Esophageal Staple Transection as a Salvage Procedure After Failure of Acute Injection Sclerotherapy P. AIDEN MCCORMICK,GRAHAML. KAm, LYNDAGREENSLADE, FABRIZIO CARDIN,KENNETH E. F. HOBBS, NEILMCINTYREAND ANDREW K. BURROUGHS Hepatobiliary and Liver Transplantation Unit, Royal Free Hospital School of Medicine, London Nw3 2QG, United Kingdom
It is not clear which therapy should be used in patients with bleeding esophageal varices that are not controlled by emergency sclerotherapy. This is a high-risk group with reported mortality rates of between 70%and 90%.We report our 7-yr experience with staple transection of the esophagus in this patient group. Of 168 patients (280 bleeding episodes) treated with sclerotherapy, 22 had emergency staple transection for failure to control bleeding. Bleeding was controlled in 20 patients (90%), and 10 patients (45%) survived to leave the hospital, including 4 of 10 patients (40%)with Pugh grade C liver disease. We suggest that emergency staple transection is an effective salvage treatment for this high-risk group. (HEPATOLOGY 1992;15:403-406.) Injection sclerotherapy of esophageal varices is an effective treatment for acute variceal bleeding (1-4). Bleeding is controlled in 70% of cases after one injection and in 80% to 90% of cases after two injections (1).If bleeding continues, further injections appear to be of little extra benefit (5). The subgroup of patients who continue t o bleed has a poor prognosis, with a mortality rate approaching 90%for patients with Child class B and C liver disease (6). Bleeding can be temporarily controlled at this stage with balloon tamponade before a major surgical procedure (1,7). However, few data exist to indicate which surgical procedure t o use (8). We present our 7-yr experience with emergency esophagogastric staple transection in patients who continue t o bleed despite treatment with endoscopic sclerotherapy.
PATIENTS AND METHODS Between June 1983 and June 1990,372 patients with a total of 655 bleeding episodes were admitted t o the Hepatobiliary and Liver Transplantation Unit of the Royal Free Hospital with bleeding esophagealvarices. They were cared for by ajoint medical-surgical team, and all information was collected prospectively as part of a project designed to predict prognosis
Received February 15, 1991,accepted October 14, 1991 Address reprint requests to Dr P A McCormick, Academic Department of Medicine, Royal Free Hospital School of Medicme, Pond Street, Hampstead, London NW3 ZQG, United Kmgdom 3111134814
in this patient group (9, 10). Not all bleeding episodes were treated with injection sclerotherapy because ongoing clinical trials comparing somatostatin to placebo (11)and emergency sclerotherapy with emergency esophageal staple transection (5) were being carried out. Sclerotherapy Failure. The definition of sclerotherapy failure evolved during the period covered by this study. The initial definition was active variceal hemorrhage requiring continuing blood transfusion despite injection sclerotherapy (a maximum of three episodes). Sclerotherapy could be declared a failure after fewer than three episodes if, in the view of senior endoscopists, further attempted sclerotherapy would be hazardous. During this period, our experience suggested that little extra benefit was to be had from more than two sessions of sclerotherapy (5).In view of this and of the f a d that increasing use of sclerotherapy may make the operation technically more difficult, it was subsequently decided to limit acute sclerotherapy to two sessions before declaring failure of sclerotherapy. It should be stressed that in our unit, a bleeding episode is considered a bleed followed by a period of 5 days. Therefore a patient who is admitted with bleeding, has two sessions of emergency sclerotherapy and then stops bleeding may have further acute sclerotherapy if bleeding occurs again after an interval of more than 5 days. A total of 168 patients received acute sclerotherapy for a total of 280 bleeding episodes. Acute sclerotherapy was performed using a flexible fibroscope (K10 Olympus; Olympus Co., Kyoto, Japan) and intravariceal injection of 5% ethanolamine. A Sengstaken-Blakemore tube was inserted if lifethreatening, uncontrolled bleeding was present. During the study, acute sclerotherapy failed to control bleeding in 40 patients, and emergency esophageal transection was performed in 22 of these patients. In one patient with nodular regenerative hyperplasia, we experienced major difficulty in procuring compatible blood for transfusion. That patient continued to bleed despite a session of sclerotherapy. However, the bleeding was relatively minor in nature, and an esophageal transection was performed as semielective surgery rather than as an emergency life-saving procedure. This patient survived, but because the bleeding may well have responded to further sclerotherapy and the surgery was not emergent, she was excluded from this analysis. Of the 1 7 patients who were not transected, 4 patients died suddenly before further therapy could be contemplated, 8 patients were terminally ill with advanced liver failure and/or HCC and were judged unfit for surgery, 1 patient had had a previous esophageal transection for variceal bleeding, 3 patients were treated with transhepatic sclerotherapy, (2 died of continuing bleeding and the third died
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TABLE 1. Characteristicsof 22 patients who underwent esophageal staple transection after failure of emergency sclerotherapy to control bleeding esophageal varices
MIF Mean age (yr) Diagnosis Alcoholic cirrhosis Cryptogenic cirrhosis PBC CAH Budd-Chiari syndrome Primary sclerosing cholangitis Idiopathic portal hypertension Pugh grade A B
C Acute sclerotherapy before surgery 1 session 2 sessions 3 sessions 4 sessions
1517 55.6 (range = 37-80) 13 3 2 1 1 1 1 2 10 10
5 10 6
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TABLE 2. Recurrent upper gastrointestinal bleeding after esophageal staple transection Bleeding
No.
Time since surgery (days)
Liver failure with terminal bleeding Death from liver failure with no further bleeding No further bleeding on follow-up Transection line-erosion bleeding" Gastric varices Upper GI bleeding
6 4
6, 10, 17, 22, 27, 42 2, 4, 5 , 5
2 4 3' 1
395, 407 8, 26, 120, 420 3, 6, 15 90
GI
= Gastrointestinal. Two patients in whom surgery failed to control the initial bleeding are excluded. "Transection-line bleeding was minor in most cases, and erosions responded to treatment with omeprazole. 'All three patients subsequently underwent shunt surgery (at 1, 4 and 8 mo after esophageal transection) because of recurrent, severe upper gastrointestinal bleeding.
1
patients underwent emergency surgery because of hemodynamic instability. We counted these patients as having had one session of variceal sclerotherapy because of liver failure despite control of bleeding) and 1patient had an we are not sure where the sclerosant went on the second emergency portacaval shunt and died of hepatic failure. The characteristics of the 22 patients treated with esophageal occasion. The third patient aspirated blood during transection are shown in Table 1.Most (20 of 22) were of Pugh attempted sclerotherapy; the procedure was therefore classes B and C. Pugh grading (12) refers to the clinical state abandoned and emergency surgery was performed. Control of Bleeding. Esophageal staple transection at the start of an episode of bleeding or at the time of admission controlled the variceal bleeding in most cases (20 of 22; to the Royal Free Hospital with variceal bleeding. Esophageal staple transection was performed through a left 90%). Two patients continued to bleed despite surgery. subcostal incision, as described previously (13), using a staple In one case, the patient was in kidney failure before gun (EEA, Auto Suture, Ascot, UK). The lower esophagus and surgery, had uncontrolled hemorrhage during surgery the periesophageal vessels were mobilized, and the staple gun and then died in the recovery room. In retrospect, it was inserted into the esophageal lumen through a small could be argued that this patient should not have been gastrotomy opening.A ligature was tied around the esophagus, trapping it between the cartridge and the anvil of the gun. The treated actively. The second patient had been diagnosed gun was then fired t o transect the esophagus and reconnect the with chronic myeloid leukemia and alcoholic cirrhosis two ends between two rows of staples. A doughnut-shaped shortly before the bleeding episode. After much disportion of transected esophagus was removed with the staple cussion surgery was performed, but transection was found to be technically impossible; splenectomy was gun. performed because of damage to the spleen at the time RESULTS of surgery. Bleeding was not controlled, and the patient Esophageal staple transection was performed in 22 died within 24 hr. patients. The surgical team reported thickening of the Subsequent events for the 20 patients with initial lower esophagus and greater difficulty in mobilizing the control of bleeding are summarized in Table 2. Diffuse esophagus compared with patients who had not un- gastrointestinal bleeding occurred as part of a generdergone prior sclerotherapy. Five of the 22 patients alized terminal bleeding diathesis in 6 of 10 patients who underwent one session of sclerotherapy. In two patients died of liver failure after surgery. Four patients had brisk bleeding occurred at endoscopy; it was not con- bleeding from esophageal staple-line erosions. These trolled by one session of acute sclerotherapy. In both episodes were usually minor in nature and responded to cases, the bleeding was not controlled by Sengstaken treatment with omeprazole. Three patients required balloon insertion. Both patients remained hemodynam- shunt surgery for severe repeated bleeding. All three ically compromised, and blood transfusion could not exhibited melena within 16 days of surgery. This settled keep pace with blood loss. Emergency surgery was with blood transfusion and intravenous omeprazole, and performed within 24 hr of the initial sclerotherapy. In endoscopy was not performed. However, all three had three more patients, a second session of emergency subsequent upper gastrointestinal bleeding episodes. It sclerotherapy was attempted. In two, visualization was was initially not clear whether this bleeding was caused very poor because of brisk bleeding. Blind injections at by superficial ulceration of the transection line, by the lower end of the esophagus were performed in both gastric varices or by congestive gastropathy. All three cases. These injections were not effective, and the patients were treated with omeprazole, and satisfactory
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healing of the staple line was achieved (14). It was presumed that the bleeding was coming from gastric varices or congestive gastropathy. One patient required shunt surgery 1 mo after esophageal transection. After this the bleeding stopped, and he was discharged from hospital and survived for another 21 mo before dying of liver failure and HCC. The other two patients were discharged, but they suffered frequent recurrent upper gastrointestinal bleeding from gastric varices. They underwent shunt surgery at 4 and 8 mo, respectively, but both experienced liver failure after surgery and died at 6 and 8 mo, respectively. One patient had a minor upper gastrointestinal bleeding episode 90 days after *O transection. The cause was not established, and there o ] I I has been no recurrent bleeding over a follow-upof 42 mo. 0 100 200 300 400 500 600 700 Suruiual. Results for survival are illustrated in Figure 1. After the transection operation, two patients Follow-up (days) died of uncontrolled hemorrhage, and 10 died of liver FIG.1.Kaplan-Meier plot showing survival after staple transection failure complicated by various combinations of sepsis, kidney failure and terminal bleeding. As would be of the esophagus. expected, both patients with Pugh grade A liver disease survived. Four of the 10 patients with Pugh grade B liver disease and 4 of the 10 patients with Pugh grade C liver (mortality = go%),and the only patient to survive had disease survived. All 10 were discharged from the Child grade A liver disease before surgery. In comhospital and were followed for a median of 28 mo parison, 4 of 10 (40%) of our patients with poor liver (range = 14 to 66 mo). Four patients died during function (Pugh grade C) survived and, overall, 10 of 22 follow-up. Two had severe recurrent bleeding episodes (45%)of our patients survived to leave the hospital. Other options for treating patients who continue to and died after portacaval shunt surgery at 6 and 8 mo after discharge. One patient died of liver failure and bleed despite emergency sclerotherapy include transheHCC at 21 mo, and another died of liver failure 66 mo patic embolization, liver transplantation, devascularafter discharge from the hospital. The other six are still ization or shunt surgery. Transhepatic sclerotherapy was previously evaluated in our unit as a primary alive at this writing. treatment for variceal hemorrhage (16),but it has now DISCUSSION been largely abandoned because of its technical difficulty We have previously shown that staple transection of and the risk of portal-vein thrombosis. It continues to be the esophagus and acute sclerotherapy are equally evaluated in some units (171, but is unlikely to have a effective in controlling acute variceal hemorrhage and major role in salvage therapy. Liver transplantation have similar mortality rates ( 5 ) .We now report the use offers the best prospect for long-term survival (18). This of staple transection of the esophagus as a salvage treatment has been used for patients with bleeding procedure for those patients who continue to bleed varices (19), and in suitable patients, transplantation despite acute sclerotherapy treatment. These patients should probably be considered as a matter of urgency if have been shown to constitute a high-risk group with a donor liver is available (20). However, because of the mortality rates between 73% and 90% (6, 8). In our frequency of extrahepatic sepsis and the presence of study, staple transection controlled the bleeding from postsclerotherapy esophageal ulcers in patients who are esophagealvarices in 20 of 22 patients (91%).In-hospital bleeding acutely, transplantation is unlikely to be used mortality was high at 12 of 22 patients (55%) but, widely in this patient group. Good results have been conversely, 10 of 22 of our patients (45%)survived to claimed for shunt surgery as a primary treatment for patients with bleeding varices (21), but little inforleave the hospital. Only one other study has looked specifically at mation exists as to its value as a salvage therapy in esophageal transection as a salvage therapy for failure of patients in whom emergency sclerotherapy fails to emergency sclerotherapy to control variceal bleeding (8). control bleeding (22). More information is available In that study, 15 patients underwent emergency esoph- about surgical salvage in patients in whom chronic ageal transection. Control of bleeding was achieved in 13 sclerotherapy fails (23, 24). Henderson and colleagues of 15 patients (87%),but only 4 of 15 patients (27%) (23) performed a distal splenorenal shunt in 12 patients survived to be discharged from hospital, and all patients treated with chronic sclerotherapy who had unconwith poor liver function (Child class C) died. In another trolled rebleeding. All 12 survived, but only three had study, 10 patients had esophageal transection after bled from esophageal varices; seven had bled from failure of vasopressin and the Sengstaken-Blakemore gastric varices or portal hypertensive gastropathy and tube to control bleeding (15). Eight of these patients had two bled from deep esophageal ulcers. Paquet, Mercado Child grade C liver disease. Nine of the 10 patients died and Gad (24) also reported encouraging results with
1
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surgical rescue when chronic sclerotherapy failed. They used a narrow-lumen mesocaval shunt or a distal splenorenal shunt in patients with good liver function and gastroesophageal disconnection in patients with poor liver function. It is difficult to compare results because our study and that of Jenkins and Shields (8) looked at failure of emergency sclerotherapy, whereas those of Henderson et al. (23) and Paquet, Mercado and Gad (24) primarily evaluated long-term sclerotherapy. From our experience with patients who continue to bleed despite endoscopic sclerotherapy, we suggest that it is important to identify sclerotherapy failure early and institute alternative therapy as soon as possible. The law of diminishing returns applies to endoscopic sclerotherapy, and after two - or at the most, 3 -injections, little benefit is to be gained from further injections (5). Furthermore, the clinical state of the patient with uncontrolled bleeding tends to deteriorate progressively over time, making subsequent alternative therapy more difficult. We also share the view with other units (4)that a joint medical-surgical team approach to patients with bleeding varices facilitates decision-making in these very difficult cases and, we hope, also improves patient care. In summary, we suggest that staple transection of the esophagus is an effective treatment for patients who continue to bleed despite acute sclerotherapy. The relative merits of staple transection and shunt surgery in this situation have not been investigated, and they deserve further study. Whatever the surgical therapy used, it is likely that survival figures will be improved if failure to respond to sclerotherapy is recognized early and surgery is performed before the patient’s clinical state deteriorates irreversibly.
Acknowledgments: We thank Jackie Blissett for secretarial assistance in typing this paper. REFERENCES 1. Terblanche J, Burroughs AK, Hobbs KEF. Controversies in the management of bleeding esophageal varices. N Engl J Med 1989;320:1393-1398. 2. Johnson GW, Rodgers HW.A review of 15 years’ experience in the use of sclerotherapy in the control of acute haemorrhage from oesophageal varices. Br J Surg 1973;60:797-800. 3. Terblanche J , Yakoob HI, Bornman PC, Stiegman GV, Bane R, Jonker M, Wright J, et al. Acute bleeding varices. A five-year prospective evaluation of tamponade and sclerotherapy. Ann Surg 1981;194:521-30. 4. Wright PD, Loose HW, Carter RF, James OFW. Two-year experience of management of bleeding esophageal varices with a coordinated treatment program based on injection sclerotherapy. Surgery 1986;99:604-609. 5. Burroughs AK, Hamilton G, Phillips A, Mezzanotte G, McIntyre N, Hobbs KEF. Comparison of sclerotherapy with staple transection of the esophagus for the emergency control ofbleeding from esophageal varices. N Engl J Med 1989;321:857-862. 6. Bornman PC, Terblanche J, Kahn D, Jonker MA, Kirsch RE.
HEPATOLOGY
Limitations of multiple injection sclerotherapy sessions for acute variceal bleeding. S Afr Med J 1986;70:34-36. 7. Paquet K-J, Falk J-F, Koussouris P. Immediate endoscopic sclerosis of bleeding esophageal varices: a prospective evaluation over five years. Surg Endosc 1988;2:18-23. 8. Jenkins SA, Shields R. Variceal haemorrhage after failed injection sclerotherapy: the role of emergency oesophageal transection. Br J Surg 1989;76:49-51. 9. Burroughs AK, Qadiri M, Jeffrey G, Kibbler C, Hamilton G, Hobbs K, McIntyre N. Predictive factors for early failure to control active variceal bleeding and occurrence of early rebleeding I Abstract]. J Hepatol 1985;1:5203. 10. Burroughs AK, Mezzanotte G, Phillips A, McCormick PA, McIntyre N. Cirrhotics with variceal hemorrhage: the importance of the time interval between admission and the start of analysis for survival and rebleeding rates. HEPATOLOGY 1989;9:801-807. 11. Burroughs AK, McCormick PA, Hughes MD, Sprengers D, D’Heygere F, McIntyre N. Randomized double blind placebo controlled trial of somatostatin for the emergency control of bleeding and prevention of early rebleeding from varices. Gastroenterology 1990;99:1388-1395. 12. Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646-649. 13. Osborne DR, Hobbs KEF. The acute treatment of haemorrhage from oesophageal varices: a comparison of oesophageal transection and staple gun anastomosis with mesocaval shunt. Br J Surg 1981;68:734-737. 14. Kaye GL, Siringo S, Mistry P, McCormick PA, Hobbs KEF, Burroughs AK. Omeprazole in the management of staple line erosion of the oesophagus after EEA gun transection for variceal bleeding [Abstract]. Gut 1989;30:A745. 15. Durtschi MB, Carrico CJ, Johansen KH. Esophageal transection fails to salvage high-risk cirrhotic patients with variceal bleeding. Am J Surg 1985;150:18-23. 16. Smith-Laing G, Scott J , Long R, Dick R, Sherlock S. Role of percutaneous transhepatic obliteration of varices in the management of hemorrhage from gastroesophageal varices. Gastroenterology 1981;80:1031-1036. 17. O’Connor KW, Lehman G, Yune H, Brunelle R, Christiansen P, Hast J, Compton M, et al. Comparison of three nonsurgical treatments for bleeding esophageal varices. Gastroenterology 1989;96:899-906. 18. Wood RP, Shaw BW, Rikkers LF. Liver transplantation for variceal hemorrhage. Surg Clin N Am 1990;70:449-461. 19. Iwatsuki S, Starzl TE, Todo S, Gordon RD, Tzamis AG, Marsh W, Makouska L, et al. Liver transplantation in the treatment of bleeding esophageal varices. Surgery 1988;104:697-705. 20. Millikan WJ, Henderson JM, GallowayJR, Dodson TF, Shires GT, Stewart M. Surgical rescue for failures of cirrhotic sclerotherapy. Am J Surg 1990;160:117-121. 21. Cello JP, Grendell JH, Crass RA, Weber TE, Trunkey DD. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up. N Engl J Med 1987;316:11-15. 22. Langer BF, Greig PD, Taylor BR. Emergency surgical treatment of variceal hemorrhage. Surg Clin N Am 1990;70:307-317. 23. Henderson JM, Kutner MH, Millikan WJ, Galambos JT, Riepe SP, Brooks WS, Bryan FC, et al. Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis: a prospective, randomized trial. Ann Intern Med 1990;112:262-269. 24. Paquet KJ, Mercado MA, Gad HA. Surgical procedures for bleeding esophagogastric varices when sclerotherapy fails: a prospective study. Am J Surg 1990;160:43-47.
It is not clear which therapy should be used in patients with bleeding esophageal varices that are not controlled by emergency sclerotherapy. This is a high-risk group with reported mortality rates of between 70%and 90%.We report our 7-yr experience with staple transection of the esophagus in this patient group. Of 168 patients (280 bleeding episodes) treated with sclerotherapy, 22 had emergency staple transection for failure to control bleeding. Bleeding was controlled in 20 patients (90%), and 10 patients (45%) survived to leave the hospital, including 4 of 10 patients (40%)with Pugh grade C liver disease. We suggest that emergency staple transection is an effective salvage treatment for this high-risk group. (HEPATOLOGY 1992;15:403-406.) Injection sclerotherapy of esophageal varices is an effective treatment for acute variceal bleeding (1-4). Bleeding is controlled in 70% of cases after one injection and in 80% to 90% of cases after two injections (1).If bleeding continues, further injections appear to be of little extra benefit (5). The subgroup of patients who continue t o bleed has a poor prognosis, with a mortality rate approaching 90%for patients with Child class B and C liver disease (6). Bleeding can be temporarily controlled at this stage with balloon tamponade before a major surgical procedure (1,7). However, few data exist to indicate which surgical procedure t o use (8). We present our 7-yr experience with emergency esophagogastric staple transection in patients who continue t o bleed despite treatment with endoscopic sclerotherapy.
PATIENTS AND METHODS Between June 1983 and June 1990,372 patients with a total of 655 bleeding episodes were admitted t o the Hepatobiliary and Liver Transplantation Unit of the Royal Free Hospital with bleeding esophagealvarices. They were cared for by ajoint medical-surgical team, and all information was collected prospectively as part of a project designed to predict prognosis
Received February 15, 1991,accepted October 14, 1991 Address reprint requests to Dr P A McCormick, Academic Department of Medicine, Royal Free Hospital School of Medicme, Pond Street, Hampstead, London NW3 ZQG, United Kmgdom 3111134814
in this patient group (9, 10). Not all bleeding episodes were treated with injection sclerotherapy because ongoing clinical trials comparing somatostatin to placebo (11)and emergency sclerotherapy with emergency esophageal staple transection (5) were being carried out. Sclerotherapy Failure. The definition of sclerotherapy failure evolved during the period covered by this study. The initial definition was active variceal hemorrhage requiring continuing blood transfusion despite injection sclerotherapy (a maximum of three episodes). Sclerotherapy could be declared a failure after fewer than three episodes if, in the view of senior endoscopists, further attempted sclerotherapy would be hazardous. During this period, our experience suggested that little extra benefit was to be had from more than two sessions of sclerotherapy (5).In view of this and of the f a d that increasing use of sclerotherapy may make the operation technically more difficult, it was subsequently decided to limit acute sclerotherapy to two sessions before declaring failure of sclerotherapy. It should be stressed that in our unit, a bleeding episode is considered a bleed followed by a period of 5 days. Therefore a patient who is admitted with bleeding, has two sessions of emergency sclerotherapy and then stops bleeding may have further acute sclerotherapy if bleeding occurs again after an interval of more than 5 days. A total of 168 patients received acute sclerotherapy for a total of 280 bleeding episodes. Acute sclerotherapy was performed using a flexible fibroscope (K10 Olympus; Olympus Co., Kyoto, Japan) and intravariceal injection of 5% ethanolamine. A Sengstaken-Blakemore tube was inserted if lifethreatening, uncontrolled bleeding was present. During the study, acute sclerotherapy failed to control bleeding in 40 patients, and emergency esophageal transection was performed in 22 of these patients. In one patient with nodular regenerative hyperplasia, we experienced major difficulty in procuring compatible blood for transfusion. That patient continued to bleed despite a session of sclerotherapy. However, the bleeding was relatively minor in nature, and an esophageal transection was performed as semielective surgery rather than as an emergency life-saving procedure. This patient survived, but because the bleeding may well have responded to further sclerotherapy and the surgery was not emergent, she was excluded from this analysis. Of the 1 7 patients who were not transected, 4 patients died suddenly before further therapy could be contemplated, 8 patients were terminally ill with advanced liver failure and/or HCC and were judged unfit for surgery, 1 patient had had a previous esophageal transection for variceal bleeding, 3 patients were treated with transhepatic sclerotherapy, (2 died of continuing bleeding and the third died
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TABLE 1. Characteristicsof 22 patients who underwent esophageal staple transection after failure of emergency sclerotherapy to control bleeding esophageal varices
MIF Mean age (yr) Diagnosis Alcoholic cirrhosis Cryptogenic cirrhosis PBC CAH Budd-Chiari syndrome Primary sclerosing cholangitis Idiopathic portal hypertension Pugh grade A B
C Acute sclerotherapy before surgery 1 session 2 sessions 3 sessions 4 sessions
1517 55.6 (range = 37-80) 13 3 2 1 1 1 1 2 10 10
5 10 6
HEPATOLOGY
TABLE 2. Recurrent upper gastrointestinal bleeding after esophageal staple transection Bleeding
No.
Time since surgery (days)
Liver failure with terminal bleeding Death from liver failure with no further bleeding No further bleeding on follow-up Transection line-erosion bleeding" Gastric varices Upper GI bleeding
6 4
6, 10, 17, 22, 27, 42 2, 4, 5 , 5
2 4 3' 1
395, 407 8, 26, 120, 420 3, 6, 15 90
GI
= Gastrointestinal. Two patients in whom surgery failed to control the initial bleeding are excluded. "Transection-line bleeding was minor in most cases, and erosions responded to treatment with omeprazole. 'All three patients subsequently underwent shunt surgery (at 1, 4 and 8 mo after esophageal transection) because of recurrent, severe upper gastrointestinal bleeding.
1
patients underwent emergency surgery because of hemodynamic instability. We counted these patients as having had one session of variceal sclerotherapy because of liver failure despite control of bleeding) and 1patient had an we are not sure where the sclerosant went on the second emergency portacaval shunt and died of hepatic failure. The characteristics of the 22 patients treated with esophageal occasion. The third patient aspirated blood during transection are shown in Table 1.Most (20 of 22) were of Pugh attempted sclerotherapy; the procedure was therefore classes B and C. Pugh grading (12) refers to the clinical state abandoned and emergency surgery was performed. Control of Bleeding. Esophageal staple transection at the start of an episode of bleeding or at the time of admission controlled the variceal bleeding in most cases (20 of 22; to the Royal Free Hospital with variceal bleeding. Esophageal staple transection was performed through a left 90%). Two patients continued to bleed despite surgery. subcostal incision, as described previously (13), using a staple In one case, the patient was in kidney failure before gun (EEA, Auto Suture, Ascot, UK). The lower esophagus and surgery, had uncontrolled hemorrhage during surgery the periesophageal vessels were mobilized, and the staple gun and then died in the recovery room. In retrospect, it was inserted into the esophageal lumen through a small could be argued that this patient should not have been gastrotomy opening.A ligature was tied around the esophagus, trapping it between the cartridge and the anvil of the gun. The treated actively. The second patient had been diagnosed gun was then fired t o transect the esophagus and reconnect the with chronic myeloid leukemia and alcoholic cirrhosis two ends between two rows of staples. A doughnut-shaped shortly before the bleeding episode. After much disportion of transected esophagus was removed with the staple cussion surgery was performed, but transection was found to be technically impossible; splenectomy was gun. performed because of damage to the spleen at the time RESULTS of surgery. Bleeding was not controlled, and the patient Esophageal staple transection was performed in 22 died within 24 hr. patients. The surgical team reported thickening of the Subsequent events for the 20 patients with initial lower esophagus and greater difficulty in mobilizing the control of bleeding are summarized in Table 2. Diffuse esophagus compared with patients who had not un- gastrointestinal bleeding occurred as part of a generdergone prior sclerotherapy. Five of the 22 patients alized terminal bleeding diathesis in 6 of 10 patients who underwent one session of sclerotherapy. In two patients died of liver failure after surgery. Four patients had brisk bleeding occurred at endoscopy; it was not con- bleeding from esophageal staple-line erosions. These trolled by one session of acute sclerotherapy. In both episodes were usually minor in nature and responded to cases, the bleeding was not controlled by Sengstaken treatment with omeprazole. Three patients required balloon insertion. Both patients remained hemodynam- shunt surgery for severe repeated bleeding. All three ically compromised, and blood transfusion could not exhibited melena within 16 days of surgery. This settled keep pace with blood loss. Emergency surgery was with blood transfusion and intravenous omeprazole, and performed within 24 hr of the initial sclerotherapy. In endoscopy was not performed. However, all three had three more patients, a second session of emergency subsequent upper gastrointestinal bleeding episodes. It sclerotherapy was attempted. In two, visualization was was initially not clear whether this bleeding was caused very poor because of brisk bleeding. Blind injections at by superficial ulceration of the transection line, by the lower end of the esophagus were performed in both gastric varices or by congestive gastropathy. All three cases. These injections were not effective, and the patients were treated with omeprazole, and satisfactory
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healing of the staple line was achieved (14). It was presumed that the bleeding was coming from gastric varices or congestive gastropathy. One patient required shunt surgery 1 mo after esophageal transection. After this the bleeding stopped, and he was discharged from hospital and survived for another 21 mo before dying of liver failure and HCC. The other two patients were discharged, but they suffered frequent recurrent upper gastrointestinal bleeding from gastric varices. They underwent shunt surgery at 4 and 8 mo, respectively, but both experienced liver failure after surgery and died at 6 and 8 mo, respectively. One patient had a minor upper gastrointestinal bleeding episode 90 days after *O transection. The cause was not established, and there o ] I I has been no recurrent bleeding over a follow-upof 42 mo. 0 100 200 300 400 500 600 700 Suruiual. Results for survival are illustrated in Figure 1. After the transection operation, two patients Follow-up (days) died of uncontrolled hemorrhage, and 10 died of liver FIG.1.Kaplan-Meier plot showing survival after staple transection failure complicated by various combinations of sepsis, kidney failure and terminal bleeding. As would be of the esophagus. expected, both patients with Pugh grade A liver disease survived. Four of the 10 patients with Pugh grade B liver disease and 4 of the 10 patients with Pugh grade C liver (mortality = go%),and the only patient to survive had disease survived. All 10 were discharged from the Child grade A liver disease before surgery. In comhospital and were followed for a median of 28 mo parison, 4 of 10 (40%) of our patients with poor liver (range = 14 to 66 mo). Four patients died during function (Pugh grade C) survived and, overall, 10 of 22 follow-up. Two had severe recurrent bleeding episodes (45%)of our patients survived to leave the hospital. Other options for treating patients who continue to and died after portacaval shunt surgery at 6 and 8 mo after discharge. One patient died of liver failure and bleed despite emergency sclerotherapy include transheHCC at 21 mo, and another died of liver failure 66 mo patic embolization, liver transplantation, devascularafter discharge from the hospital. The other six are still ization or shunt surgery. Transhepatic sclerotherapy was previously evaluated in our unit as a primary alive at this writing. treatment for variceal hemorrhage (16),but it has now DISCUSSION been largely abandoned because of its technical difficulty We have previously shown that staple transection of and the risk of portal-vein thrombosis. It continues to be the esophagus and acute sclerotherapy are equally evaluated in some units (171, but is unlikely to have a effective in controlling acute variceal hemorrhage and major role in salvage therapy. Liver transplantation have similar mortality rates ( 5 ) .We now report the use offers the best prospect for long-term survival (18). This of staple transection of the esophagus as a salvage treatment has been used for patients with bleeding procedure for those patients who continue to bleed varices (19), and in suitable patients, transplantation despite acute sclerotherapy treatment. These patients should probably be considered as a matter of urgency if have been shown to constitute a high-risk group with a donor liver is available (20). However, because of the mortality rates between 73% and 90% (6, 8). In our frequency of extrahepatic sepsis and the presence of study, staple transection controlled the bleeding from postsclerotherapy esophageal ulcers in patients who are esophagealvarices in 20 of 22 patients (91%).In-hospital bleeding acutely, transplantation is unlikely to be used mortality was high at 12 of 22 patients (55%) but, widely in this patient group. Good results have been conversely, 10 of 22 of our patients (45%)survived to claimed for shunt surgery as a primary treatment for patients with bleeding varices (21), but little inforleave the hospital. Only one other study has looked specifically at mation exists as to its value as a salvage therapy in esophageal transection as a salvage therapy for failure of patients in whom emergency sclerotherapy fails to emergency sclerotherapy to control variceal bleeding (8). control bleeding (22). More information is available In that study, 15 patients underwent emergency esoph- about surgical salvage in patients in whom chronic ageal transection. Control of bleeding was achieved in 13 sclerotherapy fails (23, 24). Henderson and colleagues of 15 patients (87%),but only 4 of 15 patients (27%) (23) performed a distal splenorenal shunt in 12 patients survived to be discharged from hospital, and all patients treated with chronic sclerotherapy who had unconwith poor liver function (Child class C) died. In another trolled rebleeding. All 12 survived, but only three had study, 10 patients had esophageal transection after bled from esophageal varices; seven had bled from failure of vasopressin and the Sengstaken-Blakemore gastric varices or portal hypertensive gastropathy and tube to control bleeding (15). Eight of these patients had two bled from deep esophageal ulcers. Paquet, Mercado Child grade C liver disease. Nine of the 10 patients died and Gad (24) also reported encouraging results with
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surgical rescue when chronic sclerotherapy failed. They used a narrow-lumen mesocaval shunt or a distal splenorenal shunt in patients with good liver function and gastroesophageal disconnection in patients with poor liver function. It is difficult to compare results because our study and that of Jenkins and Shields (8) looked at failure of emergency sclerotherapy, whereas those of Henderson et al. (23) and Paquet, Mercado and Gad (24) primarily evaluated long-term sclerotherapy. From our experience with patients who continue to bleed despite endoscopic sclerotherapy, we suggest that it is important to identify sclerotherapy failure early and institute alternative therapy as soon as possible. The law of diminishing returns applies to endoscopic sclerotherapy, and after two - or at the most, 3 -injections, little benefit is to be gained from further injections (5). Furthermore, the clinical state of the patient with uncontrolled bleeding tends to deteriorate progressively over time, making subsequent alternative therapy more difficult. We also share the view with other units (4)that a joint medical-surgical team approach to patients with bleeding varices facilitates decision-making in these very difficult cases and, we hope, also improves patient care. In summary, we suggest that staple transection of the esophagus is an effective treatment for patients who continue to bleed despite acute sclerotherapy. The relative merits of staple transection and shunt surgery in this situation have not been investigated, and they deserve further study. Whatever the surgical therapy used, it is likely that survival figures will be improved if failure to respond to sclerotherapy is recognized early and surgery is performed before the patient’s clinical state deteriorates irreversibly.
Acknowledgments: We thank Jackie Blissett for secretarial assistance in typing this paper. REFERENCES 1. Terblanche J, Burroughs AK, Hobbs KEF. Controversies in the management of bleeding esophageal varices. N Engl J Med 1989;320:1393-1398. 2. Johnson GW, Rodgers HW.A review of 15 years’ experience in the use of sclerotherapy in the control of acute haemorrhage from oesophageal varices. Br J Surg 1973;60:797-800. 3. Terblanche J , Yakoob HI, Bornman PC, Stiegman GV, Bane R, Jonker M, Wright J, et al. Acute bleeding varices. A five-year prospective evaluation of tamponade and sclerotherapy. Ann Surg 1981;194:521-30. 4. Wright PD, Loose HW, Carter RF, James OFW. Two-year experience of management of bleeding esophageal varices with a coordinated treatment program based on injection sclerotherapy. Surgery 1986;99:604-609. 5. Burroughs AK, Hamilton G, Phillips A, Mezzanotte G, McIntyre N, Hobbs KEF. Comparison of sclerotherapy with staple transection of the esophagus for the emergency control ofbleeding from esophageal varices. N Engl J Med 1989;321:857-862. 6. Bornman PC, Terblanche J, Kahn D, Jonker MA, Kirsch RE.
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Limitations of multiple injection sclerotherapy sessions for acute variceal bleeding. S Afr Med J 1986;70:34-36. 7. Paquet K-J, Falk J-F, Koussouris P. Immediate endoscopic sclerosis of bleeding esophageal varices: a prospective evaluation over five years. Surg Endosc 1988;2:18-23. 8. Jenkins SA, Shields R. Variceal haemorrhage after failed injection sclerotherapy: the role of emergency oesophageal transection. Br J Surg 1989;76:49-51. 9. Burroughs AK, Qadiri M, Jeffrey G, Kibbler C, Hamilton G, Hobbs K, McIntyre N. Predictive factors for early failure to control active variceal bleeding and occurrence of early rebleeding I Abstract]. J Hepatol 1985;1:5203. 10. Burroughs AK, Mezzanotte G, Phillips A, McCormick PA, McIntyre N. Cirrhotics with variceal hemorrhage: the importance of the time interval between admission and the start of analysis for survival and rebleeding rates. HEPATOLOGY 1989;9:801-807. 11. Burroughs AK, McCormick PA, Hughes MD, Sprengers D, D’Heygere F, McIntyre N. Randomized double blind placebo controlled trial of somatostatin for the emergency control of bleeding and prevention of early rebleeding from varices. Gastroenterology 1990;99:1388-1395. 12. Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646-649. 13. Osborne DR, Hobbs KEF. The acute treatment of haemorrhage from oesophageal varices: a comparison of oesophageal transection and staple gun anastomosis with mesocaval shunt. Br J Surg 1981;68:734-737. 14. Kaye GL, Siringo S, Mistry P, McCormick PA, Hobbs KEF, Burroughs AK. Omeprazole in the management of staple line erosion of the oesophagus after EEA gun transection for variceal bleeding [Abstract]. Gut 1989;30:A745. 15. Durtschi MB, Carrico CJ, Johansen KH. Esophageal transection fails to salvage high-risk cirrhotic patients with variceal bleeding. Am J Surg 1985;150:18-23. 16. Smith-Laing G, Scott J , Long R, Dick R, Sherlock S. Role of percutaneous transhepatic obliteration of varices in the management of hemorrhage from gastroesophageal varices. Gastroenterology 1981;80:1031-1036. 17. O’Connor KW, Lehman G, Yune H, Brunelle R, Christiansen P, Hast J, Compton M, et al. Comparison of three nonsurgical treatments for bleeding esophageal varices. Gastroenterology 1989;96:899-906. 18. Wood RP, Shaw BW, Rikkers LF. Liver transplantation for variceal hemorrhage. Surg Clin N Am 1990;70:449-461. 19. Iwatsuki S, Starzl TE, Todo S, Gordon RD, Tzamis AG, Marsh W, Makouska L, et al. Liver transplantation in the treatment of bleeding esophageal varices. Surgery 1988;104:697-705. 20. Millikan WJ, Henderson JM, GallowayJR, Dodson TF, Shires GT, Stewart M. Surgical rescue for failures of cirrhotic sclerotherapy. Am J Surg 1990;160:117-121. 21. Cello JP, Grendell JH, Crass RA, Weber TE, Trunkey DD. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage. Long-term follow-up. N Engl J Med 1987;316:11-15. 22. Langer BF, Greig PD, Taylor BR. Emergency surgical treatment of variceal hemorrhage. Surg Clin N Am 1990;70:307-317. 23. Henderson JM, Kutner MH, Millikan WJ, Galambos JT, Riepe SP, Brooks WS, Bryan FC, et al. Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis: a prospective, randomized trial. Ann Intern Med 1990;112:262-269. 24. Paquet KJ, Mercado MA, Gad HA. Surgical procedures for bleeding esophagogastric varices when sclerotherapy fails: a prospective study. Am J Surg 1990;160:43-47.
