Surgical indication in Schistosomiasis mansoni portal hypertension: follow-up from 1985 to 2001

Abstract

The study had the objective to evaluate the benefits of surgical indication for portal hypertension in schistosomiasis patients followed from 1985 Key words: schistosomiasis mansoni -portal hypertension -surgical indication -evolution -esophageal varices Schistosomiasis mansoni is a widespread parasitic disease which could have about 3% of hepatosplenic form and 100,000 patients affected by portal hypertension (Kelner 1992). The development and causative factors of the hepatosplenic form were widely discussed by Klöetzel (1964) but remains as an actual theme for discussion. According to Bina (1995), the severe forms are dependent either on the failure of specific treatment and successive reinfections. Moreover, it has been also related to the parasitic load and also to genetic factors from host (Prata 1992, Bina 2001. Interested on the clinical aspects of hepatosplenic form of schistosomiasis mansoni, Coura and colaborators have followed, since 1973, patients from Capitão Andrade, municipality from Vale do Rio Doce, in Minas Gerais, where a ratio of 5.6% of severe form has been detected (Coura et al. 1992, Conceição & BorgesBorges-Pereira 2002. Despite the fact that in schistosomiasis the portal hypertension is the main morbid element, the surgical treatment of portal hypertension in schistosomiasis patients has distinct features when compared with cirrhotic patients, mostly because hepatic function is preserved in liver schistosomiasis. A total of 102 hepatosplenic patients, aging from 14 to 53 years old, with a male predominance (61.3%), coming from Capitão Andrade (n = 26), and from different regions of the country (n = 76) as outpatients were derived to the Serviço de Doenças Infecciosas e Parasitárias from the Hospital Universitário, UFRJ, a referal hospital for schistosomiasis. They were examined and submitted to laboratorial examinations: six stool examinations (Kato-Katz method), and when negative, a rectal biopsy. Abdominal ultrasonography, digestive endoscopy, functional hepatic tests and sorology for viral detection (HCB and HCV) were done. The main criteria used for surgical indication were: digestive hemorrhage due to esofageal varices rupture, hypersplenism, pain and abdominal discomfort, and hypogonadism. Patients were submitted to the following surgical procedure: splenectomy associated to splenorenal anastomosis (n = 39), or associated to azigoportal desvascularization (n = 37), esophageal gastric descompression (n = 26), and esophageal sclerosis (n = 26). During the surgery fragments of liver and spleen were obtained and processed for histological study. Patients were followed from 1985 to 2001. The main surgical indications were: digestive hemorrhage caused by rupture of esophageal varices, hypersplenism, pain and abdominal discomfort, and hypogonadism. About 5% of patients have discontinued the clinical attending, 9.9% of the patients died because of rebleeding due to the persistence of esophageal varices. There was no significative difference between the surgical procedure employed (ManWhi...

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

“…In the hepatosplenic mansoni schistosomiasis (HSS) diffuse Symmers hepatic fibrosis occurs, which, when combined with congestion of the portal system veins, leads to hepatosplenomegaly. These patients have hemorrhage of the upper digestive tract due to varices rupture on the esophagus and stomach or peptic ulcers in the gastroduodenal mucosa [2][3][4][5][6][7][8][9][10][11][12] In HSS, presinusoidal blockage and hyperflow resulting from splenomegaly are the determining causes of portal hypertension. This model is characterized by functional-hemodynamic equilibrium with preservation of the flow of blood to the liver 6 .…”

“…On the other hand, it preserves the hepatopetal flow and reduces the pressure in the varices of the esophagus. The main aim of interrupting the flow through the LGV may be to interrupt hepatofugal circulation, through this vein, preserving the functional hemodynamic equilibrium, which may be broken by splenectomy 9,5 . The aim of the present study was to assess the effects of splenectomy and ligature of the left gastric vein on the portal hemodynamics of patients with HSS with early signs of hemorrhage of the upper digestive tract, using angiographic and pressure studies prior to surgery and between the 7 th and 15 th day after surgery.…”

Portal fibrosis and schistosomal portal hypertension: what is the best strategy for primary and secondary prevention of hemorrhage from esophageal varices

“…In this respect, several papers have evaluated different treatment strategies for secondary prevention of bleeding from EV, including pharmacological treatment (7,15,18) , sclerotherapy (5,14,16,20) , EBL (22) and surgery (3,9,12,19) . Most of these data are uncontrolled and have focused different endpoints.…”