title: Surgery as primary prophylaxis from variceal bleeding in patients with extrahepatic portal venous obstruction.
abstract: OBJECTIVE
  In patients with extrahepatic portal venous obstruction (EHO), death is usually due to variceal bleeding. This is more so in developing countries where there is a lack of tertiary health-care facilities and blood banks. Prophylactic operations in cirrhotics have been found to be deleterious. In contrast, patients with EHO have well-preserved liver function, and we therefore investigated the role of prophylactic surgery to prevent variceal bleeding.
  
  
  METHODS
  Between 1976 and 2010, we operated on selected patients with EHO, who had no history of variceal bleeding but had "high-risk" esophagogastric varices or severe portal hypertensive gastropathy and/or hypersplenism, and came from remote areas with poor access to tertiary health care. Following surgery, these patients were prospectively followed up with regard to mortality, variceal bleeding, encephalopathy, and liver function.
  
  
  RESULTS
  A total of 114 patients (67 males; mean age 19 years) underwent prophylactic operations (proximal splenorenal shunts 98 [86%]; esophagogastric devascularization 16). Postoperative mortality was 0.9%. Among 89(79%) patients who were followed up (mean 60 months), hypersplenism was cured, and six (6.7%) developed variceal bleeding. The latter were managed successfully by endoscopic sclerotherapy. No patient developed overwhelming post-splenectomy sepsis or encephalopathy, and 90% were free of symptoms.
  
  
  CONCLUSIONS
  In patients with EHO, prophylactic surgery is fairly safe and prevents variceal bleeding in ∼ 94% of patients with no occurrence of portosystemic encephalopathy. Patients with EHO who have not bled but have high-risk varices and/or hypersplenism, and poor access to medical facilities should be offered prophylactic operations.
authors.affiliation: Department of GI Surgery and Liver Transplantation, All India Institute of Medical Sciences, India. sujoypal@hotmail.com
authors.forename: Sujoy
authors.initials: S
authors.lastname: Pal
authors.forename: Vivek
authors.initials: V
authors.lastname: Mangla
authors.forename: Patta
authors.initials: P
authors.lastname: Radhakrishna
authors.forename: Peush
authors.initials: P
authors.lastname: Sahni
authors.forename: Girish Kumar
authors.initials: GK
authors.lastname: Pande
authors.forename: Subrat Kumar
authors.initials: SK
authors.lastname: Acharya
authors.forename: Tushar Kanti
authors.initials: TK
authors.lastname: Chattopadhyay
authors.forename: Samiran
authors.initials: S
authors.lastname: Nundy
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D004932:Esophageal and Gastric Varices / Q000209:etiology / Q000517:prevention & control*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011169:Portal Vein / Q000601:surgery*; D011446:Prospective Studies; D014652:Vascular Diseases / Q000150:complications / Q000601:surgery*; D055815:Young Adult