Size of gastroesophageal varices: its behavior after the surgical treatment of portal hypertension

Abstract

The size of gastroesophageal varices is one of the most important factors leading to hemorrhage related to portal hypertension. An endoscopic evaluation of the size of gastroesophageal varices before and after different operations for portal hypertension was performed in 73 patients with schistosomiasis, as part of a randomized trial: proximal splenorenal shunt (PSS n=24), distal splenorenal shunt (DSS n=24), and esophagogastric devascularization with splenectomy (EGDS n=25). The endoscopic evaluation was performed before and up to 10 years after the operations. Variceal size was graded according to Palmer's classification: grade 1 - up to 3 mm, grade 2 - from 3 to 6 mm, grade 3 - greater than 6 mm, and were analyzed in four anatomical locations: inferior, middle or superior third of the esophagus, and proximal stomach. The total number of points in the pre-operative grading minus the number of points in the post-operative grading gave a differential grading, allowing statistical comparison among the surgical groups. Good results, in terms of disappearance or decrease of variceal size, were observed more frequently after PSS than after DSS or EGDS - 95.8%, 83.3%, and 72%, respectively. When differential grading was analyzed, a statistically significant difference was observed between PSS and EGDS, but not between proximal and distal splenorenal shunts. In conclusion, shunt surgeries were more efficient than devascularization in diminishing variceal size.

Splenic artery ligation and distal splenorenal shunt in schistosomiasis

“…To avoid it, DSRS has been performed and considered one of the most effective surgical techniques [2,5]. Our study shows that the association between DSRS and SAL has the same good results as DSRS isolated.…”

“…Patients that have the hepatosplenic form develop portal hypertension due to Symmers periportal fibrosis without affecting liver function [2]. Therefore, the main complication of this disease is variceal bleeding, which may lead to death.…”

“…Clinical treatment consists of sclerotherapy, band ligation, and the use of beta blockers [2]. A number of surgical procedures (shunting and nonshunting) have been developed.…”

Trashepatic left gastric vein embolization in the treatment of recurrent hemorrhaging in patients with schistosomiasis previously submitted to non-derivative surgery

“…These findings corroborate the results reported by other authors in the literature, describing persistence of varices after non-derivative surgical management, although both size and number were substantially reduced post operatively (7,29,30,35,38) . Given that rebleeding rates reported in the literature of between 6% and 29% rise with longer outpatient follow-up time (6,7,12,28,33,34,35) , coupled with the fact that surgical treatment is clearly unable to eliminate the factors triggering portal hypertension in the liver, we can conclude that no methodology is sufficiently reliable to be able to guarantee successful outcomes for this type of therapeutic procedure. Moreover, we found few reports on treatment of schistossomotic patients with recurrent hemorrhaging after non-derivative surgery.…”

Hipertensão porta na esquistossomose mansônica: repercussões do tratamento cirúrgico no perfil histomorfométrico da mucosa gástrica

“…O objetivo final do tratamento da hipertensão porta em pacientes portadores de esquistossomose mansônica na forma hepatoesplênica é prevenir a recidiva hemorrágica eliminando as varizes esofagogástricas, ou, pelo menos reduzir o calibre e a pressão das mesmas 22 . A hemorragia digestiva pode ocorrer em 12 a 20% dos pacientes, ocorrendo geralmente naqueles cuja pressão nas varizes esofágicas supera o nível de 20mmHg.…”