Pre- and postoperative systemic hemodynamic evaluation in patients subjected to esophagogastric devascularization plus splenectomy and distal splenorenal shunt: a comparative study in schistomomal portal hypertension.
OBJECTIVE
To investigate the systemic hemodynamic effects of two surgical procedures largely employed for treatment of schistosomal portal hypertension.


METHODS
Thirty-six patients undergoing elective surgical treatment of portal hypertension due to hepatosplenic mansonic schistosomiasis were prospectively evaluated. All patients were subjected to preoperative pulmonary artery catheterization; 17 were submitted to esophagogastric devascularization and splenectomy (EGDS) and 19 to distal splenorenal shunt (DSRS). The systemic hemodynamic assessment was repeated 4 d after the surgical procedure.


RESULTS
Preoperative evaluation revealed (mean +/- SD) an increased cardiac index (4.78 +/- 1.13 L/min per m(2)), associated with a reduction in systemic vascular resistance index (1457 +/- 380.7 dynes.s/cm(5).m(2)). The mean pulmonary artery pressure (18 +/- 5.1 mmHg) as well as the right atrial pressure (7.9 +/- 2.5 mmHg) were increased, while the pulmonary vascular resistance index (133 +/- 62 dynes x s/cm(5) x m(2)) was decreased. Four days after EGDS, a significant reduction in cardiac index (3.80 +/- 0.4 L/min per m(2), P < 0.001) and increase in systemic vascular resistance index (1901.4 +/- 330.2 dynes x s/cm(5) x m(2), P < 0.001) toward normal levels were observed. There was also a significant reduction in pulmonary artery pressure (12.65 +/- 4.7 mmHg, P < 0.001) and no significant changes in the pulmonary vascular resistance index (141.6 +/- 102.9 dynes x s/cm(5) x m(2)). Four days after DSRS, a non-significant increase in cardiac index (5.2 +/- 0.76 L/min per m(2)) and systemic vascular resistance index (1389 +/- 311 dynes x s/cm(5) x m(2)) was observed. There was also a non-significant increase in pulmonary artery pressure (19.84 +/- 5.2 mmHg), right cardiac work index (1.38 +/- 0.4 kg x m/m(2)) and right ventricular systolic work index (16.3 +/- 6.3 g x m/m(2)), without significant changes in the pulmonary vascular resistance index (139.7 +/- 67.8 dynes xs/cm(5) x m(2)).


CONCLUSIONS
The hyperdynamic circulatory state observed in mansonic schistosomiasis was corrected by EGDS, but was maintained in patients who underwent DSRS. Similarly, the elevated mean pulmonary artery pressure was corrected after EGDS and maintained after DSRS. EGDS seems to be the most physiologic surgery for patients with schistosomal portal hypertension.
de Cleva
Roberto
R
Gastroenterology Department, University of Sao Paulo Medical School, Rua Cel. Artur Godoy 125, Apto 152. Vila Mariana, Sao Paulo, SP 04018-050, Brazil. roberto.cleva@hcnet.usp.br
Herman
Paulo
P
D'albuquerque
Luis Augusto Carneiro
LA
Pugliese
Vincenzo
V
Santarem
Orlando Luis
OL
Saad
William Abrão
WA
D000328:Adult; D001794:Blood Pressure; D002302:Cardiac Output; D004932:Esophageal and Gastric Varices / Q000503:physiopathology / Q000601:surgery*; D004947:Esophagus / Q000098:blood supply / Q000601:surgery*; D005260:Female; D006801:Humans; D006975:Hypertension, Portal / Q000469:parasitology / Q000503:physiopathology / Q000601:surgery*; D008026:Ligation; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011651:Pulmonary Artery / Q000503:physiopathology; D012555:Schistosomiasis mansoni / Q000150:complications* / Q000503:physiopathology / Q000601:surgery; D013156:Splenectomy; D013157:Splenic Artery / Q000601:surgery; D013164:Splenorenal Shunt, Surgical; D013270:Stomach / Q000098:blood supply / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014655:Vascular Resistance; D014656:Vascular Surgical Procedures; D016277:Ventricular Function, Left; D016278:Ventricular Function, Right