Devascularization and Transection Procedures

Transection and devascularization procedures have been by far the most popular operations for the treatment of oesophagogastric varices in Japan during the last two decades1-5 and although since the new development of endoscopic sclerotherapy during the last ten years the number of patients treated by operation has decreased considerably, these procedures still remain the treatment of choice in many of the surgical institutions in Japan, especially in good-risk patients with oesophagogastric varices.

Recurrent bleeding rate of non-shunting operations (including both bleeding from recurrent varices and bleeding from peptic ulcers and hemorrhagic gastritis) was around 20% at 10 years, irrespective of the types of operations. Postoperative follow-up by endoscopy revealed that recurrence rate of varices after operation was 5% at one year, 16% at 2 years, 26% at 3 years, 30% at 4 years and 35% at 5 years. Recurrence of varices was observed more often in patients with alcoholic cirrhosis or in those with cirrhosis complicated by hepatocellular carcinoma. Recently, recurrence of varices after these non-shunting operations have been successfully treated by endoscopic sclerotherapy. Usually a session or two of endoscopic injection sclerotherapy could erradicate the residual or recurrent varices. Our experiences have clearly shown that devascularization and transection procedures are a safe and preferable operation in patients in Child A and B categories, and also feasible as an emergency operation in these cases when necessary. However, these operations are not indicated in Child C patients6. In assessing a patient's risk for these procedures, albumin and bilirubin levels in serum, S-GOT, S-GPT, antipyrin clearance, ICG-15, K-ICG, prothrombin time and hepaplastin test are very informative (Table 1). Endoscopic sclerotherapy has become very popular in Japan during the last several years, and now the number of patients treated by this modality of treatment exceeds that of those treated by operation7. A recent nation-wide survey revealed that approximately 85 % of patients with varices were treated initially by sclerotherapy, and only 15% treated by surgery. Reasons for this drastic change are not clear, however the following may explain some of the reasons" improvement of technical skills and equipments of endoscopy, development of effective sclerosants, increasing number of aged patients, increasing incidence of hepatocellular carcinoma in post-hepatitic cirrhosis, increasing number of endoscopists in Japan and their interests and enthusiasm for this modality of treatment.
We started sclerotherapy for varices in 1969 in our department and treated 169 patients in whom surgery was not indicated, namely in Child C patients, patients complicated with unresectable hepatoma, patients with residual or recurrent varices after operation, rejection of operation by patient, or in whom treatment was performed as a prophylactic measure.
Cumulative survival rates of these patients were 72% at one year, 45% at 3 years, and 34% at 5 years. Cumulative survival rate in Child A patients was 72.0% which was not significantly different from that of non-shunting operations, but those of Child B and C patients were much lower than those of patients treated by surgery ( Figures 1,2,3). This was partly because the sclerotherapy treated group included more patients who were complicated by hepatoma. Recurrence rate of bleeding after sclerotherapy was rather high, 22% of pfitients had at least one episode of rebleeding by the end of one year after sclerotherapy, and rebleeding rate reached up to 33% at 3 years. Oesophageal varices in Child C patients did not improve even after several sessions of.sclerotherapy and patients with large caliber varices with increased blood flow were difficult to treat by sclerotherapy, who were eventually treated by surgery. It is rather disappointing for us surgeons that sclerotherapy has not been successful in many of the poor risk patients in whom operation can not be tolerated.

PROPHYLACTIC TREATMENT OF OESOPHAGOGASTRIC VARICES
Prophylactic treatment of oesophagogastric varices has been a target of controversy among surgeons for many years, since predictability of rupture of varices has been doubted.
Endoscopic findings, and intravariceal pressure are considered to be of significant value in predicting variceal rupture8-11. Correlation between Red-Color signs on endoscopy and intravariceal pressure was also found. On the basis of Red-Color signs and prognostic blue color of varices by endoscopy, prophylactic operation and prophylactic sclerotherapy have been widely performed in Japan7. Only few prospective controlled studies of prophylactic operations have been reported so far12. Mortality rate and morbidity directly related to prophylactic treatment have been very low with non-shunting operations and sclerotherapy.