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Preoperative Evaluation of Endoscopic Ultrasonography and Portography in Selecting Devascularization Surgery for Esophagogastric Varices

Posted on: Thursday, 9 June 2005, 06:00 CDT

This study assesses the role of endoscopic ultrasonography (EUS) and portography in selection of mode of devascularization surgery for esophagogastric varices (EGV) in patients with portal hypertension and reports our experience in the treatment of EGV with modified devascularization surgery. Forty-two cirrhotic patients with EGV were treated with devascularization surgery for variceal hemorrhage. Preoperatively, percutaneous transhepatic portography (PTP) and EUS were used as the guiding mode for therapy of EGV. In addition to devascularization and splenectomy, esophageal transection (ET) was performed in 26 patients with upward-flow varices (UFV), whereas 16 patients with downward-flow varices (DFV) underwent proximal gastrectomy instead of ET. In both UFV and DFV groups, grade II of intramural varices and extramural collaterals were most commonly observed on EUS imaging. There was no significant difference of EUS grading between these two groups (P > 0.05). The incidence of postoperative complications, mortality, and recurrent varices were not significantly different between these two groups. The overall 5-year survival rate for UFV group was 69.2 per cent, whereas that for the DFV group was 68.7 per cent (P > 0.05). Our study shows that devascularization surgery is highly effective for the prevention of recurrent bleeding from EGV, and it provides an alternative treatment modality. Combined PTP and EUS are very helpful in determining adequate modalities of devascularization surgery.

RECENTLY, ENDOSCOPIC INJECTION SCLEROTHERAPY (EIS) has been widely accepted as the first choice for the management of esophagogastric varices (EGV) in patients with portal hypertension.1,2 In addition, transjugular intrahepatic portosystemic shunt (TIPS), as well as liver transplantation, have also been performed for long-term prevention of recurrent variceal bleeding.3-4 However, alternative surgical treatment is indicated for certain patients in whom conservative treatment is difficult to control bleeding and for whom liver function is a good risk. The devascularization procedure is an effective nonshunting operation to treat bleeding esophageal varices and is associated with both a low rate of encephalopathy and variceal rebleed over long-term follow- up.5-8 In contrast to ElS, the goal of the devascularization and esophageal transection is to eradicate both submucosal varices and paraesophageal collaterals rather than only submucosal varices. Therefore, the assessment of the collateral vascular structures at the distal esophagus and proximal stomach is extremely important for the selection of precise surgical procedure in the management of EGV.

In the past few years, angiography had been the standard method in the study of the portal collateral circulation in patients with cirrhosis and EGV.9-11 Currently, endoscopie ultrasonography (EUS) has been applied as a new technique to demonstrate the vascular structures and the collaterals of the portal venous system in patients with portal hypertension.12-14 Using the techniques of PTP and EUS, the features of EGV and the hemodynamics of portosystemic collaterals can be specified for different types in patients with portal hypertension. Herein, we present our experience with two variants of transection procedure in the treatment of patients with different types of EGV investigated by PTP and EUS.

Patients and Methods

Patients

Between 1994 and 1999, 42 patients with portal hypertension were treated for variceal hemorrhage in our department. There were 29 males and 13 females, with ages ranging from 39 to 71. All of the 42 patients had at least one episode of hematemesis from esophagogastric varices. All patients had a liver biopsy at surgery. The etiology of portal hypertension was confirmed by liver biopsy and clinical examinations. The liver function was categorized according to ChildPugh's classification. The patient's profiles and clinical data are listed in Table 1. The diagnosis of esophagogastric varices was first made with a gastroduodenoscopy. Varices in the regions of the esophagus and stomach were divided into three types: esophageal (EV), esophagogastric (EGV), and gastric (GV) varices based on the distribution of predominant varices from endoscopie findings.

PTP

The technique for the preoperative PTP has previously been described. Selective splenic and superior mesenteric venograms were obtained before surgery in all patients to determine the location, numbers, and flow pattern of the varices. The portal venous pressure was measured and recorded using a manometer while the tip of the catheter was placed at the main stem of the portal vein. No serious complication was encountered during angiography.

EUS

EUS was applied in all cases using a mechanical sector scan Olympus GF-UM3 (Olympus Co., Tokyo, Japan) with 360-degree view at wave frequency of either 7.5 or 12 MHz. All EUS procedures were performed by the same experienced endosonographer. The presence and distribution of varices and extramural collateral vessels were determined at the esophagogastric region. Intramural varices including EV and GV were serpiginous hypoechoic structures within the wall of the esophagus and stomach, respectively. Extramural collateral vessels, including paraesophageal collateral veins (PEV) and paragastric collateral veins (PGV), were hypoechoic serpiginous vessels in the tissues and spaces exterior to the muscularis propria of the esophagus and serosa of the proximal stomach, respectively. The EUS findings of intramural varices were classified as follows: grade I: a few vessels of small size in the submucosa (<3 mm) (Fig. 1); grade II: uniformly scattered vessels of medium size in the submucosa (3-5 mm) (Fig. 2); grade III: abundant vessels of large size and with honeycomb-like pattern in the submucosa (>5 mm) (Fig. 3). The EUS grading of extramural collateral vessels was as follows: O, none; 1, small or nonconfluent varices <5 mm; and 2, large or confluent varices >5 mm.

TABLE 1. The Demographics of the 42 Patients

Surgery

All patients underwent a surgical procedure. The operative procedures consisted of transabdominal esophageal transection (ET) or proximal gastrectomy (PG), splenectomy, paraesophageal devascularization, and pyloroplasty. The decision of ET or PG was made on the basis of endoscopie, portographic, and EUS findings. An ET was selected if predominance of EV and/or upward flow direction of extrinsic collaterals were demonstrated, whereas PG was done in case of predominance of GV and/or downward flow. ET was used in all patients with EV and most patients with EGV, whereas PG was used in all GV and a few EGV. Postoperatively, the patients underwent follow- up studies including clinical examinations, conventional endoscopy, portography, and EUS for the residual and recurrent varices.

FIG. 1. Endoscopic ultrasonography (EUS) shows grade 1 intramural images (arrowheads) of UFV at the lower esophagus.

FIG. 2. EUS features show grade II intramural (arrowhead) and grade 1 extramural (arrow) UFV at the lower esophagus.

FIG. 3. EUS images show grade III intramural (arrowhead) and grade 2 extramural (arrow) DFV at the proximal stomach.

Statistics

All data analyses were made using the Statistical Package for the Social Sciences, version 8.0 (SPSS Inc., Chicago, IL). The EUS grades of esophagogastric varices and their extramural collateral veins between the upward-flow and downward-flow varices were compared using χ^sup 2^ test. The significance of the comparison of the clinical results between the two variant devascularization surgery was evaluated by χ^sup 2^ test. The overall 5-year survival rates were calculated by the Kaplan-Meier method, and the difference in survival rates between the two groups was analyzed by the log-rank test. A probability of less than 0.05 was considered to be statistically significant.

Results

PTP Findings

According to the drainage pathway of EGV, the flow pattern could be divided into two types: upwardflow (26 patients; Fig. 4) and downward-flow (16 patients; Fig. 5) pathways. The relationship of PTP and EUS findings is shown in Table 2. In the upward-flow pathway, the cranially directed hepatofugal flow arising from coronary and/or short gastric veins drained into azygous and hemiazygous veins via coexisting esophageal or paraesophageal varices. On the other hand, coronary and/or short gastric vein, arising from splenic vein and forming varices in the proximal stomach, drained caudally into the left renal vein and then into the inferior vena cava in the downward-flow pathway.

EUS

The EUS finding of EGV and extramural collateral veins are listed in Table 3. In both the UFV and DFV groups, grade II of intramural varices were most commonly observed. However, grade 1 and grade 2 of extramural collaterals were most frequently demonstrated in UFV and DFV patients, respectively. There was no significant difference of EUS grading between patients with UFV and DFV (P > 0.05).

Clinical Results

In this series, five patients subjected to emergency surgery died in the early postoperative period. Cause of death was progressive hepatic fail\ure in two patients, disseminated intravascular coagulopathy (DIC) resulting from massive blood transfusion in two patients, and pulmonary infection in one patient. Procedure-related complications, such as minor esophageal leak with subphrenic abscess, were seen in only 2 of 42 operated patients. Left subphrenic abscess due to extravasation of the pancreatic juice, caused by pancreatic tail injury during splenectomy, was observed in one patient. They were cured by continuous intraperitoneal drainage and nutritional support. Five patients suffered from esophageal stricture and dysphagia caused by mechanical stapling. Dilation was not required, and the episode was relieved spontaneously 6 months after surgery. During the period of follow-up, two developed encephalopathy, and they soon recovered after conservative management. Recurrent varices developed in five, and two with rebleeding were controlled by endoscopie sclcrotherapy. Of the 37 patients, 8 died during the follow-up period of 26 to 62 months. Causes of death were hepatic failure in 3, hepatocellular carcinoma in 3, CVD in 1, and myocardial infraction in 1. Survival rates were 88 per cent after 1 year, 83 per cent after 3 years, and 69 per cent after 5 years. There was no difference in accumulative survival rate between the ET and PG groups (Fig. 6). Furthermore, the differences in surgical mortality, variceal recurrence, and complication were not statistically significant between these two groups in this study (Table 4).

FIG. 4. Transhepatic portography shows a major upward-flow (arrow) and a minor downard-flow varices (arrowhead).

FIG. 5. Transhepatic portography shows a major downwardflow (arrow) and a minor upward-flow varices (arrowhead).

TABLE 2. The Relationship of PTP and EUS Findings

TABLE 3. Analysis of EUS Grade of the Intramural Varices and Extramural Collateral Veins

Discussion

Patients with portal hypertension tend to develop a complex network of portosystemic communications involving abdominal, retroperitoneal, and thoracic veins. Knowledge of vascular structures may be very useful for management of patients with portal hypertension. Although the flow pattern of the portosystemic collaterals have been clearly shown, esophagogastric varices in the submucosal layer and paraesophagogastric collaterals are not easily differentiated by PTP. On the contrary, EUS has been used to visualize intramural venous morphologic features inside the esophageal wall and their collateral veins in portal hypertension. In the current study, using EUS we could clearly visualize and evaluate venous structures inside and outside the distal esophagus and proximal stomach in patients with EGV. Not only the locations of EGV but also their extra-esophagogastric collaterals could be clearly found by EUS. Thus, selection of the most suitable surgical procedure could be determined via detailed understanding of the venous anatomy of the portal system under the guidance of PTP and EUS.

FIG. 6. Comparison of accumulative survival rate between the esophageal transection (ET) and proximal gastrectomy (PG) groups.

TABLE 4. Clinical Results and Follow-up in Patients with ET and PC Devascularization

Surgical treatment of bleeding EGV in portal hypertension maintains a defined role in the therapeutic armamentarium. It has been demonstrated that elective surgery with portal flow-preserving operations for good-risk patients are the best choice for this therapeutic modality. Regarding the choice of surgery, portosystemic shunts are favored for management of patients with portal hypertension in Western countries.15-18 In contrast, in Japan and other areas, nonshunt surgeries in the form of the Sugiura-Futagawa procedure and its modifications offer a good alternative choice, being associated with a low rate of encephalopathy and variceal rebleed on long-term follow-up.5-8 We selected devascularization operation as the first line of surgical treatment because of its several advantages. The selection of the operation depends on several factors, but the major determinant in our experience is the patient's vascular anatomy. Together with devascularization, transection is one of the most important steps of the operation. In the literature, a number of variants of transection procedure were demonstrated to make the operation more effective and less time- consuming.5-8, 19,20 We have modified the original procedure to simplify the technique under guidance of PTP and EUS. Preoperatively, both the features and drainage pattern of EGV should be assessed at the same time, as they are extremely important in the selection of specific procedure for treating the patients with different types of EGV. In the current series, two variants of transection procedures were used for patients with EGV according to the flow direction and venous structure. In case of an upward direction of collateral flow, an esophageal transection is sufficient to achieve portoazygos disconnection, whereas with a downward collateral flow, a proximal gastrectomy is more suitable than an esophageal transection. The rationale of our procedure in treating EGV is to interrupt directly as many varicose networks as possible. We believe that an esophageal transection or resection of a segment of proximal stomach may reduce the immediate recanalization of venous collaterals, and extensive devascularization is used to ablate as much as possible the extrinsic collaterals to the esophagus and the stomach. Compared with other results, we have found our procedure of transabdominal esophagogastric devascularization with esophagogastric stapling to be an effective, safe procedure for controlling acute variceal hemorrhage in patients with portal hypertension of different etiologies.6-8,20-22

Complete disappearance of EGV should theoretically be obtained if extensive devascularization can be successfully completed. Nevertheless, several studies and our previous work revealed that newly formed collaterals and varices existed in a considerable percentage of patients after devascularization surgery, although most patients with recurrent or residual varices did not bleed. The results with devascularization procedures in some Western studies have been discouraging. Several reports have demonstrated a high rebleeding rate with these procedures, thus not recommending them as a first therapeutic choice.21,22 Nevertheless, with our modification of this procedure, we have obtained results similar to those obtained with selective shunts.15-18 In comparison with other reports dealing with nonshunt surgery, the end results in the study seem acceptable and effective for long-term control of EGV hemorrhage.5-8 Moreover, using these two variant techniques, we found that there was no significant difference in surgical mortality and longterm results among patients with different types of EGV. Our survival rate is comparable to the figure obtained from other reports with the extensive devascularization incorporating splenectomy.3-8

EIS is an effective method of preventing acute bleeding from EGV and is preferable to surgery because it remains suitable for severely ill patients. However, the endoscopie sclerotherapy is associated with significant rebleeding rate.1, 2 Some extrinsic collaterals will still exist and develop newly formed recurrent varices, even after repeated EIS treatments, recurrent variceal bleeding will be excepted finally. However, those patients of good surgical risk may require a onetime procedure that can achieve good long-term control of variceal hemorrhage. The results in the current series suggest that devascularization surgery is highly effective for the prevention of recurrent bleeding from EGV and provides an alternative of treatment modality. Furthermore, it is evident that combined PTP and EUS is of great help for the selection of the best therapeutic modality for individual patients, as PTP and EUS allow simultaneous visualization of the venous structures and flow pattern of the portal venous system and its collaterals. Therefore, combined PTP and EUS is strongly recommended preoperatively and postoperatively for treating patients with specific types of EGV.

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20. Hosking SW, Johnson AG. What happens to esophageal varices after transection and devascularization? Surgery 1987; 101: 531-4.

21. Wexter M, Stein BL. Nonshunting operations for variceal hemorrhage. Surg Clin North Am 1990:70:425-48.

22. Barbot DJ, Rosato EF. Experience with the esophagogastric devascularization procedure. Surgery 1987; 101:685-94.

JAN-SING HSIEH, M.D.,* CHANG-MING JAN, M.D.,t CHIEN-YU LU, M.D.,t, FANG-MING CHEN, M.D.,* JAW-YUAN WANG, M.D.,* TSUNG-JEN HUANG, M.D.*

From the Departments of *Surgery and [dagger]Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Address correspondence and reprint requests to Fang-Ming Chen, M.D., Department of Surgery, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung City 807, Taiwan.

Copyright The Southeastern Surgical Congress May 2005

Source: American Surgeon, The

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