Bleeding due to esophagogastric varices is the major cause of death in patients with hepatic disease. The most frequent treatment of these varices in elective conditions are based in mechanisms that interrupt the connection between splancnic and systemic venous bed. Surgical procedures are divided into portosystemic shunts (selective and non-selective) and disconnection. In portasystemic shunt, the purpose is to derive the splancnic flux, diminishing the esophagogastric varices and prevent re-bleeding. But literature is controversial about the index of re-bleeding and hepatic encephalophaty after proximal or distal splenorenal shunts. We performed this study to evaluate the evolution of esophagogastric varices after proximal splenorenal (PS) or distal splenorenal (DS) shunt. Postoperative outcome of oesophageal and gastric varices were retrospectively evaluated in forty patients submitted to one of two following procedures: A (n=27), distal splenorenal shunt (DS), and B (n=13), proximal splenorenal shunt (PS). All patients had portal hypertension with oesophageal or gastric varices due to schistosomiasis, and a pre-operative history of variceal bleeding. Patients were submitted to the surgical procedure according to personal preference of the assistant surgeon, and preoperatively and after endoscopy was performed six, twelve and eighteen months after surgery. Endoscopy data were collected and compared bet were the two groups according the presence or absence of gastric and oesophageal varices in pre and postoperative period. Results showed no rebleeding in this group, and no of encephalopathy. The incidence of oesophageal varices was 100% in pre-operative period in two groups. There was a significative decrease in oesophageal varices after six (40%, p = 0,0002), twelve (30%, p = 0,003) and eighteen months (27.5%, p = 0,003). In the six months period, the incidence of oesophageal varices was higher in DS group, when compared with PS group (51.9% vs. 15.4%, p = 0,03). In twelve and eighteen months periods, there was no difference among these two groups in relation to the presence of oesophageal varices (twelve months, 37% vs. 15.4%; eighteen months, 25.9 vs. 30.8%). In relation to the gastric varices, there was an higher incidence of this type of varices in PS group in preoperative period when compared with DS group (26% vs. 69.2%, p = 0,005). However, in the six months period there was no difference between the groups (16,6% vs. 0%), which is also observed in twelve months period (33.3% vs. 0%) or in the eighteen months period (33.3% vs. 11.1%). The overall incidence of gastric varices was 37.5%, with a significative reduction in the six month period (2.5%, p=0.005), but with an increase in twelve month period (5%, p=0.00001) and eighteen month period (7.5%, p=0.02). In conclusion we observed both surgical techniques make similar results in relation to resolution of oesophageal and gastric varices after 18 months, but the results suggest that the decrease in oesophageal varices in both groups is accompanied by an increase in gastric varices, probably due to overture of new collateral vessels in cases of persistence of a higher portal pressure or splenorenal shunt failure.
Portal hipertension; Schistosomiasis; Splenorenal shunt
