10 YEARS OF EXPERIENCE WITH PATIENTS WITH CHRONIC ACTIVE LIVER-DISEASE VARICEAL BLEEDING - ABLATIVE VERSUS SELECTIVE DECOMPRESSIVE THERAPY

Variceal hemorrhage is an added major threat to survival in patients w ith chronic active liver disease (CALD). The hemodynamic consequences of surgical therapy and the continued activity of the underlying liver disease both contribute to the hepatic dysfunction and determine pati ent survival. Methods. Two hundred and seventy two consecutive cases o f (Child A or B) variceal bleeding with chronic hepatitis were surgica lly treated during a 10-year period. Histologic chronic active hepatit is (CAH) was documented in 160 (59%) patients, whereas chronic persist ent hepatitis (CPH) was evident in 112 (41%). The applied surgical pro cedure was distal splenorenal shunt (DSRS) in 99 (36%) patients, splen ectomy and gastroesophageal devascularization (SGD) in 108 (40%), and splenectomy with left gastric ligation (SLGL) in 65 (24%) patients. Th e preoperative data base obtained on these patients was matched compar ing the three surgical modalities within each pathologic group (p > 0. 05). Results. The operative mortality was low among the patients with CAH (DSRS, 5. 1%; SGD, 4.2%) with no deaths occurring in the CPH group . Among the individuals with CAH, recurrent variceal hemorrhage occurr ed significantly (p < 0.05) more often after SLGL (26%) and SGD (17%) than after DSRS (5%). Sclerotherapy rescued 93% (SGD) and 70% (SLGL) o f the patients with rebleeding. DSRS significantly (p < 0.05) increase d the risk of encephalopathy (28%) compared with SGD (4.2%) and SLGL ( 8%). The morbidity rates were quite low among the patients with CPH wi th no significant (p > 0.05) differences noted when the three surgical modalities were compared. Both groups experienced a significant (p < 0.05) increase in aspartate aminotransferase levels after the three pr ocedures with a significant (p < 0.05) increase in bilirubin level occ urring only after DSRS. The 5-year survival rate for the patients with variceal bleeding with CAH was 76% (DSRS), 73% (SGD), and 88% (SLGL). The leading causes of death were liver failure after DSRS (70%), vari ceal hemorrhage after SLGL (60%), and equally divided between septicem ia (43%) and liver failure (43%) after SGD. The patients with CPH had a better 5-year survival of 89% (DSRS) and 100% (nonshunt operation). Conclusions. These data showed that (1) CALD is common among cases of variceal bleeding; (2) elective surgical treatment of variceal hemorrh age in patients with Child A or B CALD has a low operative mortality; (3) SLGL backed up by sclerotherapy is a better surgical alternative t o either selective shunt or SGD in patients with active hepatitis, and (4) both DSRS and nonshunt operation are equally good surgical option s for patients with CPH.