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The comparative characteristic of the efficacy of prophylaxis and treatment methods for bleeding esophageal and gastric varices in portal hypertension


Author: Mişin Igor
Degree:doctor habilitat of medicine
Specialities: 14.00.27 - Surgery
14.00.27 - Surgery
Year:2008
Scientific consultant: Gheorghe Ghidirim
doctor habilitat, professor, State University of Medicine and Pharmacy "Nicolae Testemitanu"
Institution:
Scientific council:

Status

The thesis was presented on the 26 January, 2008
Approved by NCAA on the 28 February, 2008

Abstract

Adobe PDF document2.98 Mb / in romanian

Thesis

CZU 616.36-004+616.149-008.341.1]-089.168-06+616.149.1+616.145.7]-007.64-005.1-02-08

Adobe PDF document 7.81 Mb / in romanian
274 pages


Keywords

portal hypertension, esophageal and gastric varices, hemorrhage, prophylaxis and treatment, endoscopic sclerotherapy, endoscopic ligation, azygo-portal disconnection, splenectomy, accessory spleen.

Summary

Aim – To improve the treatment results as well as to ameliorate the efficacy of primary and secondary prophylaxis of bleeding esophageal and gastric varices by means of elaborating, refinement and comparative appreciation of endoscopic, surgical and combined techniques.

The topographic study results. The presence of perforating veins in portal hypertension was proved not only in the distal third but also in the middle esophageal third (n:3.9±0.2 vs. 2.6±0.3, p<0.05; Ø:1.88±0.1 vs. 1.52±0.1 mm, p>0.05). For the first time was described the presence of a significant diameter PV, located distally to the esophago-gastric junction and representing the anterior brunch of the coronary gastric vein, in cases of the association of EV and gastric varices (Sarin I). The endoscopic stigmata of “red color signs” (RCS) were proved to be located strictly above the PV.

Clinical studies. The study represents a prospective analysis of the investigation and treatment results of 263 patients with PH, esophageal and gastric varices. The etiology of PH: LC (n=222), LC+HCC (n=13), LC+PST (n=19), PST(n=8) and IPH (n=1). According to the Child-Pugh classification: “A”-29, “B”-109, “C”-125. Treatment methods: EST with FG or TrC (n=56), EBL (n=206), EL with endo-loop (n=7), EC (n=7) and APD (n=52). Isolated endoscopic treatment procedures were performed in 188 (71.5%) cases, while the combined ones in – 23 (8.7%). Isolated APD were performed in 16 (6.1%), while in 36 (13.7%) – combined with endoscopic treatment procedures (EST, EL, EC). According to the terms the treatment procedures were classified: primary (n=64) and secondary (n=38) prophylaxis, urgent (n=161). The terminology, tactics and efficacy criteria used, were in compliance with International Consensus Conferences Baveno I-IV.

The combined index type NIEC (>40 points) proved to be the most rational in patients’ selection for primary prophylaxis of the first EV bleeding episode. EBL and extended APD proved to be the most effective procedures for prophylactic esophageal and gastric veins treatment, influencing favorably the survival terms, especially for Child-Pugh class “A” (p<0.001, according Kaplan-Meier). The theoretical, methodological and technical particularities of EST with FG and TrC were justified. The use of FG for hemostasis of bleeding esophageal and gastric varices (efficacy 92.8%) were pathogenetically justified. The basic advantages of EST with FG for bleeding esophageal and gastric varices are: a) obtains a physiologic hemostasis due to its properties to imitate the final stages of coagulation on a higher concentration level; b) complete filling of the variceal lumen (Cw-Th); c) the absence of local complications which are characteristic for conventional sclerosants; d) localized character of EV thrombosis.

EBL was proved to be the method of choice being the most effective hemostatic (efficacy 97.8%) as well as prophylaxis procedure for esophageal bleeding. There were established the rebleeding risk factors: grade III and IV hemorrhage (p<0.001), Child-Pugh “С” patients (p<0.001), active bleeding on primary endoscopy (p<0.05), low EBL intensity (< de 5 bands) (p<0.05), as well as Rockall index (7.56±0.3 vs. 5.01±0.2, p<0.001).

The proximal collapse of EV in the middle esophageal third during EBL in the distal esophagus (74.3%) proves the prevalence of vertical blood stream, being a positive factor accompanied with a long-term absence of recidivating EV. There was noted an increased efficacy of EBL regarding EV eradication (F0, RCS (-) - 79.5%; Nakase index -3.32±0.03 vs. 0.5±0.05, (p<0.001). The chronological sequence of morphological esophageal modifications after EBL was described for the first time. There was demonstrated that the evolutive modifications in the ligation sites and the terms of rubber bands slippage are not similar in clinical and experimental studies. It was proved that early rubber band slippage (1.9%) is associated with an elevated variceal bleeding risk due to the imperfect thrombogenesis in the variceal lumen. It was proved that the risk factors for this complication are active variceal hemorrhage during EBL (B1a+1b) as well as Child-Pugh score (“C”). In the present study it was demonstrated that EBL with mini-loop has several advantages compared to other esophageal and gastric treatment procedures. It was demonstrated that EC has an insignificant efficacy in the EV treatment due to technical imperfections, their use being possible just for small EV (F1, RCS+).

During the present study, was demonstrated that extended APD showed significant advantages compared to the limited ones regarding esophageal and gastric varices eradication (residual varices - 32.5% vs. 100% p<0.001; Nakase index p/o – 0.48±0.12 vs. 1.86±0.26, p<0.01). It was proved that the essential component of APD procedures is paraesophageal devascularization but not esophageal transection. It was demonstrated that combined Hassab-Paquet procedure with EBL is an alternative for transabdominal esophageal transection (Sugiura-Futagawa), being associated with low complication rate. For the first time were studied the morphological and functional modifications as well as the hematological significance of the accessory spleen in liver cirrhosis and portal hypertension. For the first time in the literature was described the hipersplenism recurrence due to the accessory spleen preservation, in the late postoperative period after APD with SE. It was demonstrated that hemodynamic significant SPSS (Ø ≥ 5mm) does not represent protective mechanisms for EV and variceal bleeding prophylaxis. It was proved that their ligation during APD with SE procedures is a pathogenetically justified step in order to eliminate hepatofugal blood stream and must be considered as a prophylactic and treatment procedure for portal encephalopathy. For the first time was proved that the potential factor for portal system thrombosis as a result of APD with SE is the low natural anticoagulant (antithrombine III - 76.51.5 vs. 845.1 (p<0.05) concentration, as a result of impaired liver function (A vs. B:p<0.05, B vs. C: p<0.01, A vs. C: p<0.001).

There were standardized the treatment policy, bleeding stigmata, as well as rational use of the elaborated and perfected endoscopic and surgical treatment procedures, fact that decreased mortality rate in patients with variceal bleeding to 18.01% (29/161), all the deaths being reported to Child-Pugh “C” class. In this group of patients, lethality was 31.5% (29/92), while in the groups “A” and “B” no mortality was registered (“С” vs. “A” vs. “B”, p<0.001). It was demonstrated that the potential factors influencing negatively the in-hospital mortality rate in case of variceal bleeding are the following: Child-Pugh class “С” (p<0.001) and bleeding recurrence (p<0.001).