RESUMO
The results of treatment of hemorrhagic portal hypertension with selective shunts over a 21-year period in a selected patient population are reported. Patients selected for surgical treatment had good cardiopulmonary and renal function, and most also had adequate liver function (141 Child-Pugh class A, 59 class B). Among 734 patients treated surgically for bleeding portal hypertension, 221 had selective shunts (168 distal splenorenal and 53 splenocaval shunts). Global operative mortality (in the 21-year period) was 14% and 12% for Child-Pugh A patients. Operative mortality in Child-Pugh A patients in the last 5 years was only 5%. The rate of rebleeding was 6%, rate of incapacitating encephalopathy was 5%, and rate of survival was 65% at 15 years (last 5 years: 88% at 1 year and 85% at 5 years). Good quality of life was demonstrated in 80% of surviving patients. Shunt patency was 94%. Postoperative portal blood flow changes occurred in 23% of cases (8% diameter reduction, 14% thrombosis). Compared with other forms of therapy (pharmacotherapy, sclerotherapy, and transjugular intrahepatic shunting), only liver transplantation offers similar results for these patients. In countries in which liver transplantation is not routinely performed, shunting with selective shunts is the treatment of choice for patients with good liver function.
Assuntos
Hemorragia/etiologia , Hipertensão Portal/cirurgia , Derivação Esplenorrenal Cirúrgica , Angiografia , Encefalopatias/etiologia , Seguimentos , Humanos , Hipertensão Portal/complicações , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Derivação Portossistêmica Cirúrgica/efeitos adversos , Derivação Portossistêmica Cirúrgica/mortalidade , Hemorragia Pós-Operatória/etiologia , Derivação Esplenorrenal Cirúrgica/efeitos adversos , Derivação Esplenorrenal Cirúrgica/mortalidade , Taxa de Sobrevida , Grau de Desobstrução VascularRESUMO
Foi realizado um estudo prospectivo comparando a anastomose espleno-renal distal seletiva (AERDS) com a escleroterapia endoscopica das varizes esofagianas, em 60 pacientes, tendo sido alocado metade dos pacientes em cada grupo. Todos os pacientes eram esquistossomoticos hepatesplenicos. O seguimento dos pacientes foi de quatro anos. A recidiva hemorragica no grupo esclerosado foi de 33,3% contra 6,6%, no grupo AERDS. Entretanto, apenas metade do grupo esclerosado (16,6%) necessitou mudar a terapia, isto e, realizar a cirurgia, para controlar a recidiva hemorragica. Quanto a mortalidade, no grupo da esclerose, nao observamos nenhum obito. No grupo AERDS ocorreram dois obitos no P.O. imediato. A encefalopatia nao foi observada no grupo esclerosado. Um paciente apresentou os sintomas dois anos apos a cirurgia. Os pacientes portadores de esplenomegalia volumosa, frequentemente associada ao hiperesplenismo, nao se benefician neste particular com a escleroterapia. A escleroterapia necessita de uma selecao dos pacientes com melhor nivel socio-cultural, pois a terapia incompleta com o abandono ou irregularidade do programa, levara fatalmente ao insucesso
Assuntos
Humanos , Escleroterapia , Derivação Esplenorrenal Cirúrgica , Varizes Esofágicas e Gástricas/prevenção & controle , Estudos Prospectivos , Esquistossomose , Derivação Esplenorrenal Cirúrgica/mortalidadeRESUMO
A retrospective study of 43 patients who were operated on for portal hypertension was performed (29 distal splenorenal shunts, 7 total portosystemic shunts, five Sugiura's operations and 2 splenectomies with gastric devascularization). Eighteen patients had recurrence of hemorrhage, 10 had ascitis and six encephalopathy. Thirteen of the 43 patients (seven Warren's operations, five Sugiura's and one mesocaval shunt) received postoperative sclerotherapy. The overall operative mortality was 34.8%. In the period 1977-1982, six of 20 patients (30%) died, and in 1983-1988 nine of 23 died (39.1%) (p greater than 0.05); so, we concluded that we must improve the perioperative care and that this kind of operations must be performed only by experienced surgeons.