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      Avaliação intra-operatória da pressão portal e resultados imediatos do tratamento cirúrgico da hipertensão portal em pacientes esquistossomóticos submetidos a desconexão ázigo-portal e esplenectomia Translated title: Intra-operative evaluation of portal pressure and immediate results of surgical treatment of portal hypertension in schistosomotic patients submitted to esophagogastric devascularization with splenectomy

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          Abstract

          RACIONAL: No Brasil a principal causa de hipertensão portal é a esquistossomose mansônica na sua forma hepatoesplênica. Com relação ao seu tratamento, a preferência da maioria dos autores no Brasil recai sobre a desconexão ázigo-portal e esplenectomia geralmente associada à escleroterapia endoscópica pós-operatória para tratamento dessa enfermidade. No entanto, não estão bem estabelecidas as alterações hemodinâmicas portais decorrentes do tratamento cirúrgico da hipertensão portal e sua influência no resultado desse tratamento. OBJETIVOS: Avaliar o impacto imediato da desconexão ázigo-portal e esplenectomia na pressão portal e também os resultados do tratamento cirúrgico da hipertensão portal no que se refere à recidiva hemorrágica e ao calibre das varizes de esôfago. CASUÍSTICA E MÉTODO: Foram estudados 19 pacientes com esquistossomose hepatoesplênica e hipertensão portal, com história de hemorragia digestiva alta por ruptura de varizes esofágicas, com idade média de 37,9 anos. Estes pacientes não haviam sido submetidos a tratamento prévio e foram, eletivamente, tratados cirurgicamente com desconexão ázigo-portal e esplenectomia. Durante a cirurgia, foi avaliada a pressão portal, no início e no final do procedimento, através da cateterização da veia porta por cateter de polietileno introduzido por veia jejunal. Todos os pacientes foram submetidos a endoscopia no pré e no pós-operatório (em torno do 60º dia do pós-operatório) para avaliar, segundo classificação de Palmer, a variação do calibre das varizes esofagianas após a desconexão ázigo-portal e esplenectomia. RESULTADOS: Todos os pacientes apresentaram queda da pressão portal, sendo a média desta queda, após a desconexão ázigo-portal e esplenectomia, de 31,3%. Na avaliação pós-operatória (endoscopia após cerca de 60 dias) houve redução significativa do calibre das varizes esofagianas quando comparadas ao pré-operatório. CONCLUSÃO: A desconexão ázigo-portal e esplenectomia promoveram queda imediata na pressão portal, com conseqüente diminuição do calibre das varizes esofágicas. Observou-se ainda que não é insignificante o risco de mortalidade e complicações graves relacionados a essa técnica.

          Translated abstract

          BACKGROUND: The main cause of portal hypertension in Brazil is the hepato-splenic form of mansonic schistosomiasis and the most employed technique for the surgical approach of this disease is the esophagogastric devascularization with splenectomy, generally associated to postoperative endoscopical esophageal varices sclerotherapy. The hemodynamic alterations after surgical treatment and its possible influence on the outcome are not well established. AIM: To evaluate the immediate impact of esophagogastric devascularization with splenectomy upon portal pressure as well as the results of the surgical treatment on digestive hemorrhage recurrence and on esophageal varices. METHODS: Nineteen patients with mean age of 37.9 years and portal hypertension and previous episodes of digestive hemorrhage caused by esophageal varices rupture due to hepato-splenic schistosomiasis were studied. None of the patients had received any treatment prior to the surgery and underwent to elective esophagogastric devascularization with splenectomy. Portal pressure was assessed at the beginning and at the end of esophagogastric devascularization with splenectomy through portal vein catheterization with a polyethylene catheter introduced through a jejunal branch vein. All patients were submitted to digestive endoscopy before and after the surgery, in order to classify the size of esophageal varices after esophagogastric devascularization with splenectomy according to Palmer’s classification. RESULTS: In all patients the portal pressure had diminished with a mean decrease of 31.3% after esophagogastric devascularization with splenectomy. In the postoperative endoscopic follow-up (1 month), the esophageal varices showed a statistically significant reduction in their size, when compared to the pre-surgical measurements. CONCLUSION: These results have demonstrated that the esophagogastric devascularization with splenectomy promotes immediate decrease in the portal pressure and a consequent reduction in the esophageal varices size. We also observed that the risk of mortality and severe complications related to this technique is not insignificant.

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          Most cited references37

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          A new procedure for the treatment of bleeding esophageal varices by transgastric azygo-portal disconnection.

          Eighty-eight patients with bleeding esophageal varices due to portal hypertension underwent splenectomy and devascularization of the upper half of the stomach and the abdominal esophagus. A Hegar dilator no. 17 was introduced into the esophagus through a gastrotomy. A ring of separated stitches was applied at cardia level, the needle being inserted as far as the metallic surface so as to include the entire wall of the esophagus. Complete interruption of all gastroesophageal vascular communication was thus obtained. After suture of the gastrotomy, a Nissen or Lind's fundoplication was performed. In 62 (70.45%) patients, the immediate postoperative course was uneventful, 21 had non-lethal complications, 13 had abdominal evisceration, six pulmonary complications, four subphrenic abscesses, five patients died, two in hepatic coma, two after reoperation for subphrenic abscess and one after massive hemorrhage due to an acute gastric ulcer. Forty-three patients (48.8%) developed transient ascites which disappeared before they were discharged from the hospital. In thirteen patients (15.6%), the hemorrhage recurred. Of the 32 patients operated one to two years ago, only one rebled. Of the 35 patients operated three to five years ago, nine rebled and three, of the 16 patients operated from five to seven years ago, rebled. With radiological and endoscopic investigations, reduced varices were seen above the suture line, in many cases, passively filled up with blood returning from the azygos vein. Reflux esophagitis was observed in 17 patients who had had a Lortat-Jacob procedure to reduce the His angle; of these, eight rebled later. No gastroesophageal reflux was seen after Nissen or Lind's fundoplication. No fistulae, dysphagia or stenosis was observed.
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            Hepato-splenic form of the schistosomiasis: contributions to the natural history

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              Splenectomy and vasoligation for patients with haematemesis secondary to bilharzial hepatic fibrosis.

              One hundred and thirteen patients with haematemesis secondary to bilharzial hepatic fibrosis had splenectomy and vasoligation. There were 6 deaths in the immediate and 28 in the late postoperative period. The commonest cause of death was recurrent haematemesis followed by hepatic failure. Transient jaundice, ascites and infection were common in the postoperative period. The operation improved the cellular elements of the blood but the 20 per cent incidence of recurrent bleeding is unacceptable.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Journal
                ag
                Arquivos de Gastroenterologia
                Arq. Gastroenterol.
                Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia - IBEPEGE (São Paulo )
                1678-4219
                September 2004
                : 41
                : 3
                : 150-154
                Affiliations
                [1 ] Universidade Federal de Goiás Brazil
                [2 ] Universidade de São Paulo
                Article
                S0004-28032004000300003
                10.1590/S0004-28032004000300003
                15678198
                2ce7e3ff-9113-49b8-8b21-9e5b333f780c

                http://creativecommons.org/licenses/by/4.0/

                History
                Product

                SciELO Brazil

                Self URI (journal page): http://www.scielo.br/scielo.php?script=sci_serial&pid=0004-2803&lng=en
                Categories
                GASTROENTEROLOGY & HEPATOLOGY

                Gastroenterology & Hepatology
                Portal hypertension,Portal pressure,Splenectomy,Hipertensão portal,Pressão na veia porta,Esplenectomia

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