Emergency treatment of bleeding esophageal varices in cirrhosis

9. 10. II. 12. 13.

14. 15. 16. I7. 18. 19. 20.

L u d i n g t o n , L. G . : A s t u d y of 158 cases of e s o p h a g e a l varices, Surg., G y n e e . & Obst. 1 0 6 : 5 1 9 , 1958. M e r e n d i n o , K. A., a n d V o l w i l e r , W . : M e d i c a l a n d surgical aspects o f p o r t a l h y p e r t e n s i o n : R e p o r t of 12 cases, N o r t h w e s t /~,led. 5 2 : 7 2 4 , 1953. Peskin, G. W., B e r g g r e n , R. B., a n d C r i c h l o w , R. W . : E v a l u a t i o n o f v e n o u s s h u n t i n g p r o c e d u r e s for p o r t a l h y p e r t e n s i o n , S. Clin. N o r t h A m e r i c a 4 0 : 1551, 1960. R a t n o f f , O. D., a n d P a t e k , A . J., Jr.: T h e n a t u r a l h i s t o r y o f L a e n n e c ' s cirrhosis o f the liver: A n a n a l y s i s o f 386 cases, M e d i c i n e 2 1 : 2 0 7 , 1942. R o u s s e l o t , L." M . , e t a l . : E x p e r i e n c e s with p o r t a c a v a l a n a s t o m o s i s . A n a l y s i s of 104 elective end-to-side s h u n t s f o r the p r e v e n t i o n o f r e c u r r e n t h e m o r r h a g e f r o m e s o p h a g o g a s t r i c v a r i c e s ( 1 9 5 2 t h r o u g h 1 9 6 1 ) , A m . J. Meal. 3 4 : 2 9 7 , 1963. Siderys, H., a n d Vellios, F , : P o r t a l h y p e r t e n s i o n w i t h o u t c i r r h o s i s o r e x t r a h e p a t i c o b s t r u c t i o n . R e p o r t of a case, A n n . Surg. 1 0 8 : 7 8 5 , 1964. W a n t z , G. E., a n d P a y n e , M. A . : E x p e r i e n c e w i t h p o r t a c a v a l s h u n t f o r p 0 r t a l h y p e r t e n s i o n , N e w E n g l a n d J. Meal. 2 6 5 : 7 2 1 , 196 I. W e l c h , C. S., e t a l . : T r e a t m e n t o f b l e e d i n g f r o m p o r t a l h y p e r t e n s i o n in patients w i t h c i r r h o s i s o f the liver, N e w E n g l a n d ]. M e d . 2 5 4 : 4 9 3 , 1956. M a e s , U., a n d D a v i s , H . A . : F l u i d r e p l a c e m e n t in s u r g i c a l states, with p a r t i c u l a r r e f e r e n c e to t r a n s f u s i o n of ascitic fluid: A clinicat a n d e x p e r i m e n t a l study, A r c h . Surg. 4 2 : 4 5 3 , 194I. D a v i s , H. A . , a n d Blalock, J. F., Jr.: A u t o l o g o u s a n d h o m o l o g o u s t r a n s f u sion o f h u m a n ascitic fluid, J. Clin. Invest. 1 8 : 2 1 9 , 1939. g a m a h i r o , H . S., a n d R e y n o l d s , T. B.: Effects o f ascitic fluid infusion on s o d i u m e x c r e t i o n , b l o o d v o l u m e , a n d c r e a t i n i n e c l e a r a n c e in cirrhosis, G a s t r o e n t e r o l o g y 4 0 : 4 9 7 , 1961. K i n g , H., e t a l . : Ascitic fluid i n f u s i o n . A m e t h o d a n d a p p a r a t u s f o r the t r e a t m e n t o f ascites, J . A . M . A . 184: 1042, 1963.

Emergency Treatment of Bleeding Esophageal Varices in Cirrhosis M A R S H A L L J. ORLOFF UNTIL RECENTLY, approximately 2 out of 3 cirrhotic patients who entered the hospital with their first episode of varix hemorrhage failed to leave the hospital alive. Table 1 shows the results of a number of studies conducted between 1916 and 1961. The differences in mortality rates shown in Table 1 appear to have been due mainly to differences in patient material. The experience of our institution with bleeding esophageal varices up to 1961 was similar to that of most hospitals which care for indigent patients, and the death rate of 84% i n d i c a t e s c l e a r l y t h a t it w a s a n u n h a p p y one. Moreover, the mortality rate of varix hemorrhage did not change significantly during a period of 4 decades, either in our own hospital or at institutions throughout th:e c o u n t r y . 13

TABLE

1 .~I~IORTAI_I"I'X' OF FIRST VARIX HERtORRItAGE ll'q CIRRItOSIS

AUIIIORS

YEAR ~I~PORTED

T~'PE OF HOSPITAL

N o . OF PATIENTS

MORTALITY (~ )

106

40

1947 1954 1955

5 Privateteaching City indigent City indigent City indigent

45 59 102

76 83 59

1958 1959 1960 1962

City indigent Veterans City indigent City indigent

456 102 74 87

74 45 76 84

1,031

MEAN 73

Ratnoff and Patek (42)

I942

Higgins (23) Atik and Simeone (1) Nachlas. O'Neil and Campbell (35) Cohn and Blaisdell (13) Taylor and Jontz (50) lMerigan e t al. (31) Harbor General (36)

TOTAL

F r o m t h e s e statistics, it is a p p a r e n t t h a t the e m e r g e n c y t r e a t m e n t of b l e e d i n g e s o p h a g e a l v a r i c e s is t h e single m o s t i m p o r t a n t a s p e c t of t h e t h e r a p y of p o r t a l h y p e r t e n s i o n . T h e e l e c t i v e t r e a t m e n t is m u c h less i m p o r t a n t in t e r m s of t h e n u m b e r of lives i n v o l v e d , since n o t m o r e t h a n 25 % of the b l e e d i n g c i r r h o t i c p o p u l a t i o n h a s b e c o m e eligible f o r e l e c t i v e t h e r a p y . T h e o n l y h o p e of s i g n i f i c a n t l y i m p r o v i n g t h e s u r v i v a l r a t e of p a t i e n t s w i t h v a r i x h e m o r r h a g e lies in t h e p r o m p t a n d effective c o n t r o l of t h e initial b l e e d i n g e p i s o d e , a n d it is t o w a r d this o b j e c t i v e t h a t o u r m a j o r efforts m u s t be d i r e c t e d .

EMERGENCY DIAGNOSIS In m o s t p a t i e n t s w h o e n t e r t h e h o s p i t a l w i t h u p p e r g a s t r o i n t e s t i n a l h e m o r r h a g e , t h e d i a g n o s i s of b l e e d i n g e s o p h a g e a l v a r i e e s d e p e n d s or, a f f i r m a t i v e a n s w e r s to t h r e e q u e s t i o n s . T h e s e a r e : ( 1 ) D o e s t h e p a t i e n t h a v e cirrhosis? ( 2 ) Does the patient' have portal h y p e r t e n s i o n and e s o p h a g e a l v a r i c e s ? ( 3 ) A r e t h e v a r i c e s t h e site of t h e b l e e d i n g , r a t h e r t h a n s o m e o t h e r l e s i o n s u c h as a d u o d e n a l or g a s t r i c ulcer, g a s t r i t i s o r h i a t u s h e r n i a ? I n o u r e x p e r i e n c e , i n f o r m a t i o n sufficient to a n s w e r t h e s e q u e s t i o n s u s u a l l y c a n be o b t a i n e d w i t h i n 2 to 4 h o u r s of t h e p a t i e n t ' s a d m i s s i o n to the h o s p i t a l b y m e a n s of an o r g a n i z e d d i a g n o s t i c p l a n w h i c h i n c l u d e s s o m e , a n d if n e c e s s a r y all, of t h e f o l l o w i n g steps, in o r d e r of p e r f o r m a n c e : 1. H I S T O R Y AND PHYSICAL EXAMINATION, The symptoms and signs of c i r r h o s i s a n d of o t h e r lesions r e s p o n s i b l e f o r u p p e r g a s t r o i n t e s t i n a l b l e e d i n g are d e s c r i b e d in n u m e r o u s t e x t b o o k s a n d a r e f a m i l i a r to all s u r g e o n s . It is e r r o n e o u s to a s s u m e t h a t r u p t u r e d v a r i c e s a l w a y s b l e e d s u d d e n l y a n d m a s s i v e l y , since we h a v e o b s e r v e d m a n y p a t i e n t s w h o h a v e bled f r o m e s o p h a g e a l v a r i c e s at a r e l a t i v e l y m o d e r a t e r a t e over several days. 14

2. BLOOD S T U D 1 E S . - - B l o o d s a m p l e s f o r t y p i n g a n d c r o s s - m a t c h i n g and for studies are drawn immediately on admission. The studies in, e l u d e a c o m p l e t e b l o o d c o u n t , liver f u n c t i o n tests ( B r o m s u l p h a l e i n excretion, prothrombin, bilirubin, alkaline phosphatase, albumin, ~obulin, t h y m o t t u r b i d i t y , c e p h a l i n f l o e c u l a t i o n , s e r u m g l u t a m i e o x a l o a c e t i c t r a n s a m i n a s e ) , u r e a n i t r o g e n , e l e c t r o l y t e s , p H a n d b l o o d gases. I n o u r e x p e r i e n c e , t h e liver f u n c t i o n tests w h i c h a r e m o s t c o n s i s t e n t l y a b n o r m a l a n d of g r e a t e s t v a l u e a r e t h e p r o t h r o m b i n a n d B r o m s u l p h a lein e x c r e t i o n (if p e r f o r m e d in the a b s e n c e of j a u n d i c e a n d a l t e r h y p o volemic shock has been corrected). We have not found the bloodammonia determination (29), which mainly indicates the presence of p o r t a l - s y s t e m i c c o l l a t e r a l s a n d d o e s n o t p i n p o i n t t h e b l e e d i n g site, to b e of s i g n i f i c a n t a d d i t i o n a l v a l u e . 3. UPPER GASTROINTESTINAL X-RAYS. -' A s s o o n as s h o c k h a s b e e n corrected and the patient's condition stabilized, a barium contrast upp e r g a s t r o i n t e s t i n a l series is o b t a i n e d . It is to be e m p h a s i z e d t h a t r o e n t g e n o g r a p h i e s t u d i e s a r e d i r e c t e d at d e t e r m i n i n g t h e p r e s e n c e o r a b s e n c e n o t o n l y of e s o p h a g e a l v a r i c e s b u t also of o t h e r l e s i o n s s u c h as a d u o d e n a l ulcer, g a s t r i c u l c e r o r h i a t u s h e r n i a . T h e r e p o r t e d a c c u r a c y o f r o e n t g e n o g r a p h y i n the d i a g n o s i s o f e s o p h a g e a l vaxices h a s ( a r i e d g r e a t l y (3, 15, 2 5 ) , m o s t likely b e c a u s e of w i d e d i f f e r e n c e s in t h e effort a n d a t t e n t i o n d e v o t e d to c o n d u c t i n g this e x a m i n a t i o n . I n o u r e x p e r i e n c e , x - r a y s t u d i e s c a n b e p e r f o r m e d safely in a l m o s t all p a t i e n t s and have accurately demonstrated esophageal varices at the time of b l e e d i n g in 95 % of o u r c a s e s . In our institution, the emergency diagnosis of bleeding esophageal v a r i c e s h a s b e e n m a d e a c c u r a t e l y ] r o m i n f o r m a t i o n o b t a i n e d in t h e s e first t h r e e s t e p s in o v e r 9 0 % o f o u r p a t i e n t s . 4. SPLENIC MANOMEWRV. T h e s p l e n i c p u l p p r e s s u r e a c c u r a t e l y reflects t h e p o r t a l p r e s s u r e a n d c a n b e d e t e r m i n e d r e a d i l y a t t h e b e ~ side by p e r c u t a n e o u s p u n c t u r e of the s p l e e n u n d e r local a n e s t h e s i a ( 3 9 ) . A l t h o u g h this p r o c e d u r e d o e s n o t d e t e r m i n e t h e s i t , e~Of b l e e d i n g , it i n d i c a t e s t h e p r e s e n c e o r a b s e n c e of p o r t a l h y p e r t e n s i o n . B l e e d i n g from esophageal varices infrequently occurs with a splenic pulp pressure below 3 0 0 ram. saline and rarely occurs with a pressure b e l o w 250 mm. We have performed splenic manometry only when convent i o n a l r o e n t g e n o g r a p h y h a s f a i l e d to d e m o n s t r a t e v a r i c e s , a n d in t h e m a j o r i t y of o u r c a s e s it h a s p r o v i d e d c o n f i r m a t i o n t h a t the p a t i e n t w a s not bleeding from varices. 5. ESOPHAGOSCOPV. I f t h e m e a s u r e s d e s c r ] b e d a b o v e h a v e f a i l e d to p r o v i d e t h e d i a g n o s i s , e s o p h a g o s c o p y is p e r f o r m e d . A l t h o u g h m a n y c l i n i c i a n s r e l y h e a v i l y o n e s o p h a g o s c o p y ( 6 , 16, 20, 2 4 ) , w e h a v e f o u n d t h a t t h e r e s u l t s of this p r o c e d u r e a r e s o m e t i m e s difficult to int e r p r e t in t h e f a c e of m a s s i v e b l e e d i n g . M o r e i m p o r t a n t , if t h e d i a g n o s t i c a c c u r a c y of r o e n t g e n o g r a p h y is e q u a l to o r g r e a t e r t h a n t h a t of e n d o s c o p y , as w e h a v e o b s e r v e d , t h e r e is little d o u b t t h a t x - r a y s t u d i e s ~5

s h o u l d b e d o n e first, since t h e y a r e less difficult a n d h a z a r d o u s . E s o p h a g o s c o p y h a s b e e n r e q u i r e d in o n l y 7 % of o u r p a t i e n t s . 6. BALLOON TAIvlPONADE CONTROL OF BLEEDING. C o n t r o l of b l e e d i n g b y e s o p h a g e a l b a l l o o n t a m p o n a d e is p r e s u m p t i v e e v i d e n c e t h a t e s o p h a g e a l varices are t h e site q f b l e e d i n g . T h i s d i a g n o s t i c test is a c c u r a t e in a p p r o x i m a t e l y t h r e e - f o u r t h s of p a t i e n t s a n d m a y b e att e m p t e d if the o t h e r d i a g n o s t i c m e a s u r e s are n o t successful. 7. SPLENOPORTOGRAPHY. V i s u a l i z a t i o n of t h e p o r t a l v e n o u s syst e m a n d its c o l l a t e r a l c o n n e c t i o n s b y p e r c u t a n e o u s injection of c o n t r a s t m e d i a i n t o the s p l e e n is r a r e l y r e q u i r e d f o r d i a g n o s i s o f v a r i x h e m o r r h a g e in p a t i e n t s w i t h cirrhosis. H o w e v e r , in p a t i e n t s w i t h n o r r e a l liver f u n c t i o n w h o are s u s p e c t e d o f h a v i n g e x t r a h e p a t i c p o r t a l o b s t r u c t i o n , this p r o c e d u r e is d i a g n o s t i c a n d i n v a l u a b l e . R e c e n t l y , it has been suggested that splenoportography, by d e m o n s t r a t i n g the patt e r n of c o l l a t e r a l c i r c u l a t i o n a n d the v o l u m e o f b l o o d p e r f u s i n g t h e Iiver, m a y be of v a l u e in s e l e c t i n g p a t i e n t s w i t h c i r r h o s i s f o r p o r t a c a v a l s h u n t ( 8 , 5 7 ) . S h o u l d f u r t h e r studies e s t a b l i s h t h e v a l i d i t y of this s u g gestion, t h e time, effort a n d r i s k i n v o l v e d in p e r f o r m i n g s p l e n o p o r t o g r a p h y as a n e m e r g e n c y p r o c e d u r e m a y p r o v e to b e w o r t h while. During the past 4 ½ years, the diagnostic plan described above has b e e n a p p l i e d to all a d u l t p a t i e n t s in w h o m c i r r h o s i s a n d v a r i x h e m o r r h a g e w e r e s u s p e c t e d on a d m i s s i o n to H a r b o r G e n e r a l H o s p i t a l . T a b l e 2 s u m m a r i z e s the results of this d i a g n o s t i c a p p r o a c h in 89 c o n s e c u t i v e T A B L E 2.

DIAGNOSTIC FINDINGS IN 8 9 CONSECUTIVE CIRRItOTIC PATIENTS SUSPECTED OF BLEEDING FROM ESOPHAGEAL VARICES tx: <,re,

~

0

1~ rO

--

:>, 0

"FINAl. DIAGNOSIS

Bleeding varices Peptic ulcer Gastritis

74 6 9

74 6 9

74 6 9

74 6 9

70/74 0/6 0/9

4/74 6/6 0/9

2/2 .... 0/9

2/2 0/2 0/2

patients. U p p e r g a s t r o i n t e s t i n a l x - r a y s w e r e o b t a i n e d in all p a t i e n t s a n d c o r r e c t l y d e m o n s t r a t e d t h e p r e s e n c e or a b s e n c e o f varices in 9 6 % . R o e n t g e n o g r a p h y g a v e false n e g a t i v e results in 4 % of t h e cases. S p l e n i c m a n o m e t r y w a s p e r f o r m e d in 11 p a t i e n t s in w h o m x - r a y s failed to s h o w v a r i c e s ; in 2 p a t i e n t s , p o r t a l h y p e r t e n s i o n w a s f o u n d a n d b l e e d i n g varices w e r e d e m o n s t r a t e d s u b s e q u e n t l y at o p e r a t i o n , w h i l e in 7 p a t i e n t s the finding of a n o r m a l p o r t a l p r e s s u r e c o r r e s p o n d e d to the a b s e n c e of varices o n x - r a y . E s o p h a g o s c o p y was p e r f o r m e d in 6 p a t i e n t s in w h o m n o v a r i c e s w e r e d e m o n s t r a t e d b y r o e n t g e n o g r a p h y ; 16

in 2 p a t i e n t s , b l e e d i n g v a r i c e s w e r e o b s e r v e d a n d s u b s e q u e n t l y p r o v e d at o p e r a t i o n , w h i l e in t h e o t h e r 4 p a t i e n t s t h e a b s e n c e of v a r i c e s w a s c o n f i r m e d b y e n d o s c o p y . I n 97 % of t h e p a t i e n t s , t h e d i a g n o s t i c w o r k u p w a s c o m p l e t e d w i t h i n 6 h o u r s of a d m i s s i o n to t h e h o s p i t a l . F i f t y n i n e of t h e 89 p a t i e n t s w e r e s u b j e c t e d to e m e r g e n c y o p e r a t i o n s w i t h t h e p r e o p e r a t i v e d i a g n o s i s of c i r r h o s i s a n d b l e e d i n g e s o p h a g e a l v a r i c e s , a n d in n o i n s t a n c e did this d i a g n o s i s p r o v e t o b e i n c o r r e c t . GENERAL

MEASURES

OF TREATMENT

C i r r h o s i s of the liver is a s e v e r e , d e b i l i t a t i n g d i s e a s e with r e m o t e m a n i f e s t a t i o n s , o n l y o n e of w h i c h is b l e e d i n g f r o m e s o p h a g e a l variees. D e a t h a f t e r v a r i x r u p t u r e is f r e q u e n t l y d u e to h e p a t i c d e c o m p e n s a t i o n , r e n a l f a i l u r e o r infection, r a t h e r t h a n to e x s a n g u i n a t i o n . W h i l e c o n t r o l of b l e e d i n g is of p r i m a r y i m p o r t a n c e , the effectiveness of t h e r a p y of t h e u n d e r l y i n g liver disease o f t e n d e t e r m i n e s t h e o u t c o m e . T h e r e f o r e , t h e r e are c e r t a i n g e n e r a l p r i n c i p l e s of t r e a t m e n t w h i c h a p p l y to all p a tients, r e g a r d l e s s of the specific t h e r a p e u t i c m e a s u r e s u s e d to s t o p t h e h e m o r r h a g e . T h e s e include: I. PROMPT RESTORATION OF THE BLOOD VOLUME. V i g o r o u s rep l a c e m e n t of b l o o d loss w i t h w h o l e b l o o d t r a n s f u s i o n s is essential. T h e r e is n o r a t i o n a l basis f o r p u r p o s e l y m a i n t a i n i n g h y p o v o l e m i a o r a b l o o d p r e s s u r e w h i c h is b e l o w n o r m a l . E v e r y effort is m a d e to o b t a i n fresh b l o o d , less t h a n 12 h o u r s old, f o r a d m i n i s t r a t i o n b e c a u s e of t h e s e r i o u s d e f e c t s in c o a g u l a t i o n a s s o c i a t e d w i t h liver d i s e a s e p l u s t h o s e s u p e r i m p o s e d by m u l t i p l e t r a n s f u s i o n s . T h e b l o o d is w a r m e d to b o d y t e m p e r a t u r e by p a s s a g e t h r o u g h a h e a t e x c h a n g e coil d u r i n g i n f u s i o n to r e d u c e the u n c o n t r o l l e d h y p e r k a l e m i a of c o l d b a n k b l o o d . 2. PREVENTION OF HEPATIC c o M A . b A l t h o u g h t h e n e r v o u s diso r d e r s a s s o c i a t e d with liver disease a r e diverse a n d p o o r l y u n d e r s t o o d , t h e e n c e p h a l o p a t h y o b s e r v e d in p a t i e n t s with b l e e d i n g e s o p h a g e a l v a r ices s o m e t i m e s a p p e a r s t o be d u e to the a b s o r p t i o n of large q u a n t i t i e s of a m m o n i a directly into t h e s y s t e m i c c i r c u l a t i o n via port~il-systemic collaterals. F o r this r e a s o n , m e a s u r e s d i r e c t e d at d e s t r o y i n g a m m o n i a f o r m i n g b a c t e r i a a n d e l i m i n a t i n g all n i t r o g e n f r o m t h e g a s t r o i n t e s t i n a l t r a c t a r e initiated s o o n after a d m i s s i o n of t h e p a t i e n t to the h o s p i t a l . T h e s e i n c l u d e r e m o v a l of b l o o d f r o m t h e s t o m a c h b y I a v a g e with iced saline, instillation of c a t h a r t i c s a n d n e o m y c i n i n t o t h e s t o m a c h a n d t h o r o u g h a n d r e p e a t e d c l e a n s i n g of t h e colon with e n e m a s c o n t a i n i n g n e o m y c i n . A l t h o u g h w e h a v e used a m m o n i a - b i n d i n g agents, s u c h as s o d i u m g l u t a m a t e a n d arginine,' a n d i o n - e x c h a n g e resins, w e h a v e o b t a i n e d no e v i d e n c e t h a t t h e y h a v e b e e n of value. 3. SUPPORT O F T H E F A I L I N G LIVER.-r--Parenterally a d m i n i s t e r e d h y p e r t o n i c g l u c o s e s o l u t i o n s c o n t a i n i n g t h e r a p e u t i c d o s e s of v i t a m i n s K, B a n d C are i n c l u d e d in t h e initial t r e a t m e n t r e g i m e n . A p p r o p r i a t e 17

a m o u n t s of electrolytes are a d d e d to the p a r c n t e r a l fluids to c o r r e c t a n y a c i d - b a s e a b n o r m a l i t i e s . Severe h y p o k a l e m i a is n o t u - l c o m m o n a n d requires the a d m i n i s t r a t i o n of sizable quantities of p o t a s s i u m . 4 . F R E Q U E N T M O N I T O R I N G O F V I T A L F U N C T I O N S . - - - T h e u s u a l technics are used to d e t e r m i n e the m a g n i t u d e of b l e e d i n g and a d e q u a c y of b l o o d v o l u m e r e p l a c e m e n t . T h e s e include m e a s u r e m e n t s of vital signs, urine o u t p u t by w a y of an indwelling catheter, c e n t r a l v e n o u s p r e s s u r e via a p o l y e t h y l e n e c a t h e t e r t h r e a d e d t h r o u g h an a r m c u t d o w n into the superior v e n a cava, h e m a t o c r i t and rate of b l o o d loss b y c o n t i n u o u s suction t h r o u g h a n a s o g a s t r i c tube.

SPECIFIC MEDICAL TREATMENT E m e r g e n c y m e d i c a l m e a s u r e s p r e s e n t l y used specifically to s t o p varix b l e e d i n g include e s o p h a g e a l b a l l o o n t a m p o n a d e , i n t r a v e n o u s posterior p i t u i t a r y e x t r a c t and g a s t r o e s o p h a g e a l h y p o t h e r m i a . A l t h o u g h e a c h of these m e a s u r e s is c a p a b l e of t e m p o r a r i l y c o n t r o l l i n g bleeding e s o p h a g e a l varices, it has been o u r e x p e r i e n c e , as well as that r e p o r t e d b y m a n y o t h e r w o r k e r s , that they h a v e not significantly influenced the m o r t a l i t y rate of varix h e m o r r h a g e in cirrhotic patients. ESOPHAGEAL BALLOON TAMPONADE T h e m o s t widely used n o n o p e r a t i v e m e t h o d of t r e a t m e n t has b e e n e s o p h a g e a l b a l l o o n t a m p o n a d e . Since its i n t r o d u c t i o n in 1 9 3 0 b y W e s t p h a l ( 6 0 ) , a n d its p o p u l a r i z a t i o n in 1950 by S e n g s t a k e n a n d B l a k e m o r e ( 4 8 ) , b a l l o o n t a m p o n a d e has b e e n a d o p t e d b y a l m p s t every h o s p i t a l in the c o u n t r y as s t a n d a r d t r e a t m e n t for b l e e d i n g e s o p h ageal varices. A s s h o w n in T a b l e 3, t h e r e is no d o u b t that this p o p u l a r m o d e of t h e r a p y has initially s t o p p e d varix b l e e d i n g in m a n y p a t i e n t s

T A B L E 3 . ~ R E S U L T S OF ESOPHAGEAL BALLOON TAMPONADE IN CIRRHOTIC PATIENTS WITH BLEEDING VARICES A Lr'il[ORS

Reynolds, Freedman and Windsor (44)

Hamilton (21) Ludington (28) Conn(14) Read e t al. (43) Merigan e t a L ( 31 ) Harbor General (36)

REPORTED

N O . OF

PATIENTS

INITIAL CONTROL,

ULTIMATE CONTROL

1952 1955 ]958 1958 1960 1960 1962

32 20 58 50 38 68 45

66 45 75 70 84 56

50 -43 .. 24 -20

YEAR

TOTAL

31 I

18

(%)

(%)

MORTALITY

(.~)

47 75 82 74 80 82 MEAN

74

( 5 6 % in o u r series, and as high as 8 4 % in the e x p e r i e n c e of o t h e r s ) . T h e d i s h e a r t e n i n g aspect of this f o r m of m a n a g e m e n t has b e e n t h a t m a n y of the p a t i e n t s h a v e r e s u m e d b l e e d i n g w h e n the b a l l o o n s were deflated ( 8 0 % in o u r series, a n d as Iow as 5 0 % in the e x p e r i e n c e of o t h e r s ) . M o r e o v e r , we a n d others ( 5 , 14, 31, 36, 4 3 ) h a v e o b s e r v e d f r e q u e n t a n d s o m e t i m e s lethal c o m p l i c a t i o n s of b a l l o o n t a m p o n a d e , w h i c h include p e r f o r a t i o n of the e s o p h a g u s , a s p h y x i a t i o n f r o m regurgitation of the b a l l o o n into the p h a r y n x , and a s p i r a t i o n p n e u m o n i a . M o s t i m p o r t a n t , d a t a f r o m a n u m b e r of institutions ( T a b l e 3 ) clearly indicate t h a t b a l l o o n t a m p o n a d e h a s failed to m e a s u r a b l y influence the m o r t a l i t y rate of bleeding e s o p h a g e a l varices d u r i n g a trial of 15 years. F o r these r e a s o n s , we have" a b a n d o n e d the use of b a l l o o n t a m p o n a d e as a definitive f o r m of t r e a t m e n t a n d use it only on i n f r e q u e n t occasions as a t e m p o r a r y m e a s u r e to p r e p a r e patients for o p e r a t i o n w h e n m a s s i v e b l e e d i n g c a n n o t be t e m p o r a r i l y c o n t r o l l e d by o t h e r m e a n s . POSTERIOR PITUITARY EXTRACT It has b e e n s h o w n in b o t h e x p e r i m e n t a l a n i m a l s (2, I 1 , 22, 3 0 ) and in m a n ( 1 8, 26, 47, 49, 51 ) t h a t p o s t e r i o r p i t u i t a r y extract ( V a s o pressin, Pituitrin, P i t r e s s i n ) r e d u c e s p o r t a l p r e s s u r e a n d b l o o d flow by c o n s t r i c t i n g the s p l a n c h n i c arterioles. T h e r e s p o n s e is directly r e l a t e d to the dose and r a p i d i t y of injection, and in the u s u a l clinical d o s a g e r a n g e has a d u r a t i o n of I h o u r o r less. H o w e v e r , as s h o w n in T a b l e 4, .i

TABLE

• i

4.

ii

RESULTS OF INTRAVENOUS POSTERIOR PITUITARY EXTRACT IN BLEEDING CIRRHOTIC PATIENTS No.

AU1

I'-I O R S

S c h w a r t z et al. ( 4 7 ) Merigan, P]otkin and Davidson (32) Shaldon and Sherlock

Harbor General

(49)

OF

INITIAL SUCCESS

PATIENTS

TaI~,LS

1I

27

89

15 8 45

22 ~25 45

73 100 88

18

~18

(%)

88

REBLED

(%)

MORTALITY

(%)

Frequent Frequent 63 Immediate operation 83

93 75

the transient r e d u c t i o n of p o r t a l p r e s s u r e h a s b e e n sufficient t e m p o rarily to stop varix h e m o r r h a g e in a large p e r c e n t a g e of patienfs ( 8 8 % in o u r s e r i e s ) . U n f o r t u n a t e l y ; in o u r e x p e r i e n c e and t h a t of others, m o s t of the p a t i e n t s h a v e rebled unless o p e r a t i o n was p e r f o r m e d within 8 h o u r s of t r e a t m e n t , and s u b s e q u e n t a d m i n i s t r a t i o n of the d r u g has b e e n m u c h less effective in s t o p p i n g bleeding. It is a p p a r e n t , t h e r e f o r e , t h a t p o s t e r i o r p i t u i t a r y e x t r a c t a l o n e is not a definitive f o r m of treatm e n t b u t m a y be of c o n s i d e r a b l e i m m e d i a t e v a l u e while o t h e r m e a s u r e s ]9

are being readied or the patient is being p r e p a r e d for operation. E v e r y patient admitted to our institution with bleeding esophageal varices is given posterior pituitary extract soon after admission. T h e agent is administered intravenously over a I5- to 2 0 - m i n u t e period in a dose of 20 units diluted in 200 ml. of solution. This m e a s u r e of t h e r a p y h a s largely replaced esophageal balloon t a m p o n a d e as a m e a n s of o b t a i n ing i m m e d i a t e control of h e m o r r h a g e . GASTROESOP HAGEAL H Y P O T H E R M I A

Use of this p r o c e d u r e is based on the d e m o n s t r a t i o n that lowering the t e m p e r a t u r e of the s t o m a c h to 1 0 - 1 4 ° C. abolishes the digestive activity of gastric juice and p r o d u c e s a significant r e d u c t i o n of blood flow in the s t o m a c h ( 5 3 ) . Cooling is accomplished with balloons in t h e s t o m a c h a n d e s o p h a g u s t h r o u g h w h i c h is circulated a cold alcoholw a t e r solution. T h e r a t i o n a l e of g a s t r o e s o p h a g e a l cooling in p a r t hinges on the theory, first p r o p o s e d by W a n g e n s t e e n and B a r o n o f s k y in 1945 (4, 5 2 ) , that r u p t u r e of esophageal varices is the result of reflux acid-peptic esophagitis. H o w e v e r , recent studies by Orloff a n d T h o m a s ( 3 7 ) , w h i c h involved gross and microscopic biopsy e x a m i n a tions of the distal esophagus at the time of varix bleeding, revealed esophagitis in only 1 of 20 patients and cast c o n s i d e r a b l e doubt on the acid-peptic hypothesis. E x p e r i e n c e with g a s t r o e s o p h a g e a l h y p o t h e r m i a has been small, b u t p r e l i m i n a r y reports indicate t h a t this technic, alt h o u g h effective in t e m p o r a r i l y stopping bleeding, h a s failed to l o w e r the mortality rate of varix h e m o r r h a g e . In a series of 24 p a t i e n t s treated by W a n g e n s t e e n and Smith ( 5 4 ) , 6 7 % died; 21 of the p a t i e n t s h a d cirrhosis a n d 7 1 % of these s u c c u m b e d . SPECIFIC OPERATIVE TREATMENT Because of the high mortality rate associated with medical t r e a t m e n t of bleeding esophageal varices a n d the failure to achieve i m p r o v e m e n t of results during two decades of intensive effort, there has been considerable recent interest in e m e r g e n c y operative m a n a g e m e n t . R e s u l t s obtained during the past 5 years have been e n c o u r a g i n g and suggest that i m m e d i a t e operation is the t r e a t m e n t of choice. E x p e r i e n c e is insufficient as yet to establish definite criteria for selection of patients for operation; while it is clear that the risk of operation is great in p a t i e n t s with d e c o m p e n s a t e d cirrhosis, it is also certain that such patients h a v e little c h a n c e of surviving with n o n o p e r a t i v e therapy. Currently, e m e r gency o p e r a t i v e t r e a t m e n t is largely confined to the use of two o p e r a tions, t r a n s e s o p h a g e a l varix ligation and the e m e r g e n c y p o r t a c a v a l shunt. B o t h p r o c e d u r e s stop varix bleeding in almost all patients, a n d the p r o b l e m associated with t h e m is mainly that of hepatic d e c o m p e n 20

s a t i o n w h i c h r e s u l t s w h e n a c r i t i c a l l y ill p a t i e n t w i t h a s e v e r e l y d a m a g e d liver is s u b j e c t e d to a n e s t h e s i a a n d m a j o r t r a u m a . TRANSESOPHAGEAL VARIX LIGATION R e p o r t e d e x p e r i e n c e w i t h t r a n s e s o p h a g e a i v a r i x l i g a t i o n is m e a g e r a n d it h a s b e e n difficult to assess t h e r e s u l t s . B e c a u s e of this, we u n d e r t o o k a p r o s p e c t i v e e v a l u a t i o n of this p r o c e d u r e s e v e r a l y e a r s a g o ( 3 6 ) . E v e r y c i r r h o t i c p a t i e n t a d m i t t e d to t h e h o s p i t a l with v a r i x b l e e d i n g w a s i n c l u d e d in t h e s t u d y with n o a t t e m p t at selection. A t t h e s t a r t of t h e study, the patients were assigned, by blindly drawing a card, to either a ligation or n o n o p e r a t i v e t r e a t m e n t group; after the 29th patient, r a n d o m i z a t i o n was a b a n d o n e d and every patient was treated operatively. T h e d i a g n o s i s w a s c o m p l e t e d w i t h i n 6 h o u r s of a d m i s s i o n t o the h o s pital and operation was performed within 8 hours. The study group vvas m a d e u p e n t i r e l y o f c h r o n i c a l c o h o l i c s w i t h m o d e r a t e t o a d v a n c e d c i r r h o s i s a n d m a s s i v e v a r i x h e m o r r h a g e . I n a d d i t i o n to b l e e d i n g v a r ices, 5 2 % of t h e p a t i e n t s h a d j a u n d i c e , 5 0 % h a d a s c i t e s a n d 2 5 % had hepatic encephalopathy. T a b l e 5 s u m m a r i z e s t h e r e s u l t s o f t h e s t u d y , w h i c h i n v o l v e d 43 p a TABLE

5.

EMERGENCY "I'RANSESOPHAGEAL VARIX LIGATION-S U R V I V A L R A T E S AND C A U S E S O F D E A T H MEDICAL TREA'r'MENT~ STUDY G R O U P

( I4 P a t i e n l s ) %

U EDICA L TREATMENT~ PRESTUDY G R O U P

(45 P a t i e n : s ) %

LIGATION-STUDY G R O U P

(28 P a t i e n t s ) %

Survival Rate

Early Long-term *

14 14 (shunt)

18 0

50 42 8 0

4I 38 19 3

54 36 (shunt)

Cause o/Early Death

Hepatic fail ure Exsanguination Balloon tube complication Undetermined

I00 0 0 0

*All l o n g - t e r m s u r v i v o r s h a d u n d e r g o n e p o r l a e a v a l s h u n t s w i t h i n 8 -,veeRs o f varix bleeding.

tients, 28 of w h o m u n d e r w e n t v a r i x ligation. T h e s u r v i v a l r a t e in the: medical t r e a t m e n t group was only 1 4 % , and balloon t a m p o n a d e cont r o l l e d t h e b l e e d i n g in o n l y 2 9 % of the p a t i e n t s . T h e s e r e s u l t s w e r e s i m i l a r to t h e s u r v i v a l r a t e of ] 8 % o b t a i n e d in a l a r g e r p r e s t u d y g r o u p of 45 b l e e d i n g c i r r h o t i c p a t i e n t s , all of w h o m r e c e i v e d i d e n t i c a l m o d e r n m e d i c a l t h e r a p y . In c o n t r a s t , 5 4 % of t h e p a t i e n t s s u b j e c t e d to. t r a n s e s o p h a g e a l v a r i x ligation s u r v i v e d the o p e r a t i o n . T h e b l e e d i n g in e v e r y p a t i e n t in t h e s u r g i c a l g r o u p w a s c o n t r o l l e d b y l i g a t i o n , a n d t h ~ i n v a r i a b l e c a u s e of d e a t h was h e p a t i c failure. 21

E x p e r i e n c e has s h o w n t h a t t r a n s e s o p h a g e a l varix ligation is n o t a d e p e n d a b l e p r o c e d u r e f o r t h e p r o l o n g e d c o n t r o l of varix b l e e d i n g ( 1 2 ) . A c c o r d i n g l y , all s u r v i v o r s w e r e u r g e d to u n d e r g o an elective p o r t a c a v a l s h u n t d u r i n g t h e s a m e p e r i o d of h o s p i t a l i z a t i o n . T e n of t h e 15 s u r v i v o r s a g r e e d to this p l a n a n d all s u r v i v e d the shunt. F i v e s u r vivors r e f u s e d a s e c o n d o p e r a t i o n a n d all u l t i m a t e l y r e b l e d a n d died. F o l l o w - u p of t h e p a t i e n t s i n v o l v e d in this s t u d y h a s n o w b e e n c o n d u c t e d f o r f r o m 3 to 6 years. F o u r p a t i e n t s h a v e b e e n lost to f o l l o w - u p a n d the o t h e r 6 a r e still alive. T h u s , t h e m a x i m u m possible l o n g - t e r m s u r v i v a l r a t e is 3 6 % . If the 4 p a t i e n t s lost to f o l l o w - u p are c o n s i d e r e d dead, t h e survival r a t e is 2 1 % . T h e results of t r a n s e s o p h a g e a l varix ligation o b t a i n e d b y o t h e r w o r k e r s a r e s h o w n in T a b l e 6. A c c u r a t e a s s e s s m e n t of these results is TABLE

6 . - - R E S U L T S OF TRANSESOPHAGEAL VARIX LIGATION IN CIRRHOTIC PATIENTS XVITtt BLEEDING VARICES

AIJ'TFIoRS

I~AT|ENTS

L i n t o n and Ellis ( 2 7 ) Cohn and Mathewson (12) BrRton and Crile ( 9 ) Hamilton (21) L u d i n g t o n (28) Welch (59) C r a w f o r d , H e n l y and Kelsey (17) Orloff

20 17 14 8 7 6 6 28

OPERATIVE ~IORTALFI'Y ( °,'b. )

15 35 43 75 86 50 17 46

n o t p o s s i b l e b e c a u s e the cases h a v e v a r i e d so g r e a t l y as to etiology, severity of the u n d e r l y i n g disease, p r i o r t r e a t m e n t a n d time lapse bet w e e n o n s e t of h e m o r r h a g e a n d ligation. O n t h e basis of o u r c o m p a r i s o n of t r a n s e s o p h a g e a l varix ligation a n d m e d i c a l t h e r a p y , it is a p p a r e n t t h a t s u r g i c a l t r e a t m e n t has signific a n t l y i n c r e a s e d b o t h t h e i m m e d i a t e a n d l o n g - t e r m s u r v i v a l rates of b l e e d i n g c i r r h o t i c p a t i e n t s . A s with m e d i c a l t h e r a p y , ligation has the d i s a d v a n t a g e of n o t b e i n g a definitive p r o c e d u r e , b u t m u s t be c o n s i d e r e d t h e first of t w o stages in t r e a t m e n t , t h e s e c o n d stage of w h i c h is a p o r t a e a v a l s h u n t . T h e r e f o r e , m o r t a l i t y statistics m u s t i n c l u d e t h e m o r t a l i t y r a t e of t h e s u b s e q u e n t shunt. 'vVhiIe varix tigation a p p e a r s to h a v e distinct a d v a n t a g e s o v e r n o n o p e r a t i v e t h e r a p y , it r e m a i n s to be d e t e r m i n e d w h e t h e r it is the best e m e r g e n c y o p e r a t i v e p r o c e d u r e available. EMERGENCY

PORTACAVAL SHUNT

T h e p o r t a c a v a l s h u n t is t h e definitive t r e a t m e n t f o r p o r t a l h y p e r t e n s i o n a n d e s o p h a g e a l varices. If it c a n be successfully a c c o m p l i s h e d 22

d u r i n g t h e b l e e d i n g e p i s o d e , t h e r e is e v e r y r e a s o n t o e x p e c t t h a t it w i l l p e r m a n e n t l y s o l v e t h e p r o b l e m o f b l e e d i n g ,_'.n t h e m a j o r i t y o f p a t i e n t s . T h e q u e s t i o n is, c a n c i r r h o t i c p a t i e n t s t o l e r a t e a n o p e r a t i o n o f t h i s m a g n i t u d e w h e n it is p e r f o r m e d a s a n e m e r g e n c y i n t h e f a c e o f b l e e d ing? To answer this question, we are conducting a prospective evalu a t i o n o f e m e r g e n c y , p o r t a c a v a l s h u n t , i d e n t i c a l in n a t u r e t o o u r v a r i x ligation study. Every bleeding cirrhotic patient admitted to Harbor G e n e r a l H o s p i t a l is i n c l u d e d in t h e s t u d y w i t h o u t s e l e c t i o n , t h e d i a g n o s t i c w o r k - u p is c o m p l e t e d w i t h i n 6 h o u r s o f a d m i s s i o n a n d o p e r a t i o n is p e r f o r m e d w i t h i n 8 h o u r s . T o d a t e , 31 c o n s e c u t i v e p a t i e n t s h a v e b e e n s u b j e c t e d t o a n e m e r g e n c y p o r t a l - s y s t e m i c a n a s t o m o s i s w i t h i n a n a v e r a g e 61/5 h o u r s o f h o s p i t a l a d m i s s i o n . T h e c h a r a c t e r i s t i c s o f this g r o u p o f p a t i e n t s a r e s u m m a r i z e d in T a b l e 7. A l l o f t h e p a t i e n t s h a d m o d e r a t e t o a d v a n c e d T A B L E 7.

RESULTS BLEEDING

OF THREE TYPES OF EMERGENCY TREATMENT ESOPHAGEAL VARICES IN UNSEI.EC"fED PATIENTS WITH CIRRHOSIS MEDICAL TREATMENT

(59 Patients)

Mean liver index* Preoperative Jaundice ( % ) status -1 Ascites ( % ) L Encephalopathy ( % ) Mean bIood required (L.) E a r l y survival ( % ) Long-term surviva| ( % ) ?

2.5 42 41 25 7.2 17 3

VARIX L IGATIOI~

(28 Patients)

2.6 52 50 25 4.2 54 21-36

OF

PORTACAVAL S tlUNT

(31 Patients)

2.9 58 52 23 4.2 48 45

*Liver index reflects the results of liver function tests and is calculated according to the method of McDermott (29). "~Long-term survivors of all forms of treatment had portacavaI shunts. The 2 survivors in the Medical Treatment G r o u p h a v e b e e n f o l l o w e d f o r 4 a n d 5W~ y e a r s . T h e s u r v i v o r s i n t h e Varix Ligation Group have been followed for 3-6 years. Tile survivors in the Portacavai Shunt Group have been followed for 3-32 months.

alcoholic cirrhosis and massive varix hemorrhage; 58% had jaundice, 5 2 % h a d a s c i t e s a n d 2 3 % h a d h e p a t i c e n c e p h a l o p a t h y at t h e t i m e Of admission. The portal pressure before shunt averaged 420 ram. saline and after shunt was reduced to 217 ram. F i f t e e n p a t i e n t s s u r v i v e d t h e o p e r a t i o n a n d left t h e h o s p i t a l , a n i m m e d i a t e s u r v i v a l r a t e o f 4 8 % . O f t h e 16 o p e r a t i v e d e a t h s , 12 w e r e due to liver failure, 3 were due to the development of a gastric ulcer w h i c h b l e d ( 2 p a t i e n t s ) o r p e r f o r a t e d (1 p a t i e n t ) d u r i n g t h e s e c o n d t o f o u r t h p o s t o p e r a t i v e w e e k a n d 1 d e a t h o c c u r r e d s u d d e n l y f r o m art undiscovered cause. Survival rate following side-to-side anastomosis (20 operations) was 55%, while with end-to-side shunt (1I operat i o n s ) it w a s 3 6 % . H y p o t h e r m i a t o 31 ° C. w a s u s e d in 11 o p e r a t i o n s a n d it d i d n o t i n f l u e n c e s u r v i v a l . T h e 1 5 s u r v i v o r s h a v e b e e n f o l l o w e d f o r f r o m 3 to 3 2 m o n t h s ( 1 1 f o r o v e r I y e a r ) . O n e p a t i e n t h a s d i e d 23

f r o m i n t r a c t a b l e e n c e p h a l o p a t h y a n d t h e o t h e r s a r e still alive, a l o n g t e r m s u r v i v a l r a t e of 45 % . T h e r e a r e s e v e r a l t e c h n i c a l a s p e c t s of t h e e m e r g e n c y s h u n t o p e r a t i o n w h i c h s h o u l d b e e m p h a s i z e d . F i r s t l y , t h e s a f e s t a n e s t h e s i a in o u r e x p e r i e n c e h a s c o n s i s t e d of a c o m b i n a t i o n of n i t r o u s o x i d e - o x y g e n , int r a v e n o u s dernerol, a n d s m a l l q u a n t i t i e s of a m u s c l e r e l a x a n t . S e c o n d l y , u s e of a r i g h t s u b c o s t a l i n c i s i o n h a s e l i m i n a t e d m a n y of t h e p o s t o p e r a tive c o m p l i c a t i o n s a s s o c i a t e d w i t h t h e p r e v i o u s l y p o p u l a r t h o r a c o a b d o m i n a l a p p r o a c h . T h i r d l y , l i b e r a l u s e of t h e e l e c t r o c a u t e r y h a s r e d u c e d b o t h the b l o o d loss a n d t h e l e n g t h of t h e o p e r a t i o n . F i n a l l y , in o u r o p i n i o n , t h e p o r t a c a v a l s h u n t is s u p e r i o r to t h e s p l e n o r e n a l a n a s t o m o s i s b e c a u s e it p r o d u c e s a g r e a t e r r e d u c t i o n in p o r t a l p r e s s u r e , is a s s o c i a t e d w i t h a l o w e r i n c i d e n c e of t h r o m b o s i s a n d r e b l e e d i n g , a n d is t e c h n i c a l l y less difficult a n d t i m e c o n s u m i n g . E i t h e r of t h e t w o t y p e s o f p o r t a c a v a l s h u n t s , t h e s i d e - t o - s i d e o r t h e e n d - t o - s i d e , is s a t i s f a c t o r y a n d t h e t h e o r e t i c a l h e m o d y n a m i c a d v a n t a g e s of t h e s i d e - t o - s i d e a n a s t o m o s i s m a y b e o u t w e i g h e d s o m e t i m e s by t h e g r e a t e r e a s e of p e r f o r m a n t e a n d s a v i n g in t i m e of t h e e n d - t o - s i d e s h u n t . H o w e v e r , w h e n r e v e r s a l of p o r t a l flow is p r e s e n t , as i n d i c a t e d b y a p o r t a l p r e s s u r e o n t h e h e p a t i c s i d e of a c l a m p o c c l u d i n g t h e p o r t a l v e i n w h i c h is g r e a t e r t h a n t h e f r e e p o r t a l p r e s s u r e , a s i d e - t o - s i d e s h u n t is m a n d a t o r y . T a b l e 7 p r e s e n t s a c o m p a r i s o n of o u r c u r r e n t r e s u l t s o f m e d i c a l t h e r a p y , v a r i x l i g a t i o n a n d p o r t a c a v a l s h u n t in t h e e m e r g e n c y m a n a g e m e n t of b l e e d i n g e s o p h a g e a l v a r i c e s . B e c a u s e t h e c h a r a c t e r i s t i c s , t r e a t m e n t r e g i m e n s a n d o u t c o m e w e r e a l m o s t i d e n t i c a l in t h e s t u d y a n d p r e s t u d y m e d i c a l t r e a t m e n t g r o u p s r e f e r r e d to p r e v i o u s l y , t h e t w o h a v e b e e n c o m b i n e d into a s i n g l e g r o u p of 5 9 p a t i e n t s . It c a n b e s e e n t h a t t h e t h r e e t y p e s of t r e a t m e n t w e r e e v a l u a t e d in c o m p a r a b l e p a t i e n t s u n d e r s i m i l a r c i r c u m s t a n c e s . T h e a v e r a g e v o l u m e of b l o o d t r a n s f u s e d b e f o r e a n d d u r i n g o p e r a t i o n w a s t h e s a m e in the t w o s u r g i c a l t r e a t m e n t groups; however, patients treated by immediate operations required s i g n i f i c a n t l y less b l o o d t h a n t h o s e t r e a t e d m e d i c a l l y . T h e e a r l y s u r v i v a l r a t e s f o l l o w i n g t h e t w o f o r m s of o p e r a t i v e t h e r a p y w e r e s i m i l a r a n d were about three times greater than that resulting from nonoperative treatment. Long-term survival was strikingly more frequent following operative m a n a g e m e n t than after medical t r e a t m e n t . Of the two f o r m s of s u r g i c a l t h e r a p y , t h e e m e r g e n c y s h u n t r e s u l t e d in a slightly g r e a t e r l o n g - t e r m s u r v i v a l r a t e t h a n d i d v a r i x l i g a t i o n , at a n e x p e n d i t u r e - o f c o n s i d e r a b l y less h o s p i t a l i z a t i o n t i m e a n d effort. M o r e o v e r , t h e s u r vival r a t e o f 3 6 % f o r v a r i x l i g a t i o n m a y b e g e n e r o u s , since it i n c l u d e s 4 p a t i e n t s w h o h a v e b e e n lost to f o l l o w - u p a n d m a y n o t be living; if t h e s e p a t i e n t s a r e c o n s i d e r e d d e a d , t h e s u r v i v a l r a t e is 2 1 % . O n t h e o t h e r h a n d , t h e v a r i x l i g a t i o n g r o u p h a s b e e n f o l l o w e d f o r a signific a n t l y g r e a t e r p e r i o d of t i m e t h a n h a s t h e s h u n t g r o u p . T h e e x p e r i e n c e of o t h e r s w i t h t h e e m e r g e n c y p o r t a c a v a l s h u n t is s u m m a r i z e d in T a b l e 8. A l l of t h e s e s t u d i e s i n v o l v e d s e l e c t e d p a t i e n t s , 24

TABLE

8.

E.~tERGENCY PORTACAVAL S H U N T IN VARIX HEI~tORRHAGE

~gk.

p.,

~ttt

AUTHORS

COMMENT

Mikkelsen ( 33,~ 34 )

1962

37

65

Selected private and indigent patients (emergency and semiemergency)

Wantz and Payne (10, 38, 55, 56)

1961

34

59

Ekman and Sandblom (19)

1964

30

80

Preston and Trippel (41 )

1965

25

56

Brick and Palmer ( 7 )

1964

18

61

Peskin e t a l , (40)

1964

13

77

Weinberger and Maier (58)

1961

13

77

Selected private and indigent patients Selected patients (emergency and semiemergency) Selected V A H patients (all developed bleeding while in hospital) Selected private, indigent and A r m y patients Selected private and indigent patients Selected private and indigent patients (emergency and semiemergency)

Rousselot, Gilbertson and Panke (45)

I960

I1

64

H a r b o r General

t966

31

48

Selected private and indigent patients (emergency and semiemergency) Unselected, consecutive indigent patients

s o m e n o t b l e e d i n g a t t h e t i m e o f o p e r a t i o n . T h e r e f o r e , it is n o t p o s s i b l e t o c o m p a r e t h e s e r e s u l t s w i t h t h o s e o b t a i n e d in o u r i n s t i t u t i o n in u n selected, consecutive patients. Nevertheless, the immediate survival of o n e - h a l f t o t h r e e - f o u r t h s o f t h e p a t i e n t s is c e r t a i n l y e n c o u r a g i n g . O n t h e b a s i s o f o u r s t u d i e s a n d t h o s e o f o t h e r s , it is a p p a r e n t t h a t emergency operative management has significantly improved the surv i v a l o f c i r r h o t i c p a t i e n t s With v a r i x h e m o r r h a g e . A s y e t , i t is n o t certairt w h e t h e r the e m e r g e n c y p o r t a c a v a l s h u n t or varix ligation foll o w e d b y elective s h u n t will p r o d u c e the m o s t l o n g - l a s t i n g benefits, although the evidence on hand would seem to favor the shunt proced u r e . W h i l e f u r t h e r e x p e r i e n c e is r e q u i r e d t o d r a w v a l i d c o n c l u s i o n s r e g a r d i n g t h e o p e r a t i o n o f c h o i c e , t h e r e is l i t t l e q u e s t i o n t h a t o p e r a t i v e t h e r a p y has b e c o m e the k e y s t o n e of e m e r g e n c y t r e a t m e n t of b l e e d i n g esophageal varices. REFERENCES .

Atik, M., and Simeone, U.: Massive gastrointestinal bleeding: A study of 296 patients at City Hospital of Cleveland, A.M.A. Arch. Surg. 69:355, 1954. 25

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14, 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

B a i n b r i d g e , F . A . , a n d T r e v a n , J. W . : S o m e a c t i o n s o f a d r e n a l i n u p o n liver, J. P h y s i o l . 5 1 : 4 6 0 , 1917. B a i r d , R. J., e t a l . : T h e s u r g i c a l t r e a t m e n t o f 7 l p a t i e n t s w i t h e s o p h a g e a l v a r i c e s , C a n a d . M . A. J. 9 2 : 103, 1965. B a r o n o f s k y , I., a n d W a n g e n s t e e n , O. H . : O b s t r u c t i o n o f s p l e n i c v e i n i n c r e a s e s weigl~t o f s t o m a c h a n d p r e d i s p o s e s t o e r o s i o n o r u l c e r , P r o c . S o c . E x p e r . B i o l . & M e d . 5 9 : 2 3 4 , 1945. B e n n e t t , H . O., B a l s e r , L., a n d B a k e r . L. A . : C o m p l i c a t i o n s in u s e o f esophageal compression balloons (Sengstaken tube), A.M.A. A r c h . Int. M e d . 9 0 : 196, 1952. B r i c k , I. B." E s o p h a g o s c o p y b y a n d f o r i n t e r n i s t : R e v i e w o f r e s u l t s in t h o u s a n d p a t i e n t s , A m . J. M . Sic. 2 4 1 : 2 8 9 , 1 9 6 I . B r i c k , I. B., a n d P a l m e r , E. D . : O n e t h o u s a n d c a s e s o f p o r t a l c i r r h o s i s o f t h e liver, A r c h . Int. M e d . 1 1 3 : 5 0 1 , 1964. B r i t t o n , R. C . : I n f l u e n c e o f p o r t a l - s y s t e m i c c o l l a t e r a l p a t t e r n s a n d d i s t r i b u tion of varices on results of surgical treatment of bleeding esophageal v a r i c e s , S u r g e r y 5 3 : 5 6 7 , 1963. B r i t t o n , R. C., a n d C r i l e , G . , Jr.- L a t e r e s u l t s o f t r a n s e s o p h a g e a l s u t u r e o f b l e e d i n g e s o p h a g e a l v a r i c e s , Surg.. G y n e c . & O b s t . 117: 10, 1963. C h i l d , C. G . : T h e p o r t a l c i r c u l a t i o n , N e w E n g l a n d J. M e d . 2 5 2 : 8 3 7 , 1955. Clark, G. A.: C o m p a r i s o n of effects o f A d r e n a l i n and Pituitrin on portal c i r c u l a t i o n , J. P h y s i o l . 6 6 " 2 7 4 , 1928. C o h n , R., a n d M a t h e w s o n , C., Jr.: O b s e r v a t i o n s o n p a t i e n t s d u r i n g t h e surgical treatment of acute massive hemorrhage from esophageal varices s e c o n d a r y to c i r r h o s i s o f t h e liver, S u r g e r y 41 "94, 1957. C o h n , R., a n d B l a i s d e l l , F. W." T h e n a t u r a l h i s t o r y o f t h e p a t i e n t w i t h c i r r h o s i s o f t h e l i v e r w i t h e s o p h a g e a l v a r i c e s f o l l o w i n g t h e first m a s s i v e h e m o r r h a g e , S u r g . , G y n e c . & O b s t . 1 0 6 : 6 9 9 , 1958. C o n n , H . O . : H a z a r d s a t t e n d i n g t h e use o f e s o p h a g e a l t a m p o n a d e , N e w E n g l a n d J. Nled. 2 5 9 : 7 0 1 , 1958. C o r m , H. O., M i t c h e l l . J. R., a n d B r o d o f f , M . G . : A c o m p a r i s o n o f t h e r a d i o l o g i c a n d e s o p h a g o s c o p i c diagnosis of e s o p h a g e a l varices, N e w Engl a n d J. M e d . 2 6 5 : I 6 0 , 1961. C o n n , I-I. O., S m i t h , H . W . , a n d B r o d o f f , M . : O b s e r v e r v a r i a t i o n in t h e e n d o s c o p i c d i a g n o s i s o f e s o p h a g e a l v a r i c e s , N e w E n g l a n d J. M e d . 2 7 2 : 8 3 0 , 1965. C r a w f o r d , E. S., H e n l y , W. S., a n d K e l s e y , J.: L i g a t i o n o f e s o p h a g e a l v a t i c e s : A n e w t e c h n i q u e , A n n . S u r g . 2 5 " 8 0 5 , 1959. D a v i s , W . D . , Jr., e t al." E f f e c t o f P i t u i t r i n in r e d u c i n g p o r t a l p r e s s u r e in h u m a n b e i n g " P r e l i m i n a r y r e p o r t , N e w E n g l a n d J. Meal. 256" 108, 1957. E k r n a n , C. A., a n d S a n d b l o m , P.: S h u n t o p e r a t i o n is a c u t e b ] e e d i n g f r o m e s o p h a g e a l v a r i c e s , A n n . S u r g . 1 6 0 : 5 3 1 , 1964. F r i e d b e r g , S . A . , e t al.: E s o p h a g e a l v a r i c e s in h e p a t i c c i r r h o s i s . E n d o s c o p i c s t u d y , A n n . O t o l . R h i n . & L a r y n g . 6 4 : 5 9 9 . 1955. H a m i l t o n , J. E . : l ~ , l a n a g e m e n t o f b l e e d i n g e s o p h a g e a l v a r i c e s a s s o c i a t e d w i t h c i r r h o s i s o f liver, A n n . Surg. 1 4 1 : 6 3 7 , 1955. H e i m b u r g e r , I., T e r a m o t o , S., a n d S h u m a c k e r , H. B., Jr." Effect o f s u r g i c a l Pittaitrin u p o n p o r t a l a n d h e p a t i c c i r c u l a t i o n , S u r g e r y 4 8 : 7 0 6 , 1960. H i g g i n s , W . H., Jr.: T h e e s o p h a g e a l v a r i x : A r e p o r t o f o n e h u n d r e d a n d f i f t e e n cases, A m . J. M. Sc. 2 1 4 : 4 3 6 , 1947. K a t z , D . , e t al.: E a r l y e n d o s c o p i c d i a g n o s i s o f a c u t e u p p e r g a s t r o i n t e s t i n a l h e m o r r h a g e , ] ' . A . M . A . 1 8 8 : 4 0 5 , 1964. K i r s h , J. E., B l a c k w e l l , C. C., a n d B e n n e t t , H. D . : R o e n t g e n d i a g n o s i s o f e s o p h a g e a l v a r i c e s " C o m p a r i s o n o f r o e n t g e n a n d e s o p h a g o s c o p i c f i n d i n g s in 502 c a s e s , A m . J. R o e n t g e n o l . 7 4 : 4 7 7 , 1955. K o h n , P. M., C h a r m s , B. L., a n d B r o f r n a n , B. L.: E f f e c t o f e p i n e p h r i n e a n d p o s t e r i o r p i t u i t a r y e x t r a c t o n t h e w e d g e d - h e p a t i c - v e i n p r e s s u r e in n o r 26

27. 28. 29. 30. 3I. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. ~. 48. 49. 50.

m a I p a t i e n t s a n d in t h o s e w i t h l i v e r d i s e a s e , N e w E n g l a n d J. M e d . 2 6 t : 3 2 3 , 1959. L i n t o n , R. R., a n d Ell~s, D . S.: E m e r g e n c y a n d d e f i n i t i v e t r e a t m e n t o f b l e e d i n g e s o p h a g e a l v a r i c e s , J . A . M . A . 160: 1017, 1956. L u d i n g t o n , A . G . : A s t u d y o f 158 c a s e s o f e s o p h a g e a l v a r i c e s , S u r g . , G y n e ¢ . & O b s t . 1 0 6 : 5 1 9 , 1958. M c D e r m o t t , W . V., Jr., a n d H u s t o n , C. J. W . : T h e o r a l a m m o n i u m t o l e r a n c e test as a i d in the i n v e s t i g a t i o n o f s u s p e c t e d e s o p h a g o g a s t r i c v a r i c e s , Ann. Surg. 158:820, I963. M c M i c h a e l , J . i P o r t a l c i r c u I a t i o n . I. A c t i o n o f A d r e n a l i n a n d p i t u i t a r y p r e s s o r e x t r a c t , J. P h y s i o l . 75 : 241, 1932. M e r i g a n , T . C . , Jr., et a L : G a s t r o i n t e s t i n a l b l e e d i n g w i t h c i r r h o s i s : S t u d y o f 172 e p i s o d e s in 158 p a t i e n t s , N e w E n g l a n d J. M e d . 2 6 3 : 5 7 9 , 1960. M e r i g a n , T . C., Jr., P l o t k i n , G . R., a n d D a v i d s o n , C . S.: T h e effect o f intravenous PiIuitrin on hemorrhage from bleeding esophageal varices, New E n g l a n d J. M e d . 2 6 6 : 134, 1962. M i k k e l s e n , V¢'. P., a n d P a t t i s o n , A . C . : E m e r g e n c y p o r t a c a v a l s h u n t , A m . J. S u r g . 9 6 : 1,83, 1958. M i k k e l s e n , W . P . : E m e r g e n c y p o r t a c a v a l s h u n t , R e v . S u r g . 1 9 : 1 4 I , 1962. N a c h l a s , M . M . , O ' N e i l , J. E., a n d C a m p b e l l , A . J. A . : T h e l i f e h i s t o r y o f patients with cirrhosis of the liver and bleeding esophageal varices, Ann. S u r g . ~ 4 1 : | 0 , 1955. Orloff, ~¢1. J.: A c o m p a r a t i v e s t u d y of e m e r g e n c y t r a n s e s o p h a g e a I l i g a t i o n a n d n o n s u r g i c a l t r e a t m e n t o f b l e e d i n g e s o p h a g e a l v a r i c e s in u n s e l e c t e d patient.s w i t h c i r r h o s i s , S u r g e r y 5 2 : 103, 1962. O r l o f f , M . /l'., a n d T h o m a s , H . S.: P a t h o g e n e s i s o f e s o p h a g e a l v a r i x r u p ture. A s t u d y b a s e d o n g r o s s a n d m i c r o s c o p i c e x a m i n a t i o n o f t h e e s o p h a g u s a t the t i m e o f b l e e d i n g , A r c h . S u r g . 87: I 3 1 , 1963. O'Sullivan, W. D., and Payne, M. A.: The emergency portacaval shunt, Surg., G y n e c . & O b s t . 1 0 2 : 6 6 8 , 1956. P a n k e , W . F., R o u s s e l o t , L. M . , a n d M o r e n o , A . H . : S p l e n i c p u l p m a n o m e t r y as e m e r g e n c y test in d i f f e r e n t i a l d i a g n o s i s o f a c u t e u p p e r g a s t r o i n t e s tinal b l e e d i n g , S u r g . , G y n e c . & O b s t . 1 0 9 : 2 7 0 , 1959. P e s k i n , G . W . , et al.: P o r t a c a v a l s h u n t in the e m e r g e n c y t r e a t m e n t o f v a r i t e a l b l e e d i n g , S u r g e r y 56: 800, 1964. P r e s t o n , F. W . , a n d T r i p p e l , O. H . : E m e r g e n c y 1 J o r t a c a v a l s h u n t , A r c h . S u r g . 9 0 : 7 7 0 , 1965. R a t n o f f , O. D., a n d P a t e k , A. J., Jr.: T h e n a t u r a l h i s t o r y of L a e n n e c ' s cirr h o s i s o f i h e liver, M e d i c i n e 2 1 : 2 0 7 , 1942. R e a d , A . E., e t al.: B l e e d i n g o e s o p h a g e a I v a r i c e s t r e a t e d b y o e s o p h a g e a l c o m p r e s s i o n t u b e , Brit. M . J. I : 2 2 7 , 1960. R e y n o l d s , T. B., F r e e d m a n , T., a n d W i n s o r , W . : R e s u l t s o f t h e t r e a t m e n t o f b l e e d i n g e s o p h a g e a l v a r i c e s w i t h b a l l o o n t a m p o n a g e , A m . J, M . Sc. 2 2 4 : 500, 1952. RotJsselot, L. M . , G i l b e r t s o n , F. E., a n d P a n k e , W . F . : S e v e r e h e m o r r h a g e f r o m e s o p h a g o g a s t r i c v a r i c e s . Its e m e r g e n c y m a n a g e m e n t w i t h p a r t i c u l a r r e f e r e n c e to p o r t a c ~ v ~ i ~inastoil"it~sis,New E n g l a n d J. M e d . 2 6 2 : 2 6 9 , 1960. Scbatzki, R~.z_~6v~'~n d . . e m 0 n s t r a t i o n o f e s o p h a g e a l v a r i c e s . Its c l i n i c a l ~9.~~,~rch. S u r g . 41~ 1084, 1 9 4 0 . S ~ [ i w a r t z , S. 1., el al.: U s e o f i n t r a v e n o u s P i t u i t r i n in t r e a t m e n t of b l e e d i n g e s o p h a g e a l v a r i c e s , S u r g e r y 4 5 : 72, 1959. S e n g s t a k e n , R . W . , a n d B l a k e m o r e , A. H . : B a l l o o n t a m p o n a g e f o r the c o n trol of hemorrhage from esophageal varices, Ann. Surg. 13I:781, I950. S h a l d o n , S., a n d S h e r l o c k , S.: T h e u s e o f v a s o p r e s s i n ( P i t r e s s i n ) in t h e c o n t r o l o f b l e e d i n g f r o m o e s o p h a g e a l v a r i c e s , L a n c e t 2 : 2 2 2 , 1960. T a y l o r , F. W . , a n d J o n t z , J. (3.: C i r r h o s i s w i t h h e m o r r h a g e , A . M . A . A r c h . S u r g . 7 8 : 7 8 6 , 1959. 2Y

51.

52.

53. 54. 55. 56. 57. 58. 59. 60.

Tsakiris, A., H a e m m e r l i , V. P., a nd B i i h l m a n n , A.: R e d u c t i o n o f portal venous pressure in cirrhotic patients with bleeding f r o m oesophageal varices, by a d m i n i s t r a t i o n of a vasopressin derivative, p h e n y l a l a n i n e e - l y s i n e8vasopressin, A m . J. Med. 36:825, 1964. W a n g ensteen, O. I-I.: T h e ulcer p r o b l e m . (1) Etiology, with special reference to an inter-relationship between the vascular a nd acid-peptic digestive factors; (2) C haracterization of a satisfactory operation whic h will protect against recurrent ulcer, C ana d. M.A.J. 53 : 309, 1945. Wangensteen, O. H., e t a l . : Studies of local gastric cooling as related to peptic ulcer, Ann. Surg. 150:346, 1959. ~Vangensteen, S. L., and Smith, R. B., III: Intragastric cooling for u p p e r gastrointestinal bleeding, Ann. N e w Yor k Acad. So. 115:328, 1964. Wantz, G. E., and Payne, g . A.: T h e e m e r g e n c y portacaval shunt, Surg., Gynec. & Obst. 109:549, 1959. "~Vantz, G. E., a n d Payne, NI. A.: Expe r ie nc e with p o r t a c a v a l shunt for portal hypertension, N e w E n g l a n d J. Med. 2 6 5 : 7 2 I , 1961. W a r r en, W. D., e t a l . : T h e i m p o r t a n c e of he.modynamic studies in ma n agement of portal hypertension, A n n . Surg. 158:387, 1963. Weinberger, H. A., and Maier, H. C.: E a r l y portacaval shunt in selected eases of massive h e m o r r h a g e f r o m esophageal varices, Surgery 49:707, 1961. Welch, (2. S.: M a n a g e m e n t of patients with mass h e m o r r h a g e f r om esophageal varices and cirrhosis of the liver, Surgery 41:1029, 1957. Westphal, K.: l~lber eine K o m p r e s s i o n s b e h a n d l u n g der Blutungen aus Oesophagusvarizen, Deutsche reed. SVchnschr. 56:1135, 1930.

Surgical Treatment

of Intractable

C i r r h o t i c Ascites

MARSHALL J. ORLOFF A S C I T E . S is a s e r i o u s c o m p l i c a t i o n o f c i r r h o s i s . I n m a n y p a t i e n t s it develops suddenly in association with severe hepatocellular damage ;and is a m a n i f e s t a t i o n o f h e p a t i c d e c o m p e n s a t i o n . I n o t h e r s it d e v e l o p s g r a d u a l l y a n d p e r s i s t s as a c h r o n i c d i s t u r b a n c e w h i c h l e a d s to p r o g r e s sive discomfort, nutritional depletion and debilitation. I n t h e m a j o r i t y o f c i r r h o t i c p a t i e n t s , a s c i t e s d i s a p p e a r s in r e s p o n s e to a r e g i m e n c o n s i s t i n g of a b s t i n e n c e f r o m a l c o h o l , a n o u r i s h i n g diet, salt r e s t r i c t i o n a n d o n e or m o r e of a v a r i e t y of d i u r e t i c a n d a n t i a l d o s t e r o n e d r u g s . N e v e r t h e l e s s , i n a s m a l l b u t d i s t u r b i n g g r o u p of p a t i e n t s , a s c i t e s is r e f r a c t o r y t o t h e s e m e a s u r e s . It is f o r t h i s g r o u p t h a t t h e s u r g e o n h a s a t t e m p t e d to d e v i s e o p e r a t i v e m e a s u r e s o f r e l i e f . T h e h i s t o r y o f t h e s u r g i c a l t r e a t m e n t o f a s c i t e s is m a r k e d b y a h o s t of ingenious but usually unsuccessful operations. Included among t h e s e are v a r i o u s m e t h o d s to p r o m o t e d r a i n a g e of ascitic fluid, .to.~reate portal-systemic communications, to r e d u c e p o r t a l . , . v e n o u s i n f l o w a n d to m o d i f y e n d o c r i n e i n f l u e n c e s o n fluid f o r m a t i o n . In r e c e n t y e a r s , h o w e v e r , c l a r i f i c a t i o n of s o m e of the h e m o d y n a m i c a b n o r m a l i t i e s in28