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CASE PRESENTATION GS intern 장장장

Esophageal varix surgical treatment

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surgical treatment of esophageal varix Sugiura operation Kobayashi operation 식도정맥류 정맥류의 수술적 치료

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Page 1: Esophageal varix surgical treatment

CASE PRESENTATIONGS intern 장규호

Page 2: Esophageal varix surgical treatment

Chief complaint

Nausea

Patient ID : 0328635 Sex /Age : F/44

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Present illness

44 세 여환 HCV LC 로 현재 본원 GI f/u 중인 자 .

본원 내원 전 E.varix bleeding 으로 수 차례 타병원에서 EVL 시행한 병력 있으며 올해 3 월 본원 GI 입원하여 E. varix, s/p EVL 한 차례 더 시행한 병력 있음 .

퇴원 이후 특이 소견 없이 지내다가 7/29 nu-asea 심해 울산병원 내원하여 DFS 시행하였고 Esophageal varix, Cardiac varix 확인되어 7/30 EVL 시행후 OP 위해입원함 .

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Past medical history

HTN/DM/Hep/Tb : +/+/+(HCV)/- Esophageal varix s/p EVL #10 Cardicac varices s/p EVL #2

Social Hx Smoking : (-) Alcohol : (-)

Surgical Hx : Cholecystectomy(07’)

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Review of systemGeneral Fever(-), chilling(-), poor oral intake(-), general weakness(-)

Respiratory Cough/sputum/rhinorrhea(-/-/-), dyspnea(-), cyanosis(-)

Cardiovascular Chest pain(-), chest discomfort(-)

Gastrointestinal Abdominal pain(-), RUQ pain(-), diarrhea/constipation(-/-)

Musculoskeletal Myalgia(-), arthralgia(-), paresthesia(-)

Genitourinary Dysuria/frequency/urgency/voiding difficulty (-/-/-/-)

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Physical ExamVital sign BP: 115/77mmHg- HR 59 회 / 분 - RR 20 회 / 분 -BT 36.0℃

Mental state: Alert

General appearance Not so ill looking

Body measurements Height : 150.4cm, weight : 45.6kg, BMI : 20.1

HEENT Anemic conjunctiva/Anicteric sclera(-/-)

Chest Symmetric chest wall movement without deformity Clear breathing sounds without crackle Regular heart beat without murmur

Abdomen Soft and distended abdomen(-)Hypoactive bowel sound(-) Tenderness(Murphy sign)/rebound tenderness(-/-), Hepatomegaly/splenomegaly(-/-) Palpable mass(-)

Back/Extremities CVA tenderness(-/-) Pretibial pitting edema(-/-)Joint swelling/tenderness/heating/redness(-/-/-/-) Varicose vein(-), dermopathy(-)

Skin Jaundice(-)

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Initial Lab

CBC WBC 17490, Hgb 8.1, PLT 210K, ANC 13030

Chemistry AST/ALT: 40/33 IU/L total/direct bilirubin: 0.2/0.1 mg/dl BUN/Cr.: 12.8/0.73 mg/dl total protein/albumin: 5.5/3.2 g/dl

Electrolyte Na/K/Cl: 139/4.8/108

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Cardiac varixEVL(140729)

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CT(140731)

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Initial Problem list

#1.esophageal varix #2.HCV-LC #3.HTN #4.DM

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ADMISSION NOTE

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HD 1

#1.esophageal varix S : n-s O : V/S - BP: 115/77mmHg- HR 59

회 / 분 - RR 20 회 / 분 -BT 36.0℃

A : esophageal varix P : Kobayashi OP

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Operation(141015) Preoperation diagnosis

Hepatic sclerosis Postoperation diagnosis

HCV/LC Operation(Kobayashi OP)

Paraesophago-gastirc devascularization/ Esopageal R&A/ TV /Pyloroplasty

OP findings liver macronodularity Ascites - mild splenomegaly

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POD 1

S : 수술부위 통증 O : V/S - BP: 142/96mmHg- HR 78

회 / 분 - RR 20 회 / 분 -BT 36.4℃ A : esophageal varix P : ICU care, NPO, pain control

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POD 3

S : 수술부위 통증 O : V/S - BP: 138/87mmHg- HR 81 회 / 분 - RR 20 회 / 분 -BT 36.3℃ Hgb – 8.1 A : esophageal varix P : transfusion, NPO, pain control

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VARIX TREATMENT

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1.Endoscpic therapy

definitive treatment of choice for ac-tive variceal hemorrhage Endoscopic variceal ligation (EVL) 

it involves placing small elastic bands around varices 

Endoscopic sclerotherapy (ES)  injection of a sclerosant solution into the

varices

EVL and ES are initially successful in 70 to 100 percent of patients

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Gastric varix

Bleeding from gastric varices is diffi-cult to control endoscopically

TIPS may be less effective than surgery Flow through collaterals that feed the

gastric varices often persists after TIPS

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2. Management if endoscopic therapy fails 

definition of failed treatment for acute variceal hemorrhage Fresh hematemesis or nasogastric aspiration of

≥100 mL of fresh blood ≥2 hours after the start of a specific drug treatment or therapeutic endoscopy

Development of hypovolemic shock A 3-gm drop in hemoglobin (or a 9 percent drop in

hematocrit) within any 24-hour period if no transfu-sion is administered

rebleeding occurs a second time, more defini-tive therapy (TIPS placement or surgery) is re-quired. 

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Transjugular intrahepatic por-tosystemic shunt

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Absolute contraindications heart failure, severe pulmonary hypertension,

uncontrolled systemic infection or sepsis, se-vere tricuspid regurgitation.

Relative contraindications hepatocellular carcinoma, portal vein thrombo-

sis, and severe coagulopathy or thrombocy-topenia

Complications  portosystemic encephalopathy, technical com-

plications (eg, cardiac arrhythmias, traversal of the liver capsule), and TIPS stenosis

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Surgery

The ideal patient for surgical therapy well-preserved liver function who fails

emergent endoscopic treatment  no complications from the bleeding or

endoscopy contraindication to TIPS placement

two basic types of operations shunt operations nonshunt operations

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Shunt operations Nonselective (figure A)

decompress the entire portal tree and divert all flow away from the portal system, such as porta-caval shunts

Selective (figure B) compartmentalize the portal tree

into a decompressed variceal system while maintaining sinu-soidal perfusion via a hyperten-sive superior mesenteric-portal compartment, such as a distal splenorenal shunt

Partial Those that incompletely decom-

press the entire portal tree and thereby also maintain some he-patic perfusion

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Non-shunt operations esophageal transection (in which the distal

esophagus is transected and then stapled back together after varices have been lig-ated)  bleeding can occur from the suture line, and

varices recur after a variable period of time because transection does not treat the portal hypertension.

devascularization of the gastroesophageal junction used in patients who are not candidates for a

shunt operation such as those with extensive portal vein thrombosis with extension into the splenic and superior mesenteric veins

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Shunt OP vs non-shunt OP

Shunt OP 술후 간 혈류량 감소로 인한 간부전 간성뇌증

Non-shunt OP 문맥압 감압효과는 없지만 간혈류 유지 가능 술후 간부전이나 간성뇌증 유발하지 않음 재출혈의 위험성이 높음

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Sugiura operation

단점 : 1 차 수술 4~6 주 후 2 차 수술이 필요함 1 차 수술의 시간이 오래걸리며 광범위한 devascularization으로 출혈 및 문합부 누출 발생

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Kobayashi operation

1.Spleenectomy 2. 복부식도와 위근위부 devascularization & Truncal vagotomy3.EEA stappler 를 이용한 식도절단 및 문합술4.Pyloroplasty

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식도정맥류에 대한 Kobayashi procedure

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술후 식도정맥류 변화 술후 2~4 주후 식도조영술 시행 정맥류 완전소실 : 23 예중 12 예 현저한감소 : 9 예 약간의변화 : 2 예

원격 추적 조사 술후 3 개월 ~4 년 10 개월까지 추적조사한 21 예 중 2 예 (9.5%) 사망 - 술후 2 개월 - 간성혼수 - 술후 9 개월 - 재출혈 & 간성혼수

재출혈 2 예 (9.5%)- 고식적치료와 경화요법으로 지혈식도협착 -5 예 (23.8%)

식도정맥류의 Kobayashi 술식의 효과

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Reference

Uptodate Methods to achieve hemostasis in pa-

tients with acute variceal hemorrhage 식도정맥류에 대한 Kobayashi procedure

외과학회지 vol30, No6, June, 1986 식도정맥류의 Kobayashi 술식의 효과

외과학회지 vol40, No2, February, 1991