Bleeding esophagogastric varices from extrahepatic portal hypertension

40 Years' experience with portal-systemic shunt

Marshall J. Orloff, Mark S. Orloff, Barbara Girard, Susan Orloff

Research output: Contribution to journalArticle

101 Citations (Scopus)

Abstract

BACKGROUND: This article discusses the largest and longest experience reported to date of the use of portalsystemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT). STUDY DESIGN: Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93%); 166 were eligible for and received 10 or more years of regular followup (83%). RESULTS: The etiology of PVT was unknown in 65% of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15%), umbilical vein catheterization in 14 patients (7%), and peritonitis in 14 patients (7%). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76%), the portal vein and adjacent superior mesenteric vein in 10 patients (5%), and the portal and splenic veins in 56 patients (28%). Postoperative survival to leave the hospital was 100%. Actuarial 5-year, 10-year, and 15-year survival rates were 99%, 97%, and 95%, respectively. Five patients (2.5%), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97% of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected. CONCLUSION: PSS is the only consistently effective therapy for bleeding esophagogastric varices from PVT and extrahepatic portal hypertension, resulting in many years of survival, freedom from recurrent bleeding, normal liver function, and no encephalopathy.

Original languageEnglish (US)
Pages (from-to)717-730
Number of pages14
JournalJournal of the American College of Surgeons
Volume194
Issue number6
DOIs
StatePublished - 2002

Fingerprint

Varicose Veins
Portal Hypertension
Hemorrhage
Portal Vein
Thrombosis
Liver
Surgical Splenorenal Shunt
Hypersplenism
Splenic Vein
Biopsy
Mesenteric Veins
Umbilical Veins
Survival
Hepatic Encephalopathy
Liver Function Tests
Brain Diseases
Peritonitis
Catheterization
Blood Transfusion
Survival Rate

ASJC Scopus subject areas

  • Surgery

Cite this

Bleeding esophagogastric varices from extrahepatic portal hypertension : 40 Years' experience with portal-systemic shunt. / Orloff, Marshall J.; Orloff, Mark S.; Girard, Barbara; Orloff, Susan.

In: Journal of the American College of Surgeons, Vol. 194, No. 6, 2002, p. 717-730.

Research output: Contribution to journalArticle

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abstract = "BACKGROUND: This article discusses the largest and longest experience reported to date of the use of portalsystemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT). STUDY DESIGN: Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93{\%}); 166 were eligible for and received 10 or more years of regular followup (83{\%}). RESULTS: The etiology of PVT was unknown in 65{\%} of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15{\%}), umbilical vein catheterization in 14 patients (7{\%}), and peritonitis in 14 patients (7{\%}). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76{\%}), the portal vein and adjacent superior mesenteric vein in 10 patients (5{\%}), and the portal and splenic veins in 56 patients (28{\%}). Postoperative survival to leave the hospital was 100{\%}. Actuarial 5-year, 10-year, and 15-year survival rates were 99{\%}, 97{\%}, and 95{\%}, respectively. Five patients (2.5{\%}), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97{\%} of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected. CONCLUSION: PSS is the only consistently effective therapy for bleeding esophagogastric varices from PVT and extrahepatic portal hypertension, resulting in many years of survival, freedom from recurrent bleeding, normal liver function, and no encephalopathy.",
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