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2016, Number 5

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Ann Hepatol 2016; 15 (5)

Schistosomal portal hypertension: Randomized trial comparing endoscopic therapy alone or preceded by esophagogastric devascularization and splenectomy

Costa Lacet, Celina Maria; Batista NJ, Tenório RL, Silva OF, Fernandes WR, Strauss E

Language: English
References: 40
Page: 738-744
PDF size: 147.81 Kb.


ABSTRACT

Background. Upper gastrointestinal bleeding is a major cause of morbidity and mortality in patients with portal hypertension secondary to schistosomiasis mansoni. Aim. To evaluate the efficacy of combined surgery and sclerotherapy versus endoscopic treatment alone in the prophylaxis of esophageal variceal rebleeding due to portal hypertension in schistosomiasis. Material and methods. During a two-years period consecutive patients with schistosomiasis and a recent bleeding history were evaluated for prospective randomization. Absolute exclusion criteria were alcoholism or other liver diseases, whereas platelet count ‹ 50,000/mm3, INR › 1.5 or presence of gastric varices were relative exclusion criteria. By random allocation 25 (group A) have received endoscopic sclerotherapy for esophageal varices alone and 22 (group B) combined treatment: esophagogastric devascularization with splenectomy followed by sclerotherapy. Interim analysis at 24 months has shown significant statistical differences between the groups and the randomization was halted. Results. Mean age was 38.9 ± 15.4 years and 58.46% were male. Mean follow-up was 38.6 ± 20.1 months. Endoscopic comparison of the size of esophageal varices before and after treatment did not show significant differences among the two groups. Treatment efficacy was assessed by the rate of recurrent esophageal variceal bleeding, that was more common in group A- 9/25 patients (36.0%) vs. 2/22 (9.0%) in group B (p = 0.029). Other complications were odynophagia, dysphagia and esophageal ulcer in group A and ascites and portal vein thrombosis in the surgical group. Conclusion. In portal hypertension due to schistosomiasis, combined surgical and endoscopic treatment was more effective for the prevention of recurrent esophageal variceal bleeding.


REFERENCES

  1. Andrade ZA. Schistosomiasis in Brazil after one century of research. Rev Soc Bras Med Trop 2002; 35: 509-513.

  2. Chitsulo L, Engels D, Montresor A, Savioli L. The global status of schistosomiasis and its control. Acta Trop 2000; 77: 41-51.

  3. Lambertucci JR. Revisiting the concept of hepatosplenic schistosomiasis and its challenges using traditional and new tools. Rev Soc Bras Med Trop 2014; 47: 130-6.

  4. Andrade ZA. Schistosomiasis and liver fibrosis. Parasite Immunol 2009; 31: 656-63.

  5. Coura JR, Conceicao J, dos Santos ML, de Mendonca ZG, Cutrim RN. Cross-sectional and evolutive studies of schistosomiasis mansoni in untreated and mass treated endemic areas in the southeast and northeast of Brazil. Mem Inst Oswaldo Cruz 1992; 87 (Suppl. 4): 175-82.

  6. Kelner S. Critical evaluation of schistosomiasis portal hypertension surgery. Mem Inst Oswaldo Cruz 1992; 87 (Suppl. 4): 357-68.

  7. Domingues ALC. Schistosomiasis mansoni. In: Mattos AA, Dantas EB (Eds.). Tratado de Hepatologia. Vol. 1. Rio de Janeiro: Rubio; 2010, p. 301-16.

  8. Ferraz AA, Bacelar TS, Silveira MJ, Coelho AR, Camara Neto RD, de Araujo Junior JG, Ferraz EM. Surgical treatment of schistosomal portal hypertension. Int Surg 2001; 86: 1-8.

  9. Sakai P, Boaventura S, Ishioka S, Mies S, Sette H, Jr., Pinotti HW. Sclerotherapy of bleeding esophageal varices in schistosomiasis. Comparative study in patients with and without previous surgery for portal hypertension. Endoscopy 1990; 22: 5-7.

  10. Cordeiro F. Variceal sclerosis in schistosomotic patients: a 5- year follow-up study. Gastrointest Endosc 1990; 36: 475-8.

  11. Mies S, Neto OB, Beer A, Jr., Baia CE, Alfieri F, Jr., Pereira LM, Sette MJ, et al. Systemic and hepatic hemodynamics in hepatosplenic Manson’s schistosomiasis with and without propranolol. Dig Dis Sci 1997; 42: 751-61.

  12. Kiire CF. Controlled trial of propranolol to prevent recurrent variceal bleeding in patients with non-cirrhotic portal fibrosis. BMJ 1989; 298: 1363-5.

  13. Farias AQ, Kassab F, da Rocha EC, Dos Santos Bomfim V, Vezozzo DC, Bittencourt PL, Carrilho FJ. Propranolol reduces variceal pressure and wall tension in schistosomiasis presinusoidal portal hypertension. J Gastroenterol Hepatol 2009; 24: 1852-6.

  14. Makdissi FF, Herman P, Pugliese V, de Cleva R, Saad WA, Cecconello I, D’Albuquerque LA. Long-term results of esophagogastric devascularization and splenectomy associated with endoscopic treatment in schistosomal portal hypertension. World J Surg 2010; 34:2682-8.

  15. Raia S, da Silva LC, Gayotto LC, Forster SC, Fukushima J, Strauss E. Portal hypertension in schistosomiasis: a longterm follow-up of a randomized trial comparing three types of surgery. Hepatology 1994; 20: 398-403.

  16. Sakai P. Endoscopic sclerosis of esophageal varices after surgical treatment of portal hypertension in patient with hepatosplenic schistosomiasis. Arq Gastroenterol 2001; 38: 81-3.

  17. WHO. Proposal for a practical guide to the standardized use of the ultrasound in the assessment of pathological changes. Meeting on Ultrasonography in Schistosomiasis. In: Organization WH (Ed.). Cairo; 1990.

  18. Paquet KJ. Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices — a prospective controlled randomized trial. Endoscopy 1982; 14: 4-5.

  19. Bernard-Chaubert B, Sauerbruch T, Lo G-H, Sanyal AJ, Henderson M, Vinel JP, Lebrec D. Prevention of Rebleeding. In: De Franchis R (Ed.). Portal Hypertension - Fourth Baveno International Consensus Workshop. Oxford, UK: Blackwell Publishing Ltda; 2006, p. 262-82.

  20. Siqueira ES, Rohr MR, Libera ED, Castro RR, Ferrari AP. Band ligation or sclerotherapy as endoscopic treatment for oesophageal varices in schistosomotic patients: results of a randomized study. HPB Surg 1998; 11: 27-32.

  21. da Silveira Rohr MR, Siqueira ES, Brant CQ, Morais M, Libera ED, Jr., Castro RR, Ferrari AP. Prospective study of bacteremia rate after elastic band ligation and sclerotherapy of esophageal varices in patients with hepatosplenic schistosomiasis. Gastrointest Endosc 1997; 46: 321-3.

  22. Krige JE, Bornman PC, Goldberg PA, Terblanche J. Variceal rebleeding and recurrence after endoscopic injection sclerotherapy: a prospective evaluation in 204 patients. Arch Surg 2000; 135: 1315-22.

  23. Bittencourt PL, Farias AQ, Strauss E, Mattos AA. Variceal bleeding: consensus meeting report from the Brazilian Society of Hepatology. Arq Gastroenterol 2010; 47: 202-16.

  24. Laosebikan AO, Thomson SR, Naidoo NM. Schistosomal portal hypertension. J Am Coll Surg 2005; 200: 795-806.

  25. Raia S, Mies S, Macedo AL. Surgical treatment of portal hypertension in schistosomiasis. World J Surg 1984; 8: 738-52.

  26. Hassab MA. Gastro-esophageal decongestion and splenectomy GEDS (Hassab), in the management of bleeding varices. Review of literature. Int Surg 1998; 83: 38-41.

  27. Strauss E, Sakai P, Gayotto LC, Cardoso RA, Forster S, Raia S. Size of gastroesophageal varices: its behavior after the surgical treatment of portal hypertension. Rev Hosp Clin Fac Med Sao Paulo 1999; 54: 193-8.

  28. Bittencourt PL. Portal fibrosis and schistosomal portal hypertension: what is the best strategy for primary and secondary prevention of hemorrhage from esophageal varices. Arq Gastroenterol 2003; 40: 1-3.

  29. de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53: 762-8.

  30. Evangelista-Neto J, Pereira FF, Franca ST, Amaral FJ, Brandt CT, Fonseca-Neto OC, Lacerda CM. Splenectomy and gastric vein ligature in hepatosplenic schistosomiais: effects upon esophageal variceal pressure and endoscopic risk factors of esophageal variceal bleeding. Arq Bras Cir Dig 2012; 25: 41-8.

  31. Alves A, Jr., Fontes DA, de Melo VA, Machado MC, Cruz JF, Santos EA. Schistosomal portal hypertension: influence of the portal blood flow in serum levels of hepatic enzymes. Arq Gastroenterol 2003; 40: 203-8.

  32. Correia HS, Domingues AL, Lopes EP, Morais CN, Sarteschi C, Moura IM. Serum globulin levels and intensity of hepatic fibrosis in patients with mansonic schistosomiasis. Arq Gastroenterol 2009; 46: 194-8.

  33. Raia S, Mies S, Alfieri Junior F. Portal hypertension in mansonic schistosomiasis. World J Surg 1991; 15: 176-87.

  34. Petroianu A, De Oliveira AE, Alberti LR. Hypersplenism in schistosomatic portal hypertension. Arch Med Res 2005; 36: 496-501.

  35. Drummond SC, Pereira PN, Otoni A, Chaves BA, Antunes CM, Lambertucci JR. Thrombocytopenia as a surrogate marker of hepatosplenic schistosomiasis in endemic areas for Schistosomiasis mansoni. Rev Soc Bras Med Trop 2014; 47: 218-22.

  36. Manoukian N, Borges DR. Prealbumin, prekallikrein and prothrombin in hepatosplenic schistosomiasis: increased turnover of the clotting proteins? Rev Inst Med Trop Sao Paulo 1984; 26: 237-40.

  37. Lacerda CM, Ramos H, Raia S, Kelner S. Physiopathology of schistossomal portal hypertension and effects of splenectomy with ligation of esophageal varices. Acta Cir Bras 1993; 8: 113-7.

  38. Santos MF. Portal thrombosis in patients with schistossomiasis submitted to azygo-portal deconnection with splenectomy. São Paulo: Faculdade de Ciências Médicas da Santa Casa; 2002.

  39. Chaib E, Pugliesi V, Capacci Mde L, D’Albuquerque LC, Widman A, Bernardini AP, Silva Ade O, et al. Portal thrombosis: early complication of azygo-portal disconnection in the treatment of bleeding esophageal varices. Rev Hosp Clin Fac Med Sao Paulo 1990; 45: 205-7.

  40. de Cleva R, Herman P, Saad WA, Pugliese V, Zilberstein B, Rodrigues JJ, Laudanna AA. Postoperative portal vein thrombosis in patients with hepatosplenic mansonic schistosomiasis: relationship with intraoperative portal pressure and flow. A prospective study. Hepatogastroenterology 2005; 52: 1529-33.




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