Surgical management of acute variceal hemorrhage

Abstract

The advent of more effective nonoperative therapies, mainly endoscopic variceal sclerosis, has decreased the need for emergency surgery for control of acute variceal hemorrhage. In centers where it is available, nonoperative portal decompression by transjugular intrahepatic portosystemic shunting (TIPS) is likely to have a further impact. When acute or chronic sclerotherapy fails or when bleeding is secondary to gastric varices or portal hypertensive gastropathy, emergency surgery may be life-saving and should be done promptly before worsening hepatic functional decompensation develops. Child's class C liver disease is not a contraindication to emergency surgery; many patients who fail nonoperative attempts at control of bleeding are of this risk status. The most commonly utilized emergency procedures are portacaval and interposition mesocaval shunts, both of which are effective, and esophageal transection, which is associated with a higher incidence of late rebleeding. An emergency distal splenorenal shunt is appropriate for selected patients who are not actively bleeding at the time of surgery. TIPS is the preferred alternative for acute or chronic endoscopic sclerotherapy failures who are candidates for liver transplantation within the succeeding 6 to 12 months.

Current state of portosystemic shunt surgery

“…There are only uncontrolled series of TIPS [5,12] and surgical shunts [13] in acute variceal bleeding which do not show clear differences in outcome. Mortality in emergency situations ranges from 20% to 60%, similar in both procedures depending on liver function.…”

Devascularization for Portal Hypertension not Obsolete: Technical Details and Experience of 104 Cases

“…TIPS require intense post procedure endoscopic surveillance and it is temporary short term measure (34,35) . Esopagogastric devascularisation has prime role in the management of emergency and elective variceal bleeding, it's indication already mentioned in the material and methods (30,36) . Liver transplantation is the curative treatment of chronic liver disease with portal hypertension and related complications (6)(7)(8)(9) .…”

“…Bernard B et al and Gu DY et al reported that operative mortality varies between 15-90% depending upon the liver function (51,52) . Hepatic functional reseve is the main determinant of mortality (30,40,53) . In ChildPugh grade A operative mortality rate may be as low as 15%, but in Child-Pugh grade C, it may be as high as 90%.In our studyout of 13 Child C cirrhotic patients, 9 patients died which is 69.23% which is lesser as compared to world literature.…”

“…However, The role of shunt and devascularization in portal hypertension still a topic of debate (29) . These surgical shunts have their own limitations like availability of the veins, requires longer operative time than devascularistion which is main concern in hemodynamically compromised patients, surgical expertise, preoperative angiography to declineate anatomy abdominal vessels and higher risk of shunt thrombosis (30)(31)(32)(33) . Particularly in non-selective shunts there is risk of postoperative encephalopathy and detoriation of liver function due to diversion of portal blood flow.…”

The use and misuse of transjugular intrahepatic portasystemic shunts

“…Although emergent surgery is extremely effective in arresting hemorrhage and preventing rebleeding, it is associated with an approximately 50% mortality rate [14,17,18] because many patients die of liver failure and complications of surgery despite achievement of hemostasis. Those patients with severe hemorrhage, tense ascites, deep coma, aspiration pneumonia, renal failure, or sepsis are particularly at risk for dying [17,19,20]. Indeed, it has been recommended that such patients should not undergo surgery [17].…”