Avaliação crítica da cirurgia na hipertensão portal esquistossômica

Abstract

There are over 100,000 patients affected by schistosomotic portal hypertension, that may suffer rupture of the esophageal varices. Besides the portal hypertension, local factors must be emphasized as responsible for the three distal centimeters of the esophagus, called "zona vulnerável" (vulnerable zone). The better liver functional reserve of these schistosomotic patients as compared to the cirrhotic, present two favorable conditions: (1) better possibility of conservative treatment during acute hemorrhage; (2) elective surgical treatment may be undergo without a mandatory step of large portal decompression. The Author only indicate surgical treatment in patients with hemorrhage antecedent and his preference consist in splenectomy plus obliterative suture of the varices at the "vulnerable zone" and when possible, ligature of left gastric vein also; 358 patients were undergone surgery with operative mortality 3.07%; 347 were followed during 1 to 25 years; late mortality 8.38%; recurrence hemorrhage 11.58%; none porto-systemic encephalopathy was observed.

Trombose de veia porta após desconexão ázigo-portal e esplenectomia em pacientes esquistossomóticos: Qual a real importância?

“…A forma hepatoesplênica, mais importante causa de morbidade e mortalidade, ocorre em 2% a 10% dos infectados (4,25,27) e é caracterizada por fibrose hepática periportal com consequente hipertensão portal, levando à formação de circulação colateral e varizes esofágicas e gástricas. A hemorragia digestiva alta por rotura de varizes esofágicas pode ocorrer em até 60% dos pacientes (2) e levar ao óbito cerca de 12% a 20 % destes (1,3,9,17,18,21,22,25,29) .O tratamento e prevenção do sangramento digestivo na esquistossomose hepatoesplênica incluem medidas clínicas, endoscópicas e cirúrgicas, mas nenhuma destas assegura o controle definitivo do sangramento. O tratamento clínico na profilaxia de hemorragia por meio de agentes betabloqueadores e nitratos exige doses elevadas de drogas, levando a efeitos medicamentosos indesejáveis e, além disto, apresentam eficácia duvidosa (28,39) .…”

Evaluation of patients with schistosomal portal hypertension treated in a tertiary hospital

“…Hemodynamic instability was observed in 75.5 % and blood transfusion was necessary in 74.2 % of the cases. The bleeding caused by esophageal varices rupture is the most relevant disease complication, leading to high rates of morbidity and mortality 3,4,8,10,16,17 . Considering the severity of previous bleeding episodes and the high recurrence rate in a short interval of time, moreover the high incidence of large esophageal varices and the presence of red spots, treatment should be aggressive to avoid bleeding recurrence.…”

“…Upper digestive bleeding from esophageal varices may occur in approximately 60 % of the patients 4,7,8,10 . In Brazil, the annual mortality caused by schistosomiasis was estimated in 0.3 per 100.000 inhabitants and in the rural population the disease represents an important cause of death 2,9 .…”

“…Hepatic failure is rare and, when present, is related to other concomitant diseases such as viral hepatitis or chronic alcohol abuse. Indeed, bleeding from esophageal varices rupture is an important cause of mortality in these patients being the most relevant disease complication 7,10,15,17 . The objective of this study was to analyze clinical, epidemiological, laboratorial and endoscopic features of the population with schistosomal portal hypertension and history of upper digestive bleeding due to esophageal varices rupture treated in a tertiary university hospital.…”

Alterações angiográficas e pressóricas determinadas pela esplenectomia e ligadura da veia gástrica esquerda em portadores de esquistossomose mansônica

“…Splenectomy and ligature of the esophageal varices (SLEV) reduces the caliber of the portal vein, increases the caliber of the hepatic artery and causes slightly heightened sinusoidal pressure. In 15% of cases, after surgery, portal blood is diverted through the left gastric vein causing arterialization of the liver and sinusoidal pressure, with a pattern of hemodynamics similar to that of late poorly diagnosed portosystemic anastomosis 13 . Without surgery, the splenoportal hyperflow ensures that liver function is preserved, and is sufficient to overcome increased intra-hepatic resistance.…”