Abstract
Background
Surgical treatment of variceal hemorrhagic complications for patients with schistosomal portal hypertension in our group comprised an esophagogastric devascularization procedure with splenectomy (EGDS). There are two different kinds of postoperative follow-up: prophylactic or on-demand endoscopic program of varices eradication. This program implies risks and costs and only proves necessary in 6–29% of cases. This study was designed to assess portal vein Doppler ultrasound data in these patients, and to verify correlations with progression in the number and size of varices, as well as the appearance of red spots and rebleeding during the postoperative period after EGDS.
Methods
Data on portal vein Doppler ultrasound from 146 patients with schistosomal portal hypertension and previous history of upper digestive bleeding due to esophagogastric varices rupture was analyzed. All subjects underwent EGDS and were analyzed before and after the procedure and compared postoperatively at four time points: 1 year, 2 years, up to 5 years, and up to 10 years. The following portal hemodynamic parameters were analyzed: diameter and mean blood flow velocity. Variceal size and number, presence of red spots, and rebleeding were all determined by endoscopic examination. Patients were divided into two groups at the each of the four time points, according to esophagogastric varices progression.
Results
Patients with variceal progression had significantly higher values of portal blood flow velocity. At time points I, II, III, and IV, the measured flow velocity from first postoperative year was 17.64 ± 4.84 vs. 13.81 ± 5.61 (p = 0.025); 16.74 ± 4.8 vs. 13.75 ± 5.8 (p = 0.039); 16.01 ± 5.00 vs. 13.23 ± 5.86 (p = 0.036); and 16.01 ± 5.00 vs. 13.23 ± 5.86 (p = 0.036), respectively.
Conclusions
Patients with schistosomal portal hypertension submitted to EGDS who had portal blood flow velocity >15.5 cm per second at the first postoperative year ha d progression of esophagogastric varices and a greater chance of rebleeding and, therefore, should be included in the endoscopic program for varices eradication.
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References
De Capua A Jr, Szutan LA, Saad R Jr, Stelmach D, Assef JC (1992) Alterações da pressão porta de doentes esquistossomóticos submetidos a operação de esplenectomia e desconexão ázigo-portal. GED Gastroenterol Endosc Dig 11:1
Kelner S (1992) Critical evaluation of schistosomiasis portal hypertension surgery. Mem Inst Oswaldo Cruz 87:357–368
Chandler JG (1993) The history of the surgical treatment of portal hypertension. Arch Surg 128:925–940
De Capua A, Szutan LA Jr (1995) Desconexão ázigo-portal e esplenectomia mais escleroterapia no tratamento da hipertensão portal. Clin Bras Cir 2:231–242
De Cleva R, Pugliese V, Zilberstein B, Saad WA, Pinotti HW, Laudanna AA (1999) Systemic hemodynamic changes in mansonic schistosomiasis with portal hypertension treated by azygoportal disconnection and splenectomy. Am J Gastroenterol 94:1632–1637
Ferraz AAB, Bacelar TS, Silveira MJ, Coelho AR, Câmara Neto RD, De Araújo Júnior JG et al (2001) Surgical treatment of schistosomal portal hypertension. Int Surg 86:1–8
Assef JC, De Capua A, Szutan LA Jr (2003) Treatment of recurrent hemorrhagic esophageal varices in schistosomotic patients after surgery. Rev Assoc Med Bras 49:406–412
Ferreira FG, Forte WC, Assef JC, De Capua A Jr (2007) Effect of esophagogastric devascularization with splenectomy on schistossomal portal hypertension patients’ immunity. Arq Gastroenterol 44:44–48
Sakai P, Boaventura S, Ishioka S, Mies S, Sette H Jr, Pinotti HW (1990) Sclerotherapy of bleeding esophageal varices in schistosomiasis. Comparative study in patients with and without previous surgery for portal hypertension. Endoscopy 22:5–7
Lacerda CM, Ramos H, Raia S, Kelner S (1993) Fisiopatologia da hipertensão portal esquistossomótica e efeitos da esplenectomia com ligadura de varizes de esôfago. Acta Cir Bras 8:113–117
Ferraz AA, Lopes EP, Barros FM, Sette MJ, Arruda SM, Ferraz EM (2001) Splenectomy plus left gastric vein ligature and devascularization of the great curvature of the stomach in the treatment of hepatosplenic schistosomiasis. Postoperative endoscopic sclerosis is necessary? Arq Gastroenterol 38:84–88
Korula J, Pandya K, Yamada S (1989) Perforation of esophagus after endoscopic variceal sclerotherapy. Incidence and clues to pathogenesis. Dig Dis Sci 34:324–329
Berner JS, Gaing AA, Sharma R, Almenoff PL, Muhlfelder T, Korsten MA (1994) Sequelae after esophageal variceal ligation and sclerotherapy: a prospective randomized study. Am J Gastroenterol 89:852–858
Kahn D, Krige JE, Terblanche J, Bornman PC, Robson SC (1994) A 15-year experience of injection sclerotherapy in adult patients with extrahepatic portal venous obstruction. Ann Surg 219:34–39
Bhargava DK, Pokharna R (1997) Endoscopic variceal ligation versus endoscopic variceal ligation and endoscopic sclerotherapy: a prospective randomized study. Am J Gastroenterol 92:950–953
Rohr MRS, Siqueira ES, Brant CQ, Morais M, Libera ED, Ferrari AP (1997) Prospective study of bacteremia rate after elastic band ligation and sclerotherapy of esophageal varices in patients with hepatosplenic schistosomiasis. Gastrointest Endosc 46:321–323
Sarin SK, Govil A, Jain AK, Guptan RC, Issar SK, Jain M et al (1997) Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence. J Hepatol 26:826–832
Reed AR, Michell WL, Krige JE (2001) Mechanical tracheal obstruction due to an intramural esophageal hematoma following endoscopic variceal sclerotherapy. Am Surg 67:690–692
Krige JE, Bornman PC, Goldberg PA, Terblanche J (2000) Variceal rebleeding and recurrence after endoscopic injection sclerotherapy: a prospective evaluation in 204 patients. Arch Surg 135:1315–1322
Krige JE, Shaw JM, Bornman PC (2005) The evolving role of endoscopic treatment for bleeding esophageal varices. World J Surg 29:966–973
Soares AC, Morais DJ, Santos JO, Lopes LR, Andreollo NA (2006) Esophageal motility studies in cirrhotic patients before and after endoscopic variceal ligation. Rev Assoc Med Bras 52:93–96
Mudawi HM, Ibrahim KB (2007) Endoscopic variceal sclerotherapy in patients with Symmers periportal fibroses. Trop Doct 37:179–181
Thomas V, Tony J, Harish K, Harikumar R, Sunilkumar K (2007) Endoscopic abnormalities in the oesophagus after variceal sclerotherapy–a long-term follow up study. Trop Gastroenterol 28:24–27
Yüksel O, Köklü S, Arhan M, Yolcu OF, Ertuğrul I, Odemiş B et al (2006) Effects of esophageal varice eradication on portal hypertensive gastropathy and fundal varices: a retrospective and comparative study. Dig Dis Sci 51:27–30
Fevery J, Nevens F (2000) Oesophageal varices: assessment of the risk of bleeding and mortality. J Gastroenterol Hepatol 15:842–848
Yin XY, Lu MD, Huang JF, Xie XY, Liang LJ (2001) Color Doppler velocity profile assessment of portal hemodynamics in cirrhotic patients with portal hypertension: correlation with esophageal variceal bleeding. J Clin Ultrasound 29:7–13
D’Amico G, Garcia-Tsao G, Cales P, Escorsell A, Nevens F, Cestari R et al (2001) Portal hypertension III. Session 2: diagnosis of portal hypertension: how and when. In: De Franchis R et al (ed) Portal hypertension III: proceedings of the third Baveno international consensus workshop on definitions. Methodology and therapeutic strategies. Blackwell, Oxford, pp 36–64
Calès P, Oberti F, Bernard-Chabert B, Payen JL (2003) Evaluation of Baveno recommendations for grading esophageal varices. J Hepatol 39:657–659
El Masri SH, Hassan MA (1982) Splenectomy and vasoligation for patients with haematemesis secondary to bilharzial hepatic fibrosis. Br J Surg 69:314–316
Carneiro JLA, Mies S, Raia S (1983) A circulação colateral gastroesofágica após desconexão ázigo-portal: portografia trans-hepática na esquistossomose mansônica. Rev Col Bras Cir 10:191–202
Chaib SA, Lessa BS, Cecconello I, Felix VN, Chaib E (1983) A new procedure for the treatment of bleeding esophageal varices by transgastric azigo-portal disconnection. Int Surg 68:353–356
Raia S, Mies S, Macedo AL (1984) Surgical treatment of portal hypertension in schistosomiasis. World J Surg 8:738–752
Kelner S, Ferreira PR, Dantas A, Lima Filho JFC, Souza AP, Carreiro JCP Jr et al (1985) Ligadura de varizes esôfago-gástricas na hipertensão porta esquistossomótica: avaliação de 25 anos. Rev Col Bras Cir 9:140–146
Silva LC, Strauss E, Gayotto LCC, Mies S, Macedo AL, Silva AT et al (1986) A randomized trial for the study of the elective surgical treatment of portal hypertension in mansonic schistosomiasis. Ann Surg 204:148–153
Cordeiro F (1990) Variceal sclerosis in schistosomotic patients: a 5-year follow-up study. Gastrointest Endosc 36:475–478
Raia S, Silva LC, Gayotto LCC, Forster SC, Fukushima J, Strauss E (1994) Portal hypertension in schistosomiasis: a long-term follow-up of a randomized trial comparing three types of surgery. Hepatology 20:398–403
Ferraz AAB (2000) Tratamento cirúrgico da hipertensão porta esquistossomótica na UFPE: aspectos históricos e contemporâneos. An Fac Med Univ Fed Pernambuco 45:153–154
Machado MM, Rosa ACF, Barros N, Azeredo LM, Rosa JBF, Cerri LMO et al (2004) Doppler evaluation in portal hypertension. Radiol Bras 37:35–39
Mies S, Mori T, Larsson E, Rosa P, Jara JG, Dos Santos LF et al (1980) Inferior vena cava and suprahepatic veins in hepatosplenic schistosomiasis. Angiographic study. Rev Hosp Clin Fac Med Sao Paulo 35:136–142
Grosmann RJ, Atterbury CE (1982) The pathophysiology of portal hypertension. Semin Liver Dis 2:177–186
Zoli M, Marchesini G, Cordiani MR, Pisi P, Brunori A, Trono A et al (1986) Echo-Doppler measurement of splanchnic blood flow in control and in cirrhotic subjects. J Clin Ultrasound 14:429–435
Brown HS, Halliwell M, Qamar M, Read AE, Evans JM, Wells PN (1989) Measurement of normal portal venous blood flow by Doppler ultrasound. Gut 30:503–509
Morgan JS, Groszmann RJ, Rojkind M, Enriquez R (1990) Hemodynamic mechanisms of emerging portal hypertension caused by schistosomiasis in the hamster. Hepatology 11:98–104
Zironi G, Gaiani S, Fenyves D, Rigamonti A, Bolondi L, Barbara L (1992) Value of measurement of mean portal flow velocity by Doppler flowmetry in the diagnosis of portal hypertension. J Hepatol 16:298–303
Kazmirik M, De Capua Neto A, Favero SSG, Francisco LDR, Szutan LA, De Capua A Jr (1994) Comparative study of portal flow in patients with cirrhotic and schistosomotic by echo-Doppler. Acta cir Brás 9:38–43
De Gaetano AM, Lafortune M, Patriquin H, De Franco A, Aubin B, Paradis K (1995) Cavernous transformation of the portal vein: patterns of intrahepatic and splanchnic collateral circulation detected with Doppler sonography. AJR Am J Roentgenol 115:389–393
Sacerdoti D, Merkel C, Bolognesi M, Amodio P, Angeli P, Gatta A (1995) Hepatic arterial resistance in cirrhosis with and without portal vein thrombosis: relationships with portal hemodynamics. Gastroenterology 108:1152–1158
Zoli M, Magalotti D, Bianchi G, Ghigi G, Orlandini C, Grimaldi M et al (1995) Functional hepatic flow and Doppler-assessed total hepatic flow in control subjects and in patients with cirrhosis. J Hepatol 23:129–134
Weill FS (1996) Ultrasound diagnosis of digestive diseases, 4th edn. Springer-Verlag, Berlin, pp 203–225
De Cleva R, Zilberstein B, Saad WA, Pinotti HW, Laudana AA (1997) Portal hypertension in schistosomiasis. Clinical and therapeutics aspects. Arq Bras Cir Dig 12:5–9
Stelmach D, De Capua A Jr (1996) Estudo da pressão portal no pós-operatório de doentes esquistossomóticos submetidos a esplenectomia e desvascularização gastro-esofágica. GED Gastroenterol Endosc Dig 5:41–48
Strauss E, Sakai P, Gayotto LC, Cardoso RA, Forster S, Raia S (1999) Size of gastroesophageal varices: its behavior after the surgical treatment of portal hypertension. Rev Hosp Clin Fac Med Sao Paulo 54:193–198
Alves Júnior A, Alves MDNT, Gonçalves KRA, Cruz JF, Melo VA, Machado MCC (2001) Hipertensão portal esquistossomótica: avaliação do fluxo sangüíneo portal antes e após tratamento cirúrgico. Rev Col Bras Cir 28:330–335
Menezes HL, Jucá MJ, Brandt CT, Gomes EGA, Patrício AR, Souto Maior PM (2001) Dopplerfluxometry of the portal system in patients with schistosomiasis mansoni who underwent splenectomy and ligature of the left gastric vein. An Fac Med Univ Fed Pernamb 46:23–27
Widman A, Oliveira IRS, Speranzini MB, Cerri GG, Saad WA, Gama-Rodrigues J (2001) Hipertensão portal por esquistossomose mansônica hepatoesplênica: efeito da desconexão ázigo-portal com esplenectomia no diâmetro e na velocidade média de fluxo do sistema portal (estudo ultra-sonográfico com Doppler). Arq Gastroenterol 38:19–23
De Cleva R, Saad WA, Herman P, Pugliese V, Zilberstein B, Laudanna AA et al (2004) Portal hyperflow in patients with hepatosplenic mansonic schistosomiasis. Rev Hosp Clin Fac Med Sao Paulo 59:10–14
Silva-Neto W, De B, Cavarzan A, Herman P (2004) Intra-operative evaluation of portal pressure and immediate results of surgical treatment of portal hypertension in schistosomotic patients submitted to esophagogastric devascularization with splenectomy. Arq Gastroenterol 41:150–154
de Cleva R, Herman P, D’albuquerque LAC, Pugliese V, Santarem OL, Saad WA (2007) Pre- and postoperative systemic hemodynamic evaluation in patients subjected to esophagogastric devascularization plus splenectomy and distal splenorenal shunt: a comparative study in schistomomal portal hypertension. World J Gastroenterol 13:5471–5475
Widman A, De Oliveira IR, Speranzini MB, Cerri GG, Saad WA, Gama-Rodrigues J (2003) Portal thrombosis: late postoperative prevalence in Mansoni’s schistosomiasis. Hepatogastroenterology 50:1463–1466
De Cleva R, Herman P, Saad WA, Pugliese V, Zilberstein B, Rodrigues JJ et al (2005) Postoperative portal vein thrombosis in patients with hepatosplenic mansonic schistosomiasis: relationship with intraoperative portal pressure and flow. A prospective study. Hepatogastroenterology 52:1529–1533
Ferreira FG, Chin EW, De Santos MF, Carvalho DLM, De Capua A Jr (2005) Portal congestion and thrombosis after esophagogastric devascularization and splenectomy. Rev Assoc Med Bras 51:233–236
Tait IS, Krige JEJ, Terblanche J (1999) Endoscopic band ligation of oesophageal varices. Br J Surg 86:812–817
Sakai P (2001) Endoscopic esophageal varices sclerotherapy post-surgical treatment for portal hypertension in patients with hepatosplenic schistosomiasis. Arq Gastroenterol 38:81–83
Lacerda CM, Freire W, Vieira de Melo PS, Lacerda HR, Carvalho G (2002) Splenectomy and ligation of the left gastric vein in schistosomiasis. The effect on esophageal variceal pressure measured by a non-invasive technique. Keio J Med 51:89–92
Wattanasirichaigoon S, Gordon FD, Resnick RH (2000) Hyperdynamic circulation in portal hypertension: a comparative model of arterio-venous fistula. Med Hypotheses 55:77–87
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Ferreira, F.G., Ribeiro, M.A., de Fátima Santos, M. et al. Doppler Ultrasound Could Predict Varices Progression and Rebleeding After Portal Hypertension Surgery: Lessons from 146 EGDS and 10 Years of Follow-Up. World J Surg 33, 2136–2143 (2009). https://doi.org/10.1007/s00268-009-0196-y
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DOI: https://doi.org/10.1007/s00268-009-0196-y