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Portacaval Shunt Versus Endoscopic Sclerotherapy
APRIL 1985, VOL 41, NO 4
AORN JOURNAL
Portacaval Shunt Versus Endoscopic Sclerotherapy
T
he major life-threatening consequence of chronic liver disease is hemorrhage from esophageal varices. The Dec 20 issue of the New England Journal of Medicine contains a study of 52 patients with severe cirrhosis, some of whom were treated with sclerotherapy and the others with portacaval shunts. Forty percent of patients admitted to hospitals for initial esophageal variceal hemorrhage will have rebleeding, and more than one third will die within six weeks after hospitalization, according to the report. But because the operative mortality for patients with severe cirrhosis exceeds 50% in most shunt studies, endoscopic sclerosis of varices is receiving wider attention as therapy for variceal hemorrhage. John P. Cello, MD, and colleagues from San Francisco Hospital and the University of California Medical Center based their study on the theory that endoscopic sclerotherapy would result in the same obliteration of varices and decrease in rebleeding associated with shunt surgery but would avoid subjecting the patient to laparotomy and portacaval anastomosis, and thus, sclerotherapy should be superior to shunt therapy. Patients were randomly assigned either to sclerotherapy or shunt surgery. Sodium morrhuate (5%) was the medication used for injection in sclerotherapy patients. All 24 patients in the shunt group and 23 of the 28 patients in the sclerotherapy group were active alcoholics. All had substantial bleeding, requiring at least six units of packed red cells or whole blood before random assignment. One-half of the sclerotherapy patients had rebleeding during their hospitalization, but only five portacaval shunt patients had gastrointestinal tract hemorrhage following surgery. Two of the shunts failed, and three shunt patients had progressive coagulopathy with bleeding from
multiple sites. Even though the sclerotherapy patients had more rebleeding episodes, the total blood required for transfusion during hospitalization was significantly higher for the shunt group. Fifteen patients in the sclerotherapy group died during hospitalization, 13 from causes directly related to bleeding, and two from progressive hepatic failure. Complications of sclerotherapy did not contribute to patient mortality. Fourteen shunt patients died while in the hospital, nine from progressive hepatic failure without further bleeding, and five from hepatic failure complicated by hemorrhage. Within the 263day follow up, 10 of the 13 discharged sclerotherapy patients had to be readmitted at least once for recurrent variceal hemorrhage. With continued therapy, all varices were obliterated in three of the 13 patients, but despite up to nine sclerotherapy sessions each, three other patients continued to have recurrent bleeding and underwent shunt therapy. When the report was written, five sclerotherapy patients had an improved cirrhosis classification. The number of patients who required rehospitalization for variceal hemorrhage and total days of hospitalization for gastrointestinal tract bleeding were significantly higher for the sclerotherapy group than for the portacaval shunt group. Total units of blood transfused, number of patients rehospitalized for encephalopathy, and total days of rehospitalization for encephalopathy did not differ between the two groups. Total health care costs were greater for the shunt patients, ranging from $20,846 to $24,068, than for the sclerotherapy patients ($13,124 to $17,584). The researchers conclude that “acute and vigorous repeated endoscopic sclerotherapy is at least as good as, and may well be better than, definitive early surgical shunting.”
735
AORN JOURNAL
Portacaval Shunt Versus Endoscopic Sclerotherapy
T
he major life-threatening consequence of chronic liver disease is hemorrhage from esophageal varices. The Dec 20 issue of the New England Journal of Medicine contains a study of 52 patients with severe cirrhosis, some of whom were treated with sclerotherapy and the others with portacaval shunts. Forty percent of patients admitted to hospitals for initial esophageal variceal hemorrhage will have rebleeding, and more than one third will die within six weeks after hospitalization, according to the report. But because the operative mortality for patients with severe cirrhosis exceeds 50% in most shunt studies, endoscopic sclerosis of varices is receiving wider attention as therapy for variceal hemorrhage. John P. Cello, MD, and colleagues from San Francisco Hospital and the University of California Medical Center based their study on the theory that endoscopic sclerotherapy would result in the same obliteration of varices and decrease in rebleeding associated with shunt surgery but would avoid subjecting the patient to laparotomy and portacaval anastomosis, and thus, sclerotherapy should be superior to shunt therapy. Patients were randomly assigned either to sclerotherapy or shunt surgery. Sodium morrhuate (5%) was the medication used for injection in sclerotherapy patients. All 24 patients in the shunt group and 23 of the 28 patients in the sclerotherapy group were active alcoholics. All had substantial bleeding, requiring at least six units of packed red cells or whole blood before random assignment. One-half of the sclerotherapy patients had rebleeding during their hospitalization, but only five portacaval shunt patients had gastrointestinal tract hemorrhage following surgery. Two of the shunts failed, and three shunt patients had progressive coagulopathy with bleeding from
multiple sites. Even though the sclerotherapy patients had more rebleeding episodes, the total blood required for transfusion during hospitalization was significantly higher for the shunt group. Fifteen patients in the sclerotherapy group died during hospitalization, 13 from causes directly related to bleeding, and two from progressive hepatic failure. Complications of sclerotherapy did not contribute to patient mortality. Fourteen shunt patients died while in the hospital, nine from progressive hepatic failure without further bleeding, and five from hepatic failure complicated by hemorrhage. Within the 263day follow up, 10 of the 13 discharged sclerotherapy patients had to be readmitted at least once for recurrent variceal hemorrhage. With continued therapy, all varices were obliterated in three of the 13 patients, but despite up to nine sclerotherapy sessions each, three other patients continued to have recurrent bleeding and underwent shunt therapy. When the report was written, five sclerotherapy patients had an improved cirrhosis classification. The number of patients who required rehospitalization for variceal hemorrhage and total days of hospitalization for gastrointestinal tract bleeding were significantly higher for the sclerotherapy group than for the portacaval shunt group. Total units of blood transfused, number of patients rehospitalized for encephalopathy, and total days of rehospitalization for encephalopathy did not differ between the two groups. Total health care costs were greater for the shunt patients, ranging from $20,846 to $24,068, than for the sclerotherapy patients ($13,124 to $17,584). The researchers conclude that “acute and vigorous repeated endoscopic sclerotherapy is at least as good as, and may well be better than, definitive early surgical shunting.”
735