Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study

An 80% dysfunction rate at 2 years limits the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of complications of portal hypertension. The use of covered stents could improve shunt patency; however, long-term effect and safety remain unknown. Eighty patients randomized to be treated by TIPS either with a covered stent (Group 1) or an uncovered prosthesis (Group 2) were followed-up for 2 years. Doppler US was performed every 3 months. Angiography and portosystemic pressure gradient measurement were performed every 6 months or whenever dysfunction was suspected. Actuarial rates of primary patency in Groups 1 and 2 were 76% and 36% respectively (P=0.001). Clinical relapse occurred in four patients (10%) in Group 1 and 12 (29%) in Group 2 (P<0.05). Actuarial rates of being free of encephalopathy were 67% in Group 1 and 51% in Group 2 (P<0.05). Probability of survival was 58% and 45% at 2 years, respectively, in Groups 1 and 2 (NS). The mean Child-Pugh score improved only in Group 1 (from 8.1+/-1.6 to 7+/-2.2 at 2 years -P<0.05). We also compared the Doppler-US parameters between patent and dysfunctioning shunts. In patent shunts, the mean velocity within the portal vein was significantly higher but the performance of Doppler-US was not accurate enough to predict shunt dysfunction. In conclusion, the improvement in TIPS patency by using covered prostheses is maintained over time with a decreased risk of encephalopathy, while the risk of death was not increased.

A study into the characteristics and outcome of variceal bleeding in a tertiary hospital in Southeast Asia

This retrospective study evaluated patients admitted to the Department of Gastroenterology, Singapore General Hospital for variceal bleeding in the year 2004. Improvement in outcome of variceal bleeding has been reported in the West. There is no regional data on this condition. This study aims to determine the characteristics and outcome of variceal bleeding in a tertiary hospital in Southeast Asia. Twenty-two patients were eligible. The main aetiologies of liver cirrhosis were chronic hepatitis B (38%) and alcohol (33%). Child's A, B and C were 29%, 48% and 24% respectively. Nineteen patients (86%) had bleeding oesophageal varices (band ligation performed). The remaining three patients (14%) had bleeding gastric varices (N-butyl-2-cyanoacrylate injection performed). Detailed description of certain endoscopic findings was absent in up to 18 patients (82%). All patients received antibiotics and vasoactive drug. In-hospital mortality and rebleeding were 9% and 18% respectively. We conclude that the relatively low in-hospital mortality and rebleeding rates in our series are most probably due to the smaller proportion of patients with severe liver dysfunction and management which adhered to recommendations. Documentation of endoscopic findings needs to be improved to facilitate the continuation of care.

Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis

BACKGROUND AND AIMS

Our aim was to identify predictors of clinical decompensation (defined as the development of ascites, variceal hemorrhage [VH], or hepatic encephalopathy [HE]) in patients with compensated cirrhosis and with portal hypertension as determined by the hepatic venous pressure gradient (HVPG).

METHODS

We analyzed 213 patients with compensated cirrhosis and portal hypertension but without varices included in a trial evaluating the use of beta-blockers in preventing varices. All had baseline laboratory tests and HVPG. Patients were followed prospectively every 3 months until development of varices or VH or end of study. To have complete information, until study termination, about clinical decompensation, medical record review was done. Patients who underwent liver transplantation without decompensation were censored at transplantation. Cox regression models were developed to identify predictors of clinical decompensation. Receiver operating characteristic (ROC) curves were constructed to evaluate diagnostic capacity of HVPG.

RESULTS

Median follow-up time of 51.1 months. Sixty-two (29%) of 213 patients developed decompensation: 46 (21.6%) ascites, 6 (3%) VH, 17 (8%) HE. Ten patients received a transplant and 12 died without clinical decompensation. Median HVPG at baseline was 11 mm Hg (range, 6-25 mm Hg). On multivariate analysis, 3 predictors of decompensation were identified: HVPG (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.05-1.17), model of end-stage liver disease (MELD) (HR, 1.15; 95% CI, 1.03-1.29), and albumin (HR, 0.37; 95% CI, 0.22-0.62). Diagnostic capacity of HVPG was greater than for MELD or Child-Pugh score.

CONCLUSIONS

HVPG, MELD, and albumin independently predict clinical decompensation in patients with compensated cirrhosis. Patients with an HVPG <10 mm Hg have a 90% probability of not developing clinical decompensation in a median follow-up of 4 years.

Shock Index Correlates with Extravasation on Angiographs of Gastrointestinal Hemorrhage: A Logistics Regression Analysis

We applied multivariate analysis to the clinical findings in patients with acute gastrointestinal (GI) hemorrhage and compared the relationship between these findings and angiographic evidence of extravasation. Our study population consisted of 46 patients with acute GI bleeding. They were divided into two groups. In group 1 we retrospectively analyzed 41 angiograms obtained in 29 patients (age range, 25-91 years; average, 71 years). Their clinical findings including the shock index (SI), diastolic blood pressure, hemoglobin, platelet counts, and age, which were quantitatively analyzed. In group 2, consisting of 17 patients (age range, 21-78 years; average, 60 years), we prospectively applied statistical analysis by a logistics regression model to their clinical findings and then assessed 21 angiograms obtained in these patients to determine whether our model was useful for predicting the presence of angiographic evidence of extravasation. On 18 of 41 (43.9%) angiograms in group 1 there was evidence of extravasation; in 3 patients it was demonstrated only by selective angiography. Factors significantly associated with angiographic visualization of extravasation were the SI and patient age. For differentiation between cases with and cases without angiographic evidence of extravasation, the maximum cutoff point was between 0.51 and 0.0.53. Of the 21 angiograms obtained in group 2, 13 (61.9%) showed evidence of extravasation; in 1 patient it was demonstrated only on selective angiograms. We found that in 90% of the cases, the prospective application of our model correctly predicted the angiographically confirmed presence or absence of extravasation. We conclude that in patients with GI hemorrhage, angiographic visualization of extravasation is associated with the pre-embolization SI. Patients with a high SI value should undergo study to facilitate optimal treatment planning.

Pregnancy and portal hypertension a pathology view of physiologic changes

The coexistent of pregnancy and liver disease represent a complex clinical situation, besides the liver complications that present in pregnancy with a previous health liver, like intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy or HELLP syndrome with bleeding disorders and viral hepatitis, the previous liver damage with portal hypertension associated represent a clear stated of hemodynamic changes which increased risk of variceal bleeding. The portal hypertension syndrome has a splanchnic blood flow increase. During pregnancy an hypervolemic stated developed as consequence there is an increased in portal flow that contributed to more portal pressure transmitted to the collaterals veins which increase variceal bleeding risk in this group of patients. The present review will focus on treatment options to prevent variceal bleeding in this clinical situation.

Hepatic hematoma and hepatic rupture in pregnancy

Hepatic perforation is an unusual complication of woman pregnancy associated with a poor outcome. A comprehensive review of epidemiology, clinical spectrum, diagnostic methods and therapeutic options is presented in this short paper.

Value of the hepatic venous pressure gradient to monitor drug therapy for portal hypertension: a meta-analysis

OBJECTIVES

The use of the hepatic venous pressure gradient (HVPG) to assess the efficacy of the pharmacological treatment of portal hypertension in cirrhosis is controversial. Our aim was to establish whether target HVPG reduction predicts variceal bleeding in cirrhotic patients receiving variceal bleeding prophylaxis.

METHODS

Data sources were MEDLINE, EMBASE, Cochrane Controlled Trials Register, citation lists, and abstracts (most recent search March 2006). Cohorts of patients on drug therapy from randomized and nonrandomized studies correlating variceal bleeding and HVPG change were used. Heterogeneity was explored by metaregression analysis.

RESULTS

Ten studies totaling 595 patients undergoing two HVPG measurements were identified. The RR of bleeding was lower in patients achieving an overall (HVPG <or=12 mmHg or decrease >or=20%) (0.27, 95% CI 0.14-0.52), complete (HVPG <or=12 mmHg) (0.48, CI 0.28-0.81), or partial (HVPG decrease >or=20%) (0.41, CI 0.20-0.81) response, with significant heterogeneity. Regression analysis identified the interval between the HVPG measurements significantly associated with the RR of bleeding. Heterogeneity was no longer significant after exclusion of an outlier trial, which showed the longest interval to HVPG remeasurement and the lowest quality score. Even considering nonvaluable patients because of bleeding as HVPG responders, the RR of bleeding was lower in overall responders than in nonresponders (0.66, CI 0.51-0.86). Overall response was associated with lower liver-related mortality (RR 0.58, CI 0.37-0.91).

CONCLUSIONS

Current evidence supports the validity of HVPG end points to monitor drug therapy efficacy for variceal bleeding prophylaxis. HVPG monitoring also provides valuable prognostic information.

High-risk ED patients with nonvariceal upper gastrointestinal hemorrhage undergoing emergency or urgent endoscopy: a retrospective analysis

OBJECTIVES

The optimal timing of interventional endoscopy within the initial 24 hours remains controversial. We designed a retrospective study to compare the outcomes between emergency endoscopy (EE) and urgent endoscopy (UE) for high-risk patients with nonvariceal upper gastrointestinal hemorrhage presenting to the emergency department (ED).

METHODS

The medical records of 189 patients with nonvariceal upper gastrointestinal hemorrhage who underwent endoscopy within 24 hours of admission to the ED were reviewed. Patients were divided into 2 groups: EE group (<8 hours) or UE group (8-24 hours). We compared the endoscopic findings, hemostatic procedures, rate of hemostasis, rebleeding, need for transfusion, length of hospitalization, and mortality between the 2 groups.

RESULTS

There were 88 patients (47%) in the EE group and 101 patients (53%) in the UE group. Ulcers with active bleeding or exposed vessel were found more frequently in the EE group than in the UE group (19% vs 8%, P = .03; 34% vs 12%, P < .001). Fifty patients had blood retention in the stomach, especially in the EE group (40% vs 15%, P < .001). Forty-four (50%) patients in the EE group and 21 (21%) patients in the UE group received endoscopic interventions. Combination modalities of endoscopic hemostasis were more commonly used in the EE group than in the UE group (40% vs 15%, P < .001). Primary hemostasis was achieved at a rate of 95% in both groups. There was no statistical difference regarding the rate of recurrent bleeding, total amount of transfusion, length of hospital stay, and mortality rate in both groups.

CONCLUSIONS

Although more active lesions were detected and more therapeutic attempts were performed in the EE group, the outcome showed no difference in both groups. Emergency endoscopy performed less than 8 hours after arrival to the ED showed no definite benefit in comparison with UE performed within 8 to 24 hours.

Acute variceal hemorrhage

Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is associated not only with a high mortality, but also with a high recurrence rate in those who survive. Therefore, management should focus on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control hemorrhage during the acute bleeding episode (emergency treatment), and to prevent rebleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This article reviews management of acute variceal bleeding.

Management of digestive bleeding related to portal hypertension in cirrhotic patients: A French multicenter cross-sectional practice survey

AIM: To investigate the conformity of management practices of gastrointestinal hemorrhage in cirrhotic patients with relevant guidelines.

METHODS: A questionnaire on the management of digestive bleeding was completed for all consecutive cirrhotic patients admitted to 31 French hospitals.

RESULTS: One hundred and twenty-six bleeding events were recorded. It was the first bleeding episode in 79 patients (63%), of whom 40 (51%) had a prior diagnosis of cirrhosis and 25 (32%) had previously undergone an endoscopy. The bleeding episode was a recurrence in 46 patients (37%). The median time between onset and admission was 4 h, but exceeded 12 h in 42% of cases. There was an agreement between centers for early vasoactive drug administration (87% of cases), association with ligation (42%) more often than sclerosis (21%) at initial endoscopy, and antibiotic prophylaxis (64%). By contrast, prescription of beta-blockade alone or in combination (0 to 100%, P = 0.003) for secondary prophylaxis and lactulose (26% to 86%, P = 0.04), differed among centers.

CONCLUSION: In French hospitals, management of bleeding related to portal hypertension in cirrhotic patients is generally in keeping with the consensus. Broad variability still remains concerning beta-blockade use for secondary prophylaxis. Screening for esophageal varices, the use of antibiotic prophylaxis and patients information need to be improved.

[Prevention and treatment of esophageal variceal bleeding]

Portal hypertension leads to special complications, which tend to progression. Increase in the size of varices, and variceal-wall tension may cause life-threatening bleeding, which affects mortality. Therefore the reduction of portal hypertension is essential. For prevention of the first bleeding (primary prevention) beta-blockers must be given. For estimation of the effectiveness of this drug, patients should be followed. In case of inefficiency or intolerability variceal ligation or sclerotherapy can prevent bleeding. In case of acute variceal hemorrhage, hemodynamic stabilization of the patient is the first step. Transfusion if necessary, somatostatin or terlipressin should be given for reduction of portal hypertension and also endoscopic treatment of varices is mandatory. Early antibiotic administration for prophylaxis or treatment of infections is associated with a significant reduction in mortality. Up to now in absence of exact data, correction of haemostasis is suggested by the administration of fresh frozen plasma. For secondary prevention i. e. to prevent repeated bleeding beta-blockers (probably with nitrates) can be used. If necessary, drug administration should be complemented with varix ligation or sclerotherapy. In case of inefficiency TIPS implantation or liver transplantation must be considered.

The utility of upper endoscopy in patients with concomitant upper gastrointestinal bleeding and acute myocardial infarction

Patients who present with upper gastrointestinal bleeding (UGIB) in the setting of acute myocardial infarction (AMI) may have suffered an UGIB that subsequently led to an AMI or endured an AMI and subsequently suffered a UGIB as a consequence of anticoagulation. We hypothesized that patients in the former group bled from more severe upper tract lesions. The aim of this study was to evaluate predictors for endoscopic therapy in patients who suffer a concomitant UGIB and AMI. Retrospective, single center medical record abstraction of hospital admissions from January 1, 1996-December 31, 2002. During the study period, 183 patients underwent an esophagogastroduodenoscopy (EGD) within 7 days of suffering an AMI and UGIB (AMI group N=105, UGIB group N=78). A higher proportion of patients in the UGIB group (41%) was found to have high-risk UGI lesions requiring endoscopic treatment compared to patients in the AMI group (17%; P < 0.004). UGIB as the inciting event and patients suffering from hematemesis and hemodynamic instability were significantly associated with requiring endoscopic therapy. Although predominantly diagnostic, endoscopic findings in the AMI group did alter the decision to perform cardiac catheterization in 43% of patients. Severe complications occurred in 1% (95% confidence interval, 0%-4%) of patients. We conclude that in patients suffering from concomitant UGIB and AMI, urgent endoscopy was most beneficial in patients with UGIB as the initial event and those presenting with hematemesis and hemodynamic instability. In patients without these clinical features, urgent endoscopy may be delayed, unless cardiac management decisions are dependent on endoscopic findings.

Hemodynamics after endoscopic submucosal injection of epinephrine in patients with nonvariceal upper gastrointestinal bleeding: a matter of concern

We report about detailed hemodynamic changes and one major cardiac complication occurring after submucosal injection of epinephrine (1 : 10 000) for management of upper gastrointestinal bleeding in a series of four consecutive patients. Cardiac contractility and afterload, determined by the cardiac index and the systemic vascular resistence index (SVRI), were assessed by transpulmonary thermodilution using the Pulse Contour Cardiac Output monitoring system (PiCCO; Pulsion Medical Systems, Munich, Germany), and the mean arterial pressure and heart rate were recorded. We observed a distinct rise in both mean arterial pressure and heart rate, and this effect was pronounced in the three patients with esophageal lesions. The increase in the mean arterial pressure was caused by an elevation of the cardiac index in two patients, a rise in both cardiac index and SVRI in one patient, and a rise in the SVRI only in the fourth patient. One patient, who had received 30 ml epinephrine for treatment of a bleeding Mallory-Weiss tear, developed an acute myocardial infarction during the postprocedural follow-up period. In conclusion, submucosal injection of epinephrine may cause significant hemodynamic changes that can potentially lead to adverse cardiac events. Close cardiac monitoring during and after submucosal application of epinephrine therefore seems a prudent precaution. In the treatment of esophageal lesions, the total amount of epinephrine injected should be carefully titrated, so that the lowest possible volume that achieves adequate hemostasis is used.

The management of severe alcoholic liver disease and variceal bleeding in the intensive care unit

PURPOSE OF REVIEW

To address recent advances in the understanding and management of alcohol-related chronic liver disease and its acute complications.

RECENT FINDINGS

Refinements have been made in the prognosis and treatment of alcoholic hepatitis, and new insights have been gained into the pathophysiology of the hepatorenal syndrome. Further trial evidence has emerged concerning therapy in the hepatorenal syndrome, and there has been some clarification of the benefits and risks relating to albumin dialysis/extracorporeal liver support, and consensus in the early management of variceal haemorrhage.

SUMMARY

Recent developments have led to modifications in the standard of care of patients with severe alcoholic liver disease, many of which are highly applicable to the general critical care setting. These changes apply specifically to alcoholic hepatitis, the hepatorenal syndrome and variceal bleeding, common conditions with a high mortality rate, upon which changes in practice can have a significant impact.

Hemodynamic response-guided therapy for prevention of variceal rebleeding: an uncontrolled pilot study

The clinical usefulness of assessing hemodynamic response to drug therapy in the prophylaxis of variceal rebleeding is unknown. An open-labeled, uncontrolled pilot trial was performed to evaluate the feasibility and efficacy of using the hemodynamic response to pharmacological treatment to guide therapy in this setting. Fifty patients with acute variceal bleeding underwent a hepatic venous pressure gradient (HVPG) measurement 5 days after the episode. Nadolol and nitrates were initiated, and a second HVPG was measured 15 days later. Responder patients (> or =20% decrease in HVPG from baseline) were maintained on drugs, partial responders (> or =10% and <20%) had banding ligation added to the drugs, and nonresponders (<10%) received a transjugular intrahepatic portal-systemic shunt (TIPS). Mean follow-up was 22 months. Eight patients (16%) did not receive the second HVPG, 6 of them because of early variceal rebleeding. Of the other 42 patients, 24 were classified as responders (57%); 10 as partial responders (24%), who had banding added; and 8 as nonresponders (19%), who received a TIPS. Patients with cirrhosis of viral etiology compared to alcoholic cirrhosis tended to present more early rebleedings, less response to drugs and needed more TIPS. Variceal rebleeding occurred in 22% of all patients but only in 12% of patients whose hemodynamic response was assessed. The 3 therapeutic groups were not different. In conclusion, using hemodynamic response to pharmacological treatment to guide therapy in secondary prophylaxis to prevent variceal bleeding is feasible and effectively protects patients from rebleeding. In this context, viral cirrhosis seems to present a worse outcome than alcoholic cirrhosis.

Hemodynamic efficacy of the new resolution clip device in comparison with high-volume injection therapy in spurting bleeding: a prospective experimental trial using the compactEASIE simulator

BACKGROUND AND STUDY AIMS

Peptic ulcers are the most frequent cause of gastrointestinal bleeding. The use of hemoclips has become established as an effective form of treatment in addition to injection therapy. However, hemoclips have not previously been compared with injection therapy in an experimental setting using objective parameters.

MATERIALS AND METHODS

In a prospective, randomized, and controlled trial, the disposable Resolution hemoclip device (Boston Scientific, n = 40) was compared with conventional injection therapy (n = 40) in an experimental setting, using the compactEASIE simulator equipped with an upper gastrointestinal organ package to simulate bleeding. Four investigators with different levels of endoscopic experience participated in the study. On a randomized basis, each investigator treated 20 bleeding sites either by applying one clip (n = 10) or by carrying out high-volume four-quadrant injection (4 x 10 ml saline) of a spurting vessel. The efficacy of the hemostasis was assessed by continuous measurement of pressure within the afferent vessel before and after clip application or injection therapy and calculating the relative reduction in the vessel's diameter with each treatment method. The system pressure was recorded 1 min before and 1 min after treatment. The ease of application of each method was rated by the endoscopist and by the assisting nurse using a visual analogue scale (0 - 100, with 100 being best).

RESULTS

All of the 40 hemoclipping and injection treatments were carried out successfully. Both methods led to a significant increase in peak pressure (Resolution clip 71.8 +/- 66.8 mm Hg, P < 0.001; injection 71.9 +/- 53.8 mm Hg, P < 0.001), representing a significant relative reduction in the vessel diameter. There were no significant differences in peak pressure between the two treatments ( P = 0.995). The mean increase in pressure during the first minute after the intervention (clip 49.3 +/- 67.0 mm Hg vs. injection 19.9 +/- 41.6 mm Hg) was significantly greater with the hemoclipping procedure ( P = 0.021). More experienced investigators achieved a greater increase in system pressure, but the difference was not significant. The assessments of the ease of application by the assistants (84 +/- 13) and endoscopists (86 +/- 16) did not show any significant differences ( P = 0.402) for the clipping device.

CONCLUSIONS

No significant differences between the two treatment methods were detected with regard to the immediate efficacy of hemostasis. However, long-term hemostasis was better with hemoclipping. The endoscopist's level of experience also appears to play a role, particularly when hemoclips are used.

Diagnosis and management of acute diverticulitis

Although the diagnosis of acute diverticulitis is somewhat standardized, the scientific evidence and basis for treatment has been questioned. For years, medical and surgical management of acute diverticulitis has been based on the theory that more than 2 significant attacks of diverticulitis would lead to the recommendations of surgical resection. This should be questioned and further investigated with prospective randomized trials. Only a small number of well-published articles support the surgical management with good scientific data. Although our ability to take a history and skill of physical examination has not changed, the use of improved technology such as high-speed computerized axial tomography has afforded us the ability to make earlier and more accurate diagnoses. This may further allow us to standardize treatment and study outcomes. The time has come to further investigate and justify this management. It is possible that only the most critical situations may necessitate an operation. Clearly, the age group less than 40 years, as well as the immunocompromised, steroid-dependent, diabetic, and transplant patients, seem to be at greater risk with increased morbidity if not treated early and aggressively. And those individuals who present with perforation or compromised obstruction most likely will continue to need emergent intervention. We should try to set the rules by evidence-based medicine, while remaining within the confines of excellent and cost-effective care.

Traumatic pseudoaneurysm of the pharyngeal artery: An unusual cause of hematemesis and hematochezia after craniofacial trauma

BACKGROUND

Traumatic aneurysms of the internal maxillary artery are extremely rare. We report a case of traumatic pseudoaneurysm of the pharyngeal artery, a branch of the internal maxillary artery, presenting with hematemesis and hematochezia.

CASE DESCRIPTION

An 18-year-old man presented with deep drowsy consciousness after a motor vehicle accident, in which he had a severe craniofacial injury. Three days later, he had hematemesis and hematochezia with a marked decrease in circulating hemoglobin level. External carotid arteriography performed to rule out vascular injury revealed active leakage from a false aneurysm of the pharyngeal artery. The lesion was successfully obliterated by superselective endovascular embolization.

CONCLUSIONS

In patients with craniofacial injury associated with multiple traumas, traumatic pseudoaneurysm of the pharyngeal artery should be suspected as one of the possible causes of hematemesis and hematochezia. Selective endovascular embolization with cerebral angiography is an effective modality for the treatment and diagnosis of this lesion.

[Electrocardiographic changes related to acute upper gastrointestinal hemorrhage]

INTRODUCTION

Upper gastrointestinal bleeding is a common cause of medical attention, with a mortality in Mexico of 8.5%. Our main objective was to determine the association of this pathology with cardiac conduction disturbances and other clinical variables.

MATERIAL AND METHODS

We reviewed the electrocardiograms and files of patients attended for acute upper gastrointestinal bleeding at the Internal Medicine Service of the National Medical Center "20 de Noviembre", they must have had a previous normal electrocardiogram; excluding those with severe hemorrhage, this means, presented with hypotension managed with intravenous fluids and/or vasoactive drugs. Statistical analysis was performed using the SPSS10 program.

RESULTS AND CONCLUSIONS

56 patients were included, 34 women and 22 men; 60.7% were older than 70 years. We report an association between acute upper gastrointestinal bleeding and electrocardiographic changes, principally right bundle branch block in 30.35% of cases.

[Hemodynamic study of the patient with hemorrhagic portal hypertension: importance of the left renal vein in patients with a distal splenorenal shunt (Warren)]

INTRODUCTION

There is no information in the literature about surgical outcome of the distal splenorenal shunt (Warren shunt) in those patients with anomalous flow in the left renal vein to the inferior vena cava.

OBJECTIVE

The purpose of this manuscript was to evaluate the incidence of thrombosis in the Warren shunt in those patients with anomalous flow in the left renal vein to the inferior vena cava.

METHODS

We performed a prospective, descriptive and longitudinal study in those patients who performed a surgical procedure to the treatment of hemorrhagic portal hypertension in a tertiary referral center in Mexico City during a one year period (2002-2003). Before the surgical procedure an arterial and venous angiographic study was done including celiac axis, superior mesenteric artery and splenic artery. The patients were scheduled in the outpatient office the first, third, sixth month and the year after the surgical procedure. We looked in them for gastrointestinal bleeding secondary to portal hypertension. In those patients with Warren shunt an angiographic study was done during the first month after the surgical procedure.

RESULTS

Twenty eight patients were included, 17 of them women (60.7%). Median patient age was 48 years old. In 20 patients a Warren shunt were done and in eigth patients a devascularization operation were done. The anomalous flow of the left renal vein was identified in nine patients (28.7%). In seven of them a Warren shunt were done and in two of them a devascularization operation were done. We didn't find gastrointestinal bleeding or thrombosis of the Warren shunt in any of these patients.

CONCLUSION

In those cases of patients with anomalous flow in the left renal vein a Warren shunt can be performed. In this study we didn't find thrombosis of the shunt or gastrointestinal bleeding. In this way a surgical decompression of the portal system can be done preventing bleeding episodes.