Left-Sided Portal Hypertension - SASSiT

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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 Springer
Dig Dis Sci (2007) 52:1141–1149 1147 gastrointestinal hemorrhage before death [22]. None of the patients with nonmalignant disorders (three and eight patients with and without splenectomy, respectively) had bleeding during a mean period of 30 months. Similarly, in another prospective study none of the 23 patients with splenoportal vein thrombosis and LSPH (10 without splenectomy and 13 with splenectomy) had digestive tract bleeding during the 30-month follow-up period after diagnosis [10]. Conclusion LSPH is a clinical syndrome that usually occurs as a result of isolated SVT, which in turn arises from various etiologies, mainly pancreatic diseases. LSPH should be considered in the presence of gastrointestinal bleeding with normal liver function tests and unexplained splenomegaly. It may be difficult to diagnose this entity both endoscopically and radiologically. However, noninvasive techniques including CT and MR angiography are making the diagnosis easier. Endoscopic ultrasonography is sensitive in determining isolated gastric varices and should be considered in highly suspect patients. Treatment should be directed to the underlying diseases, and while splenectomy is the treatment of choice for cases complicated by variceal bleeding, there is no consensus on the treatment of asymptomatic patients. Recurrent hemorrhage is not usual and the prognosis mainly depends on the underlying etiology. References 1. Glynn MJ (1986) Isolated splenic vein thrombosis. Arch Surg 121:723–725 2. Weber SM, Rikkers LF (2003) Splenic vein thrombosis and gastrointestinal bleeding in chronic pancreatitis. World J Surg 27:1271–1274 3. Madsen MS, Petersen TH, Sommer H (1986) Segmental portal hypertension. Ann Surg 204:72–77 4. Sutton JP, Yarborough DY, Richard JT (1970) Isolated splenic vein occlusion. Review of literature and report of an additional case. Arch Surg 100:623–626 5. Evans GRD, Yellin AE, Weaver FA, et al. (1990) Sinistral (leftsided) portal hypertension. Am Surg 56:758–763 6. Adams DB, Mauterer DJ, Vujic IJ, et al. (1990) Preoperative control of splenic artery inflow in patients with splenic venous occlusion. South Med J 83:1021–1024 7. Sakorafas GH, Sarr MG, Farley DR, et al. (2000) The significance of sinistral portal hypertension complicating chronic pancreatitis. Am J Surg 179:129–133 8. Little AG, Moossa AR (1981) Gastrointestinal hemorrhage from left-sided portal hypertension. An unappreciated complication of pancreatitis. Am J Surg 141:153–158 9. Hwang TL, Jan YY, Jeng LB, et al. (1999) The different manifestation and outcome between pancreatitis and pancreatic malignancy with left-sided portal hypertension. Int Surg 84:209–212 10. Bernades P, Baetz A, Levy P, et al. (1992) Splenic and portal venous obstruction in chronic pancreatitis: A prospective longitudinal study of a medical-surgical series of 266 patients. Dig Dis Sci 37:340–346 11. Leger L, Lenriot JP, Lemigre G (1968) L’hypertension et la stase portales sgmentaires dans les pncreatites chronique: A propos de 126 cas examines par spleno-portographie et spleno-manometrie. J Chir (Paris) 95:599–608 12. Lavender S, Lloyd-Davis RW, Thomas ML (1970) Retroperitoneal fibrosis causing localized portal hypertension. Br Med J 3:627–628 13. Salam AA, Warren WD, Tyras DH (1973) Splenic vein thrombosis: A diagnosable and curable form of portal hypertension. Surgery 74:961–972 14. Rösch W (1974) Isolated gastric varices: a hint of pancreatic disorders. Endoscopy 6:217–220 15. Itzchak Y, Glickmann MG (1977) Splenic vein thrombosis in patients with a normal size spleen. Invest Radiol 12:158–163 16. Moossa AR, Gadd MA (1985) Isolated splenic vein thrombosis. World J Surg 9:384–390 17. KöklüS,Köksal A, Bayram G, et al. (2004) Isolated splenic vein thrombosis: An unusual cause and review of the literature. Can J Gastroenterol 19:837–838 18. Salam AA, Warren WD (1974) Anatomic basis of the surgical treatment of portal hypertension. Surg Clin North Am 54:1247– 1257 19. Brooks DH (1975) Surgery of the spleen. Surg Clin North Am 55:287–301 20. Warshaw AL, McChesney T, Evans GW, et al. (1972) Intrasplenic dissection by pancreatic pseudocysts. N Engl J Med 287:72–75 21. Nogueira Soriano JM, Diez GF, Pelaez DG, et al. (1991) Segmental portal hypertension due to a retroperitoneal abscess of tuberculous etiology. Rev Esp Enferm Dig 79:211–213 22. Köklü S,Yüksel O, Arhan M, et al. (2005) Report of 24 leftsided portal hypertension cases: a single-center prospective cohort study. Dig Dis Sci 50:976–982 23. Heider TR, Azeem S, Galanko JA, et al. (2004) The natural history of pancreatitis-induced splenic vein thrombosis. Ann Surg 239:876–882 24. Manenti A (1981) Splenic vein obstruction secondary to pancreatic carcinoma. Acta Chir Belg 80:245–248 25. Keith RG, Mustard RA Jr, Saibil EA (1982) Gastric variceal bleeding due to occlusion of splenic vein in pancreatic disease. Can J Surg 25:301–304 26. Illig KA, Spitzer RM, Oates TK (1997) Optimal diagnosis of splenic vein thrombosis. Am Surg 63:1005–1006 27. Lankısch PG (1990) The spleen in inflammatory pancreatic disease. Gastroenterology 98:509–516 28. Longstreth GF, Newcomer AD, Green PA (1971) Extrahepatic portal hypertension caused by chronic pancreatitis. Ann Intern Med 75:903–908 29. McElroy R, Christiansen PA (1972) Hereditary pancreatitis in a kinship associated with portal vein thrombosis. Am J Med 52:228–241 30. Wolf JH, Long RJ, Miller FJ, et al. (1977) Pancreatic islet cell tumour presenting as bleeding gastric varices secondary to splenic vein occlusion. Am J Dig Dis 22:652–655 31. Gallardo-Navarra V, Phillips E, Neyfeld P, et al. (1973) Segmental portal hypertension and islet cell adenoma of the pancreas. JAMA 226:1466 32. Bok EJ, Cho KJ, Williams DM, et al. (1984) Venous involvement in islet cell tumours of the pancreas. Am J Roentgenol 142:319– 322 33. Sheers R (1980) A pancreatic cystadenoma complicated by varices: Case report. Br J Surg 67:144–145 34. Rogers C, Klatt EC (1989) Splenic vein thrombosis in patients with acute pancreatitis. Int J Pancreatol 5:117–121 Springer
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