식도정맥류의 외과적치료와 그의 변천

Abstract

The general surgical treatment of esophageal varices had been practiced for the past 100 years, since theoperation of portasystemic shunt was performed by Eck in the 19th century and by Whipple and Blakemore in 1945, but it still is not free from controversy. However, this treatment has been revised and developed from total shont to elective shunt, nonshunt direct approach, nonshunt and endoscopic sclerosing treatment, PTO, esophageal manometry etc. The author conducted clinical observations on 133 cases and studied the changing process of surgical procedures by Surgiura, Kobayashi and TEPC in shunt operations for the past 11 years in the Department of surgery of Keimyung University. Preventive, elective and emergency nonshunt operations were performed on 133 male and female patients with esophgeal varices between the ages of 11 to 65 for the past 11 years from January 1979 to December, 1989. Of the 133 cases, 98 cases were male patients and 35 cases were female patients which showed more male patients than female (2.8:1) and the ages of 83 cases were among 30s and 40s (62%). Of the 133 cases, 96 cases (72%) were operated by using Sugiura's method. 21 cases (16%) by Kobayashi's 11 cases (8.3%) by TEPG, and 5 cases(4.0%) by Hassab's respectively. Of the 96 cases by Sugiura's method,57 cases were operated during the same stage and 39 cases during the two different stage. Of the 39 cases, 10 were with thoracic surgery only, 20 cases with abdominal surgery, and 9 cases with both types of surgery. By classification of the operation selection, 21 cases (16%) were preventive surgery, 95 cases (71%) were elective, and 17 cases (13%) were emergency. By pre-operative group of Child classification, 47 cases (35%) belong to A group, 62 cases (47%) in B goup, and 24 cases (18%) in group. The portal venous pressure which was measured through the splenic vein or the superior mesenteric vein during the operation were higher than 200mmH₂O in 127 cases, below 200mmH₂O in 4 cases and the highest case was 450mmH₂O. By th results of liverbiopsy, 88 cases(78.6%) were indicative of cirrhosis, 12 cases of chronic inflammation, 9 cases of fibrosis and 3 cases non specific. 2 cases of cirrhosis were accompanied with chronic active hepatitis including one case with hepatoma. Among the major complications, wound disruption, transient pleural effusion, hepatic failure and anastomotic leakage of the esophagus were found. Of the 133 cases, the mortality rate was 11.2% (15 cases): 1 case (4.7%) of the 21 cases of preventive surgery, 8 cases (6%) of the 95 cases of elective surgery and 6 cases (35%) of the 17 emergency surgery. By classification of Child, the mortality rate was 2.1% in A group, 13% in B group and 25% in C group. Of the patients whose esophagogram was taken peotoperatively between 3 months, 47% indicated complete disappearance of worm-like filling defect, 44% with a significant decrease, and 9% with no marked caange. Of the 77 cases whose follow-up cheks were done from 3 months to 10 years after discharge from the hospital, 10 patients died with 4 cases due to recurring hemorrhage, 5 cases to complications such as hepatic failure, diabetes and hepatornal syndrome. and 1 case with advanced hepatoma. In 6 cases, pre and post-operative esophageal manometry were performed. Such procedure are expected to continue to study further how the injuries of an extensive devascularization and tissues damaged around the esophagus caused by surgeries influence on lower esophageal sphincter and on physiological structures that prevent regurgitation. The relationship between reflux exophagitis and bleeding esophageal varices also continue to study through acid clearance rate and test.