[Splenectomy for hemorrhage from esophageal varices with massive thrombosis of the portal bed in the absence of cirrhosis: an intervention to be reevaluated? Reflections on a clinical case].
It has been suggested that the ideal definitive treatment of hemorrhage from esophageal varices due to extrahepatic portal hypertension should be a selective shunt, avoiding splenectomy, when possible, for its unfavorable effects. We present a case with extrahepatic portal hypertension and polycythemia vera who complained acute recurrent variceal bleeding in spite of multiple sclerotherapy sessions, with a massive thrombosis of the portal bed and radicles without any possibility to perform a shunt. The combined treatment was emergency splenectomy followed by a closed program of sclerotherapy. The result was good at two years of follow-up. The optimal treatment of patients with episodes of bleeding varices for extrahepatic portal hypertension and patency of splenic vein should be a selective shunt; poor long-term results have been reported in patients without patency of the major tributaries of the portal system and treated with other operations than shunts. Splenectomy could gave a role in producing these unhappy results. After splenectomy it has been observed an increased thrombocytosis, venous infarction of the bowel, increased susceptibility to infection and also a paradoxical higher risk of bleeding by removing low risk collaterals. From this anecdotal report it can be argued that splenectomy is not necessarily followed by bad results and can be the first therapeutic option in emergency and in some selected cases with huge, high risk varices, difficult to treat by sclerosis only, and without suitable vessel for a shunt.(ABSTRACT TRUNCATED AT 250 WORDS)
Contini
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Istituto di Patologia Speciale Chirurgica dell'Università di Parma.
Di Lecce
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Carlo Botta
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D000208:Acute Disease; D003131:Combined Modality Therapy; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000601:surgery*; D006801:Humans; D006975:Hypertension, Portal / Q000150:complications; D008103:Liver Cirrhosis; D008875:Middle Aged; D011087:Polycythemia Vera / Q000150:complications; D011169:Portal Vein; D012008:Recurrence; D015911:Sclerotherapy; D013156:Splenectomy; D013927:Thrombosis / Q000209:etiology / Q000601:surgery*
La splenectomia per emorragia da varici esofagee con trombosi massiva del letto portale in assenza di cirrosi: un intervento da rivalutare? Riflessioni su un caso clinico.