Treatment of Esophageal Varices

With the development of advanced vasoactive agents (see Chapter 75B), endoscopic therapies (Chapter 75B), and transjugular intrahepatic portosystemic shunting (TIPS; see Chapter 76E), the need for surgical treatment for esophagogastric varices has decreased (Cello et al, 1984). Most patients with esophagogastric varices have cirrhosis and portal hypertension; for patients in advanced stages of liver failure, liver transplantation (see Chapter 97A, Chapter 97B, Chapter 97C, Chapter 97D, Chapter 97E ) is the optimal treatment, although shunting (see Chapter 78) or nonshunting operations can be considered for treatment of bleeding complications. Rikkers (1998) reported that portosystemic shunts and esophagogastric devascularization have an important role in selected patients with bleeding related to portal hypertension.

Compared with the risk of postoperative hepatic encephalopathy in surgical shunts and TIPS, nonshunting procedures maintain postoperative portal perfusion and long-term hepatic and systemic hemodynamics in patients with cirrhosis, which results in a low incidence of postoperative encephalopathy (Lin et al, 1993; Vons et al, 1996). The applications of shunting operations are limited in patients with extensive thrombosis of the mesenteric venous system, but nonshunting operations do not have such limitations. In addition, nonshunting operations do not alter vascular anatomy and complicate future liver transplant surgery, although they can cause significant upper abdominal adhesions, which are associated with increased bleeding at the time of transplantation.

In the era of multimodalities for bleeding esophagogastric varices, the role of nonshunting operations is redefined as 1) an emergency procedure when medical treatment, endoscopic ligation or sclerotherapy, and TIPS have failed; 2) a part of combined therapies to achieve better outcomes in selected patients (Burroughs et al, 1989); and 3) a long-term bridge to liver transplantation, particularly in patients with splanchnic thrombosis or in the absence of a facility capable of TIPS (Selzner et al, 2001).

In general, nonshunting operations include the devascularization procedure, splenectomy, and esophagus transection. The devascularization procedure has been described as obliteration of varices or disconnection of the esophagogastric veins from the hypertensive portal tributaries. These approaches, known as the Hassab (Hassab, 1998) and Sugiura procedures (Sugiura & Futagawa, 1973), and other modified procedures are discussed.

Effects of Devascularization and Splenectomy for Esophageal Varices

The principle of devascularization procedures for variceal bleeding is based on anatomic features. The coronary vein and gastric veins are anastomosed with tributaries of the superior vena cava by collateral channels in the submucosa of the esophagus, between the two muscular layers, and in the periesophageal region. In portal hypertension, the increased venous pressure can produce varices throughout the length of the esophagus and down into the upper stomach. In the region of the esophageal hiatus, periesophageal vein dilation does not usually occur, and the most blood flow goes through the esophageal submucosal varices. Hence, most bleeding occurs in the distal segment of the esophagus, in the last 5 cm, usually at the esophagogastric junction (Spence, 1984).

Spence and colleagues (1983) applied a computerized image analysis system to study the venous anatomy of the esophagus; serial sections have shown that the large vessels in the lamina propria communicate directly with dilated intraepithelial blood channels via the epithelial papillae. These intraepithelial channels seen histologically represent the cherry-red spots viewed endoscopically (Spence & Terblanche, 1987). An ideal technique of control for bleeding varices would be permanent obliteration of the varices in the lower periesophageal vessels and intraepithelial dilated vessels.

Portal hypertension, however, is not decreased even with the ideal devascularization procedures. Some methods to reduce the portal hypertension include medication with β₂-blockers, octreotide, and vasopressin (Dell’Era et al, 2008) and surgical treatment. Liver transplantation is the most effective treatment to reduce portal hypertension, but splenectomy may also have benefit in this regard. Zhang and colleagues (2009) found a decreased portal venous pressure gradient, decreased portal venous flow, and increased hepatic artery flow after splenectomy with periesophagogastric devascularization, which resulted in short-term improvement in hepatic functional reserve. De Cleva and colleagues (2007) compared esophagogastric devascularization plus splenectomy with distal splenorenal shunt in hemodynamic evaluation and found similar improved hyperdynamic circulation in schistosomal portal hypertension.

History of Esophageal Transection, Devascularization, and Splenectomy

Crile (1950) proposed transthoracic ligation of esophageal varices, and subsequently many modifications of his technique have been devised. Boerema (1949) and Vosschulte (1957) introduced the simple button technique for transabdominal esophageal transection, but unfortunately, this method was a major source of stricture formation (Johnston & Kelly, 1976). Walker (1964) used a vertical incision for the muscle layers of the esophagus and a transverse division of the mucosa and submucosa to reduce the risk of posttransection leakage. About the same time, Tanner (1961) proposed a subcardiac portoazygos disconnection with gastric transection. Hassab (1967) found that in patients with bleeding esophageal varices secondary to schistosomiasis, an adequate gastroesophageal devascularization procedure via the abdomen was possible. This technique, known as the Hassab procedure, included splenectomy but not esophageal or gastric transection, and Hassab (1998) reported a remarkably low rate of rebleeding with this method.

Japanese surgeons devised an extensive transthoracic paraesophageal devascularization and esophageal transection combined with an abdominal component consisting of splenectomy, devascularization of the upper stomach, vagotomy, and pyloroplasty (Sugiura & Futagawa, 1973). Thereafter, some Japanese surgeons modified this Sugiura procedure with a sole abdominal approach and achieved similar survival (Inokuchi, 1985).

In 1974, Vankemmel published the first report of the use of a circular stapling gun for esophageal transection. This technique removes approximately 1 cm of full-thickness esophageal wall, provides a safe suture line, and reduces the risk of stricture formation. Jin and Rikkers (1996) reported the American experience with a modified Sugiura procedure without esophagus transection as an effective method for treating variceal hemorrhage. Johnson and colleagues (2006) proposed that the same results could be achieved with a transabdominal modified devascularization procedure without esophageal stapler transection. Nakamura and colleagues (1996) simultaneously used the Hassab procedure and endoscopic injection sclerotherapy for esophageal varices. Hashizume and colleagues (1998) first applied the laparoscopic technique to perform the Hassab procedure and splenectomy successfully in 10 patients with cirrhosis and varices. Jiang and colleagues (2009) compared open and laparoscopic splenectomy with azygoportal devascularization and concluded that the laparoscopic procedure was a safe and effective method in carefully selected patients.

Hassab Procedure

Hassab (1967) proposed a method of gastroesophageal decongestion and splenectomy (GEDS) for management of bleeding varices. In this approach, the patient is in a supine position; a 30-degree, head-up tilt improves the exposure of the operative field. A midline epigastric incision is generally used. Occasionally, an extended left subcostal incision or L-shaped incision of the left upper abdomen is used for extreme splenomegaly. The left lobe of the liver is retracted. In case of left lobe hypertrophy in cirrhotic patients, division of the left lobe ligaments may be useful. Splenectomy was initially performed, and the splenic artery could be suture ligated from the upper part of the pancreatic body if pancreatic tail oozing persisted. Next, the gastrohepatic ligament is divided in the area where it is thin and usually transparent, exposing the right crus of the esophageal hiatus. The incision is carried out superiorly over the anterior aspect of the esophagus, dividing the reflection of the parietal peritoneum at the junction between the esophagus and the diaphragm. The incision is pursued down the left side of the esophagus until the left crus of the esophageal hiatus is identified. The abdominal esophagus is isolated by circumferential dissection and looped with a tape (Fig. 75C.1).

FIGURE 75C.1 Technique of esophageal exposure for devascularization. A tape has been placed around the esophagus, and the vagus nerves have been divided.

The Hassab procedure consists of splenectomy, perihiatal devascularization of the lower esophagus, ligation of the left gastric vessels, devascularization of the proximal half of the stomach, and separation of the stomach from its bed through the abdominal approach (Fig. 75C.2). The points of this technique are 1) perihiatal devascularization of the lower 3 to 4 inches of the esophagus with ligation of any vessels or vagus nerves ascending through the hiatus and diaphragm; 2) ligation of the left gastric artery branches to the stomach, taking care to avoid injury to any accessory left hepatic artery; 3) devascularization of the proximal half of the stomach, taking care to reperitonealize the greater curvature of the stomach to avoid rebleeding; and 4) aggressive pulmonary toilet, which is necessary to avoid basal collapse and chest infection. As an additional step, suction drainage of the splenic bed was suggested by Hassab (1998) to avoid subphrenic infection, although this is probably unnecessary.

FIGURE 75C.2 Diagrammatic representation of the Hassab procedure.

(From Hassab MA, 1967: Gastro-esophageal decongestion and splenectomy in the treatment of esophageal varices in bilharzial cirrhosis: further studies with a report on 355 operations. Surgery 61:170.)

Hassab (1998) suggested that combined sclerotherapy or endoscopic ligation could reduce rebleeding if there were missed obliterated esophageal perforators or if devascularization at operation was incomplete. Nakamura and colleagues (1992) applied endoscopic ultrasonography and reported that GEDS is effective for the extramural connections, but for the intramural connections, combination with sclerotherapy is necessary. Hassab (1998) reported that esophageal transection is unnecessary and instead disconnected the perigastroesophageal portoazygos connections; this is contrary to Sugiura and Futagawa (1973), who preserved them and interrupted gastroesophageal continuity with stapled transection and reanastomosis. Zhang (1991) compared treatment of variceal bleeding treated with GEDS or GEDS plus esophageal transection and found that the simple procedure without transection was effective in maintaining good quality of life with no encephalopathy. He reported maintenance of liver function and an upper gastrointestinal (GI) bleeding rate of 3.1% within 2 years. The addition of esophageal transection did not change the bleeding rate and added more serious complications early after operation.

Sugiura and Modified Sugiura Procedures

The Sugiura procedure is a nonshunting technique aimed at the eradication of esophageal varices. The operation consists of an extensive paraesophagogastric devascularization with esophageal transection and splenectomy through successive thoracic and abdominal incisions. The results obtained by Sugiura and Futagawa (1973, 1984) in Japan were impressive and led some authors to evaluate the efficacy of the operation in Western countries. In the West, the Sugiura procedure was believed to be technically complex and time consuming and was largely ignored or abandoned. Interest was renewed, however, when simplified procedures using an exclusive abdominal approach and stapled transection were described (Peracchia et al, 1980). The original procedure proposed by Sugiura and Futagawa (1973) and the modified procedure described by Ginsberg and colleagues (1982) and Umeyama and colleagues (1983), which is the procedure used routinely use today (Liao et al, 2009), are described.