Management a/Variceal Hemorrhage

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Emergency Surgical Treatment of Variceal Hemorrhage Bernard F. Langer, MD, FRCSC, FACS, * Paul D. Greig, MD, FRCSC, t and Bryce R. Taylor, MD, FRCSC, FACS:j:

The physician who undertakes the management of a patient with bleeding varices faces a complex and challenging problem. Not only does he have to treat the acute blood loss and its hemodynamic consequences, but he must also deal with a number of associated problems, which often accompany the underlying liver disease. These include coagulopathies, poor nutritional state, susceptibility to infection, impaired renal function, fluid retention and ascites, altered neurologic state, and respiratory insufficiency. Control of bleeding is the top priority in the acute situation; however, the other complications require simultaneous management and need particular attention because not only are these complications often aggravated by the fact of the bleeding episode itself, but they are sometimes made worse by the very interventions designed to control bleeding. The variety of available treatment options emphasizes the dissatisfaction of physicians with any single mode of therapy. The complexity of this disease and variation between patients suggest that a' certain amount of individualization of treatment is required in order to achieve the best outcome in the individual situation. This article concentrates on the surgical options and the process of decision making regarding surgical therapy for acutely bleeding varices. NATURAL HISTORY OF THE BLEEDING EPISODE

Minor bleeds from varices often stop spontaneously. The protocol for medical management of acute variceal hemorrhage has been outlined in From the Department of Surgery, University of Toronto, Toronto, Ontario, Canada *R. S. McLaughlin Professor and Chairman t Assistant Professor , *Associate Professor and Chairman, Division of General Surgery

Surgical Clinics of North America-Vol. 70, No.2, April 1990



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the article "N onoperative Emergency Treatment of Variceal Hemorrhage." In our own institution, vasopressin is often used in the emergency room, but it is not considered to be sufficient therapy for control in most patients. Our practice is to endoscope patients very soon after admission to make an accurate diagnosis and to identify the bleeding source. Those patients who are deemed to be bleeding from varices are treated with injection sclerotherapy at the time of the first diagnostic endoscopy. If patients are bleeding too rapidly to achieve adequate sclerotherapy, balloon tamponade is used, employing only the gastric balloon on traction. All such patients are managed in the ICU setting by a team familiar with our protocols, and patients treated with balloon tamponade are intubated and ventilated to prevent respiratory complications. Control of emergency bleeding by nonsurgical means is achieved in 50% to better than 90% of cases, depending on the patient population and the methods of nonsurgical treatment used. Recent reports in the literature would suggest that at least temporary control of bleeding using the preceding protocol can be obtained in 80 to 90% of patients.

DECISION MAKING REGARDING SURGICAL INTERVENTION Those patients who fail to stop bleeding after being treated with conservative measures or who are initially controlled, but rebleed early, have an extremely high mortality. They are also usually the patients who have the most advanced liver disease and, consequently, will tolerate either bleeding or major surgery poorly. The decision regarding operation depends on the assessment of the relative risks of persistent nonsurgical therapy and the risks of surgical treatment. In addition to the controversy as to whether surgery has any role at all in the emergency situation, there is also disagreement about the timing of emergency surgery and whether it should be first-line or second-line therapy. There is general agreement that the operative mortality after elective operations is lower than after emergency surgery. Much of this difference can be accounted for by selection-that is, bad-risk patients tend to die from uncontrolled bleeding in the acute situation, leaving better-risk survivors available for elective operations. There are patients, however, who may be in a high-risk group at the time of their acute bleed, whose condition might be improved enough following initial nonsurgical control to improve their chances of surviving an operation. The patient who has persistent or recurrent bleeding, however, often manifests deterioration of hepatic and general status as bleeding continues. To avoid this progressive multisystem decline, most surgeons prefer to operate early so the patient is not further compromised by persistent efforts at bleeding control. In our center, we try to make this decision within the first 48 hours. Marshall Orloff has long been a proponent of early surgery to avoid these complications23 and, in fact, recommends surgical therapy as the preferred emergency treatment within 6 hours of the patient's entry into the hospital.

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SURGICAL TREATMENT OPTIONS Operative approaches to the management of acutely bleeding varices can be classified into two broad groups: (1) portosystemic shunting, which is aimed at lowering venous pressure and diverting the portal flow from around the critical gastroesophageal area, where the bleeding takes place, and (2) devascularization procedures, which include either directly or indirectly interrupting blood flow to the submucosal venous plexus in the distal esophagus. All these procedures involve the general risks of operating on patients with hemodynamic instability and compromised liver function, as well as the risks specific to each of the operations.

PORTOSYSTEMIC SHUNTS Portacaval Shunt The end-to-side portacaval shunt was introduced for the management of bleeding varices in the 1940s. It became the standard for both the emergency and elective treatment of variceal hemorrhage. The procedure was also widely used prophylactically until prospective trials showed that it had no value in that setting. 6• 30 Because the operation involves ligation of the hepatic end of the portal vein, it produces an acute reduction in total hepatic blood flow, resulting in post-shunt encephalopathy in up to 50% of patients. The mortality rate of the procedure reported in controlled elective trials is less than 10%. 18. 20 The side-to-side portacaval shunt allows sinusoidal decompression of the liver as well as reduction in portal pressure. Although it is more difficult to perform than the end-to-side shunt in some patients, it may be superior in terms of control of ascites. 29. 31 Both the side-to-side and end-to-side portacaval shunts are total shunts and would appear to have similar operative risks, control rates of bleeding, incidence of postoperative encephalopathy, and long-term survival.25 Indeed, they have been used interchangeably as control procedures in trials of other operations for treatment of variceal bleeding.7. 20 The operative mortality of the .portacaval shunt is much higher in the emergency situation than in the elective situation (Table 1), and depends on many factors, including patient selection and timing of the operation. When used as a last resort, the mortality rate is in the 50% range or even higher. 9. 23. 28. 33. 40 When restricted to patients with mild or moderate liver disease, the operative mortality of emergency portacaval shunt, as reported by Villeneuve, is only 19%.42 Our own operative mortality for emergency portacaval shunt carried out for uncontrolled or recurrent bleeding in all patients except those with alcoholic hepatitis in deep coma or with marked uncontrolled coagulopathy is 33%.34 Although the role of the portacaval shunt in the prophylactic and elective therapeutic setting has been well studied, there are few useful controlled data on the emergency shunt. Two recent studies, however, are worth noting. OrlofP3 has long based his arguments for primary shunt

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Table 1. Emergency Portacaval Shunt: Operative Mortality and Recurrent Bleeding AUTHORS

NO.

OPERATIVE MORTALITY

Orloff, 196723 Edmondson, 1971"* Turcotte, 197340 Prandi, 197628 Sarfeh, 198033 Orloff, 198624 Cello, 19875 Villeneuve, 198742 t Soutter, 198934

40 50 43 93 54 21 32 36 58

47% 48% 50% 57% 56% 19% 56% 19% 33%

REBLEEDING RATE

..

Not Not Not Not

23% 12% reported reported reported 0 19% reported 15%

*Includes some patients who stopped bleeding prior to shunt. tSelected patients with "mild or moderate liver disease."

therapy to control bleeding on a consecutive series that suggested that there is improved survival and less rebleeding after portacaval shunt than after either medical therapy or transesophageal ligation. He has recently completed a prospective controlled study in which improved early and late survival was shown in patients treated by emergency portacaval shunt, as compared with a group receiving medical therapy.24 This study, however, is flawed by the fact that sclerotherapy, which is now felt to be the best nonoperative method of controlling bleeding, was not used in the control medical therapy arm of this trial. Cello and his colleagues 5 carried out a prospective randomized trial of portacaval shunt versus sclerotherapy in the management of acute variceal bleeding in patients with severe cirrhosis. In this study, portacaval shunt was not shown to have any advantage over sclerotherapy in either early or late mortality. Sclerotherapy patients, however, had more episodes of rebleeding and readmissions to hospital, and 44% of the survivors of the index hemorrhage in the sclerotherapy arm eventually came to portacaval shunting because of recurrent hemorrhage. Mesocaval Shunt The mesocaval shunt is usually carried out with a Dacron interposition graft, and behaves hemodynamically like a side-to-side portacaval shunt. In uncontrolled series 32 and in one controlled trial, 36 the early mortality rate, post-shunt encephalopathy rate, and long-term survival rates were similar to those achieved with portacaval shunt. This shunt may have an advantage over end-to-side portocaval shunt in that it allows decompression of the liver in patients with reversal of flow in the portal vein or intractable ascites. We have used the mesocaval shunt interchangeably with the portacaval shunt for the emergency control of hemorrhage, and our data34 suggest that they are equivalent in the emergency situation as well, in terms of operative mortality, encephalopathy, and long-term survival. There is, however, a higher incidence of thrombosis because of the use of prosthetic material in the mesocaval shunts (up to 30% by 2 years), but there is no good evidence that this impacts significantly on survival. One reported prospective trial compared mesocaval shunt with portacaval shunt

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as emergency therapy for bleeding varices. 19 The numbers reported were small, and the operative mortality, particularly in the mesocaval shunt group, was unusually high, suggesting that this patient population may not be representative of the cross-section of patients presenting with acute variceal hemorrhage. Distal Splenorenal Shunt The distal splenorenal shunt was designed to decompress the esophagogastric venous plexus while maintaining portal How to the liver. This operation has been studied extensively for the elective treatment of patients who have survived a variceal hemorrhage. The data would suggest that it is superior to portacaval shunt in terms of post-shunt encephalopathy, but long-term survival is no different. 18. 20 There are suggestive data from nonrandomized studies, however, that the nonalcoholic subpopulation of patients may have improved survival. 13, 46 Because the distal shunt is more difficult and more time consuming than a portacaval shunt, most surgeons do not use it in the emergency situation. Those that do, however, 26. 27 report operative mortality of approximately 30%. It is difficult to compare selection criteria with other reports of emergency portacaval shunting. We would rarely ulse this operation in an emergency situation, and then only in the very stable, nonalcoholic, actively bleeding patient. The distal shunt has been used as emergency therapy in Japan in a selected nonalcoholic population, with a mortality rate of 11 %.22

DEVASCULARIZATION PROCEDURES A number of operations have been devised to deal either directly or indirectly with the bleeding esophagogastric veins themselves. Some of these operations have been attractive as an alternative to shunting because of their apparent simplicity and because, unlike shunt surgery, they did not require vascular surgical skills and are within the abilities of most general surgeons. Transesophageal Ligation Transesophagealligation is an old operation that was first described by Boerema in 1949. 2 The operation involved a thoracotomy and esophagotomy and, although effective in short-term control of bleeding, was associated with a high rebleeding rate. Esophageal Transection Esophageal transection, first described by Milnes Walker,43 is an extension of the principle involved in transesophageal ligation, but it guarantees occlusion of all submucosal veins in the distal esophagus. The availability of the end-to-end anastomotic stapler allowed esophageal transection to be carried out quickly and effectively through an abdominal approach, 16 and, subsequently, considerable experience with this procedure has been reported. It appears to be associated with less portosystemic encephalopathy than shunts, but it has significant complications, including

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Table 2. Emergency Esophageal Transection (Uncontrolled Studies): Operative Mortality and Rebleeding AUTHORS

Wexler, 198045 Umeyama, 198341 Wanamaker, 198344 Spence, 198535 Durtschi, 19858 * Jenkins, 198917 t

NO.

OPERATIVE MORTALITY

REBLEEDING RATE

6 11 15 25 10 15

67% 45% 73% 28% 90% 73%

0 16% 50% 31% Not reported 50%

*Patients considered unsuitable for emergency shunt. tInjection sclerotherapy failures.

esophageal leak and stricture. The risks of both of these procedures are increased by prior sclerotherapy. When this operation is done in the emergency situation, especially in poor-risk patients, there is a significant operative mortality (Table 2).35.41, 44,45 Consequently, a number of authors have now abandoned this procedure in the emergency setting, 35, 44, 45 Reserving this procedure for shunt rejects 8 or sclerotherapy failures 17 is associated with a prohibitively high mortality rate. In addition, there have been several controlled trials of trans section (Table 3),4, 12, 14, 39 but because of variation in selection criteria and small numbers, firm conclusions cannot be drawn, The data suggest, however, that this operation carries with it an operative mortality rate comparable to that of shunt surgery in the emergency setting. Even though it is more easily done, it is not safer. It appears to be more effective than sclerotherapy in the control of acute bleeding, but no more effective than emergency shunt. Rebleeding (a combination of early and late) can be expected in from 20 to 50% of patients, and may require further operative procedures in about half of these patients. Esophagogastric Devascularization, Splenectomy, and Esophageal Transsection In 1973, Sugiura37 described a more extensive operation to reduce the likelihood of rebleeding from esophageal transsection alone. This included splenectomy, extensive devascularization of the distal esophagus and proximal stomach, and vagotomy through a thoracic and abdominal approach. Table 3. Emergency Esophageal Transection (Controlled Trials): Operative Mortality and Rebleeding Rates TRANSECTION

Rebleed

AUTHORS

OM

Cello, 19824 Huizinga, 198514 Teres, 198739 Low risk High risk Hamilton, 1988 12

83% 33%

0* 3*

21% 57% 31%

40%* 29% 10%

Abbreviation: OM = operative mortality. *p < 0.05.

PORTACAVAL SHUNTS

OM

19%

Rebleed

SCLEROTHERAPY

OM

Rebleed

67% 24%

33% 39%

42% 37%

17% 20%

13%

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A number of modifications of this operation have been described with and without vagotomy and thoracotomy. This operation, unlike staple transsection of the esophagus, is not a simple procedure, and, in the acutely bleeding alcoholic cirrhotic patient, it can be a real adventure. The largest experience with this procedure is in Japan, in a nonalcoholic population. Sugiura38 has reported an overall operative mortality in the emergency situation of 13% (22% in Child class C patients). In the Western alcoholic population of variceal bleeders, however, the results have been poor, with a mortality rate exceeding that of shunt surgery in comparable patients and a significant rebleeding rate (Table 4). Esophageal leak and strictures have also been significant problems in the postoperative course of emergency Sugiura procedures. 1, 10, 11, 21, 38 For these reasons, this operation would seem to have little place in the management of the acutely bleeding alcoholic cirrhotic patient. However, one might cons~der using this procedure in a good-risk nonalcoholic patient who requirea an operation because of persistent bleeding that did not stop with conservative means, but who was not shuntable because of portal, mesenteric, and splenic vein thrombosis. TRANSPLANTATION The preceding surgical approaches leave a patient with the underlying liver disease unchanged, even if the bleeding problem is controlled. The only treatment with the potential to correct portal pressure, control bleeding, and restore normal liver function is liver transplantation. As experience with this mode of therapy has evolved, and results have progressively improved, transplantation must be considered an option for patients with advanced liver disease who present with bleeding. 15 Because most centers have strict selection criteria for transplantation that exclude most patients with alcoholic liver disease, this option applies mainly to nonalcoholic variceal bleeders. If liver transplantation is not considered appropriate therapy, then one should keep in mind the possibility of future transplantation when selecting other methods of treatment. Although there has been some concern expressed in the literature that both the portacaval shunt and the distal splenorenal shunt compromise patients who might later be considered for transplantation,3 our experience and that of others suggests that none of the operations currently being used as therapy for control of bleeding constitute an insurmountable obstacle to subsequent transplantation. Table 4. E11Wrgency Esophagogastric Devascularization, Esophageal Transection, and Splenectomy (Sugiura Procedure): Operative Mortality and Rebleeding Rate AUTHORS

NO.

OPERATIVE MORTALITY

REBLEEDING RATE

Mir, 198221 Ginsberg, 1982 10 Sugiura, 198438 Gouge, 198611 Barbot, 1987 1

30 4 105 11 8

57% 100% 13% 64% 50%

23% 6% 37% 17%

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A SUGGESTED APPROACH Treatment of variceal hemorrhage requires a high degree of awareness of the variety of complications and the ability to use all treatment options. Patients should be managed in a center where there is a team approach utilizing the talents of surgeons, internists, and intensivists who are familiar with problems specific to this disease. Standard protocols, with general agreement on a diagnostic and therapeutic approach, should be established so that time is not lost on the fruitless pursuit of one line of therapy while the patient deteriorates. This standard approach should include the following: 1. leu care during the period of hemodynamic instability resulting from the bleed 2. The sequence of primary interventions (vasopressin, balloon tamponade, sclerotherapy) 3. The duration of treatment before declaring failure of therapy 4. A standard approach to surgical intervention, including timing 5. A high level of expertise available for all therapeutic options (sclerotherapy, devascularization, or shunts)

The standard therapy for acute hemorrhage in our center has been outlined previously. Within the first 48 hours of hospitalization, if bleeding is controlled, a decision is made regarding the subsequent elective therapy for prevention of rebleeding. If control is not obtained within 48 hours, or is initially obtained and rebleeding occurs, a decision is made as to whether the patient is suitable for surgical therapy. Contraindications to emergency surgery include the following: (1) presence of acute alcoholic hepatitis, (2) marked coagulopathy that is uncorrectable by fresh frozen plasma and clotting factors, and (3) the presence of major systemic complications related indirectly to the liver disease, such as acute renal failure, frank sepsis, and severe cardiac and respiratory disease. The presence of severe ascites or encephalopathy is itself not an absolute contraindication to emergency surgery. Categorization of patients as Child class C is not a contraindication; in fact, the majority of patients who do not respond to conservative measures within the first 48 hours are usually Child class C patients. Using these criteria, in the past we have operated upon about 25% of patients who presented with acute bleeding. In recent years, this number has decreased considerably because of the use of sclerotherapy in the acutely bleeding phase. Those patients whose bleeding is not controlled by the usual medical therapy, and who are not considered to be operative candidates, are managed by persistent nonsurgical means as described. In patients who are deemed to be operable, selection of treatment is determined by (1) patency of veins, (2) severity of bleeding and patient instability, and (3) the nature and severity of the underlying liver disease. The patient with patent veins and persistent or recurrent variceal bleeding is usually treated by a total portosystemic shunt. The end-to-side portacaval shunt and the mesocaval shunts are equally effective, and the choice is usually made on the basis oflocal technical considerations, although

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the mesocaval shunt is preferred if there is co-existing, difficult-to-control ascites or reversal of portal flow. In the nonalcoholic patient who has relatively good liver function, is in good general condition, and has moderate bleeding, consideration may be given to carrying out an emergency distal splenorenal shunt. The nonalcoholic patient with very advanced liver disease should be considered for liver transplantation. In those patients who are not shuntable because of thrombosed portal and mesenteric and splenic veins and who do not have alcoholic cirrhosis, the Sugiura operation is probably the most effective approach; in patients with reasonably good liver function, it carries an acceptable risk. Alcoholic cirrhotic patients with thrombosed veins pose a major problem, but these patients may be considered for esophageal transection if their liver function is not badly deranged.

CONCLUSION

Most patients with variceal hemorrhage can be controlled with a combination of sclerotherapy, balloon tamponade, and pharmacologic therapy. Those patients who persist in bleeding are generally those who have the worst liver function and accompanying coagulation problems and who are at highest risk from operative intervention. Unfortunately, they are also at an even higher risk from persistent bleeding without intervention. A number of operations are effective in controlling the acute bleeding, including portosystemic shunts, esophageal transection, and other devascularization procedures. There is no single best treatment for every patient, and the relative benefits of the various operative and nonoperative approaches to variceal bleeding require further careful study, including additional controlled clinical trials.

REFERENCES 1. Barbot oJ, Rosato EF: Experience with the esophagogastric devascularization procedure. Surgery 101:685, 1987 2. Boerema I: Surgical therapy of bleeding varices of the esophagus during hepatic cirrhosis and Banti's disease. Ned Tijdschr Geneeskd 93:4174, 1949 3. Brems JJ, Hiatt JR, Klein AS, et al: Effect of a prior portosystemic shunt on subsequent liver transplantation. Ann Surg 209:51, 1989 4. Cello JP, Crass R, Trunkey DO: Endoscopic sclerotherapy versus esophageal transection in Child's class C patients with variceal hemorrhage: Comparison with results of portacaval shunt: Preliminary report. Surgery 91:333, 1982 5. Cello JP, Grendell JH, Crass RA, et al: Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. N Engl J Med 316:11, 1987 6. Conn HO, Lindenmuth WW: Prophylactic portacaval anastomosis in cirrhotic patients with esophageal varices. N Engl J Med 279:725, 1968 7. Conn HO, Resnick RH, Grace NO, et al: ~istal splenorenal shunt versus portal-systemic shunt: Current status of a controlled trial. Hepatology 1:151, 1981 8. Ourtschi MO, Carrico CJ, Johansen KH: Esophageal transection fails to salvage high-risk cirrhotic patients with variceal bleeding. Am J Surg 150:18, 1985 9. Edmondson HT, Jackson FC, Juler GL, et aI: Clinical investigation of the portacaval

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shunt. A report of early survival from the emergency operation. Ann Surg 173:372, 1971 Ginsberg RJ, Waters PF, Zeldin RA, et al: A modified Sugiura procedure. Ann Thorac Surg 34:258, 1982 Gouge TH, Ranson JHC: Esophageal transection and para-esophagogastric devascularization for bleeding esophageal varices. Ann J Surg 151:47, 1986 Hamilton G, Burroughs AK, McIntyre N, et al: The final report on prospective randomized trial of endoscopic sclerotherapy versus esophageal stapled transection in uncontrolled variceal bleeding. Presented at Second World Congress on Hepato-pancreato-biliary Surgery. Amsterdam, The Netherlands, May 29th-April 3rd, 1988 Henderson JM, Millikan WJ, Wright-Bacon L, et al: Hemodynamic differehces between alcoholic and non-alcoholic cirrhotics following distal splenorenal shunt: Effect on survival? Ann Surg 198:325, 1983 Huizinga WKJ, Angorn IB, Baker LW: Esophageal transection versus injection sclerotherapy in the management of bleeding esophageal varices in patients of high risk. Surg Gynecol Obstet 160:539, 1985 Iwatsuki S, Starzl TE, Todo S, et al: Liver transplantation in the treatment of bleeding esophageal varices. Surgery 104:697, 1988 Johnston GW: Treatment of bleeding varices by esophageal transection with SPTU gun. N Roy Coli Surg Engl 59:3, 1977 Jenkins SA, Shields R: Variceal hemorrhage after failed injection sclerotherapy: The role of emergency esophageal transection. Br J Surg 76:49, 1989 Langer B, Taylor BR, MacKenzie DR, et al: Further report of a prospective randomized trial comparing distal splenorenal shunt with end-to-side portacaval shunt. Gastroenterology 88:424, 1985 Malt RA, Abbott WM, Warshaw AL, et al: Randomized trial of emergency mesocaval and portacaval shunts for bleeding esophageal varices. Am J Surg 135:584, 1978 Millikan WJ, Warren WD, Henderson JM, et al: The Emory prospective randomized trial: Selective versus nonselective shunt to control variceal bleeding. Ann Surg 201:712, 1985 Mir J, Ponce J, Morena E, et al: Esophageal transection and para-esophagogastric devascularization performed as an emergency measure for uncontrolled variceal bleeding. Surg Gynecol Obstet 155:868, 1982 Nagasue N, Kohno H, Ogawa Y, et al: Appraisal of distal splenorenal shunt in the treatment of esophageal varices: An analysis of prophylactic, emergency, and elective shunts. World J Surg 13:92, 1989 Orloff MJ: Emergency portacaval shunt: A comparative study of shunt, tharyx ligation, and non-surgical treatment of bleeding esophageal varices in unselected patients with cirrhosis. Ann Surg 166:456, 1967 Orloff MJ, Bell RH, Greenburg AG: A prospective randomized trial of emergency portacaval shunt and medical therapy in un selected cirrhotic patients with bleeding varices [abstract]. Gastroenterology 90:1754, 1986 Orloff MJ, Chandler JG, Charters AC, et al: Comparison of end-to-side and side-to-side portacaval shunts in dogs and human subjects with cirrhosis and portal hypertension. Am J Surg 128:195, 1974 Peterson K, Giles GR: Distal splenorenal (Warren) shunt in the management of actively bleeding esophageal varices. Br J Surg 73:618, 1986 Potts JR, Henderson JM, Millikan WJ, et al: Emergency distal splenorenal shunts for variceal hemorrhage refractory to non-operative control. Am J Surg 148:813, 1984 Prandi D, Rueff B, Roche-Sicot J, et al: Life-threatening hemorrhage of the digestive tract in cirrhotic patients. Am J Surg 131:204, 1976 Reynolds TB, Donovan AJ, Mikkelsen WP, et al: Results of a 12-year randomized trial of portacaval shunt in patients with alcoholic liver disease and bleeding varices. Gastroenterology 80:1005, 1981 Resnick RH, Chalmers TC, Ishihara AM, et al: A controlled study of the prophylactic portacaval shunt. Ann Intern Med 70:675, 1969 Resnick RH, Iber FL, Ishihara AM, et al: A controlled study of the therapeutic portacaval shunt. Gastroenterology 67:843, 1974 Reznick RK, Langer B, Taylor BR, et al: Results and hemodynamic changes after interposition mesocaval shunt. Surgery 95:275, 1984

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33. Sarfeh IJ, Carter JA, Welch HF: Analysis of operative mortality after portal decompressive procedures in cirrhotic patients. Med J Surg 140:306, 1980 34. Soutter DI, Langer B, Taylor BR, et al: Emergency portosystemic shunting in cirrhosis with bleeding varices: A comparison of portacaval and mesocaval shunts. HPB Surg 1:107, 1989 35. Spence RAJ, Johnston WG: Results in 100 consecutive patients with stapled esophageal transection for varices. Surg Gynecol Obstet 160:323, 1985 36. Stipa S, Ziparo V, Anza M, et al: A randomized controlled trial of mesentericocaval shunt with autologous jugular vein. Surg Gynecol Obstet 153:353, 1981 37. Sugiura M, Futagawa S: A new technique for treating esophageal varices. J Thorac Cardiovasc Surg 66:677, 1973 38. Sugiura M, Futagawa S: Esophageal transection with paraesophgeal devascularizations (the Sugiura procedure) in the treatment of esophageal varices. World J Surg 8:673, 1984 39. Teres J, Baroni R, Bordas JM, et al: A randomized trial of portacaval shunt, stapling transection, and endoscopic sclerotherapy in uncontrolled variceal bleeding. J Hepatol 4:159, 1987 40. Turcotte GG, Lambert MJ: Variceal hemorrhage, hepatic cirrhosis, and portacaval shunts. Surgery 73:810, 1973 41. Umeyana K, Yoshikawa K, Yamashita T, et al: Transabdominal esophageal transection for esophageal varices. Experience in 101 patients. Br J Surg 70:419, 1983 42. Villeneuve J-p, Pomier-Layrargues G, Duguay L, et al: Emergency portacaval shunt for variceal hemorrhage. Ann Surg 206:48, 1987 43. Walker-Milnes R: Esophageal transection for bleeding varices. Surg Gynecol Obstet 118:323, 1964 44. Wanamaker SR, Cooperman M, Carey LC: Use of the EEA stapling instrument for control of bleeding esophageal varices. Surgery 94:620, 1983 45. Wexler MJ: Treatment of bleeding esophageal varices by transabdominal esophageal transection with the EEA stapling instrument. Surgery 88:406, 1980 46. Zeppa R, Hensley GT, Levi JU, et al: The comparative survivals of alcoholics versus nonalcoholics, after distal splenorenal shunt. Ann Surg 187:510, 1978

Address reprint requests to Bernard Langer, MD, FRCSC, FACS Department of Surgery Toronto General Hospital 200 Elizabeth Street en 9-237 Toronto, Ontario M5G 2C4

Emergency surgical treatment of variceal hemorrhage.

Emergency surgery should be considered one of the treatment options for the patient with acute variceal bleeding in whom the usual nonsurgical modes o...
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