Left-Sided Portal Hypertension - SASSiT

1146 Dig Dis Sci (2007) 52:1141–1149
Unfortunately, these treatment methods have often failed
[1, 2, 5].
Sclerotherapy is effective in patients with esophageal
varices, but not in those with isolated varices in the fundus or
gastric body [2, 90]. Recurrent bleeding occurs in more than
half of patients who undergo endoscopic sclerosis of fundal
varices [2]. However, current approaches in sclerotherapy
have shown hopeful results. Some studies have demonstrated
that endoscopic injection of cyanoacrylate is an effective and
safe treatment for gastric variceal bleeding and obliteration
of gastric varices, especially for the localized types [91–94].
Compared with the other sclerotherapy agents, cyanoacrylate
provides better hemostasis and is associated with less bleeding
recurrence and mortality [93, 94]. However, this method
may have life-threatening complications such as hemorrhage
and peripheral embolic events (pulmonary embolism, cerebral
infarction, or portal vein embolism). At present, the risk
of peripheral embolic events limits its use in spite of currently
available cyanoacrylate analogues [91, 95–97].
A patient with active bleeding unresponsive to conservative
management should be operated on quickly [1, 8].
Splenectomy is the treatment of choice [98]. Removal of
the spleen decreases the venous outflow through the collateral
circulation and decompresses the associated varices to
prevent further hemorrhage [16, 27]. In a large splenectomy
series that included patients with isolated SVT, Moossa et al.
reviewed the English literature between 1969 and 1984 and
reported splenectomy in 79 of 144 cases [16]. Postoperative
mortality was 8% and deaths were due to causes other than
bleeding. None of the 73 patients had recurrent bleeding after
splenectomy during the mean follow-up period of 11 months.
In another study, reported by Evans et al., splenectomy was
performed as a primary therapy in 10 patients. Hemorrhage
was effectively controlled in all but one of these patients [5].
Patients with LSPH and no history of bleeding are a problem
in terms of the risk of future bleeding [8]. Recent studies
have focused on investigations of optimal management
for patients with asymptomatic SVT [23]. In a retrospective
study of pancreatitis-induced splenic vein thrombosis, 53
cases were followed up for a median period of 34 months;
of these, 2 needed splenectomy due to variceal bleeding
and 3 had hemorrhage due to nonvariceal sources. Because
of the low incidence of gastric variceal hemorrhage [4%]
and the absence of mortality related to variceal hemorrhage,
the authors suggested that splenectomy not be performed
routinely for these patients [23]. In a retrospective study
done by Sakorafas et al., none of the eight patients with
symptomatic LSPH who underwent splenectomy had recurrent
gastrointestinal bleeding. Splenectomy was performed
for three of the five asymptomatic patients with esophageal
or gastric varices and none of those five patients had gastrointestinal
hemorrhage during follow-up. Twelve of the 21
asymptomatic patients without esophageal or gastric varices
underwent splenectomy. None of those had bleeding; however,
one of the remaining nine patients had bleeding during
follow-up [7]. In our own experience, 6 of 24 patients with
LSPH presented with gastrointestinal bleeding on admission.
Urgent surgery was needed for only one patient who had a severe
variceal hemorrhage. Other patients admitted with gastrointestinal
bleeding did not need invasive treatment. None
of our patients had recurrent bleeding during follow-up [22].
Finally, there is not enough evidence supporting prophylactic
splenectomy in the treatment of asymptomatic patients.
Nonetheless, if abdominal surgery is performed for other
purposes in a patient with known asymptomatic varices, a
splenectomy may be preferred [2, 7].
Transcatheter splenic artery embolization has been suggested
by Jones and associates to produce a “nonsurgical
splenectomy” [99]. It is performed by transcatheter deposition
of gianturco coils, autologous clot, or absorbable gelatin
sponge [6]. Embolization of the splenic artery by selective
catheterization has been tried with varying success and
has not become the preferred approach [27]. However, transcatheter
embolization as a preoperative adjunct to splenectomy
for hypersplenism has been advocated. Perhaps its role
in LSPH should be as the planned first stage of a two-step
therapeutic plan, embolization followed by splenectomy [5,
6, 100]. Adams et al. showed that splenic artery occlusion
during the splenectomy procedure diminished intraoperative
blood loss [6]. However, splenectomy can be performed
with an acceptable blood loss without splenic artery inflow
control in many patients. Nevertheless, patients with LSPH
who require operation for complications of chronic pancreatitis
may benefit from preoperative placement of the splenic
artery balloon catheter [5]. Splenic infarction and abscess
formation may occur after the embolization procedure [99].
Considering these issues, embolization without splenectomy
should be restricted to patients for whom surgery would be
highly risky [5, 16].
Reconstruction of the splenic vein may be an alternative
therapy in selected patients who have peripheral thrombosis
of the splenic vein [101]. However, there are not enough data
to evaluate the utility of that procedure.
Prognosis
The prognosis of LSPH mainly depends on the underlying
disease. The occurrence or recurrence rate of gastrointestinal
bleeding cannot be estimated. Since nearly half of the
patients have an underlying malignancy, especially pancreas
adenocarcinoma, most of those patients have a shorter life
expectancy and the incidence of gastrointestinal bleeding
is very low in that short period. In our recent prospective
study, all but 1 of the 11 patients with malignancy complicated
with LSPH died within a year, and 1 patient had a
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