES Balloon Tamponade If a patient with varices vomits blood, he should be treated initially as if the bleeding were variceal. Balloon tamponade may control the situation at once and will not make other kinds of bleeding worse. Endoscopy and angiography should follow. 15 • 24 A change in diagnosis is warranted if these studies show another abnormality that is bleeding to an extent consistent with that of the hematemesis. Barium-contrast radiograms have limited use in the emergency situation.24 As long as tamponade stops bleeding, it makes little difference what kind of balloon tube is inserted while the patient is in the emergency ward. After a sure diagnosis is made, it makes considerable difference, for, in a way, the choice of tube dictates subsequent treatment. Only two types of tubes should be used beyond the emergency period: the Boyce modification of the Sengstaken-Blakemore tube,6. 32 which has an additional tube tied alongside its upper portion to allow aspiration of 'Visiting Surgeon and Chief of Gastroentero!ogical Surgery, Massachusetts General Hospital, Boston
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oronasopharyngeal secretions, or tubes of the Linton21 type, which have an integral lumen for aspiration. The choice between the two kinds is personal. The surgeon choosing the Linton-type tubes must remember to proceed to the next step in treatment within 24 hours to avoid the possibility of pressure necrosis at the esophagogastric junction from the weight that is applied to the tubes to make them effective. The Sengstaken tube can remain inflated longer, without fraction. Precautions for the correct use of all tubes are given elsewhere.B• 24
Vasopressin Infusion Our radiologists have had about 80 per cent success with few complications in several hundred trials of selective intraarterial vasopressin for the control of variceal.bleeding (S. Baum, unpublished data). I prefer to start that treatment as soon as possible after tamponade is begun. 4 • 9 The deflated tube is left in place as added insurance for 48 hours. Since selective arteriographic infusions have become feasible, I rarely use intermittent intravenous Injection of vasopressin except as a momentary adjunct while organizing the equipment for balloon tamponade. If these emergency measures succeed, well and good. The patient can be brought into homeostasis for deliberate consideration of the best treatment. If they do not succeed, the choice lies between emergency ligation of varices and an emergency portasystemic shunt. The intraesophageal button of the Murphy type5 • 13 and injection of sclerosants via an esophagoscope17 have not been extensively used in this country. Ligation of Varices Transesophageal ligation may be chosen for the very good risk patients - those with serum albumin levels over 3.5 gm per dl, bilirubin levels below 2.0 mg per dl, and nearly normal prothrombin times-in the expectation that they will do well almost irrespective of the form of surgical therapy. Ligation may also be chosen for the poorest risk patients - those with albumin levels below 2.5 gm per dl, bilirubin levels over 3.0 mg per dl, and prothrombin times more than 4 seconds prolonged, and with encephalopathy or ascites - the tacit understanding being that any form of treatment is worth a chance for these patients who are nearly certain to die. In this hospital overall, the mortality of transesophageal ligation of varices in class A patients is nil, in class B patients 55 per cent, and in class C 90 per cent. 29 At St. Bartholomew's Hospital, London, 67 per cent of patients treated with Boerema-Crile transesophageal ligation died.35 The results of transabdominal ligation have been unpredictable. Linton's method of transthoracic ligation is technically quite satisfactory.2o The patient is put into a full left lateral thoracotomy position, and an approach is made either through the seventh rib or through the seventh intercostal space. An incision somewhat higher than might be expected is employed because ofthe frequency with which the diaphragm is elevated by ascites or by an enlarged liver. The lower esophagus is opened longitudinally between 2 pairs of 3 - 0 silk stay-sutures. Often
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the initial esophagotomy penetrates an anterior column of varices; if so, bleeding is controlled by immediate application of Allis clamps to the cut edges. The esophagotomy is extended across the esophagocardiac junction into the stomach for approximately 5 cm. After placement of further stay-sutures to permit retraction, each of the two columns of varices ordinarily identified is oversewn with continuous 2-0 chromic catgut on swaged-on needles (Ethic on No. 127). Because varices are submucosal, sutures must be placed deep into the firm submucosal layer of the esophagus to control the varices satisfactorily. Otherwise, sutures will slough within a few days, with inevitable resumption of bleeding. As the oversewn suture is carried down to the stomach, gastric varices are pulled into the field by tension on the last throw of catgut, and several centimeters of gastric varices are overrun. The stitch is then halted and reversed, with overs ewing to the point of initiation. Three layers of silk are used for longitudinal closure of the esophagus. We have not used esophageal transection to interrupt varices l2 ,33 and probably would not until proof of lower morbidity and of reliability in controlling bleeding gastric varices by this method is available. Emergency Shunts Because there has been no randomized prospective study of any of the emergency methods of treatment with the exception of balloon tamponade,32 the role of any measure is dictated by individual preference. I believe that an emergency shunt should often be done for the good risk patient who has unequivocally bled from esophageal varices. However, no portacaval shunt should be essayed unless a surgeon has reasonable confidence of being able to complete it within 2112 hours using less than 2 units of blood. Like trans esophageal ligation of varices, emergency portacaval shunt at present can be limited to the extremes of risk.!' 2,16,28 But for this operation to be considered, additional considerations must be invoked. The older the patient, the more likely he will be to suffer from chronic encephalopathy; 17, 37 a reasonable definition of older might be older than 45 years. The fatter the patient, the more difficulty any surgeon will find. The larger the palpable mass of regenerating liver, the greater the likelihood of technical difficulty and of failing to decompress the portal system. Constriction of the intrahepatic vena cava by a swollen liver will elevate the caval pressure and thus reduce the gradient from the portal vein to the vena cava. 43 In the absence of a satisfactory gradient to permit decompression, a shunt from the portal system to the right atrium or pulmonary artery may be the only alternative. 23 We had no fatalities in 15 consecutive emergency good-risk portacaval shunts and are now embarked on a randomized, prospective study, comparing this operation with an emergency interposition mesocaval shunt. Although the mesocaval shunt with an interposed Dacron prosthesis may reduce some of the technical difficulty and lessen the problem.ilf encephalopathy, this operation has not had wide enough use for its role to be identified. ll , 14
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ELECTIVE PROCEDURES From the Veterans Administration Hospitals study, data support the view that life is prolonged by an elective therapeutic portacaval shunt (one that is done for treatment of a bleeding episode).18 With this evidence and with the indication from the Boston Inter-hospital Liver Group's study that shunting is efficacious in prolonging life with a probability of 0.06 (termed "not significant" in the forthcoming offical BILG publication), one is on reasonable ground in recommending a shunt for somebody who has bled and who can withstand the operation. In contradistinction, the prophylactic portacaval shunt (a shunt in anticipation of bleeding) fails to prolong life, although it does prevent bleeding;IO, 19,34 patients with a prophylactic shunt compared with the unshunted group die of hepatic failure rather than recurrent bleeding. Despite the hallowed axiom that merely inducing the patient to refrain from drinking alcohol will prolong his life, observations fail to substantiate the wish. 38
•
-Portacaval Shunt Hypotensive spinal anesthesia may be used if unusual difficulty is anticipated, but, ordinarily, the mild degree of hypotension created with muscle relaxants is sufficient. Castor oil is given the day before the operation to evacuate feces. I use no antibiotics. Although a midline incision is used if there is any question of portal vein thrombosis, a subcostal incision is usually more convenient. The right costal margin is elevated approximately 20° with a folded blanket. The incision parallels the right costal margin at a sufficient distance to enable easy closure. At its medial extent the incision is through the left anterior rectus sheath, without division of the muscle, continuing laterally to the right to divide all of the musculature to the anterior axillary line. The falciform ligament is not divided, since the collateral venous drainage contained within it may be useful as a pathway of retrograde flow from the liver.3! There are usually filmy adhesions between the gallbladder and the omentum or the right colon, which need to be divided. The right colon is packed downward, and the viscera of the left upper quadrant are packed away as well. A single deep retractor, either of the Deaver or the St. Mark's pelvic retractor type, is placed at the right margin of the wound and on the liyer, directly over the gallbladder. Although a large self-retaining ring retractor is a convenience, it is not necessary. Exposure is slightly improved by the reverse Trendelenberg position. The objective in the exposure is to bare only those structures that are to be joined. The vena cava and the portal vein are identified directly. Irrespective of the thickness and vascularity of the retroperitoneum, the cava is readily identified by unroofing it posterior to the duodenum (Fig. 1). The duodenum can usually be reflected with Kocher's maneuver without loss of blood, or, at the most, with necessity for dividing a few small blood vessels that can be coagulated with the diathermy current. As there is no need to uncover vast areas that are not to be used in the operation, likewise there is no need to expose the whole vena cava. Only the an-
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* Figure 1. Exposure of a limited portion of the vena cava and portal vein in preparation for a portacaval shunt, after the technique of McDermott.
terior and medial aspects of the cava are to be used in the ultimate anastomosis; only those areas need to be exposed. The vena cava is visually identified or ballotted under the reflected duodenum. A cut to the vena cava is made directly at right angles to the posterior abdominal wall and paraspinous area, and the peritoneum over the cava is divided longitudinally. Bleeding points from the retroperitoneal edges are often best handled by continuous whip stitches of 2-0 chromic catgut. Since the usual place at which the cava is first uncovered is just above the right renal vein, ordinarily the dissection progresses upward from the point at which the vena cava is first identified. The secret of identifying the portal vein is to have confidence that the 'vein is always the most posterior structure in the portal triad and that there are no tributaries on the anterior, lateral, or posterior aspects. There are usually only two medial tributaries, one of which is the coronary vein. Because, under most circumstances, these tributaries are close to the pancreas on the medial side of the portal vein, dissection over most of the working area can proceed without fear of tearing any tributaries to the vein. Like the vena cava, the portal vein in a patient with portal hypertension is a turgid, almost ballotable structure, compressible between the left index finger in the foramen of Winslow and the thumb above the portal triad (Fig. 2). With confidence that the portal vein is posterior and that it has been felt, exposure is obtained by having the assistant retract everything above the portal vein towards his side of the table with two peanut sponges held on the ends of curved clamps (see Fig. 1), as taught by McDermott.
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____ - Inf. Vena Cava Common Bile Duct Portal Vein ic Artery
Figure 2.
Location of the portal vein with respect to a finger in the epiploic foramen.
The operator's left index finger placed in the foramen of Winslow then withdraws the rather ill-defined posterior tissue larerally. Dissection with the scissors in the axis of the vein penetrates through thick lymphatics and small veins that usually need to be ligated, to stop at the first point where the blue of the portal vein is seen. Once the vein is identified, dissection progresses in a very limited range around this point, the plan being to encircle the vein in a small area. The only hazardous part is at the extreme medial aspect of the vein, where it is difficult to free the vein under direct vision; blind circumnavigation with a blunt right-angle clamp is often required. After the vein is encircled and retracted with a Penrose drain, further liberation from the surrounding structures can be accomplished rapidly. The maneuver that makes this portion of the operation speedy depends on confidence that there are no medial tributaries high on the portal vein. A right angle clamp is placed around the portal vein with its points open so that it functions as a pusher. The clamp with open blades is then pressed immediately next to the surface of the vein into the hilum of the liver, where it will be stopped by the bifurcation of the portal vein (Fig. 3). The vein is clamped caudad to the bifurcation, not on the bifurcation; ligatures on the bifurcation will not be secure. After the pancreatic end of the portal vein is controlled with a Potts clamp or a bulldog clamp, the portal vein is divided just beneath the right-angle clamp. A simple single tie of 0 silk above the clamp controls the hepatic end of the portal vein, provided that an adequate length of vein has been left distal to the bifurcation. With the portal vein divided, gentle traction permits ready exposure of any medial branches and division of any portion of the pancreas necessary to make the portal vein lie with good hemodynamic lines toward the inferior vena cava. Obviously, the vein should be anastomosed to the vena cava approximately 30° medial to the midline of the vena cava. Otherwise, the vein will be kinked as it passes from its medial position to be stretched to the midline. 25
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Three Judd-Allis clamps on the vena cava at the proposed site of anastomosis lift a generous portion of the vein wall for grasping with an angled Satinsky clamp. With the help of a right-angle Blakemore scissors, a generous ellipse of cava is removed. Whether the end-to-side anastomosis is performed with interrupted stitches, with everting stitches, with continuous stitches, or from the inside or the outside makes little difference as long as synthetic sutures are used and good techniques in vascular surgery are employed. I prefer 5-0 Tevdek or 5-0 Prolene as suture materials; if Tevdek is used, the suture should be impregnated with bone wax to make it slide easily through the fragile walls. Bone wax is applied by passing the suture through a small fragment of it and then removing excess by squeezing the suture between the thumb and index fingernails so that no visible wax remains, a technique taught by Linton. 22 The properly waxed suture lies straight and glides smoothly through the structures. If either a continuous everting mattress suture or an over-and-over suture is used in the posterior wall, a mattress stay suture is placed at the superior aspect of the anastomosis. With one end held for tension, the other end is used for the running stitch, snugging the two veins together as the stitch travels inferiorly. The stitch is then joined to a second suture also placed as a mattress stay suture at the inferior aspect of the anastomosis. The union is completed with a simple over-and-over stitch in the anterior lip. Shortly before completing the anastomosis, the clamp on the
* Figure 3. Clamping the hepatic end of the portal vein before division. A Potts clamp or other instrument will be placed on the caudal end of the vein before it is cut across.
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portal vein is opened to flush any clots from the portal vein. After the anastomosis is completed and the clamps are removed, there is rarely any bleeding that will not stop spontaneously. Because there is little correlation between pressure measurements made at the operating table and those found in a recumbent unanesthetized patient, there is not much point in meticulous pressure measurements at the operating table when a portacaval anastomosis is done. Practically the only exception is the situation in which the vena cava pressure is high relative to the portal pressure because of intrahepatic constriction. Patency of an anastomosis can otherwise be tested easily without pressure measurements by direct inspection of the currents of blood swirling through the anastomosis, by palpation of a thrill, or by actual invagination of the vena cava with the finger into the portal vein. Closure of the abdominal wall must be secure and absolutely watertight. Because of the danger of ascites leaking through suture holes that penetrate the entire thickness of abdominal wall, I do not use all-layer sutures. Either buried figure-of-eight no. 28 stainless steel sutures or 0 Polydek or Ethiflex sutures work well. Continuous chromic catgut in the subcutaneous tissue and a gently approximating continuous suture in the skin are rapid means of finishing the closure. Side-to-side shunts are not considered here because their principal utility is in the rare cases of massive ascites refractory to a good nonoperative program and in the Budd-Chiari syndrome. In uncomplicated portal hypertension, they are needlessly hard to perform, they have greater frequency of closure, overall they are associated with an increased chance of hepatic encephalopathy,39 and life expectancy is less than with end-to-side shunts (Boston Inter-hospital Liver Group, unpublished). Hazards and precautions in the postoperative period after an end-toside portacaval shunt are not appropriate to the discussion here. Large amounts of albumin or Albumisol may be required. No matter how big the abdomen becomes with ascites, to implicate thrombosis of the portal vein'as a cause is most improbable, despite the pronouncements of nonsurgical consultants. Even if the portal vein were thrombosed, the hemodynamic situation would be little changed from that found before the operation when portal pressure was high, but portal flow was sluggish. 27 Splenorenal and Mesocaval Shunts The two principal competitors to the portacaval shunt as an elective remedy for portal hypertension are the mesocaval shunt, mentioned earlier, and the splenorenal shunt. The relative advantages of each of these three major types of decompression have not been authoritatively defined and await a detailed, if difficult, study to differentiate them. Although there is less hepatic encephalopathy with the conventional splenorenal anastomosis and the mesocaval shunt than with the portacaval shunt, the selection of patients who undergo each kind of operation might be quite different. 18 , 26 Better-risk patients in the hands of more experienced surgeons tend to undergo mesocaval and splenorenal shunts; poorer-risk patients on ward services tend to undergo portacaval shunts. If these qualifications regarding selection are kept in mind, one can then state that the evidence suggests that patients with splenorenal
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shunts may have less encephalopathy, but a higher chance of rebleeding. On the other hand, they tolerate their rebleeding better than patients with portacaval anastomoses. One guide to prediction about which kind of shunt is better would be information on whether the portal system is interconnected everywhere or whether it is functionally compartmentalized into subsystems that need to be individually shunted,40 but facts are not available for human beings. The splenorenal shunt may be performed either through an incision wholly within the abdomen or through a thoracoabdominal approach. Though far easier through the thoracoabdominal approach,22 a shunt through this exposure adds the hazard of a diaphragmatic division in a patient who may accumulate ascites postoperatively, with attendant hazard of a left hydrothorax. Nonetheless, unless a surgeon does many splenorenal shunts, the difficulty of this operation usually makes it wiser to operate through an incision in the bed of the tenth rib with the left side of the patient propped at about 45° .22 Otherwise, good exposure is achieved through a midline or left paramedian incision continued at right angles under the left costal margin to open up the entire left upper quadrant. As the spleen is removed, the splenic vein is preserved carefully, with the objective of developing just enough of it consistent with its reaching the renal vein. After the spleen is out and traction is placed upon the stump of the splenic vein, every one of the pancreatic tributaries to the splenic vein must be individually isolated and ligated with 5-0 silk ties. Metal clips are appropriate on the pancreatic ends of these veins, but not on the splenic ends, where they tend to become dislodged by subsequent movement. The position of the renal vein is identified expeditiously either by projecting imaginary lines from the left kidney or by using the methods described by Warren.42 When the anastomosis is carried out, if it is convenient to do so, care may be given not to occlude the left renal vein completely with the side-biting pediatric Satinsky clamp. Despite attention in this respect, the vein is temporarily obstructed many times. This does not appear to be a major problem in patients with portal hypertension. When the splenic vein is considerably larger than 1 em in diameter, it makes little difference what kind of an anastomosis is performed - whether the posterior row is done from the inside or the outside, whether it is everting or continuous. If, however, the splenic vein is less than 1 cm in diameter, meticulous technique is necessary if patency is to be assured. From experience with this kind of anastomosis and from microvascular experience, the preferred type of union appears to be interrupted sutures of some kind; interrupted everting mattresses on the posterior layer and interrupted simple stitches on the anterior layer are probably best. Aside from the necessity of bringing the splenic vein to the renal vein with good hemodynamic lines, the other injunction is to avoid being so exuberant in freeing the splenic vein that redundant length is brought down. Buckling of the redundancy when the patient stands seems to be responsible for some instances of postoperative thrombosis. 25 A splenorenal anastomosis done by the techniques just described is a proximal, central splenorenal shunt because the largest portion of the splenic vein consistent with being anastomosed to the renal vein is
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employed. Although there may be advantage to performing a distal, selective splenorenal shunt, leaving the spleen in place as a collateral drainage for the stomach and the esophagus,1' 41. 42 the role of this modification, with or without division of the splenic artery, is, like practically all operations on the portal system at the moment, governed largely by opinion. With completion of a randomized prospective study being pursued by Warren, the situation may change. Although a direct mesocaval shunt is excellent for portal decompression in children, the Marion-Clatworthy mesocaval shunt is a poor choice for adults. Division .of the vena cava frequently produces incapacitating bilateral edema of the thighs and calves. The H-graft or interposition graft as the mesocaval shunt/I. 14 however, is a promising substitute. To practically everyone's surprise, the 19 to 22 mm Dacron vascular prosthesis between the inferior vena cava and the superior mesenteric vein remains patent. Creating a type of side-to-side shunt, it may combine advantages of a splenorenal shunt with even greater ease of performance than a portacaval shunt. The interposition shunt is expeditious in the patients whose right upper quadrant should be avoided for any reason: for example, previous operations, respiratory difficulties, and extreme obesity. Only a small segment of vena cava above the bifurcation and a few centimeters of superior mesenteric vein need to be exposed. I can add nothing to Drapanas' detailed exposition. l l There is little hope that the controversy surrounding this and almost every other aspect of the emergency treatment of portal hypertension will be put to rest without good randomized trials.
REFERENCES 1. Baird, R J., Tutassaura, H., and Miyagishima, R: Emergency portal decompression: a review of 31 patients operated upon via a midline approach. Arch. Surg., 103:73-75, 1971. 2. Balasegararn, M., and Damodaran, A.: Emergency shunt surgery for bleeding oesophagogastric varices. Austr. N. Z. J. Surg., 40:152-157,1970. 3. Barnes, B. A., Ackroyd, F. W., Battit, G. E., et al.: Elective portasystemic shunts. Morbidity and survival data. Ann. Surg., 174:76-84, 1971. 4. Baum, S., and Nusbaum, M.: The control of gastrOintestinal hemorrhage by selective mesenteric arterial infusion of vasopressin. Diag. Radiol., 98:497-505, 1971. 5. Boerema, I., Klopper, P. J., and Holscher, A. A.: Transabdorninalligation-resection of the esophagus in cases of bleeding esophageal varices. Surgery, 67:409-413, 1970. 6. Boyce, H. W., Jr.: Modification of the Sengstaken-Blakemore balloon tube. New Eng. J. Med., 267:195-196, 1962. 7. Britton, R. C., Voorhees, A. B., Jr., and Price, J. B., Jr.: Selective portal decompression. Surgery, 67:104-113, 1970. 8. Conn, H. 0.: The prognosis and management of bleeding esophageal varices. Ann. N. Y. Acad. Sci., 170:345-357,1970. 9. Conn, H. 0., Ramsby, G. R, and Storer, E. H.: Selective intraarterial vasopressin in the treatment of upper gastrointestinal hemorrhage. Gastroenterology, 63:634-645, 1972. 10. Conn, H. 0., Lindenmuth, W. W., May, C. J., et 31: Prophylactic portacaval anastomosis: a tale of two studies. Medicine, 51 :27-40, 1972. 11. Drapanas, T.: Interposition mesocaval shunt for treatment of portal hypertension. Ann. Surg., 176:435-448,1972. 12. George, P., Brown, C., Ridgway, G., et al.: Emergency oesophageal transection in uncontrolled variceal haemorrhage. Brit. J. Surg., 60:635-640, 1973. 13. Gignoux, M., Vewwaerde, J. C., Leteurtre, C., et al.: Ruptures de varices oesophagiennes: traitement par ligature sur bouton de Murphy. Med. Chir. Dig., 1 :315-320, 1972. 14. Gliedman, M. L., and Margulies, M.: The mesocaval shunt for portal decompression.
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In Haimovici, H. (ed.): The Surgical Management of Vascular Diseases, Philadelphia,
J. B. Lippincott Co., 1970. 15. Hedberg, S. E.: Endoscopy in gastrointestinal bleeding. SURG. CLIN. N. AMER., 54:549559, 1974. 16. Hoffman, D. C., Jepson, R P., and Harris, J. D.: Experiences with emergency porta-caval shunt. Aust. Ann. Med., 18:238-242,1969. 17. Hunt, P. S., Johnston, G. W., and Rodgers, H. W.: The emergency management of bleeding oesophageal varices with sclerosing injections. Brit. J. Surg., 56:305-307, 1969. 18. Jackson, F. C., Perrin, E. B., Felix, W. R, et al.: A clinical investigation of the portacaval shunt. V. Survival analysis of the therapeutic operation. Ann. Surg., 174:672-701,1971. 19. Jackson, F. C., Perrin, E. B., Smith, A. G., et al.: A clinical investigation of the portacaval shunt. II. Survival analysis of the prophylactic operation. Amer. J. Surg., 115 :22-42, 196B. 20. Linton, R R: The emergency treatment of massive bleeding from esophageal varices by transesophageal suture of these vessels at the time of acute hemorrhage. Surgery, 33:243-255, 1953. 21. Linton, R R: The treatment of esophageal varices. SURG. CLIN. N. AMER., 46:485-498, 1966. 22. Linton, R R: An Atlas of Vascular Surgery. Philadelphia, W. B. Saunders Co., 1973. 23. Luttwak, E. M., Charuzi, I., Licht, A., et al.: Emergency splenic vein-right-atrial shunt for massive esophageal hemorrhage with cirrhosis of liver and inferior vena cava occlusion: report of an operation and follow-up. Ann. Surg., 177:411-412, 1973. 24. Malt, R A.: Control of massive upper gastrointestinal hemorrhage. N. Eng. J. Med., 286: 1043-1046, 1972. 25. McDermott, W. V., Jr.: Postoperative liver failure and complications of shunt surgery. In Artz, C. P., and Hardy, J. D. (eds.): Complications in Surgery and their Management. Philadelphia, W. B. Saunders Co., 1967. 26. McDermott, W. V., Jr., Barnes, B. A., Nardi, G. L., et al.: Postshunt encephalopathy. Surg. Gynec. Obstet., 126:585-590, 1968. 27. Moreno, A. H., Burchell, A. R, Rousselot, L. M., et al.: Portal blood flow in cirrhosis of the liver. J. Clin. Invest., 46:436-445, 1967. 28. Orloff, M. J.: Emergency portacaval shunt: a comparative study of shunt, varix ligation and nonsurgical treatment of bleeding esophageal varices in unselected patients with cirrhosis. Ann. Surg., 166:456-478, 1967. 29. Ottinger, L. W., and Moncure, A. C.: Transthoracic ligation of bleeding esophageal varices in patients with intrahepatic portal obstruction. Ann. Surg., 179:35-38,1974. 30. Palmer, E. D.: The vigorous diagnostic approach to upper-gastrointestinal tract hemorrhage: a 23-year prospective study of 1,400 patients. J.A.M.A., 207:1477-1480,1969. 31. Panke, W. F., Rousselot, L. M., and Burchell, A. R: A sixteen-year experience with end-toside portacaval shunt for variceal hemorrhage: analysis of data and comparison with other types of portasystemic anastomoses. Ann. Surg., 168:957-965, 1968. 32. Pitcher, J. L.: Safety and effectiveness of the modified Sengstaken-Blakemore tube: a prospective study. Gastroenterology, 61 :291-298, 1971. 33. Pugh, R N. H., Murray-Lyon, I. M., Dawson, J. L., et al.: Transection of the oesophagus for bleeding oesophageal varices. Brit. J. Surg., 60:646-649, 1973. 34. Resnick, R H., Chalmers, T. C., Ishihara, A. M., et al.: A controlled study of the prophylactic portacaval shunt. Ann. Int. Med., 70:675-688, 1969. 35. Rothwell-Jackson, R L., and Hunt, A. H.: The results obtained with emergency surgery in the treatment of persistent haemorrhage from gastro-oesophageal varices in the cirrhotic patient. Brit. J. Surg., 58:205-215,1971. 36. Sherlock, S.: Diseases of the Liver and Biliary System, 4th ed. Philadelphia, F. A. Davis Company, 1968. 37. Sherlock, S., Hourigan, K., and George, P.: Medical complications of shunt surgery for portal hypertension. Ann. N. Y. Acad. Sci., 170:392-405,1970. 38. Soterakis, J., Resnick, R H., Iber, F. L., et al.: Effect of alcohol abstinence on survival in cirrhotic portal hypertension. Lancet, 2:65-67, 1973. 39. Turcotte, J. G., and Lambert, M. J., III: Variceal hemorrhage, hepatic cirrhosis, and portacaval shunts. Surgery, 73:810-817, 1973. 40. Waddell, E. G., Bouchard, A. G., Wellington, J. L., and Ewing, J. B.: Functional relations of the proximal portal manipulations. Can. J. Surg., 16:3-16, 1973. 41. Warren, W. D., Fomon, J. J., and Zeppa, R: Further evaluation of selective decompression of varices by distal splenorenal shunt. Ann. Surg., 169:652-660,1969. 42. Warren, W. D., Salam, A. A., Faraldo, A., et aI.: End renal vein-to-splenic vein shunts for total or selective portal decompression. Surgery, 72:995-1006, 1972. 43. Welling, R E., and McDermott W. V., Jr.: Combined caval and portal hypertension with cirrhosis of the liver: a problem in management. Ann. Surg., 177:164-166,1973. Massachusetts General Hospital Boston, Massachusetts 02114
Emergency and Elective Operations for Bleeding Esophageal Varices Ronald A. Malt, M.D. *
The source of hematemesis in adult patients with portal hypertension is often something other than varices - something like gastritis, peptic ulceration, or an esophageal tear. 30 Although fashion has decreed that these other sources predominate, the fashion is doubtless too extreme. It is based on the frequency with which gastritis is found by endoscopy in patients with portal hypertension who were expected to have had bleeding varices. But since gastritis may occur within a few minutes after a gastric tube is inserted for aspiration'or lavage, and since massive bleeding from varices selects against a patient's undergoing instant endoscopic examination, estimates of non variceal sites of bleeding are likely to have been exaggerated. Whether the margin of error is small or large is impossible to state.
EMERGENCY PROCEDURES Balloon Tamponade If a patient with varices vomits blood, he should be treated initially as if the bleeding were variceal. Balloon tamponade may control the situation at once and will not make other kinds of bleeding worse. Endoscopy and angiography should follow. 15 • 24 A change in diagnosis is warranted if these studies show another abnormality that is bleeding to an extent consistent with that of the hematemesis. Barium-contrast radiograms have limited use in the emergency situation.24 As long as tamponade stops bleeding, it makes little difference what kind of balloon tube is inserted while the patient is in the emergency ward. After a sure diagnosis is made, it makes considerable difference, for, in a way, the choice of tube dictates subsequent treatment. Only two types of tubes should be used beyond the emergency period: the Boyce modification of the Sengstaken-Blakemore tube,6. 32 which has an additional tube tied alongside its upper portion to allow aspiration of 'Visiting Surgeon and Chief of Gastroentero!ogical Surgery, Massachusetts General Hospital, Boston
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oronasopharyngeal secretions, or tubes of the Linton21 type, which have an integral lumen for aspiration. The choice between the two kinds is personal. The surgeon choosing the Linton-type tubes must remember to proceed to the next step in treatment within 24 hours to avoid the possibility of pressure necrosis at the esophagogastric junction from the weight that is applied to the tubes to make them effective. The Sengstaken tube can remain inflated longer, without fraction. Precautions for the correct use of all tubes are given elsewhere.B• 24
Vasopressin Infusion Our radiologists have had about 80 per cent success with few complications in several hundred trials of selective intraarterial vasopressin for the control of variceal.bleeding (S. Baum, unpublished data). I prefer to start that treatment as soon as possible after tamponade is begun. 4 • 9 The deflated tube is left in place as added insurance for 48 hours. Since selective arteriographic infusions have become feasible, I rarely use intermittent intravenous Injection of vasopressin except as a momentary adjunct while organizing the equipment for balloon tamponade. If these emergency measures succeed, well and good. The patient can be brought into homeostasis for deliberate consideration of the best treatment. If they do not succeed, the choice lies between emergency ligation of varices and an emergency portasystemic shunt. The intraesophageal button of the Murphy type5 • 13 and injection of sclerosants via an esophagoscope17 have not been extensively used in this country. Ligation of Varices Transesophageal ligation may be chosen for the very good risk patients - those with serum albumin levels over 3.5 gm per dl, bilirubin levels below 2.0 mg per dl, and nearly normal prothrombin times-in the expectation that they will do well almost irrespective of the form of surgical therapy. Ligation may also be chosen for the poorest risk patients - those with albumin levels below 2.5 gm per dl, bilirubin levels over 3.0 mg per dl, and prothrombin times more than 4 seconds prolonged, and with encephalopathy or ascites - the tacit understanding being that any form of treatment is worth a chance for these patients who are nearly certain to die. In this hospital overall, the mortality of transesophageal ligation of varices in class A patients is nil, in class B patients 55 per cent, and in class C 90 per cent. 29 At St. Bartholomew's Hospital, London, 67 per cent of patients treated with Boerema-Crile transesophageal ligation died.35 The results of transabdominal ligation have been unpredictable. Linton's method of transthoracic ligation is technically quite satisfactory.2o The patient is put into a full left lateral thoracotomy position, and an approach is made either through the seventh rib or through the seventh intercostal space. An incision somewhat higher than might be expected is employed because ofthe frequency with which the diaphragm is elevated by ascites or by an enlarged liver. The lower esophagus is opened longitudinally between 2 pairs of 3 - 0 silk stay-sutures. Often
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the initial esophagotomy penetrates an anterior column of varices; if so, bleeding is controlled by immediate application of Allis clamps to the cut edges. The esophagotomy is extended across the esophagocardiac junction into the stomach for approximately 5 cm. After placement of further stay-sutures to permit retraction, each of the two columns of varices ordinarily identified is oversewn with continuous 2-0 chromic catgut on swaged-on needles (Ethic on No. 127). Because varices are submucosal, sutures must be placed deep into the firm submucosal layer of the esophagus to control the varices satisfactorily. Otherwise, sutures will slough within a few days, with inevitable resumption of bleeding. As the oversewn suture is carried down to the stomach, gastric varices are pulled into the field by tension on the last throw of catgut, and several centimeters of gastric varices are overrun. The stitch is then halted and reversed, with overs ewing to the point of initiation. Three layers of silk are used for longitudinal closure of the esophagus. We have not used esophageal transection to interrupt varices l2 ,33 and probably would not until proof of lower morbidity and of reliability in controlling bleeding gastric varices by this method is available. Emergency Shunts Because there has been no randomized prospective study of any of the emergency methods of treatment with the exception of balloon tamponade,32 the role of any measure is dictated by individual preference. I believe that an emergency shunt should often be done for the good risk patient who has unequivocally bled from esophageal varices. However, no portacaval shunt should be essayed unless a surgeon has reasonable confidence of being able to complete it within 2112 hours using less than 2 units of blood. Like trans esophageal ligation of varices, emergency portacaval shunt at present can be limited to the extremes of risk.!' 2,16,28 But for this operation to be considered, additional considerations must be invoked. The older the patient, the more likely he will be to suffer from chronic encephalopathy; 17, 37 a reasonable definition of older might be older than 45 years. The fatter the patient, the more difficulty any surgeon will find. The larger the palpable mass of regenerating liver, the greater the likelihood of technical difficulty and of failing to decompress the portal system. Constriction of the intrahepatic vena cava by a swollen liver will elevate the caval pressure and thus reduce the gradient from the portal vein to the vena cava. 43 In the absence of a satisfactory gradient to permit decompression, a shunt from the portal system to the right atrium or pulmonary artery may be the only alternative. 23 We had no fatalities in 15 consecutive emergency good-risk portacaval shunts and are now embarked on a randomized, prospective study, comparing this operation with an emergency interposition mesocaval shunt. Although the mesocaval shunt with an interposed Dacron prosthesis may reduce some of the technical difficulty and lessen the problem.ilf encephalopathy, this operation has not had wide enough use for its role to be identified. ll , 14
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ELECTIVE PROCEDURES From the Veterans Administration Hospitals study, data support the view that life is prolonged by an elective therapeutic portacaval shunt (one that is done for treatment of a bleeding episode).18 With this evidence and with the indication from the Boston Inter-hospital Liver Group's study that shunting is efficacious in prolonging life with a probability of 0.06 (termed "not significant" in the forthcoming offical BILG publication), one is on reasonable ground in recommending a shunt for somebody who has bled and who can withstand the operation. In contradistinction, the prophylactic portacaval shunt (a shunt in anticipation of bleeding) fails to prolong life, although it does prevent bleeding;IO, 19,34 patients with a prophylactic shunt compared with the unshunted group die of hepatic failure rather than recurrent bleeding. Despite the hallowed axiom that merely inducing the patient to refrain from drinking alcohol will prolong his life, observations fail to substantiate the wish. 38
•
-Portacaval Shunt Hypotensive spinal anesthesia may be used if unusual difficulty is anticipated, but, ordinarily, the mild degree of hypotension created with muscle relaxants is sufficient. Castor oil is given the day before the operation to evacuate feces. I use no antibiotics. Although a midline incision is used if there is any question of portal vein thrombosis, a subcostal incision is usually more convenient. The right costal margin is elevated approximately 20° with a folded blanket. The incision parallels the right costal margin at a sufficient distance to enable easy closure. At its medial extent the incision is through the left anterior rectus sheath, without division of the muscle, continuing laterally to the right to divide all of the musculature to the anterior axillary line. The falciform ligament is not divided, since the collateral venous drainage contained within it may be useful as a pathway of retrograde flow from the liver.3! There are usually filmy adhesions between the gallbladder and the omentum or the right colon, which need to be divided. The right colon is packed downward, and the viscera of the left upper quadrant are packed away as well. A single deep retractor, either of the Deaver or the St. Mark's pelvic retractor type, is placed at the right margin of the wound and on the liyer, directly over the gallbladder. Although a large self-retaining ring retractor is a convenience, it is not necessary. Exposure is slightly improved by the reverse Trendelenberg position. The objective in the exposure is to bare only those structures that are to be joined. The vena cava and the portal vein are identified directly. Irrespective of the thickness and vascularity of the retroperitoneum, the cava is readily identified by unroofing it posterior to the duodenum (Fig. 1). The duodenum can usually be reflected with Kocher's maneuver without loss of blood, or, at the most, with necessity for dividing a few small blood vessels that can be coagulated with the diathermy current. As there is no need to uncover vast areas that are not to be used in the operation, likewise there is no need to expose the whole vena cava. Only the an-
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* Figure 1. Exposure of a limited portion of the vena cava and portal vein in preparation for a portacaval shunt, after the technique of McDermott.
terior and medial aspects of the cava are to be used in the ultimate anastomosis; only those areas need to be exposed. The vena cava is visually identified or ballotted under the reflected duodenum. A cut to the vena cava is made directly at right angles to the posterior abdominal wall and paraspinous area, and the peritoneum over the cava is divided longitudinally. Bleeding points from the retroperitoneal edges are often best handled by continuous whip stitches of 2-0 chromic catgut. Since the usual place at which the cava is first uncovered is just above the right renal vein, ordinarily the dissection progresses upward from the point at which the vena cava is first identified. The secret of identifying the portal vein is to have confidence that the 'vein is always the most posterior structure in the portal triad and that there are no tributaries on the anterior, lateral, or posterior aspects. There are usually only two medial tributaries, one of which is the coronary vein. Because, under most circumstances, these tributaries are close to the pancreas on the medial side of the portal vein, dissection over most of the working area can proceed without fear of tearing any tributaries to the vein. Like the vena cava, the portal vein in a patient with portal hypertension is a turgid, almost ballotable structure, compressible between the left index finger in the foramen of Winslow and the thumb above the portal triad (Fig. 2). With confidence that the portal vein is posterior and that it has been felt, exposure is obtained by having the assistant retract everything above the portal vein towards his side of the table with two peanut sponges held on the ends of curved clamps (see Fig. 1), as taught by McDermott.
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____ - Inf. Vena Cava Common Bile Duct Portal Vein ic Artery
Figure 2.
Location of the portal vein with respect to a finger in the epiploic foramen.
The operator's left index finger placed in the foramen of Winslow then withdraws the rather ill-defined posterior tissue larerally. Dissection with the scissors in the axis of the vein penetrates through thick lymphatics and small veins that usually need to be ligated, to stop at the first point where the blue of the portal vein is seen. Once the vein is identified, dissection progresses in a very limited range around this point, the plan being to encircle the vein in a small area. The only hazardous part is at the extreme medial aspect of the vein, where it is difficult to free the vein under direct vision; blind circumnavigation with a blunt right-angle clamp is often required. After the vein is encircled and retracted with a Penrose drain, further liberation from the surrounding structures can be accomplished rapidly. The maneuver that makes this portion of the operation speedy depends on confidence that there are no medial tributaries high on the portal vein. A right angle clamp is placed around the portal vein with its points open so that it functions as a pusher. The clamp with open blades is then pressed immediately next to the surface of the vein into the hilum of the liver, where it will be stopped by the bifurcation of the portal vein (Fig. 3). The vein is clamped caudad to the bifurcation, not on the bifurcation; ligatures on the bifurcation will not be secure. After the pancreatic end of the portal vein is controlled with a Potts clamp or a bulldog clamp, the portal vein is divided just beneath the right-angle clamp. A simple single tie of 0 silk above the clamp controls the hepatic end of the portal vein, provided that an adequate length of vein has been left distal to the bifurcation. With the portal vein divided, gentle traction permits ready exposure of any medial branches and division of any portion of the pancreas necessary to make the portal vein lie with good hemodynamic lines toward the inferior vena cava. Obviously, the vein should be anastomosed to the vena cava approximately 30° medial to the midline of the vena cava. Otherwise, the vein will be kinked as it passes from its medial position to be stretched to the midline. 25
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Three Judd-Allis clamps on the vena cava at the proposed site of anastomosis lift a generous portion of the vein wall for grasping with an angled Satinsky clamp. With the help of a right-angle Blakemore scissors, a generous ellipse of cava is removed. Whether the end-to-side anastomosis is performed with interrupted stitches, with everting stitches, with continuous stitches, or from the inside or the outside makes little difference as long as synthetic sutures are used and good techniques in vascular surgery are employed. I prefer 5-0 Tevdek or 5-0 Prolene as suture materials; if Tevdek is used, the suture should be impregnated with bone wax to make it slide easily through the fragile walls. Bone wax is applied by passing the suture through a small fragment of it and then removing excess by squeezing the suture between the thumb and index fingernails so that no visible wax remains, a technique taught by Linton. 22 The properly waxed suture lies straight and glides smoothly through the structures. If either a continuous everting mattress suture or an over-and-over suture is used in the posterior wall, a mattress stay suture is placed at the superior aspect of the anastomosis. With one end held for tension, the other end is used for the running stitch, snugging the two veins together as the stitch travels inferiorly. The stitch is then joined to a second suture also placed as a mattress stay suture at the inferior aspect of the anastomosis. The union is completed with a simple over-and-over stitch in the anterior lip. Shortly before completing the anastomosis, the clamp on the
* Figure 3. Clamping the hepatic end of the portal vein before division. A Potts clamp or other instrument will be placed on the caudal end of the vein before it is cut across.
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portal vein is opened to flush any clots from the portal vein. After the anastomosis is completed and the clamps are removed, there is rarely any bleeding that will not stop spontaneously. Because there is little correlation between pressure measurements made at the operating table and those found in a recumbent unanesthetized patient, there is not much point in meticulous pressure measurements at the operating table when a portacaval anastomosis is done. Practically the only exception is the situation in which the vena cava pressure is high relative to the portal pressure because of intrahepatic constriction. Patency of an anastomosis can otherwise be tested easily without pressure measurements by direct inspection of the currents of blood swirling through the anastomosis, by palpation of a thrill, or by actual invagination of the vena cava with the finger into the portal vein. Closure of the abdominal wall must be secure and absolutely watertight. Because of the danger of ascites leaking through suture holes that penetrate the entire thickness of abdominal wall, I do not use all-layer sutures. Either buried figure-of-eight no. 28 stainless steel sutures or 0 Polydek or Ethiflex sutures work well. Continuous chromic catgut in the subcutaneous tissue and a gently approximating continuous suture in the skin are rapid means of finishing the closure. Side-to-side shunts are not considered here because their principal utility is in the rare cases of massive ascites refractory to a good nonoperative program and in the Budd-Chiari syndrome. In uncomplicated portal hypertension, they are needlessly hard to perform, they have greater frequency of closure, overall they are associated with an increased chance of hepatic encephalopathy,39 and life expectancy is less than with end-to-side shunts (Boston Inter-hospital Liver Group, unpublished). Hazards and precautions in the postoperative period after an end-toside portacaval shunt are not appropriate to the discussion here. Large amounts of albumin or Albumisol may be required. No matter how big the abdomen becomes with ascites, to implicate thrombosis of the portal vein'as a cause is most improbable, despite the pronouncements of nonsurgical consultants. Even if the portal vein were thrombosed, the hemodynamic situation would be little changed from that found before the operation when portal pressure was high, but portal flow was sluggish. 27 Splenorenal and Mesocaval Shunts The two principal competitors to the portacaval shunt as an elective remedy for portal hypertension are the mesocaval shunt, mentioned earlier, and the splenorenal shunt. The relative advantages of each of these three major types of decompression have not been authoritatively defined and await a detailed, if difficult, study to differentiate them. Although there is less hepatic encephalopathy with the conventional splenorenal anastomosis and the mesocaval shunt than with the portacaval shunt, the selection of patients who undergo each kind of operation might be quite different. 18 , 26 Better-risk patients in the hands of more experienced surgeons tend to undergo mesocaval and splenorenal shunts; poorer-risk patients on ward services tend to undergo portacaval shunts. If these qualifications regarding selection are kept in mind, one can then state that the evidence suggests that patients with splenorenal
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shunts may have less encephalopathy, but a higher chance of rebleeding. On the other hand, they tolerate their rebleeding better than patients with portacaval anastomoses. One guide to prediction about which kind of shunt is better would be information on whether the portal system is interconnected everywhere or whether it is functionally compartmentalized into subsystems that need to be individually shunted,40 but facts are not available for human beings. The splenorenal shunt may be performed either through an incision wholly within the abdomen or through a thoracoabdominal approach. Though far easier through the thoracoabdominal approach,22 a shunt through this exposure adds the hazard of a diaphragmatic division in a patient who may accumulate ascites postoperatively, with attendant hazard of a left hydrothorax. Nonetheless, unless a surgeon does many splenorenal shunts, the difficulty of this operation usually makes it wiser to operate through an incision in the bed of the tenth rib with the left side of the patient propped at about 45° .22 Otherwise, good exposure is achieved through a midline or left paramedian incision continued at right angles under the left costal margin to open up the entire left upper quadrant. As the spleen is removed, the splenic vein is preserved carefully, with the objective of developing just enough of it consistent with its reaching the renal vein. After the spleen is out and traction is placed upon the stump of the splenic vein, every one of the pancreatic tributaries to the splenic vein must be individually isolated and ligated with 5-0 silk ties. Metal clips are appropriate on the pancreatic ends of these veins, but not on the splenic ends, where they tend to become dislodged by subsequent movement. The position of the renal vein is identified expeditiously either by projecting imaginary lines from the left kidney or by using the methods described by Warren.42 When the anastomosis is carried out, if it is convenient to do so, care may be given not to occlude the left renal vein completely with the side-biting pediatric Satinsky clamp. Despite attention in this respect, the vein is temporarily obstructed many times. This does not appear to be a major problem in patients with portal hypertension. When the splenic vein is considerably larger than 1 em in diameter, it makes little difference what kind of an anastomosis is performed - whether the posterior row is done from the inside or the outside, whether it is everting or continuous. If, however, the splenic vein is less than 1 cm in diameter, meticulous technique is necessary if patency is to be assured. From experience with this kind of anastomosis and from microvascular experience, the preferred type of union appears to be interrupted sutures of some kind; interrupted everting mattresses on the posterior layer and interrupted simple stitches on the anterior layer are probably best. Aside from the necessity of bringing the splenic vein to the renal vein with good hemodynamic lines, the other injunction is to avoid being so exuberant in freeing the splenic vein that redundant length is brought down. Buckling of the redundancy when the patient stands seems to be responsible for some instances of postoperative thrombosis. 25 A splenorenal anastomosis done by the techniques just described is a proximal, central splenorenal shunt because the largest portion of the splenic vein consistent with being anastomosed to the renal vein is
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employed. Although there may be advantage to performing a distal, selective splenorenal shunt, leaving the spleen in place as a collateral drainage for the stomach and the esophagus,1' 41. 42 the role of this modification, with or without division of the splenic artery, is, like practically all operations on the portal system at the moment, governed largely by opinion. With completion of a randomized prospective study being pursued by Warren, the situation may change. Although a direct mesocaval shunt is excellent for portal decompression in children, the Marion-Clatworthy mesocaval shunt is a poor choice for adults. Division .of the vena cava frequently produces incapacitating bilateral edema of the thighs and calves. The H-graft or interposition graft as the mesocaval shunt/I. 14 however, is a promising substitute. To practically everyone's surprise, the 19 to 22 mm Dacron vascular prosthesis between the inferior vena cava and the superior mesenteric vein remains patent. Creating a type of side-to-side shunt, it may combine advantages of a splenorenal shunt with even greater ease of performance than a portacaval shunt. The interposition shunt is expeditious in the patients whose right upper quadrant should be avoided for any reason: for example, previous operations, respiratory difficulties, and extreme obesity. Only a small segment of vena cava above the bifurcation and a few centimeters of superior mesenteric vein need to be exposed. I can add nothing to Drapanas' detailed exposition. l l There is little hope that the controversy surrounding this and almost every other aspect of the emergency treatment of portal hypertension will be put to rest without good randomized trials.
REFERENCES 1. Baird, R J., Tutassaura, H., and Miyagishima, R: Emergency portal decompression: a review of 31 patients operated upon via a midline approach. Arch. Surg., 103:73-75, 1971. 2. Balasegararn, M., and Damodaran, A.: Emergency shunt surgery for bleeding oesophagogastric varices. Austr. N. Z. J. Surg., 40:152-157,1970. 3. Barnes, B. A., Ackroyd, F. W., Battit, G. E., et al.: Elective portasystemic shunts. Morbidity and survival data. Ann. Surg., 174:76-84, 1971. 4. Baum, S., and Nusbaum, M.: The control of gastrOintestinal hemorrhage by selective mesenteric arterial infusion of vasopressin. Diag. Radiol., 98:497-505, 1971. 5. Boerema, I., Klopper, P. J., and Holscher, A. A.: Transabdorninalligation-resection of the esophagus in cases of bleeding esophageal varices. Surgery, 67:409-413, 1970. 6. Boyce, H. W., Jr.: Modification of the Sengstaken-Blakemore balloon tube. New Eng. J. Med., 267:195-196, 1962. 7. Britton, R. C., Voorhees, A. B., Jr., and Price, J. B., Jr.: Selective portal decompression. Surgery, 67:104-113, 1970. 8. Conn, H. 0.: The prognosis and management of bleeding esophageal varices. Ann. N. Y. Acad. Sci., 170:345-357,1970. 9. Conn, H. 0., Ramsby, G. R, and Storer, E. H.: Selective intraarterial vasopressin in the treatment of upper gastrointestinal hemorrhage. Gastroenterology, 63:634-645, 1972. 10. Conn, H. 0., Lindenmuth, W. W., May, C. J., et 31: Prophylactic portacaval anastomosis: a tale of two studies. Medicine, 51 :27-40, 1972. 11. Drapanas, T.: Interposition mesocaval shunt for treatment of portal hypertension. Ann. Surg., 176:435-448,1972. 12. George, P., Brown, C., Ridgway, G., et al.: Emergency oesophageal transection in uncontrolled variceal haemorrhage. Brit. J. Surg., 60:635-640, 1973. 13. Gignoux, M., Vewwaerde, J. C., Leteurtre, C., et al.: Ruptures de varices oesophagiennes: traitement par ligature sur bouton de Murphy. Med. Chir. Dig., 1 :315-320, 1972. 14. Gliedman, M. L., and Margulies, M.: The mesocaval shunt for portal decompression.
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In Haimovici, H. (ed.): The Surgical Management of Vascular Diseases, Philadelphia,
J. B. Lippincott Co., 1970. 15. Hedberg, S. E.: Endoscopy in gastrointestinal bleeding. SURG. CLIN. N. AMER., 54:549559, 1974. 16. Hoffman, D. C., Jepson, R P., and Harris, J. D.: Experiences with emergency porta-caval shunt. Aust. Ann. Med., 18:238-242,1969. 17. Hunt, P. S., Johnston, G. W., and Rodgers, H. W.: The emergency management of bleeding oesophageal varices with sclerosing injections. Brit. J. Surg., 56:305-307, 1969. 18. Jackson, F. C., Perrin, E. B., Felix, W. R, et al.: A clinical investigation of the portacaval shunt. V. Survival analysis of the therapeutic operation. Ann. Surg., 174:672-701,1971. 19. Jackson, F. C., Perrin, E. B., Smith, A. G., et al.: A clinical investigation of the portacaval shunt. II. Survival analysis of the prophylactic operation. Amer. J. Surg., 115 :22-42, 196B. 20. Linton, R R: The emergency treatment of massive bleeding from esophageal varices by transesophageal suture of these vessels at the time of acute hemorrhage. Surgery, 33:243-255, 1953. 21. Linton, R R: The treatment of esophageal varices. SURG. CLIN. N. AMER., 46:485-498, 1966. 22. Linton, R R: An Atlas of Vascular Surgery. Philadelphia, W. B. Saunders Co., 1973. 23. Luttwak, E. M., Charuzi, I., Licht, A., et al.: Emergency splenic vein-right-atrial shunt for massive esophageal hemorrhage with cirrhosis of liver and inferior vena cava occlusion: report of an operation and follow-up. Ann. Surg., 177:411-412, 1973. 24. Malt, R A.: Control of massive upper gastrointestinal hemorrhage. N. Eng. J. Med., 286: 1043-1046, 1972. 25. McDermott, W. V., Jr.: Postoperative liver failure and complications of shunt surgery. In Artz, C. P., and Hardy, J. D. (eds.): Complications in Surgery and their Management. Philadelphia, W. B. Saunders Co., 1967. 26. McDermott, W. V., Jr., Barnes, B. A., Nardi, G. L., et al.: Postshunt encephalopathy. Surg. Gynec. Obstet., 126:585-590, 1968. 27. Moreno, A. H., Burchell, A. R, Rousselot, L. M., et al.: Portal blood flow in cirrhosis of the liver. J. Clin. Invest., 46:436-445, 1967. 28. Orloff, M. J.: Emergency portacaval shunt: a comparative study of shunt, varix ligation and nonsurgical treatment of bleeding esophageal varices in unselected patients with cirrhosis. Ann. Surg., 166:456-478, 1967. 29. Ottinger, L. W., and Moncure, A. C.: Transthoracic ligation of bleeding esophageal varices in patients with intrahepatic portal obstruction. Ann. Surg., 179:35-38,1974. 30. Palmer, E. D.: The vigorous diagnostic approach to upper-gastrointestinal tract hemorrhage: a 23-year prospective study of 1,400 patients. J.A.M.A., 207:1477-1480,1969. 31. Panke, W. F., Rousselot, L. M., and Burchell, A. R: A sixteen-year experience with end-toside portacaval shunt for variceal hemorrhage: analysis of data and comparison with other types of portasystemic anastomoses. Ann. Surg., 168:957-965, 1968. 32. Pitcher, J. L.: Safety and effectiveness of the modified Sengstaken-Blakemore tube: a prospective study. Gastroenterology, 61 :291-298, 1971. 33. Pugh, R N. H., Murray-Lyon, I. M., Dawson, J. L., et al.: Transection of the oesophagus for bleeding oesophageal varices. Brit. J. Surg., 60:646-649, 1973. 34. Resnick, R H., Chalmers, T. C., Ishihara, A. M., et al.: A controlled study of the prophylactic portacaval shunt. Ann. Int. Med., 70:675-688, 1969. 35. Rothwell-Jackson, R L., and Hunt, A. H.: The results obtained with emergency surgery in the treatment of persistent haemorrhage from gastro-oesophageal varices in the cirrhotic patient. Brit. J. Surg., 58:205-215,1971. 36. Sherlock, S.: Diseases of the Liver and Biliary System, 4th ed. Philadelphia, F. A. Davis Company, 1968. 37. Sherlock, S., Hourigan, K., and George, P.: Medical complications of shunt surgery for portal hypertension. Ann. N. Y. Acad. Sci., 170:392-405,1970. 38. Soterakis, J., Resnick, R H., Iber, F. L., et al.: Effect of alcohol abstinence on survival in cirrhotic portal hypertension. Lancet, 2:65-67, 1973. 39. Turcotte, J. G., and Lambert, M. J., III: Variceal hemorrhage, hepatic cirrhosis, and portacaval shunts. Surgery, 73:810-817, 1973. 40. Waddell, E. G., Bouchard, A. G., Wellington, J. L., and Ewing, J. B.: Functional relations of the proximal portal manipulations. Can. J. Surg., 16:3-16, 1973. 41. Warren, W. D., Fomon, J. J., and Zeppa, R: Further evaluation of selective decompression of varices by distal splenorenal shunt. Ann. Surg., 169:652-660,1969. 42. Warren, W. D., Salam, A. A., Faraldo, A., et aI.: End renal vein-to-splenic vein shunts for total or selective portal decompression. Surgery, 72:995-1006, 1972. 43. Welling, R E., and McDermott W. V., Jr.: Combined caval and portal hypertension with cirrhosis of the liver: a problem in management. Ann. Surg., 177:164-166,1973. Massachusetts General Hospital Boston, Massachusetts 02114