Br. J. Surg. Vol. 63 (1976) 117-121
Early experience with the Boerema button for bleeding oesophageal varices G . W. JOHNSTON AND J. M . KELLY* phreno-oesophageal ligament is pushed up to expose the anterior vagus nerve, which is placed in a fine rubber sling for its protection and then freed from the oesophageal wall for 4-5 cm. The oesophagus is mobilized, lifted free of the posterior vagus nerve and placed in a similar sling. In the absence of vascularized adhesions as a result of previous surgery, oesophageal mobilization has not proved a difficult or haemorrhagic procedure. A 5-cm gastrotomy opening is made in the anterior wall of the stomach, using a cautery knife to reduce bleeding. A loop of nylon thread is passed through the lower end of the now IT is well established that an effective shunt is the one collapsed Sengstaken-Blakemore tube, or other sure way of preventing recurring haemorrhage from nasogastric catheter, and attached to the upper section oesophageal varices. Unfortunately, in the emergency of the Boerema button, using the holes provided. As situation a shunt carries a prohibitive mortality, and the catheter is withdrawn from above, the upper transthoracic oesophageal transection fares little portion of the button, loosely screwed on its applicator, better (George et al., 1973; Pugh et al., 1973). Intra- is carefully guided into the lower oesophagus (Fig. 1). luminal injection of sclerosant has been shown to be A stout linen thread is placed around the oesophagus effective in controlling bleeding and provides a and ligated snugly around the stem of the button hospital discharge rate of over 80 per cent (Johnston 1-13 cm above the cardia. By pulling on the applicator, and Rodgers, 1973). However, only 1 in 3 of the the upper portion of the button is brought down survivors subsequently proves to be a suitable against the ligature, and the lower section guided candidate for a definitive shunt if postoperative upwards, and the two halves locked together, thus encephalopathy is to be avoided. The remainder, entrapping a full thickness flange of oesophageal wall because of advanced years, poor liver function or (Fig. 2). The applicator is unscrewed and removed, the absence of suitable veins, are condemned to a life of gastrotomy wound is closed in two layers with catgut recurrent haemorrhages and repeated injections. The and the abdominal cavity closed without drainage. transabdominal button anastomosis technique of This technique has recently been modified by oesophageal transection described by Boerema et al. placing a nylon thread through holes drilled in the (1970) is therefore attractive because of the acceptable lower end of the button. This thread is passed through initial mortality, coupled with the hope of longer the stomach and abdominal walls to the exterior to protection from recurrent haemorrhage. This paper facilitate easy removal via a small gastrotomy. In presents early experience with a modification of the addition, depending on the clinical state of the Boerema method, and suggests that this simple patient, ligation of the left gastric vein, splenectomy or technique is worthy of further trial. liver biopsy may be carried out. If desired, the oesophagus can be kept aspirated for a day or two Operative technique postoperatively, and then oral fluids gradually The technique now used is a simplified version of that increased. Plain X-rays of the abdomen from the originally described by Boerema et al. (1970), and has eighth postoperative day onwards are required to been arrived at following a trial of a number of confirm the migration of the button into the body of methods. On admission the patient is resuscitated with the stomach. It is then removed through a small fresh blood, and a Sengstaken-Blakemore tube gastrotomy wound on the next convenient operating inserted to limit blood loss. Neomycin, lactobacillus list. and lactulose are introduced into the bowel via the This method differs from that of Boerema et al. tube to reduce the risk of portal systemic encephalo- (1970) chiefly in: (1) preservation of both vagi; pathy. A period of 12-36 hours is required to get the ( 2 ) omission of the gastrojejunostomy ; (3) omission patient into the best possible state for surgery. The of the Braun jejunojejunostomy ; (4) preference for abdomen is opened through a midline epigastric removal of the button by gastrotomy rather than via incision and other sources of bleeding are ex- the oesophagus. cluded. The peritoneum in front of the oesophagus and the perioesophageal veins are divided. The * Royal Victoria Hospital, Belfast.
SUMMARY
Early experience with the use of the Boerema button jor bleeding oesophageal varices is reported. A simpliJed technique for its insertion is described, and of the 6 patients so treated, only 1 died. No patient has re-bled in the short follow-up period available, and oesophageal appearances suggest that prolonged relief from bleeding can be anticipated. Further exploration of the button ligation transection technique is suggested not only for control of acute bleeding, but also,forpatients unsuitable for shunt surgery.
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G. W. Johnston and J . M. Kelly episodes of bleeding. On this admission for acute bleeding she was mildly icteric, had moderate ascites and was generally frail. A liver scan was consistent with advanced cirrhosis, and a barium swallow examination confirmed the presence of gross oesophageal varices. Liver function tests showed moderate liver insufficiency: bilirubin 2.0 mg per cent; alkaline phosphatase 21 K A units; pseudocholinesterase 33 units; serum albumin 2.9 g per cent. In view of her advanced age and past history of hepatic coma, any form of portal systemic shunt was contraindicated. Since she lived about 100 miles from the central hospital, some more permanent procedure than injection therapy was considered advisable. I t was therefore decided to insert a Boerema button. At laparotomy the diagnosis of micronodular cirrhosis and portal hypertension was confirmed, and a Boerema button was inserted through a small anterior gastrotomy. On this occasion the nylon thread was attached to the upper part of the button and brought out through the nose. On the eighth postoperative day, the nasal thread ‘tightened’, and X-ray confirmed that the Boerema button had slipped into the body of the stomach. Under general anaesthesia, 3 weeks after its insertion, the button was easily removed through a small anterior gastrotomy. Subsequently, the patient developed severe dysphagia, and barium swallow showed a gross stricture immediately above the cardia. Oesophagoscopy confirmed a stricture at 40 cm and the absence of varices above. Dilatation has been required on three occasions, but the patient remains well, is gaining weight and has been free from haemorrhage for 11 months.
I’
Fig. 1. Diagram showing placement of the upper portion of the button in the oesophagus via an anterior gastrotomy. Note the preservation of the anterior vagus nerve.
1
Fig. 2. Diagram showing the two portions of the button locked in position over a flange of oesophageal wall.
Case reports Case 1 : M. C . , a female aged 72 years. This patient was trans-
ferred from a peripheral hospital, having had four major haemorrhages from oesophageal varices in the previous 5 years. Hepatic coma had occurred following one of the
118
Case 2: J. M., a female aged 13 years. This girl first presented at the age of 11 years with a 3-month history of jaundice. Hepatomegaly and splenomegaly were noted, and liver biopsy showed the presence of postnecrotic cirrhosis. She was started o n oral steroid therapy. One year later, she began to have repeatedsmall haematemeses and melaena, and barium swallow examination revealed obvious oesophageal varices. A splenic venogram confirmed the presence of a patent portal vein and the liver pattern of cirrhosis. At this stage, portal systemic shunt was considered, but rejected because of the patient’s poor liver function: bilirubin 3.3 mg per cent; alkaline phosphatase > 112 KA units; SGOT 420 K units; SGPT 138 K units; pseudocholinesterase 28 units; LD H 350 WL units; albumin 2.1 g per cent. Repeated episodes of minor bleedingoccurred, but when she was 13 she developed a major life-threatening haemorrhage. By this time the spleen had virtually filled the left side of her abdomen, and jaundice had become more marked (bilirubin 4.1 mg per cent). In addition, her electroencephalogram recording showed marked deterioration and she had now developed serious coagulation problems, partly as a result of splenic overactivity and partly because of her liver dysfunction: platelet count 28 OOO/mm3; prothrombin 29 per cent; deficiencies of factors 2, 7 and 10 and fibrinogen. The patient was considered best suited for use of the Boerema button. After transfusion with platelet-rich plasma, laparotomy was carried out, and the presence of macronodular cirrhosis was confirmed. Splenectomy, ligation of the left gastric vessels and insertion of a Boerema button were performed. On this occasion the nylon thread was attached to the inferior end of the button and brought out through the stomach and anterior abdominal wall. On the eighth postoperative day the button migrated into the body of the stomach, and on the eleventh postoperative day, under general anaesthesia, the button was removed through a small anterior gastrotomy wound. A temporary feeding gastrotomy tube was inserted through the gastric opening. Barium swallow examination 2 weeks after the insertion of the button showed no evidence of varices or stricture. She was discharged from hospital 20 days after her first operation, but required readmission 2 weeks later because of a temporary leak from the gastrotomy wound. This closed spontaneously and barium studies repeated 2 months after the initial surgery showed no abnormality of the oesophagus. Nine months after the operation she vomited about a teaspoonful of blood on two occasions, but barium studies and endoscopy showed no evidence of residual varices. It is now 10 months since surgery.
Boerema button for bleeding oesophageal varices Case 3 : J. S., a female aged 44 years. This patient first presented at the age of 40 with pain and tenderness in the right hypochondrium, pyrexia and jaundice. At laparotomy the gallbladder was found to be normal, and a n operative cholangiogram showed a normal ductal system. However, the liver was noted to be enlarged and firmer than normal, and wedge biopsy was reported as showing active hepatitis. Postoperatively, the patient developed a swinging pyrexia, thought to be due to a subhepatic abscess. Two months after surgery her bilirubin had risen to a maximum of 15.1 mg per cent. The subsequent clinical course and biochemical findings caused the diagnosis to be changed to that of chronic aggressive hepatitis, and ACTH therapy was commenced. On this regime the patient’s clinical and biochemical findings improved. However, 2 years after her initial laparotomy the patient was readmitted with increasing jaundice and marked anaemia (haemoglobin 6.6 g per cent). The liver was now firm and enlarged three fingers’ breadth below the costal margin and the spleen was also palpable. Barium studies showed a hiatus hernia and oesophageal varices. Endoscopy confirmed oesophageal varices and injection therapy was carried out. The patient was then well for 14 years, when she required admission for severe anaemia (haemoglobin 6.4 g per cent). A splenic venogram showed a patent portal vein, and the vascular pattern in the liver was that of cirrhosis. Following blood transfusion she was allowed home, but 6 months later was readmitted when her haemoglobin had dropped to 7.1 g per cent. Liver biopsy showed postnecrotic cirrhosis, and her liver function had improved sufficiently for a portacaval shunt to be considered: bilirubin 1.1 mg per cent; alkaline phosphatase 19 KA units; albumin 3.9 g per cent. At operation, however, the adhesions from the previous subhepatic abscess were such that the porta hepatis was reached only with great difficulty. It was then found that the structures in the free edge of the lesser omentum were encased in dense fibrous tissue, and it was felt wiser not to proceed with the dissection. In this situation the left gastric vessels were divided, the oesophagus mobilized, preserving the vagi, and a Boerema button inserted. The presence of a hiatus hernia made the hiatal dissection somewhat more difficult in this patient. On this occasion the nylon thread was brought up the oesophagus and through the nose. O n the ninth postoperative day the nasal thread ‘tightened’, and X-ray confirmed that the button had moved to a slightly lower position in the oesophagus. The following day, under general anaesthesia, the button was pulled up the oesophagus by traction on the nylon thread-a frightening procedure for the surgeon! Oesophagoscopy at this time showed no varices, and barium studies 17 days after surgery confirmed this. The patient was discharged on the nineteenth postoperative day, and remains free from haemorrhage 10 months after operation. Case 4:R. H., a female aged 82 years. This patient was admitted as an emergency with a severe haematemesis. Although she gave a 9-year history of diabetes controlled by diet and Diabinese and was in addition on digoxin and diuretics for mild congestive cardiac failure, there was no known hepatic problem. The liver and spleen were just palpable below the costal margin, but there was no ascites. Liver function tests were as follows: bilirubin 1.5 mg per cent: alkaline phosphatase 12 KA units; albumin 3.1 g per cent. A further severe haematemesis occurred within 24 hours, and emergency barium studies showed extensive oesophageal varices. At urgent laparotomy macronodular cirrhosis, splenomegaly and the absence of peptic ulceration were confirmed. A Boerema button was inserted in the usual way, preserving the vagi, and on this occasion the nylon thread was brought out through the stomach and anterior abdominal wall. Abdominal X-ray confirmed that the button had progressed into the body of the stomach between the eighth and ninth postoperative days. One week later the button was removed through a small anterior gastrotomy, and the patient was discharged from hospital after a further 7 days. Barium swallow examination 3 weeks after surgery showed no stricture or varices. Two months later she developed mild dysphagia due to a slight stricture which responded well to one dilatation. She remains well and free from haemorrhage 5 months after operation.
Case 5: R. H . , a male aged 78 years. This patient had had cholecystectomy and removal of common bile duct stones 14 years previously. In subsequent years he developed jaundice on a number of occasions, but had failed to attend hospital in the 10 years prior to the present admission. On this admission, dictated by a severe haematemesis and melaena, he was found t o be shocked, anaemic and jaundiced. His liver was enlarged three-finger breadths below the costal margin and there was moderate ascites. Investigations showed: haemoglobin 6.3 g per cent; bilirubin 5.2 mg per cent; blood urea 1 3 5 mg per cent; albumin 2.7 g per cent. Emergency barium studies showed the presence of oesophageal varices extending the whole length of the oesophagus, and a diagnosis of portal hypertension due to secondary biliary cirrhosis was made. A Sengstaken-Blakemore tube was employed, and blood transfusion and anti-coma therapy instituted. He had a further serious haematemesis and melaena 4 days after admission, and it was decided to insert a Boerema button. By this time ascites was severe, jaundice had become more marked (bilirubin 10.8mg per cent) and his general condition had deteriorated. At operation the presence of micronodular cirrhosis was confirmed. The oesophagus was approached with difficulty because of vascularized adhesions from the previous surgery. The Boerema button was inserted through a small gastrotomy wound, the vagi being preserved. The early postoperative phase was satisfactory, but by the fourth postoperative day he had become more jaundiced and more drowsy. He gradually deteriorated over the next 2 days and died in hepatic coma. At autopsy the Boerema button was in place, and there was no evidence of further bleeding or leakage. The micronodular cirrhosis was shown to be secondary to obstruction from calculi in the biliary tree. Case6: A. V., a female aged 65 years. Eleven years before the present admission this patient had beeninvestigated for jaundice of sudden onset. Her previous history had included essential hypertension, angina pectoris and tuberculosis of the spine and right hip with subsequent osteoarthritis. On the basis of clinical findings, biochemistry and liver biopsy, hepatitis was diagnosed and steroid therapy commenced. At that time liver failure with encephalopathy occurred : bilirubin 19.2 mg per cent; alkaline phosphatase 24 K A units; SGOT 3000 K units; SGPT 750 K units. She recovered from this severe episode of hepatitis, but went o n to develop histologically proved cirrhosis 1 year later. She continued to have intermittent jaundice and bouts of pyrexia of uncertain aetiology. Six years after the onset of hepatitis she developed a duodenal ulcer which perforated and was treated by simple closure. Four years later a severe haematemesis occurred. Splenomegaly was noted, and oesophageal varices demonstrated radiologically were shown endoscopically to be the source of bleeding. Portal systemic encephalopathy ensued, but the patient survived with conservative management. Nine months later a further haematemesis precipitated urgent surgery. At laparotomy the diagnosis of portal hypertension due to macronodular cirrhosis was confirmed. Gross vascularized adhesions from the previous perforation made visualization o f the duodenum impractical, but because of the previous perforation and continuation of steroid therapy, truncal vagotomy and posterior gastrojejunostomy were performed in addition to insertion of a Boerema button. A double lumen Burns-Menzies tube was used for gastric aspiration and jejunal feeding purposes. The early postoperative phase was temporarily complicated by the development of portal systemic encephalopathy. The button migrated into the stomach on the ninth postoperative day and was allowed to pass into the small bowel via the gastrojejunostomy. Unfortunately, it failed to negotiate a kink in the ileum and required operative removal 8 weeks later. Barium swallow examination 2 months after surgery confirmed the disappearance of varices and absence of stricture. Follow-up so far is only 3 months.
Discussion No one operative procedure is suitable for all patients with bleeding oesophageal varices, and any addition to the presently accepted methods is welcome. Assessment of its worth must be gauged by reference to its 119
G. W. Johnston and J. M. Kelly
Fig. 3. Case 4. Barium studies of the oesophagus before operation and 2 weeks after insertion of the button.
simplicity, mortality, morbidity and long term relief from bleeding. Most available methods require experience in their use before good results can be obtained, but the Boerema button technique is simple and within the scope of any surgeon. This is particularly relevant where one is denied accurate endoscopic diagnosis of upper gastro-intestinal bleeding and at laparotomy is faced with unsuspected bleeding varices. It is a simple matter to insert a button through the already performed gastrotomy prior to closing the abdomen. Although Boerema recommends the addition of vagotomy, gastrojejunostomy and Braun jejunojejunostomy, these extras must inevitably add to the morbidity and mortality. It is not difficult to mobilize the oesophagus without dividing the vagi, and thus eliminate the need for a drainage procedure. If, however, a coexistent duodenal ulcer is noted, it is reasonable to do a vagotomy and gastro-enterostomy at the same time. The button can then be inserted through the normal gastro-enterostomy opening after completion of the posterior layer of the anastomosis, as in Case 6. Recovery of the button has presented a few problems and the simplest method of removal seems to be by means of a small gastrotomy following migration of the button into the stomach. Prioton (1975) has recently developed a much smaller oesophageal clip which passes spontaneously through a normal pylorus. In none of his first 20 patients has it been necessary to remove the clip from the stomach. He finds the method so attractive that he has abandoned all forms of shunt in its favour. It is not easy to compare mortalities for various procedures unless it is known whether the operations were carried out as emergencies or definitive procedures, and whether the patients were suffering from extrahepatic or intrahepatic portal hypertension, and also the extent of liver dysfunction in the cirrhotic group. Burns and Schenk (1971) had a 100 per cent mortality for this operation in 5 patients, but all were 120
emergencies and all had severe liver failure with an average serum bilirubin of 9.7mg per cent and albumin of 2.1 g per cent. Boerema et al. (1970) reported a hospital mortality of 35 per cent in 34 patients, but not all the operations were performed to control acute bleeding, and 10 of the subjects had extrahepatic block, which carries a good prognosis. Using the similar Murphy’s device, Prioton and Michel(l972) reported a mortality of 37 per cent in 30 cirrhotic patients, but again 10 of the operations were not for acute bleeding. In the present series all 6 patients were cirrhotic, but only 3 had severe liver dysfunction, and in 1 patient button transection of the oesophagus was not carried out for control of acute bleeding but because of failure to obtain a shunt. Nevertheless, an operative mortality of 16.7 per cent is encouraging when compared with about 50 per cent for transthoracic ligation transection procedures for acute bleeding in cirrhosis (Rothwell-Jackson and Hunt, 1971; George et al., 1973; Pugh et al., 1973). Morbidity is not mentioned in the article by Boerema et al. (1970), but the problem of stricture formation in the oesophagus has been encountered by Prioton (1973), who advises systematic dilatation in all patients. This problem occurred in 2 patients in the present series, and in both instances it responded satisfactorily to dilatation. The low position of the stricture, at or below the diaphragm, makes dilatation particularly difficult, and the flexible fibroscope and flexible dilator have been found most useful. Boerema (1974) believed that stricture is more likely if ligation is done too near the oesophagogastric junction. In this position the thick gastric wall is caught between the halves of the button, and the mucous membrane of the oesophagus and stomach may be held apart, causing granulation and cicatrization. Initial disappearance of the varices (Fig. 3) has been shown radiologically in all 5 patients who survived, and has been confirmed endoscopically in 3. There has been no recurrent variceal bleeding in the short followup, and, judging by the oesophageal appearance, none is anticipated in the near future, In theory, button transection of the oesophagus should be more effective than either of the commonly used transthoracic procedures. In the Boerema-Crile operation the oesophagus is opened longitudinally and the columns of varices underrun with catgut without transection of the oesophagus. In the Walker operation the lower oesophageal muscle is divided longitudinally and only the mucosa is transected and resutured with catgut. In neither procedure is the whole thickness of the oesophageal wall divided, as occurs in the button transection. Although Pugh et al. (1973) found that the Walker procedure failed to control bleeding in the short term in 29 per cent of their patients, the incidence of recurrent bleeding in survivors is small. With transection of the whole thickness of the wall, the long term results might be expected to be better than for mucosal transection only. Certainly, Boerema et al. (1970) noted no recurrent bleeding in a maximum follow-up of almost 3 years. Although Prioton (1973) initially reported none in his first 2 years, he has
Boerema button for bleeding oesophageal varices subsequently had 4 patients who probably re-bled from oesophageal varices, but this is taken from a large series of 72 cirrhotics treated by button transection with an overall mortality of 33 per cent (Prioton, 1975). The advantages of the transabdominal approach are : 1. The procedure is shorter and should carry a lower mortality. 2. The liver can be inspected and histological confirmation of the diagnosis obtained. 3. Bleeding from sources other than varices can be dealt with at the same time. 4. Blood clots can be evacuated from the stomach, thus reducing the nitrogenous load on the liver. 5 . Many general surgeons called upon to deal with bleeding varices feel more competent when operating below the diaphragm. If hopes of prolonged control of bleeding are realized on longer follow-up, then the technique should be considered not only in the emergency situation, but also for the many patients where a shunt is contraindicated because of the high risk of portal systemic encephalopathy. Since button transection diverts no blood from the liver, this complication is minimized.
Acknowledgements We wish to thank our colleagues Dr M. Reid, Dr T. Fulton, Mr J. Balmer and Mr J. Strahan for referring patients included in the series.
and SCHENK w. G. (1971) Pilot experience with the ‘Boerema button’ in emergency management of bleeding oesophageal varices. Am. J. Surg. 121, 115-117. GEORGE P., BROWN C., RIDGWAY G., CROFTS B. and SHERLOCK s. (1973) Emergency oesophageal transection in uncontrolled variceal haemorrhage. Br. J. Surg. 60,635-640. JOHNSTON G. w. and RODGERS H. w. (1973) A review of fifteen years’ experience in the use of sclerotherapy in the control of acute haemorrhage from oesophageal varices. Br. J . Surg. 60,797-800. PRIOTON J. B. (1973) La ligature de l’oesophage sur bouton de Murphy dans les hkmorragies par rupture de varices oesophagiennes. Ann. Chir. 27, 343-349. PRIOTON J. B. (1975) Personal communication. PRIOTON J. B. and MICHEL H. (1972) Esophageal ligation with Murphy’s device in bleeding due to esophageal varix rupture, Proceedings of the Ninth International Congress of Gastro-enterology, Paris, 5th-12th Jury 1972. P. 618C. BURNS G. P.
PUGH R. N. H., MURRAY-LYON I. M., DAWSON J. L., PIETRONI M. C. and WILLIAMS R. (1973) Transection
of the oesophagus for bleeding oesophageal varices. Br. J . Surg. 60, 646-649. ROTHWELL-JACKSON R. L. and HUNT A. H. (1971) The results obtained with emergency surgery in the treatment of persistent haemorrhage from gastrooesophageal varices in the cirrhotic patient. Br. J. Surg. 58, 205-215.
References BOEREMA I. (1974) Personal communication. BOEREMA I., KLOPPER P. J. and HOLSCHER A. A.
(1970) Transabdominal ligation-resection of the oesophagus in cases of bleeding oesophageal varices. Surgery 67, 40941 3.
121
Early experience with the Boerema button for bleeding oesophageal varices G . W. JOHNSTON AND J. M . KELLY* phreno-oesophageal ligament is pushed up to expose the anterior vagus nerve, which is placed in a fine rubber sling for its protection and then freed from the oesophageal wall for 4-5 cm. The oesophagus is mobilized, lifted free of the posterior vagus nerve and placed in a similar sling. In the absence of vascularized adhesions as a result of previous surgery, oesophageal mobilization has not proved a difficult or haemorrhagic procedure. A 5-cm gastrotomy opening is made in the anterior wall of the stomach, using a cautery knife to reduce bleeding. A loop of nylon thread is passed through the lower end of the now IT is well established that an effective shunt is the one collapsed Sengstaken-Blakemore tube, or other sure way of preventing recurring haemorrhage from nasogastric catheter, and attached to the upper section oesophageal varices. Unfortunately, in the emergency of the Boerema button, using the holes provided. As situation a shunt carries a prohibitive mortality, and the catheter is withdrawn from above, the upper transthoracic oesophageal transection fares little portion of the button, loosely screwed on its applicator, better (George et al., 1973; Pugh et al., 1973). Intra- is carefully guided into the lower oesophagus (Fig. 1). luminal injection of sclerosant has been shown to be A stout linen thread is placed around the oesophagus effective in controlling bleeding and provides a and ligated snugly around the stem of the button hospital discharge rate of over 80 per cent (Johnston 1-13 cm above the cardia. By pulling on the applicator, and Rodgers, 1973). However, only 1 in 3 of the the upper portion of the button is brought down survivors subsequently proves to be a suitable against the ligature, and the lower section guided candidate for a definitive shunt if postoperative upwards, and the two halves locked together, thus encephalopathy is to be avoided. The remainder, entrapping a full thickness flange of oesophageal wall because of advanced years, poor liver function or (Fig. 2). The applicator is unscrewed and removed, the absence of suitable veins, are condemned to a life of gastrotomy wound is closed in two layers with catgut recurrent haemorrhages and repeated injections. The and the abdominal cavity closed without drainage. transabdominal button anastomosis technique of This technique has recently been modified by oesophageal transection described by Boerema et al. placing a nylon thread through holes drilled in the (1970) is therefore attractive because of the acceptable lower end of the button. This thread is passed through initial mortality, coupled with the hope of longer the stomach and abdominal walls to the exterior to protection from recurrent haemorrhage. This paper facilitate easy removal via a small gastrotomy. In presents early experience with a modification of the addition, depending on the clinical state of the Boerema method, and suggests that this simple patient, ligation of the left gastric vein, splenectomy or technique is worthy of further trial. liver biopsy may be carried out. If desired, the oesophagus can be kept aspirated for a day or two Operative technique postoperatively, and then oral fluids gradually The technique now used is a simplified version of that increased. Plain X-rays of the abdomen from the originally described by Boerema et al. (1970), and has eighth postoperative day onwards are required to been arrived at following a trial of a number of confirm the migration of the button into the body of methods. On admission the patient is resuscitated with the stomach. It is then removed through a small fresh blood, and a Sengstaken-Blakemore tube gastrotomy wound on the next convenient operating inserted to limit blood loss. Neomycin, lactobacillus list. and lactulose are introduced into the bowel via the This method differs from that of Boerema et al. tube to reduce the risk of portal systemic encephalo- (1970) chiefly in: (1) preservation of both vagi; pathy. A period of 12-36 hours is required to get the ( 2 ) omission of the gastrojejunostomy ; (3) omission patient into the best possible state for surgery. The of the Braun jejunojejunostomy ; (4) preference for abdomen is opened through a midline epigastric removal of the button by gastrotomy rather than via incision and other sources of bleeding are ex- the oesophagus. cluded. The peritoneum in front of the oesophagus and the perioesophageal veins are divided. The * Royal Victoria Hospital, Belfast.
SUMMARY
Early experience with the use of the Boerema button jor bleeding oesophageal varices is reported. A simpliJed technique for its insertion is described, and of the 6 patients so treated, only 1 died. No patient has re-bled in the short follow-up period available, and oesophageal appearances suggest that prolonged relief from bleeding can be anticipated. Further exploration of the button ligation transection technique is suggested not only for control of acute bleeding, but also,forpatients unsuitable for shunt surgery.
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10
117
G. W. Johnston and J . M. Kelly episodes of bleeding. On this admission for acute bleeding she was mildly icteric, had moderate ascites and was generally frail. A liver scan was consistent with advanced cirrhosis, and a barium swallow examination confirmed the presence of gross oesophageal varices. Liver function tests showed moderate liver insufficiency: bilirubin 2.0 mg per cent; alkaline phosphatase 21 K A units; pseudocholinesterase 33 units; serum albumin 2.9 g per cent. In view of her advanced age and past history of hepatic coma, any form of portal systemic shunt was contraindicated. Since she lived about 100 miles from the central hospital, some more permanent procedure than injection therapy was considered advisable. I t was therefore decided to insert a Boerema button. At laparotomy the diagnosis of micronodular cirrhosis and portal hypertension was confirmed, and a Boerema button was inserted through a small anterior gastrotomy. On this occasion the nylon thread was attached to the upper part of the button and brought out through the nose. On the eighth postoperative day, the nasal thread ‘tightened’, and X-ray confirmed that the Boerema button had slipped into the body of the stomach. Under general anaesthesia, 3 weeks after its insertion, the button was easily removed through a small anterior gastrotomy. Subsequently, the patient developed severe dysphagia, and barium swallow showed a gross stricture immediately above the cardia. Oesophagoscopy confirmed a stricture at 40 cm and the absence of varices above. Dilatation has been required on three occasions, but the patient remains well, is gaining weight and has been free from haemorrhage for 11 months.
I’
Fig. 1. Diagram showing placement of the upper portion of the button in the oesophagus via an anterior gastrotomy. Note the preservation of the anterior vagus nerve.
1
Fig. 2. Diagram showing the two portions of the button locked in position over a flange of oesophageal wall.
Case reports Case 1 : M. C . , a female aged 72 years. This patient was trans-
ferred from a peripheral hospital, having had four major haemorrhages from oesophageal varices in the previous 5 years. Hepatic coma had occurred following one of the
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Case 2: J. M., a female aged 13 years. This girl first presented at the age of 11 years with a 3-month history of jaundice. Hepatomegaly and splenomegaly were noted, and liver biopsy showed the presence of postnecrotic cirrhosis. She was started o n oral steroid therapy. One year later, she began to have repeatedsmall haematemeses and melaena, and barium swallow examination revealed obvious oesophageal varices. A splenic venogram confirmed the presence of a patent portal vein and the liver pattern of cirrhosis. At this stage, portal systemic shunt was considered, but rejected because of the patient’s poor liver function: bilirubin 3.3 mg per cent; alkaline phosphatase > 112 KA units; SGOT 420 K units; SGPT 138 K units; pseudocholinesterase 28 units; LD H 350 WL units; albumin 2.1 g per cent. Repeated episodes of minor bleedingoccurred, but when she was 13 she developed a major life-threatening haemorrhage. By this time the spleen had virtually filled the left side of her abdomen, and jaundice had become more marked (bilirubin 4.1 mg per cent). In addition, her electroencephalogram recording showed marked deterioration and she had now developed serious coagulation problems, partly as a result of splenic overactivity and partly because of her liver dysfunction: platelet count 28 OOO/mm3; prothrombin 29 per cent; deficiencies of factors 2, 7 and 10 and fibrinogen. The patient was considered best suited for use of the Boerema button. After transfusion with platelet-rich plasma, laparotomy was carried out, and the presence of macronodular cirrhosis was confirmed. Splenectomy, ligation of the left gastric vessels and insertion of a Boerema button were performed. On this occasion the nylon thread was attached to the inferior end of the button and brought out through the stomach and anterior abdominal wall. On the eighth postoperative day the button migrated into the body of the stomach, and on the eleventh postoperative day, under general anaesthesia, the button was removed through a small anterior gastrotomy wound. A temporary feeding gastrotomy tube was inserted through the gastric opening. Barium swallow examination 2 weeks after the insertion of the button showed no evidence of varices or stricture. She was discharged from hospital 20 days after her first operation, but required readmission 2 weeks later because of a temporary leak from the gastrotomy wound. This closed spontaneously and barium studies repeated 2 months after the initial surgery showed no abnormality of the oesophagus. Nine months after the operation she vomited about a teaspoonful of blood on two occasions, but barium studies and endoscopy showed no evidence of residual varices. It is now 10 months since surgery.
Boerema button for bleeding oesophageal varices Case 3 : J. S., a female aged 44 years. This patient first presented at the age of 40 with pain and tenderness in the right hypochondrium, pyrexia and jaundice. At laparotomy the gallbladder was found to be normal, and a n operative cholangiogram showed a normal ductal system. However, the liver was noted to be enlarged and firmer than normal, and wedge biopsy was reported as showing active hepatitis. Postoperatively, the patient developed a swinging pyrexia, thought to be due to a subhepatic abscess. Two months after surgery her bilirubin had risen to a maximum of 15.1 mg per cent. The subsequent clinical course and biochemical findings caused the diagnosis to be changed to that of chronic aggressive hepatitis, and ACTH therapy was commenced. On this regime the patient’s clinical and biochemical findings improved. However, 2 years after her initial laparotomy the patient was readmitted with increasing jaundice and marked anaemia (haemoglobin 6.6 g per cent). The liver was now firm and enlarged three fingers’ breadth below the costal margin and the spleen was also palpable. Barium studies showed a hiatus hernia and oesophageal varices. Endoscopy confirmed oesophageal varices and injection therapy was carried out. The patient was then well for 14 years, when she required admission for severe anaemia (haemoglobin 6.4 g per cent). A splenic venogram showed a patent portal vein, and the vascular pattern in the liver was that of cirrhosis. Following blood transfusion she was allowed home, but 6 months later was readmitted when her haemoglobin had dropped to 7.1 g per cent. Liver biopsy showed postnecrotic cirrhosis, and her liver function had improved sufficiently for a portacaval shunt to be considered: bilirubin 1.1 mg per cent; alkaline phosphatase 19 KA units; albumin 3.9 g per cent. At operation, however, the adhesions from the previous subhepatic abscess were such that the porta hepatis was reached only with great difficulty. It was then found that the structures in the free edge of the lesser omentum were encased in dense fibrous tissue, and it was felt wiser not to proceed with the dissection. In this situation the left gastric vessels were divided, the oesophagus mobilized, preserving the vagi, and a Boerema button inserted. The presence of a hiatus hernia made the hiatal dissection somewhat more difficult in this patient. On this occasion the nylon thread was brought up the oesophagus and through the nose. O n the ninth postoperative day the nasal thread ‘tightened’, and X-ray confirmed that the button had moved to a slightly lower position in the oesophagus. The following day, under general anaesthesia, the button was pulled up the oesophagus by traction on the nylon thread-a frightening procedure for the surgeon! Oesophagoscopy at this time showed no varices, and barium studies 17 days after surgery confirmed this. The patient was discharged on the nineteenth postoperative day, and remains free from haemorrhage 10 months after operation. Case 4:R. H., a female aged 82 years. This patient was admitted as an emergency with a severe haematemesis. Although she gave a 9-year history of diabetes controlled by diet and Diabinese and was in addition on digoxin and diuretics for mild congestive cardiac failure, there was no known hepatic problem. The liver and spleen were just palpable below the costal margin, but there was no ascites. Liver function tests were as follows: bilirubin 1.5 mg per cent: alkaline phosphatase 12 KA units; albumin 3.1 g per cent. A further severe haematemesis occurred within 24 hours, and emergency barium studies showed extensive oesophageal varices. At urgent laparotomy macronodular cirrhosis, splenomegaly and the absence of peptic ulceration were confirmed. A Boerema button was inserted in the usual way, preserving the vagi, and on this occasion the nylon thread was brought out through the stomach and anterior abdominal wall. Abdominal X-ray confirmed that the button had progressed into the body of the stomach between the eighth and ninth postoperative days. One week later the button was removed through a small anterior gastrotomy, and the patient was discharged from hospital after a further 7 days. Barium swallow examination 3 weeks after surgery showed no stricture or varices. Two months later she developed mild dysphagia due to a slight stricture which responded well to one dilatation. She remains well and free from haemorrhage 5 months after operation.
Case 5: R. H . , a male aged 78 years. This patient had had cholecystectomy and removal of common bile duct stones 14 years previously. In subsequent years he developed jaundice on a number of occasions, but had failed to attend hospital in the 10 years prior to the present admission. On this admission, dictated by a severe haematemesis and melaena, he was found t o be shocked, anaemic and jaundiced. His liver was enlarged three-finger breadths below the costal margin and there was moderate ascites. Investigations showed: haemoglobin 6.3 g per cent; bilirubin 5.2 mg per cent; blood urea 1 3 5 mg per cent; albumin 2.7 g per cent. Emergency barium studies showed the presence of oesophageal varices extending the whole length of the oesophagus, and a diagnosis of portal hypertension due to secondary biliary cirrhosis was made. A Sengstaken-Blakemore tube was employed, and blood transfusion and anti-coma therapy instituted. He had a further serious haematemesis and melaena 4 days after admission, and it was decided to insert a Boerema button. By this time ascites was severe, jaundice had become more marked (bilirubin 10.8mg per cent) and his general condition had deteriorated. At operation the presence of micronodular cirrhosis was confirmed. The oesophagus was approached with difficulty because of vascularized adhesions from the previous surgery. The Boerema button was inserted through a small gastrotomy wound, the vagi being preserved. The early postoperative phase was satisfactory, but by the fourth postoperative day he had become more jaundiced and more drowsy. He gradually deteriorated over the next 2 days and died in hepatic coma. At autopsy the Boerema button was in place, and there was no evidence of further bleeding or leakage. The micronodular cirrhosis was shown to be secondary to obstruction from calculi in the biliary tree. Case6: A. V., a female aged 65 years. Eleven years before the present admission this patient had beeninvestigated for jaundice of sudden onset. Her previous history had included essential hypertension, angina pectoris and tuberculosis of the spine and right hip with subsequent osteoarthritis. On the basis of clinical findings, biochemistry and liver biopsy, hepatitis was diagnosed and steroid therapy commenced. At that time liver failure with encephalopathy occurred : bilirubin 19.2 mg per cent; alkaline phosphatase 24 K A units; SGOT 3000 K units; SGPT 750 K units. She recovered from this severe episode of hepatitis, but went o n to develop histologically proved cirrhosis 1 year later. She continued to have intermittent jaundice and bouts of pyrexia of uncertain aetiology. Six years after the onset of hepatitis she developed a duodenal ulcer which perforated and was treated by simple closure. Four years later a severe haematemesis occurred. Splenomegaly was noted, and oesophageal varices demonstrated radiologically were shown endoscopically to be the source of bleeding. Portal systemic encephalopathy ensued, but the patient survived with conservative management. Nine months later a further haematemesis precipitated urgent surgery. At laparotomy the diagnosis of portal hypertension due to macronodular cirrhosis was confirmed. Gross vascularized adhesions from the previous perforation made visualization o f the duodenum impractical, but because of the previous perforation and continuation of steroid therapy, truncal vagotomy and posterior gastrojejunostomy were performed in addition to insertion of a Boerema button. A double lumen Burns-Menzies tube was used for gastric aspiration and jejunal feeding purposes. The early postoperative phase was temporarily complicated by the development of portal systemic encephalopathy. The button migrated into the stomach on the ninth postoperative day and was allowed to pass into the small bowel via the gastrojejunostomy. Unfortunately, it failed to negotiate a kink in the ileum and required operative removal 8 weeks later. Barium swallow examination 2 months after surgery confirmed the disappearance of varices and absence of stricture. Follow-up so far is only 3 months.
Discussion No one operative procedure is suitable for all patients with bleeding oesophageal varices, and any addition to the presently accepted methods is welcome. Assessment of its worth must be gauged by reference to its 119
G. W. Johnston and J. M. Kelly
Fig. 3. Case 4. Barium studies of the oesophagus before operation and 2 weeks after insertion of the button.
simplicity, mortality, morbidity and long term relief from bleeding. Most available methods require experience in their use before good results can be obtained, but the Boerema button technique is simple and within the scope of any surgeon. This is particularly relevant where one is denied accurate endoscopic diagnosis of upper gastro-intestinal bleeding and at laparotomy is faced with unsuspected bleeding varices. It is a simple matter to insert a button through the already performed gastrotomy prior to closing the abdomen. Although Boerema recommends the addition of vagotomy, gastrojejunostomy and Braun jejunojejunostomy, these extras must inevitably add to the morbidity and mortality. It is not difficult to mobilize the oesophagus without dividing the vagi, and thus eliminate the need for a drainage procedure. If, however, a coexistent duodenal ulcer is noted, it is reasonable to do a vagotomy and gastro-enterostomy at the same time. The button can then be inserted through the normal gastro-enterostomy opening after completion of the posterior layer of the anastomosis, as in Case 6. Recovery of the button has presented a few problems and the simplest method of removal seems to be by means of a small gastrotomy following migration of the button into the stomach. Prioton (1975) has recently developed a much smaller oesophageal clip which passes spontaneously through a normal pylorus. In none of his first 20 patients has it been necessary to remove the clip from the stomach. He finds the method so attractive that he has abandoned all forms of shunt in its favour. It is not easy to compare mortalities for various procedures unless it is known whether the operations were carried out as emergencies or definitive procedures, and whether the patients were suffering from extrahepatic or intrahepatic portal hypertension, and also the extent of liver dysfunction in the cirrhotic group. Burns and Schenk (1971) had a 100 per cent mortality for this operation in 5 patients, but all were 120
emergencies and all had severe liver failure with an average serum bilirubin of 9.7mg per cent and albumin of 2.1 g per cent. Boerema et al. (1970) reported a hospital mortality of 35 per cent in 34 patients, but not all the operations were performed to control acute bleeding, and 10 of the subjects had extrahepatic block, which carries a good prognosis. Using the similar Murphy’s device, Prioton and Michel(l972) reported a mortality of 37 per cent in 30 cirrhotic patients, but again 10 of the operations were not for acute bleeding. In the present series all 6 patients were cirrhotic, but only 3 had severe liver dysfunction, and in 1 patient button transection of the oesophagus was not carried out for control of acute bleeding but because of failure to obtain a shunt. Nevertheless, an operative mortality of 16.7 per cent is encouraging when compared with about 50 per cent for transthoracic ligation transection procedures for acute bleeding in cirrhosis (Rothwell-Jackson and Hunt, 1971; George et al., 1973; Pugh et al., 1973). Morbidity is not mentioned in the article by Boerema et al. (1970), but the problem of stricture formation in the oesophagus has been encountered by Prioton (1973), who advises systematic dilatation in all patients. This problem occurred in 2 patients in the present series, and in both instances it responded satisfactorily to dilatation. The low position of the stricture, at or below the diaphragm, makes dilatation particularly difficult, and the flexible fibroscope and flexible dilator have been found most useful. Boerema (1974) believed that stricture is more likely if ligation is done too near the oesophagogastric junction. In this position the thick gastric wall is caught between the halves of the button, and the mucous membrane of the oesophagus and stomach may be held apart, causing granulation and cicatrization. Initial disappearance of the varices (Fig. 3) has been shown radiologically in all 5 patients who survived, and has been confirmed endoscopically in 3. There has been no recurrent variceal bleeding in the short followup, and, judging by the oesophageal appearance, none is anticipated in the near future, In theory, button transection of the oesophagus should be more effective than either of the commonly used transthoracic procedures. In the Boerema-Crile operation the oesophagus is opened longitudinally and the columns of varices underrun with catgut without transection of the oesophagus. In the Walker operation the lower oesophageal muscle is divided longitudinally and only the mucosa is transected and resutured with catgut. In neither procedure is the whole thickness of the oesophageal wall divided, as occurs in the button transection. Although Pugh et al. (1973) found that the Walker procedure failed to control bleeding in the short term in 29 per cent of their patients, the incidence of recurrent bleeding in survivors is small. With transection of the whole thickness of the wall, the long term results might be expected to be better than for mucosal transection only. Certainly, Boerema et al. (1970) noted no recurrent bleeding in a maximum follow-up of almost 3 years. Although Prioton (1973) initially reported none in his first 2 years, he has
Boerema button for bleeding oesophageal varices subsequently had 4 patients who probably re-bled from oesophageal varices, but this is taken from a large series of 72 cirrhotics treated by button transection with an overall mortality of 33 per cent (Prioton, 1975). The advantages of the transabdominal approach are : 1. The procedure is shorter and should carry a lower mortality. 2. The liver can be inspected and histological confirmation of the diagnosis obtained. 3. Bleeding from sources other than varices can be dealt with at the same time. 4. Blood clots can be evacuated from the stomach, thus reducing the nitrogenous load on the liver. 5 . Many general surgeons called upon to deal with bleeding varices feel more competent when operating below the diaphragm. If hopes of prolonged control of bleeding are realized on longer follow-up, then the technique should be considered not only in the emergency situation, but also for the many patients where a shunt is contraindicated because of the high risk of portal systemic encephalopathy. Since button transection diverts no blood from the liver, this complication is minimized.
Acknowledgements We wish to thank our colleagues Dr M. Reid, Dr T. Fulton, Mr J. Balmer and Mr J. Strahan for referring patients included in the series.
and SCHENK w. G. (1971) Pilot experience with the ‘Boerema button’ in emergency management of bleeding oesophageal varices. Am. J. Surg. 121, 115-117. GEORGE P., BROWN C., RIDGWAY G., CROFTS B. and SHERLOCK s. (1973) Emergency oesophageal transection in uncontrolled variceal haemorrhage. Br. J. Surg. 60,635-640. JOHNSTON G. w. and RODGERS H. w. (1973) A review of fifteen years’ experience in the use of sclerotherapy in the control of acute haemorrhage from oesophageal varices. Br. J . Surg. 60,797-800. PRIOTON J. B. (1973) La ligature de l’oesophage sur bouton de Murphy dans les hkmorragies par rupture de varices oesophagiennes. Ann. Chir. 27, 343-349. PRIOTON J. B. (1975) Personal communication. PRIOTON J. B. and MICHEL H. (1972) Esophageal ligation with Murphy’s device in bleeding due to esophageal varix rupture, Proceedings of the Ninth International Congress of Gastro-enterology, Paris, 5th-12th Jury 1972. P. 618C. BURNS G. P.
PUGH R. N. H., MURRAY-LYON I. M., DAWSON J. L., PIETRONI M. C. and WILLIAMS R. (1973) Transection
of the oesophagus for bleeding oesophageal varices. Br. J . Surg. 60, 646-649. ROTHWELL-JACKSON R. L. and HUNT A. H. (1971) The results obtained with emergency surgery in the treatment of persistent haemorrhage from gastrooesophageal varices in the cirrhotic patient. Br. J. Surg. 58, 205-215.
References BOEREMA I. (1974) Personal communication. BOEREMA I., KLOPPER P. J. and HOLSCHER A. A.
(1970) Transabdominal ligation-resection of the oesophagus in cases of bleeding oesophageal varices. Surgery 67, 40941 3.
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