Long-term results of modified distal splenorenal shunts for the treatment of esophageal varices

BACKGROUND/AIMS

Long-term results were compared for 3 types of distal splenorenal shunt for the treatment of esophageal varices.

METHODOLOGY

Between July 1983 and December 1997, 45 patients with esophageal varices underwent distal splenorenal shunt. Group 1 underwent standard distal splenorenal shunt (n = 11). Group 2 underwent distal splenorenal shunt with splenopancreatic disconnection (n = 11). Group 3 underwent distal splenorenal shunt with splenopancreatic disconnection and gastric transection (n = 23).

RESULTS

Additional treatment for recurrent varices was required in group 1, (n = 1, 9.1%), group 2 (n = 2, 18.2%), and group 3 (n = 1, 4.3%). All of the patients with recurrent varices developed a shunt stenosis within the 1st year after distal splenorenal shunt. The prevalence of hyperammonemia in group 1 was 40.0% at 1, 5, and 10 years. In group 2, the prevalence was 14.3% at 1 year, 31.4% at 5 years, and 54.3% at 10 years. In group 3, the prevalence was 0% at 1 year, and 9.1% at 5 and 10 years. The differences between group 3 and groups 1 and 2 were significant (P < 0.01). The cumulative survival rates at 1 year were 90.9%, 63.6%, and 95.7% for groups 1, 2, and 3, respectively. At 10 years, the cumulative survivals rates were 70.7%, 63.6%, and 69.4% for groups 1, 2, and 3, respectively. There were no significant differences in survival between the 3 groups.

CONCLUSIONS

Distal splenorenal shunt with splenopancreatic disconnection and gastric transection may reduce the incidence of postoperative hyperammonemia.

[Splanchnic circulation after liver cirrhosis shunting]

In 47 patients during 1985-1997 years period the complex haemodynamical investigations before the operation and in 8-12 months after it were performed: in 24--distal splenorenal shunt was performed and in 23--nonselective portocaval shunt. After performance of shunting operation the volumetric speed of the blood flow had lowered together with pressure in v.porta. After the nonselective shunting performance the significantly more pronounced change of these indexes was noted, comparing with such after the selective anastomosis formation. The portal blood flow lowering had promoted the arterial hepatic blood flow increase, showing compensatory-adaptational reaction, directed for the common hepatic blood flow preservation.

Effects of end-to-side portacaval shunt and distal splenorenal shunt on systemic and pulmonary haemodynamics in patients with cirrhosis

BACKGROUND

Patients with cirrhosis exhibit splanchnic, peripheral and pulmonary vasodilation, which are thought to play a role in increasing portal pressure, promoting sodium retention and determining arterial hypoxaemia. The present study investigated whether these abnormalities are influenced by portal hypertension or by portal systemic shunting.

METHODS

Sixty-one patients with cirrhosis who had haemodynamic measurements before and after end-to-side portacaval shunt (n = 30) or distal splenorenal shunt (n = 31) were evaluated.

RESULTS

End-to-side portacaval shunts were more effective than distal splenorenal shunts in decompressing the portal system (portocaval pressure gradient 3.2 +/- 2.5 vs splenocaval gradient 6.5 +/- 3.2 mmHg, P < 0.0001), because of a greater shunt blood flow (33 +/- 12 vs 21 +/- 12 mL/min per kg, P < 0.005). Azygos blood flow and hepatic blood flow decreased significantly after both surgical shunts. However, end-to-side portacaval shunts caused a greater decrease in peripheral resistance than distal splenorenal shunts (-23 +/- 18 vs -11+/- 27%, P < 0.05). Mean arterial pressure and pulmonary vascular resistance were significantly reduced after an end-to-side portacaval shunt (-7 +/- 10%, P < 0.001 and -14 +/- 33%, P < 0.004, respectively), but not after splenorenal shunt.

CONCLUSIONS

These results show that end-to-side portacaval shunts, despite normalizing portal pressure, worsen the peripheral and pulmonary vasodilatation. The splenorenal shunt that maintained a higher portal pressure, caused less peripheral vasodilatation and did not enhance pulmonary vasodilatation. These findings suggest that portal systemic shunting is more important than increased portal pressure in determining peripheral vasodilatation in cirrhosis.

Long-term effects of distal splenorenal shunt with splenopancreatic and gastric disconnection on hypersplenism due to liver cirrhosis

BACKGROUND/AIMS

Though the distal splenorenal shunt has been applied for gastroesophageal varices caused by liver cirrhosis, many patients develop secondary hypersplenism due to the portal hypertension following liver cirrhosis. We examined whether this operation could be effective for alleviating secondary hypersplenism for a long post-operative period. The subjects were 42 cases with gastroesophageal varices following liver cirrhosis in which we had performed distal splenorenal shunts with splenopancreatic and gastric disconnection at our institution in the period from 1983 1994 and the post-operative survival periods had been over 3 years.

METHODOLOGY

White blood cell counts, platelet counts and spleen volume were measured prior to operation, 1 month after operation and during the post-operative period of 3-5 years. Quality of life and clinical symptoms were evaluated during the post-operative period of 3-5 years.

RESULTS

White blood cell counts, platelet counts and spleen volume were improved respectively at 1 month and during the 3-5-year period after surgery, compared to those prior to operation. None of the clinical symptoms of hypersplenism were observed and the long-term performance status was satisfactory.

CONCLUSIONS

We can conclude that the distal splenorenal shunt with splenopancreatic and gastric disconnection alleviated hypersplenism for post-operatively long periods.

[Splanchnic circulation after distal splenorenal anastomosis in hepatic cirrhosis]

While the result estimation of the distal splenorenal anastomosis formation operation, done in 12 patients according to the W. D. Warren method and in another 12 patients--according to the method, modified by K. Inokuchi, it was established that the hepatic portal perfusion loss causes compensational enhancement of blood flow in a. hepatica, including while the standard method application--by 22% and the modified one--by 8%. Doing the splenorenal venous disconnection improves the patients' quality of life due to the incidence rate of portosystemic encephalopathy reduction by 8.3%, and in this circumstances the life span and the hemorrhage recurrency rate do not differ with such while using the standard method.

[Blood circulation in the liver after distal spleno-renal anastomosis in cirrhosis]

Complex hemodynamical investigations were performed in 24 patients with liver cirrhosis before and after the distal splenorenal anastomosis (DSRA) conduction according to conventional and modified methods. After the conventional DSRA formation the portal blood flow had reduced down by 39.6% and after modified method--by 14%. Linear speed of the blood flow in a portal vein after the conventional DSRA formation had reduced a twice, after the modified DSRA--did not change. The pressure in a portal vein after the conventional DSRA formation had reduced by 35%, and after the modified DSRA--by 11%. The portal perfusion lowering had promoted the compensational increase of the blood flow in hepatic artery after the conventional DSRA forming by 22% and after the modified DSRA--by 8%.

[The forming of distal splenorenal anastomosis in conjunction with gastroesophageal junction suturing during treatment of the portal hypertension syndrome in children]

The results of operations in 147 patients, performed for the portal hypertension syndrome, are adduced. The patients aged from 8 mo to 14 years. The best late follow-up result was noted after the distal splenorenal anastomosis forming in conjunction with suturing of esophageal veins and left gastric vein.

Use of adrenal vein conduit for splenorenal shunts: a case report

We report a case with extrahepatic portal venous obstruction (EHPVO), who presented with recurrent bleeding following a previous devascularization procedure and needed an emergency distal spleno-renal shunt (DSRS). Due to technical difficulty because of previous scarring, the adrenal vein was used as a conduit between the splenic vein and renal vein. The shunt's patent and the patient has been bleed-free for 2 years.

Distal splenorenal shunt: role, indications, and utility in the era of liver transplantation

HYPOTHESIS

The distal splenorenal shunt (DSRS) continues to play an important role in the management of recurrent variceal bleeding with minimal negative impact on subsequent orthotopic liver transplantation (OLT).

DESIGN

Case-control study.

SETTING

Hepatobiliary surgery and liver transplantation unit in a tertiary referral medical center.

PATIENTS

From August 1, 1985, through October 31, 1997, a single team of surgeons performed 81 DSRS procedures for recurrent variceal hemorrhage. Eleven patients undergoing OLT subsequent to DSRS were compared with a group of 274 patients undergoing OLT without any previous shunt during the same period.

MAIN OUTCOME MEASURES

Operative time, use of blood products, length of hospital stay, perioperative complications, and survival rates.

RESULTS

Operative (30-day) mortality for DSRS was 6% (n = 5). From follow-up information available for 74 patients, the 1- and 5-year survival rates were 86.4% (n = 64) and 74.3% (n = 55), respectively. Recurrent variceal bleeding and hepatic encephalopathy occurred in 5 (6.8%) and 11 patients (14.9%), respectively, after DSRS. In 9 patients, DSRS was used as salvage for failed transjugular intrahepatic portosystemic shunt.

CONCLUSIONS

Distal splenorenal shunt is a safe, durable, and effective treatment for controlling recurrent variceal hemorrhage in patients with acceptable operative risk and good liver function. It does not compromise future liver transplantation and can considerably delay the time until transplantation is required. Given the early occlusion rate and need for constant surveillance, transjugular intrahepatic portosystemic shunting should be reserved for patients with Child C classification cirrhosis with chronic hemorrhage or intractable ascites or as an emergency procedure for patients with uncontrollable bleeding using endoscopic therapy.

Distal splenorenal shunt with splenopancreatic disconnection for portal hypertension in biliary atresia

This study evaluated the long-term effects of distal splenorenal shunt with splenopancreatic disconnection (DSRS-SPD) on portal hypertension (PH) in biliary atresia (BA) patients. Five patients with BA underwent DSRS-SPD at the age of 3.3 to 8.5 years. They had been free from jaundice after hepatic portoenterostomy (HPE); however, they gradually developed gastroesophageal varices and hypersplenism. Portal venous pressure after anastomosis was 37.2 +/- 6.1 cmH2O, as high as that before anastomosis (37.8 +/- 3.3 cmH2O). Postoperatively, liver function tests became worse within 2 weeks; however, they returned to preoperative levels within 1 month without any further treatment. No patient developed a significant encephalopathy throughout the observed period. During follow-up of 4 to 12 years, the shunt was patent in all patients. Spleen size decreased after operation. Abdominal-wall venous dilatation completely disappeared in two of four patients. The platelet counts gradually increased and were significantly higher 3 years (126.6 +/- 59.3 x 10(3)/mm3) after DSRS-SPD than preoperative values (66.0 +/- 24.2 x 10(3)/mm3). White blood cell counts showed no significant changes. No patient developed a gastrointestinal hemorrhage postoperatively, although three had had repeated hemorrhages before the operation. Two patients showed disappearance of varices endoscopically at 2 years and 7 months after DSRS-SPD, respectively, but had recurrent varices at 7 and 11 years, respectively. The endoscopic findings regarding varices 3 to 7 years after DSRS-SPD were as follows: decreased number (80%); decreased length (40%); improvement of form (20%); improvement of fundamental color (60%); disappearance of red-color sign (100%); disappearance of gastric varices (75%); and disappearance of acute gastric mucosal lesions (100%). Although one patient later underwent liver transplantation because of progression of liver cirrhosis, all five are doing well. From these results, DSRS-SPD may prove to be a safe and feasible procedure for intrahepatic PH after HPE for BA and may improve gastroesophageal varices and hypersplenism on long-term follow-up.

A technique for distal splenoadrenal shunting in pediatric portal hypertension

Technical modification of the DSRS by using the end-to-end splenoadrenal anastomosis allows for effective selective decompression of portal hypertension in children, can be accomplished with no perioperative mortality, and has demonstrated longterm patency and minimal morbidity. Clinical encephalopathy was seen in only 1 patient although 3 additional patients required lactulose therapy.

[Treating portal hypertension by subtotal splenectomy with retroperitoneal splenic transposition and devascularization: clinical study]

OBJECTIVE

To devise a new surgical procedure for improving the operative effect of portal hypertension caused by hepatic cirrhosis.

METHOD

In treatment group, subtotal splenectomy with retroperitoneal transposition was performed in 36 patients of cirrhotic hypertensives. In control group, 36 patients were treated by devascularization. The follow-up period ranged from 3 months to 5.5 years (average 26 months).

RESULT

In the treatment group, the rates of disappearance, improvement and absence of changes of esophageal varices were 11.5%, 61.5% and 26.9%, respectively, and in the control group those of improvement were 50.0%, absence of change 45.8% and aggravation 4.2%. There was a significant difference between them (P < 0.05). In the treatment group, hypersplenism disappeared in all. There was also significant difference between the two groups in immunological indexes (P < 0.05). DSA showed abundant collateral circulation in the residual spleen and retroperitoneal wall, which enabled the portal blood flow diverting to retroperitoneal tissues.

CONCLUSION

This method possesses the advantages of devascularization and decompression shunt. It is of value in retaining part of spleen in surgical treatment of portal hypertension.

[Distal spleno-caval shunt in 66 patients with portal hypertension]

OBJECTIVE

To evaluate the long-term results and operative experience of distal splenocaval shunt.

METHOD

66 patients with portal hypertension were treated by distal spleno-caval shunt. Of these patients 57 were males and 9 females with a mean age of 39 years. All the patients were followed up.

RESULT

The operative mortality rate was 7.58%. Only 5 patients experienced recurrent bleeding (7.58%). None of the patients had clinical hepatic encephalopathy. Five-year survival rate was 70.45%.

CONCLUSION

Distal splenocaval shunt is suitable for portal hypertension patients with hepatopetal portal flow.

Percutaneous retroperitoneal splenorenal shunt: an experimental study in swine

PURPOSE

To evaluate the technical possibility of creating a percutaneous retroperitoneal splenorenal shunt (PRESS) in swine as a minimally invasive treatment of portal hypertension.

MATERIALS AND METHODS

Five normal domestic swine underwent creation of a PRESS. A modified transjugular intrahepatic portosystemic shunt puncture set was introduced from the right femoral vein into the left renal vein. The proximal splenic vein was punctured transvenously through the retroperitoneal cavity. Noncovered metallic stents were then placed to connect both veins. The animals were sacrificed 1 hour after the procedure, after follow-up splenic venography and necropsy were performed.

RESULTS

Puncture of the splenic vein and stent placement were successfully completed in all cases. In four of five cases, the splenic venogram revealed good flow from the splenic vein to the left renal vein through the shunt track 1 hour after creation of the PRESS, and there was no evidence of leakage. No changes in vital signs were noticed. At necropsy, a small retroperitoneal hematoma along the stent and minimal intraperitoneal bleeding were observed. The stents were found in the retroperitoneal cavity connecting both veins in all animals.

CONCLUSION

Creation of a PRESS is technically possible, and further experimental studies of its efficacy are warranted.

An evaluation of splenopancreatic disconnection as a modification of the distal splenorenal shunt, studied in nonalcoholic patients by sequential angiography

To evaluate the validity and complications of modifying the distal splenorenal shunt (DSRS) by performing splenopancreatic disconnection (SPD), hemodynamic changes in the portal system were assessed by visceral angiography in 93 patients with nonalcoholic portal hypertension during early postoperative follow-up after DSRS. There were 40 patients who underwent DSRS alone and 53 who underwent DSRS plus SPD. Early follow-up angiography showed that portal vein perfusion was well maintained, and that the diameter of the portal vein had decreased significantly by the same degree in both groups. Hepatofugal collaterals for the shunt had developed to a greater extent in the DSRS group, while they were almost completely absent in the DSRS with SPD group. Nevertheless, partial portal vein thrombosis was not detected in the DSRS group, although it was seen in seven (13.2%) of the patients who underwent DSRS plus SPD, in whom the left proximal splenic vein was not visible. The proximal splenic vein was seen in significantly less of the DSRS with SPD patients (47.2%) than the DSRS group patients (85%). In conclusion, SPD more effectively prevented the early postoperative development of collateral pathways for the shunt compared with standard DSRS; however, the possible stagnation of blood flow in the left proximal splenic vein may predispose to a risk of partial portal vein thrombosis developing during the early postoperative period after DSRS with SPD.

Renal-splenic shunt for infrahepatic caval occlusion after piggy-back liver transplantation

Inferior vena cava thrombosis after liver transplantation is uncommon. We describe a case of this unusual complication occurring after piggy-back (end-to-side) graft implantation. Renal failure, lower limb edema, and hemodynamic instability were the presenting symptoms requiring immediate surgical correction with a left renal-to-splenic vein shunt over a ringed 2.5-cm prosthesis. The decision to go ahead with the shunt was preceded by an intraoperative confirmation of a 10-cm H2O pressure gradient between the caval and portal circulations. This gradient, unlike that observed in liver cirrhosis, ultimately turned a splenorenal shunt into a renal-splenic one. Six months after the procedure, the patient is alive and well with normal liver and renal function. The technique described may be useful in the management of other clinical conditions of acute infrahepatic caval hypertension.

A new autogenous conduit for the spleno-renal shunt

Management of patients with portal hypertension has been significantly advanced by new medical, surgical and radiologic procedures. In the presence of portal vein thrombosis, a splenorenal shunt is the procedure of choice for relief of portal hypertension. The gonadal vein is an autogenous conduit of ideal diameter to accomplish this objective. Several advantages of this new operation are described.

Selective distal splenorenal shunts for intractable variceal bleeding in pediatric portal hypertension

The treatment of portal hypertension in the pediatric population has undergone an evolution toward less invasive methods of care. With the advent of endoscopic sclerotherapy, surgery is less common in the acute care of these patients. Few reports deal with the role of portosystemic shunting in the emergent management of variceal hemorrhage in children. To address this issue, the authors studied the medical records of all pediatric patients at their institution who underwent placement of a shunt for portal hypertension during the last 10 years. Nine patients underwent a total of 10 emergent or semiurgent shunting procedures. Seven were boys and two were girls. Six patients had portal hypertension as a result of intrahepatic disease. Two had extrahepatic portal vein thrombosis. Five children had abnormal hepatic function. The median age at the time of the procedure was 9 years. The indication for surgical shunting in all cases was gastrointestinal hemorrhage not responsive to sclerotherapy. Eight patients underwent emergent distal splenorenal shunts (DSRS), and two underwent a nonselective mesocaval shunt, with one undergoing both. Postoperatively all patients had cessation of bleeding. Operative mortality was zero. Early complications included ascites (3), small bowel obstruction (1), and hepatorenal syndrome (1). The child who underwent a nonselective shunt procedure had encephalopathy. Two DSRS thrombosed, requiring reexploration; eight shunts remained patent. Three patients eventually had orthotopic liver transplantation (OLT) because of progressive hepatic failure. Two children died; neither death was shunt related.(ABSTRACT TRUNCATED AT 250 WORDS)

[A non-traditional procedure in the surgical treatment of portal hypertension in a child]

The authors present the case-history with a uncommon surgical procedure in a child with portal hypertension and hypersplenism. Half the spleen was resected and concurrently a distal splenorenal anastomosis of the Warren type was created. This procedure was selected because the child had a very enlarged spleen and marked hypersplenism. The postoperative course was free from complications and the satisfactory condition of the child 15 months after operation with normal haematological values confirms the justification of the selected procedure.

[Surgical treatment of extrahepatic portal hypertension in children]

In the period from 1985 to 1992 sixty-three patients aged from 7 months to 15 years were treated for the portal hypertension syndrome, 60 had the extrahepatie form. Forty-five various operations for portosystemic shunting were carried out: formation of proximal splenorenal anastomosis in 31, distal splenorenal anastomosis in 4, mesentericocaval anastomosis in 6, gastrocaval anastomisis in 2, and an atypical vascular shunt in 2 cases. Nonshunting operations were performed on 8 patients. Since 1986 39 sessions of endoscopic sclerotherapy were conducted, 16 of them were carried out in cases with esophagogastric bleeding.

[Staged surgery in the treatment of Budd-Chiari's syndrome of mixed type]

9 patients with Budd-Chiari's syndrome of mixed type were operated upon. Among them 3 cases were treated by percutaneous transluminal angioplasty using balloon catheters, and 1 to 2 weeks after followed by Hassab's procedure and Linton's procedure. Two cases were treated by incision and plasty of IVC, and 1 month after followed by Hassab's procedure and Linton's procedure. The remaining 4 were treated by prehepatic cavoatrial shunt, succeeded by Hassab's procedure and Linton's procedure one month after. 6 to 24 months' follow up of the 9 cases revealed satisfactory results.

Role of distal splenorenal shunt for long-term management of variceal bleeding

Distal splenorenal shunt (DSRS) has been studied extensively over the past 25 years to define its role in management of variceal bleeding. The operative technique of the shunt has not changed, but more aggressive attempts at portal-azygos disconnection have been studied for their effect on maintenance of portal perfusion. Control of variceal bleeding is achieved in about 90% of patients. Portal flow to the liver is maintained in > 90% of patients with nonalcoholic etiology of portal hypertension and in 50% to 84% of patients with alcoholic cirrhosis depending on the degree of portal-azygos disconnection. Encephalopathy and liver failure do not seem to be accelerated by DSRS but depend on the severity of the underlying liver disease. Reported survival likewise depends on the etiology of portal hypertension and the severity of liver disease: > 90% survival can be achieved in portal vein thrombosis and patients with cirrhosis and normal liver function, but 50% to 60% 3- to 5-year survivals are reported for patients with more advanced disease. DSRS offers one treatment modality for management of variceal bleeding that must fit into an overall strategy for these patients. Full evaluation is the key to allow selection of patients for pharmacotherapy, sclerotherapy, variceal decompression, or liver transplantation.