survival and quality of life after portal blood flow preserving procedures in patients with portal...

Survival and Quality of Life After Portal Blood Flow Preserving Procedures in Patients With

Portal Hypertension and Liver Cirrhosis Hector Orozco, MD, Miguel Angel Mercado, MD, Takeshi Takahashi, MD, Gilberto Rojas, MD,

Jorge Hem~indez, MD, Manuel Tielve, MD, Tlalpan, Mexico

Between 1 9 7 9 and 1991 , 156 patients with histologically proven liver cirrhosis, good liver function, and bleeding portal hypertension un- derwent operation with portal blood flow preserving procedures (selective shunts: 101; Sugiura-Futagawa: 55). Long-term results of the procedures and the quality of life of the 145 patients who survived the operation were studied. During the observation period (range 3 to 156 months), 2 8 patients died. The main causes of death were liver failure and hep- atoma. Twenty-three patients were lost for follow-up. Twenty-six patients (18%) developed 1 or more encephalopathic episodes. Four patients (3%) experienced rebleeding. One hundred eight patients (74%) had a good quality of life, and 26 (18%) had a poor quality of life. Eleven (15%) of 73 patients with a history of alcoholism continued drinking. Five-year survival for the selective shunt group was 81% and for the devascularization group was 83%. In 81% of the patients, portal blood flow was maintained. It is concluded that both procedures are effective in the long-term. Most patients are able to rehabilitate from the use of alcohol, and most of them have a good quality of life. For patients with good liver function (whose main problem is bleeding), surgery is the best choice of treatment.

F 'or patients with good liver function and portal hypertension, surgery is the treatment of choice for long-term

control of variceal bleeding. In this subset of patients, the superiority of surgical treatment to prevent the recurrence of bleeding compared with other treatment modalities is clear. 1.2 Among the variety of surgical options available for treatment, the procedures that maintain portal blood flow are preferred; of these, two are most commonly performed. The first one is the distal splenorenal shunt (DSRS), 3 and, in those patients in whom it is not possible to perform a selective shunt, mainly because of anatomic considerations,

From the Portal Hypertension Clinic (HO,MAM,'IT,GR) and Radiology Deparnnent (JH,MT), Instituto Nacional de la Nutricion, Tlalpan, Mexico.

Requests for reprints should be addressed to Hector Orozco, MD, Portal Hypertension Clinic, Instituto Nacional de la Nutricion, "Salvador Zubiran," Vasco de Quiroga 15, Tlalpan 14000, Mexico, D.F., Mexico.

Manuscript submitted July 10, 1992, and accepted in revised form March 11, 1993.

a devascularizating procedure (Sugiura-Futagawa) 4 is done. Our experience with these kinds of operations has shown low rates of rebleeding and encephalopathy, as well as good long-term survival. 5-7 The main advantage of the two procedures is the preservation of portal blood flow. The Warren shunt diverts the dangerous esophagogastric area, and the Sugiura-Futagawa operation is undertaken for devascularization of the area.

Thirteen years ago, we published the survival rate and the quality of life of the first 55 patients with liver cirrhosis and portal hypertension after surgical treatment with portal blood flow preserving procedures. 8

Patients with liver cirrhosis and portal hypertension represent a special kind of population in the treatment of variceal bleeding. Progression of liver disease is the rule in some patients and not enough information is available concerning long-term results and quality of life.

The present study evaluates long-term survival and quality of life in patients with liver cirrhosis, good liver function, and bleeding portal hypertension, treated with portal blood flow preserving operations.

P A T I E N T S A N D METHODS Patients undergoing operation because of bleeding por-

tal hypertension are carefully evaluated preoperatively. Only patients with good liver function are selected for surgical treatment (Child's classification A or B). Patients with liver disease categorized as Child's C are routinely excluded for operation and are mainly treated with phar- macotherapy and/or sclerotherapy. In Table I, the parameters and limits for Child's classification are listed. If a patient exceeds one or more of these parameters, he or she

TABLE I Selection of Patients for Portal Hypertension Surgery

Adequate cardiopulmonary function Exclusion of hepatic malignancies

Alpha fetoprotein determination Ultrasound and/or computed tomography Angiography if necessary

Child's classification Good nutritional status No encephalopathy Total bilirubin less than 2 mg/dL Seric albumin more than 3 g/dL No ascites Prothrombin time no longer than 2 seconds from control Absence of hepatic disease activity

Biopsy if necessary

10 THE AMERICAN JOURNAL OF SURGERY VOLUME 168 JULY 1994

PORTAL BLOOD FLOW PRESERVING PROCEDURE~OROZCO ET AL

is routinely excluded for operation. Patients with histologically proven liver cirrhosis operated on between 1979 and 1991 with portal blood flow preserving procedures were included in this study, and their actual status was evaluated, as well as their quality of life. The portal blood flow preserving procedures performed were the DSRS and the esophagogastric devascularization with esopaghic transection (Sugiura-Futagawa). In Figure 1, the criteria for the selection of the operations are listed. The results obtained by our group with each procedure have been published elsewhere. 5,6 One hundred fifty-six patients with histologically proven liver cirrhosis were included.

The general data of these 156 patients who were divided into 2 groups (shunt and devascularization) are shown in Table H. No demographic differences were found between the Warren group (n = 101) and the Sugiura-Futagawa group (n = 55). Both groups were comparable, excepting for the anatomic conditions that conditioned the decision for the kind of operation. The operative decision was made according to angiographic results. If adequate vessels were found, a shunt was performed. If inadequate vessels were found (thrombosis, small diameter, anatomical disposition), a Sugiura-Futagawa procedure was done. A survival curve was constructed for both groups according to the Kaplan- Meier 9 method (Figure 2). Rebleeding and encephalopathy were also recorded, and quality of life was judged according to the following parameters: good: the patient is able to return to his or her usual activities, with no physi- cian or hospital dependence; regular: inability to return to his or her usual activities, and the patient requires hospital control and takes medication (diuretics, anti-encephalopatic measures, etc.); bad: incapacitated patients with frequent hospitalizations (due to re-bleeding, encephalopathy, liquid retention) and total hospital dependence.

Parameters were qualified by independent observers and not related to the surgeons who performed the operations (HO, MAM). All patients were evaluated at the hospital at different intervals and are cited as ambulatory patients for follow-up. Rebleeding was defined as the presence of hematemesis and/or melena with endoscopic evidence of no other causes of bleeding other than bleeding of the esophagogastric area that caused hemodynamic descom- pensations (required management with intravenous solu- tion, plasma, and blood). Postoperative encephalopathy was determined clinically with number connections tests. In some specific conditions, and not on a routine basis, an electroencephalogram was obtained. Postoperative angiography was performed in the first 2 postoperative weeks and later every 12 months in order to evaluate the status of the shunt (when performed) and the angiographic char- a~teristics of the portal veins (diameter, flow direction and capillary distribution of portal blood flow).

SELECTlrON OF THE OPERATION

FULFILLED ¢RITEII|A OF TABLE 1

I VEI4OU$ ANGI~EAPNY (CELIAC ADD LEFT RENAL)

I I PATENT 14i[lIO, SPLERO, PORTAL ADEGUATB DRAINAGE AND ADEQUATE

SYSTEJ4 ANATOHICAL POSITION OF LEFT I RENAL VEIN I

NO YSS No I I I

SUGXUNA*FUTNGAkUt SELECTIVE S H U N T SUG|UNA-FUTAGANA

Figure 1. Criteria for selection of operation.

TABLE II General Data*

DSRS Sugiure- group Futagawa group Total

Patients 94 51 145 Age (y) 50.8 (24-76) 49 (20-76) Male/female 59/35 33/18 Child's A 88 31 Child's B 6 20 Type of cirrhosis

Alcoholic 50 23 73 Hepatitis B 5 0 5

Primary biliary 1 3 4 cirrhosis

Hepatitis C 0 1 1 Post necrotic 38 24 62 * Excluding patients with operative mortality. DSRS = distal splerorenal shunt.

RESULTS All 156 patients had a liver biopsy with histologically

proven liver cirrhosis. All patients had a history of bleeding varices, and all of them were treated surgically with a portal blood flow preserving procedure (101 distal splenorenal shunt [Warren] and 55 devascularizating procedures [Sugiura-Futagawa]). In 73 patients, cirrhosis was secondary to alcoholism, and the remaining patients had previously had hepatitis. The mean age was 50.2 years (range 20 to 76 years). The Child's classification was as follows: 125 Child's A patients, 31 Child's B. The mean follow-up was 57.5 months (range 3 to 156 months). Twenty-three patients (15%) were lost for follow-up. General data and the postoperative month in which they were lost for follow-up are shown in Table 111. Some of these patients who had rebleeding and encephalopathy and some who were to lost to follow-up but who had some long-term follow-up were included in the analysis.

TABLE III Characteristics of PaUents Lost for Follow-up

Selective shunt Devascularization with transection

Encephalopathy 5 (7 months, 16,48,72,156) 4 (2 months, 6, 52, 63) Rebleeding 1 (18 months) 0 No rebleeding 8 (3 months, 5, 7, 15, 22, 24, 26, 48) 5 (1 month, 2, 28, 35, 40) Total 14 9

THE AMERICAN JOURNAL OF SURGERY VOLUME 168 JULY 1994 11

PORTAL BLOOD FLOW PRESERVING PROCEDURES/OROZCO ET AL

S U R V I V A L

I00-

% 50- 8 F o-I-÷ ÷ o

OSRSc

M O N T H S Figure 2. Survival curve according to Kaplan-Meier. DSRS = distal splenorenal shunt SF = Sugiura-Futagawa

TABLE IV Causes of Death

DSRS Group Sugiura-Futagawa Group

Liver failure 15 Liver failure 5 Hepatocarcinoma 3 Hepatocarcinoma 1 Subdural hematoma 1 Primary peritonitis 1 Renal carcinoma 1 Myocardial infarction 1

DSRS = distal splenorenal shunt.

Operative Mortality Operative mortality was defined as occurring from 0 to

30 days after surgery. In the selective shunt group, 7 of 101 patients (7%) died. In the Sugiura-Futagawa group, 4 of 55 (7%) died.

Late Mortality During the observation period (mean 50.8 months), a to-

tal of 28 of 145 patients died. The main cause of death was liver failure followed by liver cancer. Causes of death are summarized in Table IV.

Encephalopathy Patients who died during the operation were excluded from

this analysis. Since some of the patients lost to follow-up had encephalopathy, they were included in the analysis (Table HI). Of the 145 patients analyzed, 26 (18%) developed 1 or more encephalopathic episodes. Seventeen patients were in the DSRS group, and the remaining 9 were in the Sugiura- Futagawa group. Nine patients (7 treated by means of a DSRS and 2 with the Sugiura-Futagawa procedure) required hospitalization. Of the 9 patients with severe encephalopathy, 6 died of liver failure during the observation period. Seventeen patients were treated as outpatients, with a low protein diet and lactose enemas, with a good response.

Rebleeding Five patients experienced rebleeding (3%), 3 were treated

with a DSRS (1 lost was to follow-up at the 19th month) and the remaining 2 with the Sugiura procedure. These pa-

tients were considered to have had a failure of surgical treatment. Some of the patients who died of liver failure had gastrointestinal bleeding as a part of the terminate event. These patients were excluded from the analysis of rebleeding.

Portal Vein Alterations Preoperatively, in 131 patients, patency of the meso-

splenoportal system was shown. Each patient was anglo- graphically controlled each year after the routine postoperative angiography. Even the 28 patients who died during the observation period were angiographicaUy evaluated, as well as the 23 patients lost to follow-up, until it was impossible to undertake the angiography. In 18 patients (19%) treated with DSRS, postoperative alteration of the portal vein was found. Eight patients had portal thrombosis, and another 10 patients experienced a reduction in diameter. Eight of these patients were classified as having a pancreatic syphon (8.5%). In four patients in the Sugiura- Futagawa group (11%), postoperative portal vein alterations were observed.

Quality of Life According to the aforementioned criteria, 108 patients

(74%) had a good quality of life: 71 in the DSRS group (75%), and 37 in the Sugiura-Futagawa group (72%). Thirteen patients (9%) were considered to have a regular quality of life (9.5% in the DSRS group and 9% in the Sugiura group), and 26 (18%) patients had a bad quality of life (14 in the DSRS [14.8%] and 12 in the Sugiura- Futagawa group [19%]).

Alcohol Consumption Of the 73 patients with a history of alcoholism, 11 (15%)

(8 in the DSRS groups and 3 in the Sugiura group) continued drinking after the surgical procedure.

Survival In the DSRS group, survival at 1 year was 94%, and at

5 years 81%. In the Sugiura-Futagawa group, survival was 89% at 1 year and 83% at 5 years. (Figure 2)

COMMENTS Surgical treatment remains the best choice for patients with

a history of bleeding varices. The subset of patients who ob- tain the most benefit from this therapy are those with good liver function who undergo operation in an elective fashion. In this type of patient, the challenging event that can reduce life expectancy is variceal bleeding. The surgical procedures are well tolerated in most cases, with low rates of mortality, rebleeding, and encephalopathy. Portal flow preserving procedures are now the most widely used operations, with selective shunts as the f'trst choice and a devascularizating procedure (Sugiura-Futagawa) for those patients in whom a shunt is not feasible. In our experience, both procedures have shown comparable good results, t° The Sugiura-Futagawa procedure has been described elsewhere and, in 85% of the patients, must be done in two surgical stages.

Patients with liver cirrhosis represent a special population, in whom surgical treatment has been challenged as the fh'st choice. Some studies have shown no benefit in long-term survival when compared with other kind of therapies, and

19. THE AMERICAN JOURNAL OF SURGERY VOLUME 168 JULY 1994


it is thought that only the causes of death are changed (liver failure instead of bleeding). Nevertheless, patients with well- compensated liver cirrhosis have good life expectancy but for those patients who develop hemorrhagic portal hypertension, variceal bleeding can be life threatening. The pur- pose of this study was to investigate the quality of life and status of liver function in long-term survivors treated by means of portal blood flow preserving procedures.

Effectiveness of the Procedures Both procedures are effective in preventing variceal re-

bleeding. The long-term rebleeding rate is low (less than 5%), and operative mortality and postoperative complica- tions are equally comparable. There is no doubt that surgery has a low rebleeding rate when compared with other forms of therapy. 1'2 We have obtained good results with the Sugiura-Futagawa operations. 6'7 This is in part due to a strict patient selection (only low risk). We perform the operation in two stages in most of the cases and follow some of the technical aspects described by Sugiura and Futagawa. We do some modifications but the principles of the procedure are maintained.

Portal Blood Flow Both procedures preserve portal flow, at least in the early

postoperative period. In 19% of the patients treated by means of DSRS and in 11% of the patients treated by means of the Sugiura-Futagawa operation, changes in the portal vein were shown. It is difficult to determine if these patients were going to develop such alterations without the operation, but it is possible that the operation produced these changes. Nevertheless, liver function remained high in most of the patients. Some of the patients with portal vein thrombosis in the postoperative period have remark- ably good liver function, meaning that in these cases portal blood flows into the liver through collateral veins. It is difficult, if not impossible, to predict which patient is going to develop good collateral veins to the liver.

Encephalopathy Patients with well-compensated liver cirrhosis associated

with portal blood flow preserving procedures have a low encephalopathy rate (12%). Whether or not these patients with good liver function were going to develop encephalopathy spontaneously is an unanswered question, but obviously the influence of the operation on liver function in some cases cannot be denied (for instance, the pancreatic syphon).

Mortality As expected, liver failure was the main cause of death in

"the long-term follow-up (20 cases) followed by development of hepatic neoplasm (4 cases). Other causes of death (excepting the cases of primary peritonitis) were not related to the liver disease. As is the case with encephalopathy, the influence of the operation on mortality can not be discounted.

Quality of Life The ability of the patient to work and to have a normal

lifestyle was found to be excellent or good in more than 70% of the population studied. Only 26 of the 145 cases

had a bad quality of life, meaning that these patients had to have frequent hospital visits, were unable to work, and/or to perform their normal activities.

The question of quality of life has implications regard- ing other forms of therapy for portal hypertension, ie, liver transplantation. II These data show that, for patients in whom bleeding portal hypertension is the main problem and who have normal (or near normal) liver function, surgical treatment remains the first choice. Most of these patients, as shown here, have a good quality of life after an average of 5 years of follow-up, without the problems related to immune suppression. We did not calculate here the cost for the treatment of these patients, which is cer- tainly lower compared with those treated with a liver transplant. The costs of a shunt operation in our institution are significantly lower than a liver transplant. Patients considered for liver transplant in our hospital are those with liver failure and/or rapid progressive liver disease. In those cases, variceal bleeding is not the main problem.

In 18% of the cases, postoperative quality of life was not good. These were patients who had a good liver function prior to the operation and a history of life-threatening up- per gastrointestinal bleeding secondary to portal hypertension. That is why they were selected for operation. Most of these patients are now good candidates for liver transplantation, because their liver function deteriorated after the operation. The influence of the operative procedure on the development of liver failure is still to be determined, since we do not have a comparative group to assess the hepatic functional behavior without surgery. It is very difficult (if not impossible) to predict which patient is going to develop postoperative hepatic failure.

Alcoholism Of the 145 patients, 73 had alcoholic liver disease, and

only 11 patients continued drinking, meaning that the chance of postoperative rehabilitation is very high for this subset of patients. Rehabilitation after portal hypertension operation is good, as well as after liver transplantation. 12

In many centers, sclerotherapy is the treatment choice, and if that falls, surgical rescue is consideredJ 3 We agree with these procedures, except for in patients with good liver function. In this subset of patients, low mortality and good postoperative results are to be expected. There is no reason to risk rebleeding (at a relatively high rate of 30% to 50%), 14 and then take the patient to the operating room with a worse Child's classification.

In our experience, results of survival after surgical rescue are affected by two facts: some patients die as a con- sequence of rebleeding, and most importantly, liver function at the time of rescue is not always as good as it was before the bleeding. In our experience, after rebleeding, most patients who are Child's A classification experience a change in their functional class. (mostly to class C). That is why we strongly recommend that those patients who have adequate liver function be treated primarily with a surgical portal flow preserving procedure

It is concluded that surgery remains the first choice for treatment of patients with well-compensated liver cirrhosis and a history of variceal bleeding. Long-term results are very encouraging with a low encephalopathy and re-

THE AMERICAN JOURNAL OF SURGERY VOLUME 168 JULY 1994 13


bleeding rate. Most of the patients retain good liver function, and most also have a good quality of life. Most of the patients with a history of alcoholism have a very good chance of rehabilitation.

The authors have demonstrated that good results can be achieved with selective distal shunts or extensive devascularization in good risk patients with cirrhosis and variceal bleeding. The comparison between procedures may be less important than the selection of very good risk operative candidates.

R E F E R E N C E S 1.Henderson JM, Kumer MH, Millikan WS Jr, et al. Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis. Ann Intern Med. 1990; 112:262-269. 2. Rikkers LF, Bumett DA, Volentine GD, et al. Shunt surgery ver- sus endoscopic sclerotherapy for long-term av.atment of variceal bleeding: early results of a randomized trial. Ann Surg. 1987; 206:261-271. 3. Warren WD, Zeppa R, Fomon JJ: Selective trans-splenic decom- pression of gastroesophageal varices by distal splenorenal shunt. Ann Surg. 1967;166:437--455. 4. Sugiura M, Futagawa S: A new technique for treating esophageal

varices. J Thorac Cardiovasc Surg. 1973;66:677--694. 5. Orozco H, Mercado MA, Takahashi T, et al. Role of the distal splenorenal shunt in management of variceal bleeding in Latin America. Am J Surg. 1990;160:86-89. 6. Orozco H, Takahashi T, Mercado MA, et al. The Sugiura procedure for patients with hemorrhagic portal hypertension secondary to extrahepatic portal vein thrombosis. Surg Gynecol Obstet. 1991; 173:45---48. 7. Orozco H, Mercado MA, Takahashi T, et al. Elective treatment of bleeding varices with the Sugiura operation over 10 years. Am J Surg. 1992;163:585-589. 8. Orozco H, Guevara L, Uribe M, et al. Survival and quality of life after selective portosystemic shunts. Am J Surg. 1981; 141:183-186. 9. Kaplan EL, Meier P. Non parametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457--472. 10. Mercado MA, Orozco H. Estado actual de la cirugia de hiperten- si6n portal. Rev Gastroenterol Mex. (In press). 11. Iwatsuki S, Starzl TE, Todo S, et al. Liver transplantation in the treatment of bleeding esophageal varices. Surgery. 1987; 104:697-703. 12. Starzl TE, Van Thiel D, Tzakis AG, et al. Orthotopic liver transplantation for alcoholic cirrhosis. JAMA. 1988;260:2542-2546. 13. Paquet KJ, Mercado MA, Gad HA. Surgical procedures for esophagogastric varices when sclerotherapy fails: a prospective study. Am J Surg. 1990;160:43-47. 14. Terblanche J, Burroughs AK, Hobbs KEF. Controversies in the management of bleeding esophageal varices. Part 1 and 2. NEJM. 1989;320:1393-1398; 1469--1475.

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survival and quality of life after portal blood flow preserving procedures in patients with portal...

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