Sep 18, 1990 - selected using special criteria for shunt operation. .... to elective distal splenorenal shunt operation; about 30% of the sclerotherapy.
HPB Surgery, 1991. Vol. 4, pp 11-25 Reprints available directly from the publisher Photocopying permitted by license only
(C) 1991 Harwood Academic Publishers GmbH Printed in the United Kingdom
LONG TERM VARICEAL SCLEROTHERAPY: IS ENDOSCOPIC SCLEROSIS A UNIQUE THERAPEUTIC APPROACH AND A TRUE ALTERNATIVE TO SURGERY? K-J. PAQUET, A. LAZAR, W. RAMBACH Department of Surgery and Medicine, HEINZ-KALK-Hospital, D-8730 Bad Kissingen, Germany (Received 18 September 1990)
Endoscopic sclerotherapy has been used to control acute variceal haemorrhage which persists despite conservative therapy, prevent recurrent variceal haemorrhage in patients with a history of oesophageal haemorrhage, and to prevent a haemorrhage in patients with oesophageal varices who never bled. In this short paper will cover our personal experience with more than 2000 patients receiving particularly paravariceal endoscopic sclerotherapy of bleeding esophageal varices, and especially present the results of our prospective and controlled randomized trials (Table 1) and underline the thesis that endoscopic sclerotherapy and surgical procedures for patients with portal hypertension are complementary supporting measures or options.
KEY WORDS: Variceal sclerotherapy, surgical procedures, bleeding esophageal varices
Table I Different groups with portal hypertension endoscopic sclerotherapy Group I-Group IV
(95% cirrhotics) treated by mainly paravariceal
Acute an uncontrollable variceal haemorrhage n 653 22 (Group Ia)-232 (Group Ib) 399 Group Ia: Acute variceal haemorrhage- prospective randomized controlled trial (n 22 (43)) Jan. 1, 1980- Jan. 1983 Group Ib: Prospective evaluation (n 232) Jan. 1, 1982- Jan. 1, 1987 Group II Elective treatment of variceal haemorrhage (n-- 1247)
Group
Group IIIa: Prospective treatment of oesophageal varices (n 36 (72)) First prospective randomized controlled trial
(Jan. 1, 1978- Jan. 1, 1980) Group IIIb: Prophylactic treatment of oesophageal varices (n 43 (85)) Second prospective randomized ongoing trial (Sept. 1, 1987- July 1, 1990) Group IV Acute and elective treatment of variceal haemorrhage in babies and children (n 71)
Correspondence to: K.-J. Paquet, Department of Surgery, HEINZ-KALK-Hospital, D-8730 Bad Kissingen, Germany
K-J. PAQUET ET AL.
12
INITIAL MANAGEMENT
Emergency endoscopic sclerotherapy can be performed immediately, at the time of the first diagnostic endoscopy, as preferred and recommended by our group or it can be delayed until the variceal haemorrhage has been controlled by conservative measures with or without the use of a pharmacologic agent or balloon tamponade. The use of immediate sclerotherapy requires a high degree of skill. We recommend its use whenever possible, since it provides instant control of haemorrhage. If these conditions are not fullfilled, we recommend pharmacological therapy or balloon tamponade and transfer of the patient to a specialist center. Table 2 varices
Results of controlled trials of emergency injection sclerotherapy of bleeding esophageal
Method of emergency injection sclerotherapy i.v., p.v.
Haemostasis
Survival rate
(immediate) (%) (sc/c)
after 1 year
Reference
No.
Paquet and Feussner
21
Polidocanol 0.5 + 1% p.v.
90 (55)
79
44
Tetradecylsulfate 3% i.v.
85 (47)
62 (54)
of patients
(%)
(38)
1985
Larson et al. 1986
Endoscopic Sclerotherapy (22) 75
CUMULATIVE SURVIVAL
5O
Esophageal Tarnponade (21)
(%)
25
0.1 0
2
FOLLOW- UP (years) Figure 1 Cumulative survival curve using the method of KAPLAN-MEIER for the controlled randomized trial comparing the SENGSTAKEN-BLAKEMORE tube with emergency endoscopic sclerother-
apy during emergency.
13
LONG-TERM VARICEAL SCLEROTHERAPY
Table 3 Aetiology of the intra- and prehepatic block of prospective evaluation of immediate endoscopic injection sclerosis (IES) (n 232; Jan. 1, 1982- Jan. 1, 1987)
Number
Percent
A. Underlying disease 138 47 17 11 2
Alcoholic cirrhosis Posthepatitic cirrhosis Cirrhosis of unknown aetiology Primary biliary cirrhosis Extrahepatic bile duct atresia Secondary biliary cirrhosis Liver cirrhosis (total)
216 9 5
Prehepatic block Liver fibrosis Schistosomiasis Mucoviscidosis Non-cirrhotic patients
(total)
16
B. Classification CHILD-PUGH A* CHILD-PUGH B CHILD-PUGH C
53 70 109 232
Total Non-cirrhotic patients
classified
CHILD-PUGH A
Blon
Figure 2 Schematic presentation of the use of the LINTON-NACHLAS tube.
59.5 20.3 7.3 4.7 0.9 0.4 93.1 3.9 2.2 0.4 0.4 6.9 23 30 47 100
K-J. PAQUET ET AL.
14
After sclerotherapy has controlled the haemorrhage, we support the view that at least two to four additional sessions are necessary to obliterate the varices by intravariceal or combined injection or to protect them by scar tissue by paravariceal injections. In two controlled trials one by our group it was demonstrated that emergency injection sclerotherapy significantly improved haemostastis and survival in comparison with other conservative measures (Table 2) 1’2 The cumulative survival curve using the method of KAPLAN-MEIER (Figure 1) demonstrates a statistically significant difference in favour of sclerotherapy (IEIS) after six months (p
