LETTERS TO THE EDITOR

To the Editor:

The following letter was accidentally published without its reply in the July 2001 issue of Annals of Surgery . The original letter along with its reply have been reprinted here.

We read with interest the paper by Orozco et al ¹ published in the August 2000 issue of the Annals of Surgery. Although we appreciate the difficulties in carrying out this study comparing three established modalities of preventing recurrent variceal hemorrhage in patients with portal hypertension, we have certain reservations about the methodology and conclusions drawn. First, exclusion criteria are separately listed for the three modalities on trial. This would lead us to assume that patients were excluded after randomization to a particular arm that would affect the balance between the groups. For example, patients with gastric varices are excluded from sclerotherapy group. No mention is made of their exclusion from the pharmacotherapy group. It is well recognized that bleeding from fundal gastric varices is more severe and difficult to control compared to esophageal variceal bleeding. ^2,3

The exact etiology of the portal hypertension is not mentioned though the authors mention ‘diverse hepatopathies.’ It is not clear whether all patients were cirrhotic (biopsy proven). The large proportion of patients with anatomy unsuitable for shunt surgery (20/30) suggests that extrahepatic portal venous obstruction may be responsible for the portal hypertension in a large proportion in this group. If this was so, and the liver was normal in these cases, their prognosis would be better than that of patients with Child A cirrhosis as liver function is essentially normal.

Further, only 2 of the 46 patients subjected to endoscopic sclerotherapy are survivors without recourse to surgery. This is a far higher failure rate than reported in literature. Though initial endoscopic treatment is mentioned, little information is given about follow-up surveillance endoscopy. At our center, after initial obliteration, surveillance endoscopies are carried out 3 times per month for a year, then 6 monthly, and then yearly. Recurrent varices are resclerosed. The variceal recurrence rates are high, in the order of 60%, but post obliteration variceal rebleed rates are low, with few requiring surgery or dying of rebleed. ^4,5 Acceptance of this surveillance regime is an important issue, especially in developing countries dealing with less educated patients.

The text states that 30 patients were operated on. In Table 1, only 25 patients are accounted for in the Childs grading. Furthermore it is suggested in Table 2 that the 2 patients in the surgical group with Childs C cirrhosis that rebled accounted for 22% of the population. However, Table 1 mentions that only 3 Childs C cirrhotics underwent surgery making the rebled rate 67%.

Not unsurprisingly, Childs A patients did better than Childs Group B and C patients. Not many surgeons would offer surgery for Childs C cirrhotics over a transjugular intrahepatic portosystemic shunt (TIPSS) owing to the associated high mortality. ^6,7 Though the authors state that better results are obtained by surgery, this is not borne out in the survival curve shown in Figure 1 of the paper. Prolonging survival is the desired outcome rather than just a reduction in rebleeding.

Notwithstanding these limitations, the effort made by the authors must be lauded. We realize the difficulties of carrying out a randomized study between surgical and nonsurgical modalities at our center in a developing country, where consideration such as reliability of follow-up and ready availability of emergency care have to be taken into account before allocating patients to a sclerotherapy arm. We agree that non-shunting devascularization procedures give excellent immediate and long term results ^6,8 and are the procedure of choice in patients with unsuitable venous anatomy. ⁹ In those willing to follow-up, low rebleed rates have been obtained with endoscopic sclerotherapy even on long term follow-up, ^4,5 while surgery has its role, as stated by the authors, in patients with gastric varices as well as those rebleeding on sclerotherapy.

Sudeep R. Shah, MD