Journal of the American College of Surgeons
Volume 209, Issue 1 , Pages 25-40 , July 2009

Randomized Trial of Emergency Endoscopic Sclerotherapy Versus Emergency Portacaval Shunt for Acutely Bleeding Esophageal Varices in Cirrhosis

  • Marshall J. Orloff, MD, FACS

      Affiliations

    • Department of Surgery, University of California, San Diego Medical Center, San Diego, CA
    • Corresponding Author InformationCorrespondence address: Marshall J Orloff, MD, UCSD Medical Center, 200 West Arbor Dr, San Diego, CA 92103–8999
  • ,
  • Jon I. Isenberg, MD

      Affiliations

    • Department of Medicine/Gastroenterology, University of California, San Diego Medical Center, San Diego, CA
  • ,
  • Henry O. Wheeler, MD

      Affiliations

    • Department of Medicine/Gastroenterology, University of California, San Diego Medical Center, San Diego, CA
  • ,
  • Kevin S. Haynes, MD

      Affiliations

    • Department of Medicine/Gastroenterology, University of California, San Diego Medical Center, San Diego, CA
  • ,
  • Horacio Jinich-Brook, MD

      Affiliations

    • Department of Medicine/Gastroenterology, University of California, San Diego Medical Center, San Diego, CA
  • ,
  • Roderick Rapier, MD

      Affiliations

    • Department of Medicine/Gastroenterology, University of California, San Diego Medical Center, San Diego, CA
  • ,
  • Florin Vaida, PhD

      Affiliations

    • Department of Family and Preventive Medicine/Biostatistics and Bioinformatics, University of California, San Diego Medical Center, San Diego, CA
  • ,
  • Robert J. Hye, MD, FACS

      Affiliations

    • Department of Surgery, University of California, San Diego Medical Center, San Diego, CA

Received 16 December 2008 ,Revised 13 February 2009 ,Accepted 16 February 2009.

References 

  1. Graham DY, Smith H. The course of patients after variceal hemorrhage. Gastroenterology. 1981;80:800–809
  2. Smith JL, Graham DY. Variceal hemorrhage: a critical evaluation of survival analysis. Gastroenterology. 1982;82:968–973
  3. Burroughs AK, Mezzanotte G, Phillips A, et al. Cirrhotics with variceal hemorrhage: the importance of the time interval between admission and the start of analysis for survival and rebleeding rates. Hepatology. 1969;9:801–807
  4. Bornman PC, Krige JE, Terblanche J. Management of oesophageal varices. Lancet. 1994;353:1079–1084
  5. Khan S, Tudur Smith C, Williamson P, Sutton R. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No. CD000553. DOI: 10.1002/14651858. CD000553. Pub 2.
  6. Orloff MJ, Duguay LR, Kosta LD. Criteria for selection of patients for emergency portacaval shunt. Am J Surg. 1977;134:146–152
  7. Mikkelsen WP. Therapeutic portacaval shunt (Preliminary data on controlled trial and morbid effects of acute hyaline necrosis). Arch Surg. 1974;108:302–305
  8. Terblanche J, Burroughs AK, Hobbs KEF. Controversies in the management of bleeding oesophageal varices. N Engl J Med. 1989;320:1393–1398
  9. D'Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology. 1995;22:332–354
  10. Cello P, Brendell JH, Crass RA, et al. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and variceal hemorrhage. N Engl J Med. 1984;311:1589–1594
  11. Cello JP, Grendell JH, Crass RA, et al. Endoscopic sclerotherapy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage (Long-term follow-up). N Engl J Med. 1987;316:11–15
  12. Orloff MJ. Emergency portacaval shunt: a comparative study of shunt, varix ligation, and nonsurgical treatment of bleeding esophageal varices in unselected patients with cirrhosis. Ann Surg. 1967;166:456–478
  13. Orloff MJ, Bell RH, Hyde PV, Skovolocki WP. Long-term results of emergency portacaval shunt for bleeding esophageal varices in unselected patients with alcohol cirrhosis. Ann Surg. 1980;192:325–340
  14. Orloff MJ, Orloff MS, Rambotti M, Girard B. Is portal-systemic shunt worthwhile in Child's class C cirrhosis: Long-term results of emergency shunt in 94 patients with bleeding varices. Ann Surg. 1992;216:256–268
  15. Orloff MJ, Bell RH, Orloff MS, et al. Prospective randomized trial of emergency portacaval shunt and emergency medical therapy in unselected cirrhotic patients with bleeding varices. Hepatology. 1994;20:863–872
  16. Orloff MJ, Orloff MS, Orloff SL, et al. Three decades of experience with emergency portacaval shunt for acutely bleeding esophageal varices in 400 unselected patients with cirrhosis of the liver. J Am Coll Surg. 1995;180:257–272
  17. Moher D, Schulz KF, Altman D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. JAMA. 2001;285:1987–1991
  18. Altman DG, Schulz KF, Moher D, et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134:663–694
  19. Orloff MJ, Orloff SL, Orloff MS. Portacaval shunts: side-to-side and end-to-side. In:  Clavien P-A,  Saar MG,  Fong Y editor. Atlas of upper gastrointestinal and hepato-pancreato-biliary surgery. Berlin Heidelberg: Springer-Verlag; 2007;p. 687–702
  20. Conn HO, Liberthal MM. The hepatic coma syndromes and lactulose. Baltimore: Williams & Wilkins; 1978;
  21. Child CG, Turcotte JG. Surgery and portal hypertension. In:  Child CG editors. The liver and portal hypertension. Philadelphia: WB Saunders; 1964;p. 1–85
  22. Campbell DP, Parker DE, Anagnostopoulos CE. Survival prediction in portacaval shunt: a computerized statistical analysis. Am J Surg. 1973;126:748–751
  23. Korula J, Yelin A, Yamada S, et al. A prospective randomized controlled comparison of chronic endoscopic variceal sclerotherapy and portalsystemic shunt for variceal hemorrhage in Child's class A cirrhotics: a preliminary report. Gastroenterology. 1987;92:1745
  24. Planas R, Boix J, Broggi M, et al. Portacaval shunt versus endoscopic sclerotherapy in the elective treatment of variceal hemorrhage. Gastroenterology. 1991;100:1078–1086
  25. Isaksson B, Jeppsson B, Gengtsson F, et al. Mesocaval shunt or repeated sclerotherapy: effects on rebleeding and encephalopathy—a randomized trial. Surgery. 1995;117:498–504
  26. Henderson JM, Kutner MH, Millikan WJ, et al. Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis, a prospective randomized trial. Ann Intern Med. 1990;112:262–269
  27. Rikkers LF, Burnett DA, Volentine GD, et al. Shunt surgery versus endoscopic sclerotherapy for long-term treatment of variceal bleeding (Early results of a randomized trial). Ann Surg. 1987;206:261–271
  28. Rikkers LF, Jin G, Burnett DA, et al. Shunt surgery versus endoscopic sclerotherapy for variceal hemorrhage: late results of a randomized trial. Am J Surg. 1993;165:27–32
  29. Terés J, Bordas JM, Bravo D, et al. Sclerotherapy vs. distal splenorenal shunt in the elective treatment of variceal hemorrhage: a randomized controlled trial. Hepatology. 1987;7:430–436
  30. Spina GP, Santambrogrio R, Opocher E, et al. Distal splenorenal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding (First stage of a randomized, controlled trial). Ann Surg. 1990;211:178–186
  31. Krige JEJ, Katze UK, Bornman UC, et al. Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices. Ann Surg. 2006;244:764–770
  32. Krige JE, Shaw JM, Bornman PC. The evolving role of endoscopic treatment of esophageal varices. Wld J Surg. 2005;29:966–973
  33. Sorbi D, Gostout CJ, Peura D, et al. An assessment of the management of acute bleeding varices: a multicenter prospective member-based study. Am J Gastroenterol. 2003;98:2424–2434
  34. Gralnek IM, Jensen DM, Kovacs TO, et al. The economic impact of esophageal variceal hemorrhage: cost-effectiveness implications of endoscopic therapy. Hepatology. 1999;29:44–50
  35. Villeneuve J-P, Pomier-Layrargues G, Duguay L, et al. Emergency portacaval shunt for variceal hemorrhage (A prospective study). Ann Surg. 1987;206:48–52
  36. Soutter DI, Langer B, Taylor BR, Greig P. Emergency portosystemic shunting in cirrhotics with bleeding varices––-a comparison of portacaval and mesocaval shunts. HPB Surg. 1989;1:107–118
  37. Spina GP, Santambrogio R, Opocher E, et al. Emergency portosystemic shunt in patients with variceal bleeding. Surg Gynecol Obstet. 1990;171:456–464
  38. Borowsky SA, Stroma S, Lott E. Continued heavy drinking and survival in alcoholic cirrhotics. Gastroenterology. 1981;80:1405–1409
  39. Powell WJ, Klatskin G. Duration of survival in patients with Laennec's cirrhosis. Am J Med. 1968;98:695–716
  40. Capone RR, Buhac I, Kohberg RC, Balint JA. Resistant ascites in alcoholic liver cirrhosis. Dig Dis Sci. 1978;23:867–871
  41. Grace ND, Conn HO, Resnick RH, et al. Distal splenorenal versus portal systemic shunts after haemorrhage from varices: a randomized controlled trial. Hepatology. 1988;8:1475–1481
  42. Terpstra OT, Ausema B, Bruining HA, et al. Late results of mesocaval interposition shunting for bleeding oesophageal varices. Br J Surg. 1987;74:787–790
  43. Smith RB, Warren WD, Salam AA, et al. Dacron interposition shunts for portal hypertension (An analysis of morbidity correlates). Ann Surg. 1980;192:9–17
  44. Fletcher MS, Dawson JL, Williams R. Long term follow-up of interposition mesocaval shunting in portal hypertension. Br J Surg. 1981;68:485–487
  45. Helton WS, Belshaw A, Althaus S, et al. Critical appraisal of the angiographic portacaval shunt (TIPS). Am J Surg. 1993;165:566–571
  46. LaBerge JM. Transjugular intrahepatic portosystemic shunt–-role in treating intractable variceal bleeding, ascites, and hepatic hydrothorax. Clin Liver Dis. 2006;10:583–598
  47. Bayer TD, Haskal ZJ. The role of transjugular intrahepatic shunt in the management of portal hypertension. Hepatology. 2005;41:386–400
  48. Sanyal AJ, Freedman AM, Shiftman ML, et al. Portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt: results of a prospective controlled study. Hepatology. 1994;20:46–55
  49. Rössle M, Haag K, Ochs A, et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med. 1994;330:165–171
  50. Jalan R, Elton RA, Redhead DN, et al. Analysis of prognostic variables in the prediction of mortality, shunt failure, variceal rebleeding and encephalopathy following the transjugular intrahepatic portosystemic stent-shunt for variceal haemorrhage. J Hepatol. 1995;23:123–128
  51. Garcia N, Sanyal AJ. Portal hypertension. Clin Liver Dis. 2001;5:1–26
  52. Klempnauer J, Schrem H. Review: surgical shunts and encephalopathy. Metabolic Brain Dis. 2001;16:21–25

 Disclosure Information: Nothing to disclose.

 Supported by grant 1R01 DK41920 from the National Institutes of Health and a grant from the Surgical Education and Research Foundation.

PII: S1072-7515(09)00278-6

doi: 10.1016/j.jamcollsurg.2009.02.059

Journal of the American College of Surgeons
Volume 209, Issue 1 , Pages 25-40 , July 2009