ABCD Arq Bras Cir Dig

2025;38:e1894 ORIGINAL ARTICLE

[Link]

EDA DA PRESSÃO PORTAL APÓS

Liver transplantation in DESVASCULARIZAÇÃO
patients over 70 years old
AGOGÁSTRICA E ESPLENECTOMIA INFLUENCIA A VARIAÇÃO
ALIBRE DAS VARIZES E AS TAXAS DE RESSANGRAMENTO NA VISUAL ABSTRACT

UISTOSSOMOSE NO SEGUIMENTO EM LONGO PRAZO?

e drop in portal pressure after esophagogastric devascularization and splenectomy
n of variceal calibers and the rebleeding rates in schistosomiasis in late follow-up?

de Biase SILVA-NETO1 , Claudemiro QUIRESE1 , Eduardo Guimarães Horneaux de MOURA2 ,

Ferreira COELHO3 , Paulo HERMAN3

- Racional: O tratamento de escolha para pacientes com hipertensão portal

ossomótica com sangramento de varizes é a desconexão ázigo-portal mais
ctomia (DAPE) associada à terapia endoscópica. Porém, estudos mostram aumento
re das varizes em alguns pacientes durante o seguimento em longo prazo. Objetivo:
o impacto da DAPE e tratamento endoscópico pós-operatório no comportamento
zes esofágicas e recidiva hemorrágica, de pacientes esquistossomóticos. Métodos:
estudados 36 pacientes com seguimento superior a cinco anos, distribuídos em
• Liver transplantation in patients aged ≥70 years is feasible with selected donors.
upos: queda da pressão portal abaixo de 30% e acima de 30% comparados com o
das varizes esofágicas no pós-operatório precoce e tardio além do índice de recidiva
ágica. Resultados • Short-term outcomes were comparable to those in younger recipients.
cas que, durante o seguimento aumentaram de calibre e foram controladas com
Genzini T, Rodrigues MG, Almeida TN, Danziere FR, Fonseca LEP, Genzini MC, Lerner FK, Coelho AIM,
• Elderly patients had higher ICU
Grochoski stayPerosa
KCV [Link]ção
ABCDdoArq
and transfusion calibre das varizes no período pré e pós-
needs.
Bras Cir Dig. 2025; 37e
ortamento do calibre das varizes no pós-operatório precoce nem tardio nem os operatório precoce e tardio
de recidiva hemorrágica. Conclusão
• Advanced age should not be a contraindication for liver transplant when carefully evaluated.
rios precoces ou tardios. A comparação entre a queda de pressão do portal e as Mensagem central
A desconexão ázigo-portal e esplenectomia
ES: Esquistossomose mansoni. Hipertensão portal. Cirurgia. Pressão na veia porta. Varizes esofágicas apresenta importante impacto na diminuição
precoce do calibre das varizes esofágicas na
esquistossomose; entretanto, parece que a
associação com a terapia endoscópica é a maior
AUTHORS responsável pelo controle da recidiva hemorrágica.
T - Background: The treatment of choice for patients with schistosomiasis with
Tércio
s episode of varices GENZINI
is bleeding , Marina
esophagogastric Guitton RODRIGUES
devascularization ,
and splenectomy ARTICLE HIGHLIGHTS
n association withThais
postoperative
Natalia deendoscopic
ALMEIDA therapy., However, studies have shown • Liver transplantation (LT) in patients aged ≥70 years is feasible with
Perspectiva
T, Rodrigues MG, Almeida TN, Danziere FR, Fonseca LEP, Genzini MC, Lerner FK, Coelho AIM,
recurrence especially after long-term
Fernanda follow-up. Aim:, To assess the impact on
Ribeiro DANZIERE
selected donors.
Este estudo avaliou outcomes
• Short-term o impactowere
tardio no índice
comparable to those in younger recipients.
r of esophageal varices and bleeding recurrence after post-operative endoscopic
Grochoski KCV Perosa M. ABCD Arq Bras Cir Dig. 2025; 37e
Luiz Edmundo Pinto da FONSECA ,
nt of patients submitted to EGDS. Methods: Thirty-six patients submitted to EGDS
de ressangramento de pacientes submetidos ao
• Elderly patients had higher intensive
tratamento cirúrgico e endoscópico. A queda na
care unit (ICU) stay and trans-
Marcella Costa GENZINI , fusion needs.
ressure drop, more or less than
Fernando 30%, and compared
Kruglensky LERNER with the
, behavior of esophageal variação• do calibre das
Advanced agevarizes
shouldquando
not becomparado
a contraindication for LT when care-
and the rate of bleeding recurrence. ResultsCOELHO , o seu diâmetro no pré e pós-operatório precoce e
fully evaluated.
Aloysio Ikaro Martins tardio. A comparação entre a queda de pressão
st-operative varices caliber when compared the pre-operative data was observed portal e as taxas de MESSAGE
ressangramento, também
Keli Camila Vidal GROCHOSKI , Marcelo PEROSA CENTRAL
an increase in diameter during follow-up that was controlled by endoscopic therapy.
sion A retrospective analysis of liver transplants was performed, comparing
CORRESPONDENCE evidenciar se apenas a terapia endoscópica, ou
calibers when comparing pre-operative and early or late post-operative diameters. patients over and under 70 years of age. The elderly group was trans-
operações menos complexas poderão controlar o
mparison betweenTércio Genzini.
the portal pressure drop and the rebleeding rates was also not planted
sangramento daswith careful donor selection and obtained results comparable
varizes.
Email: tgenzini@[Link] to those of the younger group.
S: Schistosomiasis mansoni. Portal hypertension. Surgery. Portal pressure.
geal and gastric HOW
varices. TO CITE THIS ARTICLE PERSPECTIVES
This study aims to show that elderly patients over 70 years of age can
Genzini T, Rodrigues MG, Almeida TN, Danziere FR, have good results after liver transplantation, comparable to patients
Fonseca LEP, Genzini MC, et al. Liver transplantation under 70 years of age, with good donor selection and perhaps addi-
in patients over 70 years old. ABCD Arq Bras Cir tional points to favor their position on the waiting list.
Dig. 2025;37:e1894. [Link]
67202025000025e1894
[Link]/abcdrevista [Link]/abcdrevista [Link]/abcdrevista

zado no 1Serviço de Cirurgia Geral e Aparelho Digestivo, Departamento de Clínica Cirúrgica, Faculdade de Medicina, Universidade Federal de Goiás, Goiânia, GO,
o de Endoscopia, Hospital das Clínicas e Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil; 3Serviço de
gado, Hospital das Clínicas e Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil

se artigo: de Biase Silva-Neto WB, Quirese C, De Moura EGH, Coelho FF, Herman P. A queda da pressão portal após desvascularização esofagogástrica e esplenectomia

2-672020210001e1581

ência:
se da Silva Neto
e123@[Link]; Recebido para publicação: 17/09/2020
[Link] Aceito para publicação: 14/12/2020
[Link]/revistaabcd/ [Link] [Link]/Revista-ABCD-109005301640367 [Link]/company/revista-abcd

ABCD Arq Bras Cir Dig 2021;34(2):e1581 1/4 1/9

 ABCD Arq Bras Cir Dig
2025;38:e1894 ORIGINAL ARTICLE
[Link]

A QUEDA DA PRESSÃO PORTAL

Liver transplantation in patients over 70 years old
Transplante hepático em idade maior que 70 anos ESOFAGOGÁSTRICA E ESPLENE
DO CALIBRE DAS VARIZES E AS
Tércio GENZINI1,2,3,4 , Marina Guitton RODRIGUES4 , Thais Natalia de ALMEIDA4 ,
Fernanda Ribeiro DANZIERE2,4 , Luiz Edmundo Pinto da FONSECA1 , Marcella Costa GENZINI5 ,
Fernando Kruglensky LERNER5 , Aloysio Ikaro Martins COELHO3,4 , Keli Camila Vidal GROCHOSKI1,2,4
Marcelo PEROSA1,2,3,4
ESQUISTOSSOMOSE
, NO SEGUI
Does the drop in portal pressure after esophago
variation of variceal calibers and the rebleeding

ABSTRACT Walter de Biase SILVA-NETO1 , Claudemiro Q

Fabricio
Background: Liver transplantation (LT) is increasingly recognized as a treatment option for various diseases Ferreira
affecting a growingCOELHO 3
, Paulo HERMAN3
elderly population.
However, its use in patients over 70 years of age remains controversial in centers with suboptimal outcomes or high waitlist mortality. Aims: The aim of
this study was to evaluate the effectiveness of LT as a treatment option for elderly patients aged 70 years or older, in comparison with younger recipients.
Methods: This retrospective study was conducted based on medical record data from 309 liver transplant RESUMO recipients treated byOthetratamento
- Racional: same surgicalde escolha para pacie
team across three hospitals — two located in São Paulo, São Paulo state (SP) and one in Rio Branco, Acre state (AC). Patients were divided into two
esquistossomótica com sangramento de varizes é a d
groups for comparison: those aged up to 69 years (Group I) and those aged 70 years or older (Group II). Results: Donor characteristics were similar
esplenectomia (DAPE) associada à terapia endoscópica. Poré
between the two groups, except for a higher norepinephrine dose in Group I (p<0.05). Group II showed greater transfusion requirements and longer
intensive care unit (ICU) stays (p<0.05), as well as higher rates of malnutrition and comorbidities. Notably,do calibre
90-day das varizes
survival em alguns
was comparable pacientes durante o seguim
between
the groups. Conclusions: Patients aged 70 years or older can achieve outcomes comparable to those of younger Avaliar o impacto
recipients, da DAPE
provided e tratamento
they receive grafts endoscópico pós-
from carefully selected donors. This population should not be excluded from transplant waitlists, and specificdas varizespolicies
allocation esofágicas e recidiva
or scoring hemorrágica, de pacientes
adjustments
should be considered to ensure equitable access. Foram estudados 36 pacientes com seguimento superior
Keywords: Liver Transplantation. Elderly. Survival. dois grupos: queda da pressão portal abaixo de 30% e acim
calibre das varizes esofágicas no pós-operatório precoce e ta
RESUMO hemorrágica. Resultados
Racional: O transplante de fígado é cada vez mais reconhecido como uma opção de tratamento para diversas esofágicas que,
doenças quedurante o seguimento
afetam uma crescente aumentaram de cal
população idosa. No entanto, seu uso em pacientes com mais de 70 anos permanece controverso em centros com menos desenvolvidos ou alta
mortalidade em lista de espera. Objetivos: Avaliar a eficácia do transplante de fígado como opção de tratamento o comportamento
para pacientes do calibre
idosos com das varizes no pós-operatóri
70 anos
ou mais, em comparação com receptores mais jovens. Métodos: Estudo retrospectivo baseado em dados deíndices de recidiva
prontuários médicoshemorrágica. Conclusão
de 309 receptores
de transplante de fígado tratados pela mesma equipe cirúrgica em três hospitais — dois localizados em São Paulo (SP) e um em Rio Branco (AC).
Os pacientes foram divididos em dois grupos para comparação: aqueles com até 69 anos (Grupo I) e aqueles operatórios
com 70precoces
anos ou ou maistardios.
(GrupoAII).
comparação entre a qu
Resultados: As características dos doadores foram semelhantes entre os dois grupos, exceto por uma dose maior de norepinefrina no Grupo I (p<0,05).
O Grupo II apresentou maior necessidade de transfusão e maior tempo de internação na UTI (p<0,05), DESCRITORES: Esquistossomose
além de maiores taxas de mansoni. Hipertensão
desnutrição e portal. Cirurgia. Pre
comorbidades. A sobrevida em noventa dias foi comparável entre os grupos. Conclusões: Pacientes come gástricas. 70 anos ou mais podem alcançar evoluções
comparáveis aos de receptores mais jovens, desde que recebam enxertos de doadores cuidadosamente selecionados. Essa população não deve ser excluída
das listas de espera para transplante, e políticas específicas de alocação ou ajustes de pontuação devem ser considerados para garantir acesso equitativo.
Palavras-chave: Transplante de Fígado. Idosos. Sobrevida.
ABSTRACT - Background: The treatment of choice for patie
previous episode of varices is bleeding esophagogastric deva
(EGDS) in association with postoperative endoscopic therapy
varices recurrence especially after long-term follow-up. A
behavior of esophageal varices and bleeding recurrence af
treatment of patients submitted to EGDS. Methods: Thirty-s
INTRODUCTION Advanced age and its associated comorbidities are recog-
portal pressure drop, more or less than 30%, and compared w
Liver transplantation (LT) stands as one of the major advance- nized risk factors that may negatively impact transplant out-
varices and the rate of bleeding recurrence. Results
ments in 20th-century medicine, with its indications expanding comes, leading to reduced latepatient and graft
post-operative survival.
varices caliberThis sce-compared the pre
when
in parallel with improved outcomes and growing success rates. nario often raises concerns despite an increase
regarding in diameter
transplant during follow-up
candidacy in that was con
The aging of the global population and the substantial in- Conclusion
the context of organ scarcity, ultimately resulting in more re-
variceal calibers when comparing pre-operative and early or
crease in life expectancy over the last century, from 45–50 years strictive eligibility criteria for elderly recipients19.
The comparison between the portal pressure drop and the
to over 80 years19, combined with changes in the epidemio- Although Brazilian legislation permits the inclusion of
logical profile of chronic liver diseases, have led to a growing patients aged 70 andHEADINGS:
above on the Schistosomiasis mansoni.
transplant waitlist, Portal hypertensio
many
number of patients over 70 years old being referred for LT. centers still decline these Esophageal
candidates and gastric
due varices.
to the higher mor-
In many transplant centers, the number of recipients over bidity and mortality associated with this age group, as well
the age of 65 is steadily increasing; however, transplantation in as concerns about waitlist mortality among younger patients.
patients over 70 years old remains a subject of ongoing debate2,20. This decision often reflects a philosophical stance that is not

[Link]/abcdrevista ww
1
Hospital Alemao Oswaldo Cruz, Liver Transplant Unit – São Paulo (SP), Brazil.
2
Hospital Leforte, Liver Transplant Unit – São Paulo (SP), Brazil.
Hospital das Clínicas de Rio Branco, Liver Transplant Unit – Rio Branco (AC), Brazil Trabalho realizado no 1Serviço de Cirurgia Geral e Aparelho Digestivo, Depa
3

Grupo Hepato, Liver Transplant Unit – São Paulo (SP), Brazil. Brasil; 2Serviço de Endoscopia, Hospital das Clínicas e Departamento de Gas
4

Santa Casa de São Paulo, Faculdade de Ciências Médicas – São Paulo (SP), Brazil. Cirurgia do Fígado, Hospital das Clínicas e Departamento de Gastroenterolo
5

Correspondence: Tércio Genzini. Email: tgenzini@[Link]

Financial source: None Como citar esse artigo: de Biase Silva-Neto WB, Quirese C, De Moura EGH, Co
Conflict of Interests: None
Received: 02/06/2025. Accepted: 06/16/2025 /10.1590/0102-672020210001e1581

Editor: Nelson Adami Andreollo Correspondência:

Walter De Biase da Silva Neto
E-mail: wbiase123@[Link];
How to cite this article: Genzini T, Rodrigues MG, Almeida TN, Danziere FR, Fonseca LEP, Genzini MC, et al. Liver transplantation Recebido
in patients over 70 years old. ABCD Arq Bras Cirpara publicação: 17/0
Dig. 2025;37:e1894. [Link] biase@[Link] Aceito para publicação: 14/12/

2/9 ABCD Arq Br

 Liver transplantation in patients over 70 years old

entirely supported by the current literature, although it may LTs were performed over the past 5 years in São Paulo city
be justified by center-specific experiences. (SP) and since the beginning of the transplant program in
The need for this therapeutic alternative in the elderly Rio Branco (AC), which started in 2014. These timeframes
EDA DA PRESSÃO PORTAL APÓS DESVASCULARIZAÇÃO
population is unquestionable, which justifies the present study were defined based on the availability and completeness of

AGOGÁSTRICA E ESPLENECTOMIA INFLUENCIA A VARIAÇÃO

aimed at reporting the experience of a single surgical team, fol- clinical data from donors and recipients at each institution.
lowing a standardized protocol across three different hospitals. Records prior to the analyzed period were either incomplete
ALIBRE DAS VARIZES E AS TAXAS DE RESSANGRAMENTO NA or inaccessible in the electronic medical charts, making their
inclusion in the analysis unfeasible.
UISTOSSOMOSE NO SEGUIMENTO EM LONGO PRAZO?
METHODS Regarding recipient age, 292 patients were between 14 and
This was a retrospective study based on data collected from 69 years old (Group I), while 17 patients were between 70 and
e drop in portal thepressure
electronicafter medical esophagogastric
records of 309 patients devascularization
who underwentand splenectomy 78 years old (Group II).
n of variceal calibers and the rebleeding rates in schistosomiasis in late follow-up?
LT performed by the same surgical team at three hospitals — Table 1 presents the preoperative characteristics of the
two located in São Paulo, São Paulo state (SP) and one in Rio liver transplant [Link] shown, in patients aged 70 years
Branco, Acre state (AC). or older (Group II), the majority of patients (64.7%) had
de Biase SILVA-NETO 1
The3 objective, Claudemiro
of this studyQUIRESE
was to
1
perform, Eduardo
a Guimarães
comparative bloodHorneaux
type A. de
In MOURA
contrast, among
2
, patients aged up to 69 years
Ferreira COELHO , Paulo patients
analysis between HERMAN 3
aged up to 69 years and those aged (Group I), 41.8% had blood type A and 39% had blood type
70 years or older at the time of LT. O. No statistically significant differences were observed be-
- Racional: O tratamento Data were de escolha
collected para
onpacientes
preoperativecom clinical
hipertensão portal
characteristics tween the two age groups (p>0.05).
ossomótica com of sangramento
recipients, donor de varizes é a desconexão
variables, and clinicalázigo-portal
outcomes mais for 309 Regarding liver function assessed by the Model for End-
ctomia (DAPE) associada à terapia endoscópica. Porém, estudos mostram aumento
liver transplant recipients across three healthcare
re das varizes em alguns pacientes durante o seguimento em longo prazo. Objetivo:
institutions: Stage Liver Disease (MELD) score, values ranged from 7 to 56
o impacto da DAPE twoe tratamento
in the cityendoscópico
of São Paulo (SP) (Hospital
pós-operatório Alemão Oswaldo
no comportamento in Group I, with a mean of 22.1, and from 8 to 31 in Group
zes esofágicas e recidiva
Cruz and hemorrágica, de pacientes
Hospital Leforte – DASA)esquistossomóticos.
and one in theMétodos:city of Rio II, with a mean of 19.5. When classifying liver function sever-
estudados 36 pacientes Brancocom (AC)seguimento
(Hospitalsuperior a cinco
das Clínicas deanos, distribuídos em
Rio Branco). ity, the majority of patients in both age groups had an MELD
upos: queda da pressão portal abaixo de 30% e acima de 30% comparados com o
All patients and/or their legal guardians
das varizes esofágicas no pós-operatório precoce e tardio além do índice de recidiva
signed an in- score of ≤20 (56.5% in Group I and 82.4% in Group II).
ágica. Resultadosformed consent form at the time of their inclusion on the liver As for the Child-Pugh classification, most patients were cate-
cas que, durante transplant
o seguimento aumentaram
waiting de calibre
list, prior e foram controladas
to undergoing com
transplantation, gorized as Class B (49.1% in Group I and 52.9% in Group II).
authorizing the use of their clinical, laboratory, and imaging Evolução do calibre das varizes
No statistically no período
significant pré e pós- were observed between
differences
ortamento do calibre das varizes no pós-operatório precoce nem tardio nem os operatório precoce e tardio
data for research and scientific publication purposes, provided
de recidiva hemorrágica. Conclusão
the age groups (p>0.05) (Table 1).
their identities remained confidential. No significant differences were observed between the two
rios precoces ou tardios. A comparação entre a queda de pressão do portal e as Mensagem
age groups centralin terms of nutritional status or body mass index
A (BMI)
desconexão ázigo-portal
(p>0.05). In Group e esplenectomia
I, 54.6% of the patients were classi-
ES: Esquistossomose mansoni. Hipertensão portal. Cirurgia. Pressão na veia porta. Varizes esofágicas apresenta importante impacto na diminuição
Statistical analysis fied as
precoce do eutrophic,
calibre das whereas in Group
varizes esofágicas na II, 41.2% were eutrophic
Descriptive statistics included minimum, maximum, esquistossomose; and 35.3% presented entretanto, with parecemild quemalnutrition.
a BMI in Group
associação com a terapia endoscópica é a 2maior
median (P50), interquartile range (P25–P75), mean, and responsável I ranged pelofrom
controle 14datorecidiva kg/m , with a mean of 25.9 kg/m2,
43.9hemorrágica.
T - Background: standard The treatment of choice
deviation (SD), forinpatients
addition withtoschistosomiasis
percentages, to with
sum- while in Group II, it ranged from 20.8 to 33.3 kg/m2, with a
s episode of varices is bleeding esophagogastric devascularization
marize the variables studied. The association or dependence and splenectomy mean of 26.7 kg/m2. In both groups, the majority of patients
n association with postoperative endoscopic therapy. However, studies have shown Perspectiva
recurrence especially
between two categorical variables was assessed using Pearson’s
after long-term follow-up. Aim: To assess the impact on
had a BMI below 30 kg/m2, indicating the absence of obe-
Este estudo avaliou o impacto tardio no índice
r of esophageal ꭓ [Link]’s exactrecurrence
test was after
also post-operative
applied to evaluate associa- de sity (Table 1).
2
varices bleeding endoscopic ressangramento de pacientes submetidos ao
nt of patients submitted to [Link]
tions between Methods: Thirty-six patients
variables, submittedfor
particularly to compari-
EGDS tratamentoApproximately 60% of Athe
cirúrgico e endoscópico. quedapatients
na in Group I and 70.6%
sons of event proportions between groups. This test was rec- in Group II were classified under Indication Group A for
ressure drop, more or less than 30%, and compared with the behavior of esophageal variação do calibre das varizes quando comparado
ommended due to the small sample size, especially in patients o seu
and the rate of bleeding recurrence. Results
transplantation
diâmetro no pré e(including
pós-operatóriohepatocellular
precoce e carcinoma [HCC],
aged >[Link] the pre-operative data was observed tardio. A comparação
polycystic liver entre a queda
disease, de pressão
metabolic disorders, disabling enceph-
st-operative varices caliber portal e as taxas de ressangramento, também
an increase in diameter Toduring
comparefollow-up
two that was controlled
independent by endoscopic
groups (≤69 vs. therapy.
≥70 years) alopathy, intractable pruritus, viral hepatitis, and hemochro-
sion in terms of the mean of an interval variable (e.g., age), the evidenciar matosis),se apenas
whicha was terapiaconsidered
endoscópica,less ou severe by the transplant
calibers when comparing pre-operative and early or late post-operative diameters. operações menos complexas poderão controlar o
independent samples Student’s t-test was used.
mparison between the portal pressure drop and the rebleeding rates was also not
team. Additionally, 28.2% of the patients in Group I and
sangramento das varizes.
Levene’s test was applied to assess the homogeneity of vari- 17.6% in Group II fell into Indication Group B (including
S: Schistosomiasis ances mansoni.
for eachPortal
variablehypertension.
between theSurgery.
two [Link] pressure. combined liver-kidney transplantation, nonalcoholic steato-
geal and gastric varices. This test aims to determine whether the variances of a giv- hepatitis [NASH], and alcohol-related cirrhosis), which was
en variable differ significantly between groups, with a signifi- considered more severe. No statistically significant differences
cance level set at p<0.05. were observed between the two groups (p>0.05) (Table 2).
In this study, variance heterogeneity was assumed; there- The criteria for clinical severity classification were estab-
fore, results from the Student’s t-test were interpreted under lished based on the underlying etiology of liver disease, accord-
the assumption of unequal variances,
[Link]/abcdrevista providing more robust [Link]/abcdrevista
[Link]/abcdrevista ing to the medical team’s experience. Patients with conditions
statistical inferences. typically associated with slower progression or more favorable
zado no 1Serviço de Cirurgia AllGeral
results were considered
e Aparelho statistically
Digestivo, Departamento significant
de Clínica Cirúrgica,when thede Medicina,
Faculdade prognosis (e.g.,Federal
Universidade HCC andGoiânia,
de Goiás, controlled
GO, viral hepatitis) were
o de Endoscopia, Hospital
p-value das Clínicas
was lesse Departamento
than 0.05,decorresponding
Gastroenterologia,toFaculdade de Medicina,
a confidence Universidade
level de São Paulo,
considered lessSãosevere
Paulo, SP, Brasil;
and 3
Serviço deto Group A. In contrast,
allocated
gado, Hospital das Clínicas e Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
of at least 95%. those with diseases associated with higher clinical risk, need
se artigo: de Biase Silva-Neto WB, Quirese C, De Moura EGH, Coelho FF, Herman P. A queda da pressão portal apósfor desvascularização
combinedesofagogástrica e esplenectomia or severe complications
organ transplantation,
2-672020210001e1581
(e.g., alcohol-related cirrhosis, NASH, and refractory ascites)
RESULTS were categorized into higher severity groups (Groups B–D).
ência:
se da Silva Neto
A total of 309 patients were included in this study: 213 This categorization was developed exclusively for statistical
e123@[Link]; from São Pauloparastate
Recebido (SP)17/09/2020
publicação: and 96 from Acre state (AC). analysis purposes and does not reflect universally standardized
[Link] Aceito para publicação: 14/12/2020

ABCD Arq Bras Cir Dig 2021;34(2):e1581 1/4 3/9

ORIGINAL ARTICLE

Table 1. Preoperative characteristics of liver transplant recipients by age group (n=309).

Characteristics Group I (≤69 years) Group II (≥70 years) p-value

A11QUEDA DA PRESSÃO PORTAL

Blood type (%)
A 122 (41.8) (64.7)
AB 19 (6.5) ESOFAGOGÁSTRICA
1 (5.9) E ESPLENE
DO CALIBRE DAS VARIZES E AS
0.227*
B 37 (12.7) 2 (11.8)
O 114 (39.0)
ESQUISTOSSOMOSE NO SEGUI
3 (17.6)
Liver function (MELD score)
Minimum-Maximum 7.0–56.0 Does the drop in portal pressure after esophago
8.0–31.0
Mean±SD 22.1±8.8 variation of variceal calibers
19.5±6.4 0.138and
†
the rebleeding
Median (P25–P75) 21.0 (15.0; 29.0) 19.0 (15.0; 23.0)
Liver function (categories) (%) Walter de Biase SILVA-NETO1 , Claudemiro Q
≤20 165 (56.5)
Fabricio
14 (82.4)
Ferreira COELHO3 , Paulo HERMAN3
21–24 35 (12.0) 0 (0.0)
RESUMO - Racional: O tratamento de escolha para pacie
25–29 34 (11.6) 1esquistossomótica
(5.9) 0.336* de varizes é a d
com sangramento
30–35 37 (12.7) esplenectomia
2 (11.8) (DAPE) associada à terapia endoscópica. Poré
do calibre das varizes em alguns pacientes durante o seguim
>35 21 (7.2) 0Avaliar
(0.0) o impacto da DAPE e tratamento endoscópico pós-
das varizes esofágicas e recidiva hemorrágica, de pacientes
Child-Pugh classification (%)
Foram estudados 36 pacientes com seguimento superior
Class A 72 (24.7) 6dois grupos: queda da pressão portal abaixo de 30% e acim
(35.3)
calibre das varizes esofágicas no pós-operatório precoce e ta
Class B 143 (49.1) 9hemorrágica.
(52.9) Resultados 0.356*
Class C 76 (26.1) 2esofágicas
(11.8) que, durante o seguimento aumentaram de cal

Nutritional status (%) o comportamento do calibre das varizes no pós-operatóri

Eutrophic 159 (54.6) 7índices
(41.2) de recidiva hemorrágica. Conclusão
Mild malnutrition 47 (16.2) 6operatórios
(35.3) precoces ou tardios. A comparação entre a qu
0.146*
Moderate malnutrition 37 (12.7) 3 (17.6)
DESCRITORES: Esquistossomose mansoni. Hipertensão portal. Cirurgia. Pre
Severe malnutrition 48 (16.5) e gástricas.
1 (5.9)
Body mass index (BMI, kg/m2)
Minimum-Maximum 14.0–43.9 ABSTRACT
20.8–33.3 - Background: The treatment of choice for patie
previous episode of varices is bleeding esophagogastric deva
Mean±SD 25.9±4.4 26.7±3.6 0.378†
(EGDS) in association with postoperative endoscopic therapy
Median (P25–P75) 25.2 (23.0; 27.9) varices29.7)
26.6 (23.5; recurrence especially after long-term follow-up. A
behavior of esophageal varices and bleeding recurrence af
MELD: Model for End-Stage Liver Disease; BMI: Body mass index; SD: Standard deviation.
treatment of patients submitted to EGDS. Methods: Thirty-s
*ꭓ2 test; †student’s t-test for independent samples.
portal pressure drop, more or less than 30%, and compared w
varices and the rate of bleeding recurrence. Results
criteria. Rather, it represents a functional classification adapted bilirubin (TB), and direct
late bilirubin (DB)varices
post-operative — no statistically
caliber when compared the pre
to the clinical practice realities of the participating centers. despite
significant differences were an increase
observed in diameter
between during
Groups I follow-up
and that was con
In Group I, 19.5% of the patients had a history of previ- II (Table 4). Conclusion
variceal calibers when comparing pre-operative and early or
ous surgeries, compared to 11.8% in Group II. No statisti- Complete data on cold ischemia time (i.e., the interval be-
The comparison between the portal pressure drop and the
cally significant difference was observed between the groups tween organ procurement and implantation) were not consis-
(p>0.05) (Table 2). tently recorded in theHEADINGS:
electronic Schistosomiasis
medical records,mansoni. preventing Portal hypertensio
Regarding comorbidities and preoperative clinical condi- Esophageal
their inclusion in the statistical and gastric varices.
analysis.
tions, a statistically significant difference was found between Table 5 summarizes the clinical outcomes assessed in
the two age groups (p<0.05). In Group I, the majority of pa- this study. A statistically significant difference (p<0.05) was
tients (58.9%) had no documented comorbidities, whereas in observed regarding the number of blood transfusion units
Group II, 47.1% of the patients had at least one comorbid- required, with Group II presenting a significantly higher
ity—most commonly insulin-dependent diabetes and/or hy- transfusion requirement compared to Group I. For the other
[Link]/abcdrevista ww
pertension (Table 2). outcomes — including length of ICU stay, total hospital
Table 3 presents the characteristics of the donors. As shown, stay, 90-day post-transplant mortality,
Trabalho realizado no 1Serviçoneed for Geral
de Cirurgia dialysis,
e Aparelho Digestivo, Depa
statistically significant differences (p<0.05) were found only in Brasil; 2
Serviço de Endoscopia,
and 1-year post-transplant survival, no statistically Hospital das Clínicas e Departamento de Gas
signifi-
Cirurgia do Fígado, Hospital das Clínicas e Departamento de Gastroenterolo
relation to the norepinephrine dosage, which was significant- cant differences were identified at the 5% significance level.
ly higher among donors for Group I compared to those for However, at an 8% Como citar esse artigo:
significance de Biase Silva-Neto
threshold, WB, Quirese
differences be-C, De Moura EGH, Co
Group II. For all other donor-related parameters—including tween the two age groups were noted regarding 90-day mor-
/10.1590/0102-672020210001e1581
age, BMI, length of ICU stay, presence of positive cultures, tality and 1-year survival: Group I showed a higher rate of
Correspondência:
elevated serum sodium, and higher levels of alanine amino- death within 90 daysWalter
andDea Biaselower 1-year survival rate com-
da Silva Neto
transferase (ALT), gamma-glutamyl transferase (GGT), total pared to Group II. E-mail: wbiase123@[Link]; Recebido para publicação: 17/0
biase@[Link] Aceito para publicação: 14/12/

4/9 ABCD Arq Br

 Liver transplantation in patients over 70 years old

Table 2. Preoperative patient characteristics by recipient age group (n=309).

Characteristics Group I (≤69 years) Group II (≥70 years) p-value

EDA DA PRESSÃO PORTAL APÓS DESVASCULARIZAÇÃO

BMI (categories) (%)
<30 257 (88.0) 14 (82.4)
AGOGÁSTRICA
30–35 E ESPLENECTOMIA INFLUENCIA
23 (7.9) A VARIAÇÃO
3 (17.6)
ALIBRE DAS VARIZES E AS TAXAS DE RESSANGRAMENTO0 NA
0.512
35.1–40 7 (2.4) (0.0)

UISTOSSOMOSE
>40
NO SEGUIMENTO EM LONGO PRAZO? 0 (0.0)
5 (1.7)
Transplant indication (%)

e drop in portal pressure

Group A after esophagogastric devascularization
168 (57.7) and splenectomy 12 (70.6)
n of variceal calibers and the rebleeding rates in schistosomiasis in late follow-up?
Group B 82 (28.2) 3 (17.6)
0.686
Group C 36 (12.4) 2 (11.8)
Group D , Claudemiro QUIRESE , Eduardo
de Biase SILVA-NETO 1 1
5 (1.7) Guimarães Horneaux de MOURA
0 (0.0)
2
,
Ferreira COELHO
Previous,surgeries
3
Paulo HERMAN
(%)
3

No 235 (80.5) 15 (88.2)

- Racional: O tratamento de escolha para pacientes com hipertensão portal 0.750
Yes
ossomótica com sangramento 57 (19.5)
de varizes é a desconexão ázigo-portal mais 2 (11.8)
ctomia (DAPE) associada
Preoperative comorbidities and clinical conditions (%)aumento
à terapia endoscópica. Porém, estudos mostram
re das varizes em alguns pacientes durante o seguimento em longo prazo. Objetivo:
o impacto da DAPE eGroup
tratamento
A endoscópico pós-operatório no comportamento
172 (58.9) 5 (29.4)
zes esofágicas e recidiva hemorrágica, de pacientes esquistossomóticos. Métodos:
Group B 25 (8.6) 8 (47.1)
estudados 36 pacientes com seguimento superior a cinco anos, distribuídos em
upos: queda da pressão portal
Group C abaixo de 30% e acima de 30% comparados com o
23 (7.9) 3 (17.6) <0.001
das varizes esofágicas no pós-operatório precoce e tardio além do índice de recidiva
ágica. Resultados
Group D 40 (13.7) 1 (5.9)
cas que, durante o seguimento
Group E aumentaram de calibre e foram controladas com
32 (11.0) 0 (0.0)
Evolução do calibre das varizes no período pré e pós-
p-values
ortamento do calibre dasrefer to the
varizes noFisher’s exact test. precoce
pós-operatório BMI: Body masstardio
nem [Link] os operatório precoce e tardio
de recidiva hemorrágica. Conclusão

rios precoces ou Table

tardios. 3. Donor characteristics
A comparação entre a quedabyderecipient ageportal
pressão do group (n=309).Mensagem central
e as
Donor characteristics A desconexão
Group I (≤69 years) ázigo-portal
Groupe IIesplenectomia
(≥70 years) p-value
ES: Esquistossomose mansoni. Hipertensão portal. Cirurgia. Pressão na veia porta. Varizes esofágicas apresenta importante impacto na diminuição
Age precoce do calibre das varizes esofágicas na
esquistossomose; entretanto, parece que a
Minimum-maximum 5.0–71.0 11.0–70.0
associação com a terapia endoscópica é a maior
responsável pelo controle da recidiva hemorrágica.
T - Background: TheMean±SD
treatment of choice for patients with schistosomiasis39.2±15.4
with 41.7±18.1 0.589*
s episode of varices isMedian
bleeding esophagogastric
(P25–P75) devascularization and splenectomy
40.0 (24.0; 51.0) 45.0 (25.0; 56.0)
n association with postoperative endoscopic therapy. However, studies have shown Perspectiva
recurrence especially after long-term follow-up. Aim: To assess the impact on
Body mass index (BMI, kg/m )
2
Este estudo avaliou o impacto tardio no índice
r of esophageal varices and bleeding recurrence after post-operative endoscopic
Minimum-maximum 14.0–54.0 de ressangramento de pacientes17.0–38.0
submetidos ao
nt of patients submitted to EGDS. Methods: Thirty-six patients submitted to EGDS tratamento cirúrgico e endoscópico. A queda na
Mean±SD 26.1±5.2 25.5±4.6 0.637*
ressure drop, more or less than 30%, and compared with the behavior of esophageal variação do calibre das varizes quando comparado
Median (P25–P75)
and the rate of bleeding recurrence. Results
25.0 (23.0; 29.0)o seu diâmetro no pré e pós-operatório
25.0 (23.0;precoce
27.5) e
tardio. A comparação entre a queda de pressão
st-operative varicesICU
caliber
staywhen
(days)compared the pre-operative data was observed portal e as taxas de ressangramento, também
an increase in diameter during follow-up that was controlled by endoscopic therapy.
sion Minimum-maximum 0.0–23.0 1.0–11.0
evidenciar se apenas a terapia endoscópica, ou
calibers when comparing pre-operative
Mean±SD and early or late post-operative diameters.
5.5±3.4 operações menos complexas poderão controlar o
5.2±2.5 0.659*
mparison between the portal pressure drop and the rebleeding rates was also not sangramento das varizes.
Median (P25–P75) 5.0 (3.0; 7.0) 4.5 (4.0; 6.8)
S: Schistosomiasis mansoni. Portal hypertension. Surgery. Portal pressure.
Norepinephrine dose (μg/kg/min)
geal and gastric varices.
Minimum-maximum 0.00–1.22 0.00–0.31
Mean±SD 0.16±0.19 0.11±0.09 0.045*
Median (P25–P75) 0.11 (0.02; 0.21) 0.10 (0.03; 0.18)
Positive culture (%)
[Link]/abcdrevista [Link]/abcdrevista [Link]/abcdrevista
No 265 (92.7) 17 (100.0)
0.618†
Yes Geral e Aparelho Digestivo, Departamento de Clínica Cirúrgica, Faculdade
zado no 1Serviço de Cirurgia 21 (7.3) de Medicina, Universidade Federal de Goiás,
0 (0.0)
Goiânia, GO,
o de Endoscopia, Hospital das Clínicas e Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil; 3Serviço de
Highest sodium level (mEq/L)
gado, Hospital das Clínicas e Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
Minimum-maximum 125.0–200.0 139.0–177.0
se artigo: de Biase Silva-Neto WB, Quirese C, De Moura EGH, Coelho FF, Herman P. A queda da pressão portal após desvascularização esofagogástrica e esplenectomia
Mean±SD 152.6±12.9 153.2±10.1 0.809*
2-672020210001e1581
Median (P25–P75) 150.0 (143.0; 160.0) 153.0 (145.0; 158.0)
ência:
se da Silva Neto SD: Standard deviation; BMI: Body mass index; ICU: Intensive care unit.
e123@[Link]; *Student’sRecebido
t-test forpara publicação: samples;
independent 17/09/2020Fisher’s exact test.
†

[Link] Aceito para publicação: 14/12/2020

ABCD Arq Bras Cir Dig 2021;34(2):e1581 1/4 5/9

ORIGINAL ARTICLE

Table 4. Donor liver function parameters by recipient age group (n=309).

Donor characteristics Group I (≤69 years) Group II (≥70 years) p-value

A9.0–430.0
QUEDA DA PRESSÃO PORTAL
Highest ALT (U/L)
Minimum-maximum 5.0–2083.0
Mean±SD 94.4±188.0 ESOFAGOGÁSTRICA
68.8±97.5 0.338* E ESPLENE
Median (P25–P75) 47.0 (28.0; 84.0) DO
33.0 CALIBRE
(22.5; 75.5) DAS VARIZES E AS
Highest GGT (U/L)
ESQUISTOSSOMOSE NO SEGUI
Minimum-maximum 7.0–965.0 15.0–370.0
Mean±SD 103.6±136.0 Does the drop in portal pressure
78.6±87.1 0.281* after esophago
Median (P25–P75) 55.0 (26.0; 119.0) variation
48.0 of variceal calibers and the rebleeding
(26.5; 105.0)
Highest total bilirubin (mg/dL)
Minimum-maximum 0.00–6.00 Walter de Biase SILVA-NETO1 , Claudemiro Q
0.00–4.17
Mean±SD 0.79±0.88
Fabricio
0.83±1.21
Ferreira COELHO 3
, Paulo HERMAN3
0.908*
Median (P25–P75) 0.66 (0.00; 1.00) 0.39 (0.00; 1.00)
RESUMO - Racional: O tratamento de escolha para pacie
Highest direct bilirubin (mg/dL) esquistossomótica com sangramento de varizes é a d
Minimum-maximum 0.00–3.43 esplenectomia (DAPE) associada à terapia endoscópica. Poré
0.00–2.46
do calibre das varizes em alguns pacientes durante o seguim
Mean±SD 0.36±0.60 Avaliar o impacto da DAPE e tratamento
0.29±0.62 0.670* endoscópico pós-
das varizes esofágicas e recidiva hemorrágica, de pacientes
Median (P25–P75) 0.10 (0.00; 0.50) 0.00 (0.00; 0.35)
Foram estudados 36 pacientes com seguimento superior
ALT: Alanine aminotransferase; SD: Standard deviation; GGT: Gamma-glutamyl transferase. dois grupos: queda da pressão portal abaixo de 30% e acim
*Student’s t-test for independent samples. calibre das varizes esofágicas no pós-operatório precoce e ta
hemorrágica. Resultados
esofágicas que, durante o seguimento aumentaram de cal
Table 5. Clinical outcomes by recipient age group (n=309).
o comportamento do calibre das varizes no pós-operatóri
Outcome Group I (≤69 years) Group IIíndices
(≥70 years) p-value
de recidiva hemorrágica. Conclusão
Transfusion units
operatórios precoces ou tardios. A comparação entre a qu
Minimum-maximum 0.0–14.0 0.0–7.0
DESCRITORES: Esquistossomose mansoni. Hipertensão portal. Cirurgia. Pre
Mean±SD 1.6±2.4 e 3.1±2.1
gástricas. 0.009*
Median (P25–P75) 0.0 (0.0; 2.0) 3.0 (1.5; 4.5)
ICU stay (days)
ABSTRACT - Background: The treatment of choice for patie
Minimum-maximum 0.0–190.0 previous episode of varices is bleeding esophagogastric deva
2–37
(EGDS) in association with postoperative endoscopic therapy
Mean±SD 6.5±14.4 9.9±9.4 0.192*
varices recurrence especially after long-term follow-up. A
Median (P25–P75) 3.0 (2.0; 6.0) behavior
7.0 (4.0; 9.8) of esophageal varices and bleeding recurrence af
treatment of patients submitted to EGDS. Methods: Thirty-s
Hospital stay (days)
Minimum-maximum 0.0–190.0 portal pressure drop, more or less than 30%, and compared w
7.0–37.0
varices and the rate of bleeding recurrence. Results
Mean±SD 16.0±21.6 late post-operative varices caliber
16.6±9.0 0.831*when compared the pre
Median (P25–P75) 10.0 (7.0; 16.0) despite
15.0 (9.0; an increase in diameter during follow-up that was con
230)
Conclusion
90-day mortality variceal calibers when comparing pre-operative and early or
The comparison between the portal pressure drop and the
No 250 (85.6%) 17 (100.0%)
0.078†
Yes 42 (14.4%) HEADINGS:
0 (0.0%) Schistosomiasis mansoni. Portal hypertensio
Esophageal and gastric varices.
Dialysis
No 270 (92.5%) 15 (88.2%)
0.631†
Yes 22 (7.5%) 2 (11.8%)
1-year survival
No 63 (22.9%) 0 (0.0%) [Link]/abcdrevista ww
0.079†
Yes 212 (77.1%) 13 (100.0%)
Trabalho realizado no 1Serviço de Cirurgia Geral e Aparelho Digestivo, Depa
*Student’s t-test; Fisher’s exact test.
† Brasil; 2Serviço de Endoscopia, Hospital das Clínicas e Departamento de Gas
SD: Standard deviation. Cirurgia do Fígado, Hospital das Clínicas e Departamento de Gastroenterolo

Como citar esse artigo: de Biase Silva-Neto WB, Quirese C, De Moura EGH, Co
In the preoperative comparison, liver function, assessed by C: 26.6 vs. 32.5%, p=0.45, p>0.5). However, the degree of
/10.1590/0102-672020210001e1581
Child-Pugh classification and MELD-Na+ score, was similar malnutrition was higher in Group II, with 40% of cases clas-
Correspondência:
between Groups I and II (MELD-Na+: 19.6 vs. 22.4, p=0.69, sified as having severeWalter
malnutrition (p<0.05). In Group II, 8
De Biase da Silva Neto
p>0.5; Child-Pugh A: 26.6 vs. 26.3%, B: 46.6 vs. 41.1%, and patients (53.3%) were listed
E-mail: as special cases due to HCC,
wbiase123@[Link]; Recebido2para publicação: 17/0
biase@[Link] Aceito para publicação: 14/12/

6/9 ABCD Arq Br

 Liver transplantation in patients over 70 years old

(13.3%) due to refractory ascites, 1 (6.7%) due to hepatic en- Moreover, the systematic review and meta-analysis conducted
cephalopathy (HE), and 1 (6.7%) due to hepatic hydrothorax. by Charlton et al. concluded that increased recipient age was
During hospitalization, Group II had a significantly longer significantly associated with higher post-transplant mortality
EDA DA PRESSÃO PORTAL APÓS DESVASCULARIZAÇÃO
ICU stay (5 vs. 3 days, p<0.05), while mechanical ventilation (hazard ratio [HR] 2.07; 95%CI 1.71–2.50; p=0.40, p>0.5)5.

AGOGÁSTRICA E ESPLENECTOMIA INFLUENCIA A VARIAÇÃO

time was similar between groups (1 vs. 1 day, p=0.76, p>0.05). However, a shift in the etiological profile of liver transplant
Hemodialysis was more frequent in Group I, although the dif- candidates, particularly the rising prevalence of metabolism-
ALIBRE DAS VARIZES E AS TAXAS DE RESSANGRAMENTO NA
ference was not statistically significant (0 vs. 21.3%, p=0.32,
p>0.5). The overall length of hospital stay was comparable be-
related liver diseases, has led to an increase in the age of trans-
plant recipients. As a result, LT in elderly patients is becoming
UISTOSSOMOSE NO SEGUIMENTO EM LONGO PRAZO?
tween the groups (9.5 vs. 8 days, p=0.51, p>0.05). an increasingly necessary therapeutic option.
Early survival (within 90 days post-transplant) was also In 1988, only 1.7% of liver transplants performed in the
e drop in portal pressure
similar between after esophagogastric
Groups I and II (86.9 vs. devascularization
90%, p=1.0, p>0.5).and splenectomy United States were in recipients over the age of 65. By 2016,
n of variceal calibers and the rebleeding rates in schistosomiasis in late this follow-up?
percentage had risen to 18.7%2,15, and in 2017, to 20%10.
These changes have been attributed to an increase in the aver-
Classification of clinical age age at the time of waitlist2registration, as well as to shifts
de Biase SILVA-NETO , Claudemiro QUIRESE , Eduardo Guimarães
1 1
in Horneaux
the etiological deprofile
MOURA of liver ,diseases leading to transplan-
severity used in this study
Ferreira COELHO , Paulo HERMAN 3 3
tation. There has been a marked rise in conditions associated
Transplant indication groups (based on clinical severity as with metabolic syndrome, such as nonalcoholic fatty liver dis-
- Racional: O tratamento
defined byde theescolha
medicalpara pacientes com hipertensão portal
team). ease (NAFLD) and HCC, along with a decline in viral hepati-
ossomótica com •sangramento Group A –deLow varizes é a desconexão
severity: HCC, polycysticázigo-portal
liver mais
disease, tis-related indications10.
ctomia (DAPE) associada à terapia endoscópica. Porém, estudos mostram aumento
disabling encephalopathy, intractable pruritus, viral hepa-
re das varizes em alguns pacientes durante o seguimento em longo prazo. Objetivo:
In the cases analyzed by our team, this etiological pro-
o impacto da DAPE etitis, and hemochromatosis.
tratamento endoscópico pós-operatório no comportamento file was clearly evident (Table 2), with a higher incidence of
zes esofágicas e recidiva
• Group hemorrágica, de pacientes
B – Moderate esquistossomóticos.
severity: Métodos:
combined liver–kidney MASH among patients aged 70 years or older (Group II).
estudados 36 pacientes com seguimento superior
transplantation, a cinco anos, distribuídos
metabolic-associated em
steatohepatitis Several authors have reported LT outcomes in elderly
upos: queda da pressão portal abaixo de 30% e acima de 30% comparados com o
(MASH), and alcohol-related cirrhosis.
das varizes esofágicas no pós-operatório precoce e tardio além do índice de recidiva
patients, with some studies showing poor results and others
ágica. Resultados• Group C – High severity: refractory ascites, hepatic hydro- reporting favorable outcomes. There is increasing recognition
cas que, durante o seguimento aumentaram de calibre
thorax, retransplantation, e foram controladas
and Budd-Chiari syndrome. com that chronological age should not be considered an isolated
• Group D – Highest severity: fulminant hepatitis. Evolução do calibre
criterion, anddas varizes
that no período pré e pós-
physiological age may represent a more
ortamento do calibre das varizes no pós-operatório precoce nem tardio nem os operatório precoce e tardio
de recidiva hemorrágica. Conclusão
meaningful indicator of transplant eligibility19.
Preoperative comorbidities and clinical conditions (strati- Cross et al. compared liver transplant outcomes among
rios precoces ou fied tardios. A comparação entre a queda de pressão do portal e as
by severity). Mensagem
recipients central
aged 60–64 years, ≥65 years, and <60 years, and
• Group A – No comorbidities. A desconexão
found similar ázigo-portal
graft andepatient
esplenectomia
survival rates at 30 days, 1 year,
ES: Esquistossomose mansoni. Hipertensão portal. Cirurgia. Pressão na veia porta. Varizes esofágicas apresenta importante impacto 9na diminuição
• Group B – Insulin-dependent diabetes mellitus and sys- precoce and 5doyears,calibrerespectively
das varizes .esofágicas na
temic arterial hypertension. esquistossomose;
However,entretanto,
in patients parece
agedque >65 ayears, MELD scores were
associação com a terapia endoscópica é a maior
• Group C – Partial portal vein thrombosis, renal insuffi- responsável lower, pelohepatitis
controleC was less
da recidiva common, and the proportion of
hemorrágica.
T - Background: Theciency treatment of choiceclearance
(creatinine for patients with schistosomiasis
between 30 and 50 mL/min), with patients with primary biliary cholangitis was higher.
s episode of varices is prior bleeding esophagogastric
dialysis, devascularization
and anticoagulant use. and splenectomy Lipshutz et al. also demonstrated comparable outcomes
n association with postoperative endoscopic therapy. However, studies have shown Perspectiva
• Group D – Complete portal vein
recurrence especially after long-term follow-up. Aim: To assess the impact on
thrombosis, ongoing after LT in septuagenarians versus younger patients, provided
r of esophageal varices dialysis or creatinine
and bleeding clearance
recurrence <30 mL/min,
after post-operative mechanical Este
endoscopic
estudo avaliou o impacto tardio no índice
that physiological age and pretransplant clinical conditions
de ressangramento de pacientes submetidos ao
nt of patients submitted to EGDS. Methods:
ventilation, Thirty-six patients
and hospitalization in thesubmitted to EGDS
general ward. were thoroughly
tratamento assessed14.A queda na
cirúrgico e endoscópico.
• Group E – Use of vasoactive drugs (VADs), depressed Studies such as those by Kim et al.13 and Freitas et al.11
ressure drop, more or less than 30%, and compared with the behavior of esophageal variação do calibre das varizes quando comparado
level of consciousness, and admission to the intensive care o seu
and the rate of bleeding recurrence. Results
emphasize
diâmetro nothatpré eelderly patients
pós-operatório cane achieve satisfactory out-
precoce
unit (ICU). tardio.
comesA comparação
after LT,entre a queda
provided de are
they pressão
carefully selected based on a
st-operative varices caliber when compared the pre-operative data was observed portal e as taxas de ressangramento, também
an increase in diameter during follow-up that was controlled by endoscopic therapy. comprehensive evaluation of their clinical condition and their
sion evidenciar
abilitysetoapenas
tolerate a terapia
both theendoscópica,
surgicalouprocedure and the postop-
calibers when comparing pre-operative and early or late post-operative diameters. operações menos complexas poderão controlar o
DISCUSSION
mparison between the portal pressure drop and the rebleeding rates was also not
erative rehabilitation process.
sangramento das varizes.
LT in patients over 70 years of age remains a complex and Croome et al. compared simultaneous liver–kidney trans-
S: Schistosomiasis mansoni. issue,
challenging Portalprimarily
hypertension.
due toSurgery. Portalaspressure.
factors such poorer out- plantation in patients over 65 years of age (n=8,495) with those
geal and gastric comes [Link] the ethical implications of increased waitlist mor- under 65 years of age (n=4,517) and observed similar patient
tality among younger candidates. Current studies suggest that survival outcomes between the two groups8. It is important to
overall post-transplant survival is higher in younger recipients, emphasize that the decision to perform LT in elderly patients
with a mean age of approximately 40 years, based on data from must be based on an individualized approach, carefully weigh-
the United Kingdom and the United States. ing the risks and benefits of the procedure for each specific case.
Gil et al. compared liver
[Link]/abcdrevista transplant outcomes between [Link]/abcdrevista
[Link]/abcdrevista Beyond physiological reserve — which is influenced by fac-
middle-aged recipients and those aged over 70 and found that tors such as physical activity, diet, smoking, alcohol use, and
zado no 1Serviço de the riskGeral
Cirurgia of emortality in theDepartamento
Aparelho Digestivo, elderly group wasCirúrgica,
de Clínica approximately others—psychosocial
Faculdade de Medicina, Universidade Federal decomorbidities
Goiás, Goiânia, GO, such as depression can
o de Endoscopia, Hospital
four das Clínicas
times e Departamento
higher de Gastroenterologia,
after adjusting Faculdadeliver
for underlying de Medicina,
diseaseUniversidade de São Paulo,impact
significantly São Paulo,clinical
SP, Brasil; 3Serviço
outcomesde after transplantation.
gado, Hospital das Clínicas e Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
(odds ratio [OR] 4.1; 95% confidence interval [CI] 2.21– A meta-analysis of 27 studies involving over 1,000 patients
se artigo: de Biase Silva-Neto
7.58) and WB, Quirese
nearlyC, three
De Moura EGH,higher
times Coelho FF, Herman
after P. A quedafor
adjusting da pressão portal apósdemonstrated
both liv- desvascularização esofagogástrica e esplenectomia
that post-transplant depression was associated
2-672020210001e1581
er disease and perioperative complications (OR 2.92; 95%CI with a 65% increased risk of both mortality and graft loss15.
1.37–6.24)12. Furthermore, the cost of LT was shown to in- In the analyses by Chen et al. in Taiwan, increased mortal-
ência:
se da Silva Neto
crease significantly with advancing age, reinforcing the need ity was observed from the age of 60 onward6, while Sony et al.
e123@[Link]; for cautious consideration
para publicação:when selecting elderly recipients . in the United States reported similar findings18.
12
Recebido 17/09/2020
[Link] Aceito para publicação: 14/12/2020

ABCD Arq Bras Cir Dig 2021;34(2):e1581 1/4 7/9

ORIGINAL ARTICLE

However, both studies demonstrated that cardiac and renal co- tor that complicates transplantation in older recipients is the
morbidities, HE, thrombocytopenia, TB >3.5 mg/dL, and serum inability to use extended criteria donors, due to the high post-
albumin <2.65 mg/dL were associated with worse outcomes6,18. operative mortality associated with these grafts3.
These studies also showed that pretransplant BMI and A QUEDA DA PRESSÃO PORTAL
Following the team’s routine practice of carefully match-

ESOFAGOGÁSTRICA E ESPLENE
smoking history further increased post-transplant mortality in ing donors and recipients, and considering age >70 years as
elderly recipients. a relevant indicator of clinical severity, donors are selected
Slattery et al. compared LT outcomes in patients over
65 years of age (n=40) versus those under 65 years of age
DO CALIBRE DAS VARIZES E AS
based on lower vasopressor requirements and reduced ex-
pected cold ischemia times in transplants performed in this
(n=511) using data from the Irish national registry and ob- subgroup (Table 3). ESQUISTOSSOMOSE NO SEGUI
served lower survival rates in the older group — 77.8 vs. 93% In 2010, Aloia et al. published a study demonstrating an
at 1 year and 64.5 vs. 85% at 3 years17. Does
association between the sumthe of drop
donorin andportal pressure
recipient ages and after esophago
Schwartz et al. compared LT outcomes in patients with variation of variceal calibers and the rebleeding
post-transplant outcomes, showing worse results when this
HCC, aged >70 versus <70 years, and found lower survival combined age was ≥1202. Although this specific criterion is
rates in the older group, both at 1 year (81.1 vs. 88.4%) and at not applied by the team evaluated in this study, efforts1 are
5 years (55.2 vs. 72.7%)16. made to limit donor Walter
age to under de Biase SILVA-NETO
50 years, maintain3 a donor , Claudemiro Q
Aduen et al., from the Mayo Clinic, reported similar out- risk index (DRI) belowFabricio
1.4, use Ferreira
low-dose COELHO
vasopressors, , Paulo
and HERMAN
3

comes when comparing 42 liver transplants performed in ensure cold ischemia times of <8 h.
patients over 70 years of age with 42 transplants in patients In addition, the RESUMO - Racional:
higher prevalence of Odepression
tratamentoamong de escolha para pacie
under 60 years of age1. esquistossomótica
elderly individuals requiring com sangramento
medical treatment is well docu- de varizes é a d
esplenectomia (DAPE) associada à terapia endoscópica. Poré
Conversely, Collins et al., from Wisconsin, observed lower mented in the literature. However, this factor is rarely ana-
do calibre das varizes em alguns pacientes durante o seguim
survival rates at 5 years (52 vs. 75%) and 10 years (35 vs. 60%) lyzed in the context of Avaliar
transplant waitlists
o impacto da DAPEor postoperative
e tratamento endoscópico pós-
when comparing 91 transplants in patients over 60 years of age das varizes esofágicas e recidiva hemorrágica, de pacientes
outcomes in this population.
with 387 transplants in those under 60 years of age7. Foram estudados
Among the patients evaluated 36 pacientes
in this study, com seguimento
depression and superior
dois grupos: queda da pressão portal abaixo de 30% e acim
In comparative studies, elderly recipients often present loss of appetite were frequently observed, affecting approxi-
calibre das varizes esofágicas no pós-operatório precoce e ta
with lower BMI, absence or well-controlled diabetes mellitus, mately 20% of cases, andhemorrágica.
often necessitating
Resultadosenteral nutrition
lower international normalized ratio (INR), and higher serum via a nasoenteric tube. Atesofágicas
the center que,evaluated,
durante o it seguimento
is a routine aumentaram de cal
albumin levels at the time of waitlist registration. practice to place and position the nasoenteric feeding tube at
o comportamento do calibre das varizes no pós-operatóri
These factors contribute to lower MELD scores and re- the end of the surgical procedure, prior to abdominal closure.
índices de recidiva hemorrágica. Conclusão
duced clinical severity, which may partially explain the more Although the risks associated with advanced age and its re-
favorable outcomes reported in several series8,9,11,13,14. operatórios
lated comorbidities are well precoces
recognized, andou [Link]
despite A comparação
ongo- entre a qu
Indeed, nutritional status and the degree of sarcopenia are ing debate regarding the potential impact of including elderly
DESCRITORES: Esquistossomose mansoni. Hipertensão portal. Cirurgia. Pre
critical components of preoperative assessments. However, in patients on waitlists on the mortality of younger candidates,
e gástricas.
addition to age-related protein-energy malnutrition and sarco- the favorable outcomes observed in this study support the con-
penia, elderly patients often exhibit slower responses to nutri- tinued offering of LT to patients over 70 years of age.
tional therapies. Furthermore, logistical constraints related to ABSTRACT
In this cohort, elderly - Background:
recipients requiredThe treatment
a greater vol-of choice for patie
transplant waitlists frequently hinder the timely and adequate ume of transfusion due to previous
higherepisode
cardiacofrisk
varices
andis experienced
bleeding esophagogastric deva
(EGDS) in association with postoperative endoscopic therapy
implementation of such interventions. In this study, most pa- longer ICU stays. Interestingly, they had a lower incidence of
varices recurrence especially after long-term follow-up. A
tients in Group II were classified as having mild-to-moder- dialysis and achieved survival
behavioroutcomes comparable
of esophageal varices and to bleeding
their recurrence af
ate malnutrition based on the Subjective Global Assessment treatment
younger counterparts (Table 5). of patients submitted to EGDS. Methods: Thirty-s
(SGA), while a higher incidence of severe malnutrition was Moreover, an increasing number of meaningful contribu-
portal pressure drop, more or less than 30%, and compared w
observed in Group I. However, no statistically significant dif- tions to society are madevarices
by older individuals, which should,
and the rate of bleeding recurrence. Results
ference was found between the two groups (Table 1). from this perspective, justify the assignment
late post-operative varices of additional
caliber when compared the pre
In the current context, it is not feasible to selectively strat- despite waitlists
priority points on transplant an increaseand
in diameter duringallo-
preferential follow-up that was con
ify clinical severity based on advanced age. In the city of São cation of younger and Conclusion
hemodynamically stable donors for
variceal calibers when comparing pre-operative and early or
Paulo (SP), the average MELD scores at the time of trans- elderly recipients. The comparison between the portal pressure drop and the
plantation for the most common blood groups (O and A) are The sample size of patients aged 70 years or older remains
29. Since no additional points are assigned to account for the HEADINGS:
small, which limits the statisticalSchistosomiasis
power for certain mansoni.
types Portal
of hypertensio
increased risk associated with advanced age4, elderly patients Esophageal
analysis. Furthermore, donor and gastric
selection was more varices.
rigorous in
evaluated by our team competed equally with younger candi- the elderly recipient group, which, although not statistically
dates, based solely on MELD severity and, in some cases, on significant in the present analysis, introduces a potential bias
special exception points granted for refractory ascites, HCC, in outcome interpretation.
or hepatic hydrothorax (Table 2).
Elderly patients tolerate shorter waiting periods and pres- [Link]/abcdrevista ww
ent higher mortality and removal rates from the waitlist due CONCLUSIONS
to clinical deterioration. This results in a lower likelihood of LT in patients aged 70 years
Trabalho or older
realizado yields
no 1Serviço outcomes
de Cirurgia Geral com-
e Aparelho Digestivo, Depa
undergoing transplantation and a higher incidence of post- Brasil; 2
Serviço de Endoscopia,
parable to those observed in younger recipients, Hospital das Clínicas
provided e Departamento de Gas
that
Cirurgia do Fígado, Hospital das Clínicas e Departamento de Gastroenterolo
transplant complications. Patients over 70 years of age tend grafts are obtained from carefully selected donors meeting
to die with lower MELD scores, have higher dropout rates, Como citar esse artigo: de Biase Silva-Neto WB, Quirese C, De Moura EGH, Co
more stringent criteria.
and are less likely to reach higher MELD thresholds or un- As with pediatric/10.1590/0102-672020210001e1581
candidates, advanced age should be
dergo transplantation10. considered an additional allocation factor, warranting prior-
Correspondência:
Early mortality in elderly patients undergoing LT increases ity points for patientsWalter
agedDe70 years and above on liver trans-
Biase da Silva Neto
significantly when the MELD score exceeds 256. Another fac- plant waitlists. E-mail: wbiase123@[Link]; Recebido para publicação: 17/0
biase@[Link] Aceito para publicação: 14/12/

8/9 ABCD Arq Br

 Liver transplantation in patients over 70 years old

AUTHORS’ CONTRIBUTIONS score for patient selection. Ann Hepatol. 2016;15(6):870-

TG: Conceptualization, Investigation, Methodology, Writ- 80. [Link]
ing – original draft. MGR: Investigation, Literature review. 9. Cross TJS, Antoniades CG, Muiesan P, Al-Chalabi T, Alu-
EDA DA PRESSÃO PORTAL APÓS DESVASCULARIZAÇÃO
TNA: Investigation. FRD: Data analysis. LEPF: Methodol- vihare V, Agarwal K, et al. Liver transplantation in patients

AGOGÁSTRICA E ESPLENECTOMIA INFLUENCIA A VARIAÇÃO

ogy. MCG: Writing – original draft. FKL: Literature review, over 60 and 65 years: an evaluation of long-term outcomes
Writing – original draft. AIMC: Investigation, Methodology. and survival. Liver Transpl. 2007;13(10):1382-8. https://
ALIBRE DAS VARIZES E AS TAXAS DE RESSANGRAMENTO NA
KCVG: Data analysis. MP: Conceptualization. [Link]/10.1002/lt.21181
10. Durand F, Levitsky J, Cauchy F, Gilgenkrantz H, Sou-
UISTOSSOMOSE NO SEGUIMENTO EM LONGO PRAZO? brane O, Francoz C. Age and liver transplantation. J
DATA AVAILABILITY Hepatol. 2019;70(4):745-58. [Link]
e drop in portal pressure The informationafter esophagogastric devascularization
regarding the investigation, methodology,and splenectomy jhep.2018.12.009
n of variceal calibers and the rebleeding rates in schistosomiasis in late follow-up?
and data analysis of the article is archived under the responsi- 11. Freitas ACT, Espinoza FDS, Mattar CA, Coelho JCU. In-
bility of the authors. dication for liver transplantation due to hepatocellular car-
cinoma: analysis of 1,706 2procedures over the past decade
de Biase SILVA-NETO , Claudemiro QUIRESE , Eduardo Guimarães Horneaux
1 1
in the statede MOURA
of Paraná. , Cir Dig. 2022;35:e1701.
Arq Bras
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e Aparelho outcomes
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se artigo: de Biase Silva-Neto WB, Quirese C, De Moura EGH, Coelho FF, Herman P. A queda da pressão portal após desvascularização esofagogástrica e esplenectomia

2-672020210001e1581

ência:
se da Silva Neto
e123@[Link]; Recebido para publicação: 17/09/2020
[Link] Aceito para publicação: 14/12/2020

ABCD Arq Bras Cir Dig 2021;34(2):e1581 1/4 9/9