Gastrointestinal varices surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Endoscopic procedures along with pharmacotherapy is the first line management of gastrointestinal varices. During endoscopic procedures the rate of hemostasis failure is almost 10%-20%, and mortality is approximately 60% if a second unsuccessful endoscopic treatment is performed without further intervention. In such situation surgical intervention may be required to achieve hemostasis and to stop the bleeding. Surgical shunts used for the management of bleeding gastrointestinal varices include pericardial devascularization plus proximal splenorenal shunt, Warren shunt, interposition shunts, caval-mesenteric shunts, end-to-end portacaval shunts with hepatic arterialization, left gastric vena-caval shunt and conventional splenorenal shunt. Non-shunting surgical procedures include ligation of varices and esophageal transection, splenic artery ligation and splenectomy.

Surgery


Shunting procedures

The following shunting procedures may be used for the management of gastrointestinal varices:

(a) Pericardial devascularization (PCDV) plus proximal splenorenal shunt (PSRS)

(b) A distal splenorenal shunt procedure (DSRS), also called splenorenal shunt procedure and Warren shunt

(c) Interposition shunts (interposing a graft between systemic and splanchnic venous systems)

(d) Caval-mesenteric shunts (direct anastomosis of the divided inferior vena cava to the superior mesenteric vein)

(e) End-to-end portacaval shunts with hepatic arterialization

(f) Left gastric vena-caval shunt

(g) Conventional splenorenal shunt

Non-shunting procedures

The following non-shunting procedures may be used for managing uncontrolled bleeding from gastrointestinal varices:

(a) Ligation of varices and esophageal transection

(b) Splenic artery ligation

(c) Esophagogastric devascularization combined with splenectomy

(d) Splenectomy

References

  1. Xu, Chong-En; Zhang, Shu-Guang; Yu, Zhen-Hai; Li, Guang-Xin; Cao, Li-Li; Ruan, Chang-Le; Li, Zhao-Ting (2004). "Combined devascularization and proximal splenorenal shunt: is this a better option than either procedure alone?". Journal of Hepato-Biliary-Pancreatic Surgery. 11 (2): 129–134. ISSN 0944-1166. doi:10.1007/s00534-003-0881-4. 
  2. Cheema MA, Shehri MY (1995). "Surgery for bleeding esophageal varices". J Pak Med Assoc. 45 (1): 6–9. PMID 7731086. 
  3. Grace ND, Muench H, Chalmers TC (1966). "The present status of shunts for portal hypertension in cirrhosis". Gastroenterology. 50 (5): 684–91. PMID 5327472. 
  4. Turcotte JG, Wallin VW, Child CG (1969). "End to side versus side to side portacaval shunts in patients with hepatic cirrhosis". Am. J. Surg. 117 (1): 108–16. PMID 5782742. 
  5. Salam AA, Warren WD, LePage JR, Viamonte MR, Hutson D, Zeppa R (1971). "Hemodynamic contrasts between selective and total portal-systemic decompression". Ann. Surg. 173 (5): 827–44. PMC 1397510Freely accessible. PMID 4933303. 
  6. Drapanas T (1972). "Interposition mesocaval shunt for treatment of portal hypertension". Ann. Surg. 176 (4): 435–48. PMC 1355426Freely accessible. PMID 4263236. 
  7. "Big shunts for small patients with portal hypertension: A bit of history - Journal of Pediatric Surgery". 
  8. Voorhees, Arthur B. (1974). "Extrahepatic Portal Hypertension". Archives of Surgery. 108 (3): 338. ISSN 0004-0010. doi:10.1001/archsurg.1974.01350270068012. 
  9. Warren WD, Zeppa R, Fomon JJ (1967). "Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt". Ann. Surg. 166 (3): 437–55. PMC 1477423Freely accessible. PMID 6068492. 
  10. Ezzat FA, Abu-Elmagd KM, Aly MA, Fathy OM, el-Ghawlby NA, el-Fiky AM, el-Barbary MH (1990). "Selective shunt versus nonshunt surgery for management of both schistosomal and nonschistosomal variceal bleeders". Ann. Surg. 212 (1): 97–108. PMC 1358079Freely accessible. PMID 2363609. 

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