Prophylactic Portacaval Anastomosis

Conn, Harold O.; Lindenmuth, W. W.; May, Carl J.; Ramsby, Gale R.

doi:10.1097/00005792-197201000-00002

Cited by 220 publications

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“…This interesting finding supports the concept that the prevention of ascites would increase the efficacy of nadolol therapy. 21 Although withdrawals due to adverse effects were similar in both groups, most were related to ␤-blockade rather than to spironolactone (9 vs. 2). Only 2 patients in the combined treatment group developed an increase in serum creatinine and urea levels associated, in one of the patients, with hyperkalemia that improved with discontinuation of the diuretic drug.…”

Section: Discussionmentioning

confidence: 87%

“…This could be related to the inclusion of patients with less severe liver disease (mean Child-Pugh score of 5.9 Ϯ 1) and without ascites. In this regard, it has been shown that ascites is an important prognostic factor increasing the risk of bleeding 21 and was the most important indicator of both bleeding and death risks in a trial comparing patients with and without ascites treated with propranolol. 22 Vorobioff et al observed that, after 3 months of treatment with propranolol, portal pressure decreased significantly more often in patients without ascites than in those with ascites.…”

Section: Discussionmentioning

confidence: 99%

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Nadolol plus spironolactone in the prophylaxis of first variceal bleed in nonascitic cirrhotic patients: A preliminary study

Abecasis¹

2003

Hepatology

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Treatment with ␤-blockers fails to decrease portal pressure in nearly 40% of cirrhotic patients. Recent studies have suggested that treatment with spironolactone reduces pressure and flow in the portal and variceal systems. This trial was designed to assess if nadolol plus spironolactone is more effective than nadolol alone to prevent the first variceal bleeding. One hundred patients with medium and large varices who had never bled and were without ascites were included in a prospective, randomized, multicenter, double-blind, placebo-controlled trial. The patients were randomized into 2 groups: 51 received nadolol plus placebo (N ؉ P) and 49 received nadolol plus spironolactone 100 mg/d (N ؉ S). Hepatic venous pressure gradient (HVPG) and activity of the renin-aldosterone system (plasma renin activity/plasma aldosterone levels) were measured in 24 patients. There were no significant differences in the appearance of variceal bleeding and ascites between groups at a mean follow-up of 22 ؎ 16 months. However, analyzing both complications together, the incidence was significantly higher in the N ؉ P group than in the N ؉ S group (39% vs. 20%; P < .04). Clinical ascites was also higher in patients in the N ؉ P group than in the N ؉ S group (21% vs. 6%; P < .04). Significant increases in plasma renin activity and plasma aldosterone levels were only observed in patients in the N ؉ S group (P < .01). The cumulative probabilities of remaining free of bleeding and ascites were similar in both groups after 70 months of follow-up. In conclusion, these results suggest that nadolol plus spironolactone does not increase the efficacy of nadolol alone in the prophylaxis of the first variceal bleeding. However, when bleeding and ascites were considered together, the combined therapy effectively reduced the incidence of both portal-hypertensive complications. A t present, nonselective ␤-adrenergic blockers (␤-blockers) are the drugs of choice to prevent the first variceal bleeding in cirrhotic patients with large esophageal varices. 1 Previous studies have shown that reduction of the hepatic venous pressure gradient (HVPG) to less than 12 mm Hg or a decrease in HVPG greater than 20% from basal values protects against variceal hemorrhage. However, such a decrease in portal pressure could be achieved in only 20% of patients receiving ␤-blockers. 2 Moreover, 40% of treated patients do not have reduced portal pressure despite adequate ␤-blockade. 3 Therefore, the addition of drugs to ␤-blockers has been investigated to achieve effective reductions in portal pressure in a greater proportion of patients. 4 Recent data have shown that spironolactone significantly lowers portal and variceal pressures by reducing plasma volume and splanchnic blood flow. 5-9 Plasma volume depletion improves the hyperdynamic circulatory state associated with the development and maintenance of portal hypertension. 10,11 However, a correlation could not be shown between the decrease in circulating plasma volume and the decrease in HVPG. 5,6,8 It has been sugge...

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Section: Discussionmentioning

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Nadolol plus spironolactone in the prophylaxis of first variceal bleed in nonascitic cirrhotic patients: A preliminary study

Abecasis¹

2003

Hepatology

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“…These older studies suggested that, in patients with alcoholic and nonalcoholic causes of cirrhosis, the risk of variceal hemorrhage is highest in the first year after diagnosis of varices, and decreases with time afterward. [11][12][13][14][15]20 (Fig. 5).…”

Section: Discussionmentioning

confidence: 99%

“…12 Older studies on the natural history of variceal hemorrhage, primarily in alcoholic cirrhotic patients, also suggest that the majority of variceal bleeding episodes occurred within the first year of diagnosis of varices. [13][14][15] The majority of clinical studies showing the efficacy of ␤ blockers for prevention of variceal hemorrhage report a follow-up period of up to 2 years, as this was considered the period of highest risk. Because of these observations, including the lack of long-term follow up in prospective studies and lack of cost-effectiveness data for indefinite treatment, it may be proposed that ␤ blockers are necessary only during a certain high risk period.…”

mentioning

confidence: 99%

Propranolol for the prevention of first esophageal variceal hemorrhage: A lifetime commitment?

Abraczinskas

2001

Hepatology

117

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Although ␤ blockers have had significant impact in the treatment of portal hypertension, the question of how long they should be continued for prevention of variceal hemorrhage remains unknown. Prospective studies on ␤ blockers to prevent variceal hemorrhage lack long-term follow-up, and indefinite administration of ␤ blockers for primary prevention of variceal bleeding has become standard practice. The aim of this study was to determine the outcomes of patients in whom ␤ blocker therapy was discontinued. Patients completing a prospective, randomized, double-blind, placebo-controlled trial of propranolol for the primary prevention of variceal hemorrhage were tapered off of propranolol and placebo and followed prospectively for subsequent events. Of the 49 patients in the follow-up study (25 former propranolol, 24 former placebo), 9 experienced variceal hemorrhage (6 former propranolol, 3 former placebo). Following withdrawal of propranolol, the freedom from variceal bleeding was not significantly different between these 2 groups of patients, suggesting that the protective effect of propranolol against variceal hemorrhage, noted previously, was no longer present. Seventeen patients died (12 former propranolol, 5 former placebo) during the follow-up study. Cumulative survival was longer in the placebo group. These trends for EVH and survival were opposite to those observed in the original study population while patients were taking medication. When propranolol is withdrawn, the risk of variceal hemorrhage returns to what would be expected in an untreated population. Patients who discontinue ␤ blockers experience increased mortality compared with an untreated population. These observations support the current practice of indefinite prophylactic therapy. (HEPATOLOGY 2001;34:1096-1102.)

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“…Furthermore, the results of randomized clinical trials during the last 20 years, in patients with or without previous variceal hemorrhage, have not demonstrated a statistically significant increase in survival after any kind of portal-systemic shunt compared to that achievable without operation. [188][189][190][191][192][193][194] The decrease in mortality from gastrointestinal hemorrhage after shunting has been canceled by perioperative deaths and/or by a higher subsequent death rate from hepatic failure. Consequently, alternative methods to control variceal bleeding without changing the preexisting hepatic blood flow patterns have been viewed with increasing interest.…”

Section: Portal-systemic Shunt For Complications Of Portal Hypertensionmentioning

confidence: 99%

The ECK fistula in animals and humans

Starzl¹

1983

Current Problems in Surgery

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Prophylactic Portacaval Anastomosis

Cited by 220 publications

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Nadolol plus spironolactone in the prophylaxis of first variceal bleed in nonascitic cirrhotic patients: A preliminary study

Nadolol plus spironolactone in the prophylaxis of first variceal bleed in nonascitic cirrhotic patients: A preliminary study

Propranolol for the prevention of first esophageal variceal hemorrhage: A lifetime commitment?

The ECK fistula in animals and humans

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