LONG-TERM RESULTS OF RADICAL ESOPHAGOGASTRECTOMY FOR BLEEDING VARICESDUE TO UNSHUNTABLE EXTRAHEPATIC PORTAL-HYPERTENSION

This report describes the long-term results of one-stage total gastrec tomy and distal two-thirds esophagectomy, with reconstruction by esoph agojejunostomy (16 Roux-en-Y; 2 interposition), in 18 adult patients w ith recurrent variceal hemorrhage due to unshuntable extrahepatic port al hypertension (EHPH) from occlusion of all major tributaries of the portal venous system. The etiology of portal venous occlusion was unkn own in 11 patients, abdominal trauma in 3, peritonitis in 3, and throm botic coagulopathy in 1. Almost half of the patients had their first e pisode of bleeding in childhood, and 83% experienced bleeding before 4 0 years of age. The severity of the problem was reflected by frequent previous bleeding episodes (mean: 12.8, range: 4 to 21), a large cumul ative requirement for blood transfusions (mean: 129 units, range: 28 t o 247 units), repeated, costly hospital admissions (mean: 15, range: 4 to 24), and numerous previous unsuccessful operations (mean: 4.4, ran ge: 1 to 14). Blood transfusions transmitted serum hepatitis to three patients and AIDS to one, for an incidence of 22%. Bleeding recurred a fter repetitive endoscopic sclerotherapy in 10 patients and after vari ous operations in 16 (failed portal-systemic shunts in 9, splenectomy in 16, devascularization procedures in 13). All patients had large eso phageal and gastric varices on endoscopy, normal liver function, and w idespread portal venous occlusion on visceral angiography. Radical eso phagogastrectomy was usually a long and arduous operation because of d ense adhesions, extensive collateral veins, and a scarred, contracted bowel mesentery due to previous operations. Ah patients survived the o peration and are currently alive. No patient has had recurrent bleedin g during 1 to 26 years of follow-up (mean: 13.9 years, 7 or more years in 14 patients). Quality of life has been good. It is concluded that radical esophagogastrectomy is the only effective treatment of unshunt able EHPH and that the operation should be performed promptly when thi s disease, which is associated with high mortality, high morbidity, an d high costs, is diagnosed.