Selective trans-splenic decompression of gastroesophageal varices by distal splenorenal shunt

Selective shunt in the management of variceal bleeding in the era of liver transplantation

This study reports the Emory experience with 147 distal splenorenal shunts (DSRS) and 110 orthotopic liver transplants (OLT) between January 1987 and December 1991. The purpose was to clarify which patients with variceal bleeding should be treated by DSRS versus OLT. Distal splenorenal shunts were selected for patients with adequate or good liver function. Orthotopic liver transplant was offered to patients with end-stage liver disease who fulfilled other selection criteria. The DSRS group comprised 71 Child's A, 70 Child's B, and 6 Child's C patients. The mean galactose elimination capacity for all DSRS patients was 330 +/- 98 mg/minute, which was significantly (p less than 0.01) above the galactose elimination capacity of 237 +/- 82 mg/minute in the OLT group. Survival analysis for the DSRS group showed 91% 1-year and 77% 3-year survival, which was better than the 74% 1-year and 60% 3-year survivals in the OLT group. Variceal bleeding as a major component of end-stage disease leading to OLT had significantly (p less than 0.05) poorer survival (50%) at 1 year compared with patients without variceal bleeding (80%). Hepatic function was maintained after DSRS, as measured by serum albumin and prothrombin time, but galactose elimination capacity decreased significantly (p less than 0.05) to 298 +/- 97 mg/minute. Quality of life, measured by a self-assessment questionnaire, was not significantly different in the DSRS and OLT groups. Hospital charges were significantly higher for OLT (median, $113,733) compared with DSRS ($32,674). These data support a role for selective shunt in the management of patients with variceal bleeding who require surgery and have good hepatic function. Transplantation should be reserved for patients with end-stage liver disease. A thorough evaluation, including tests of liver function, help in selection of the most appropriate therapeutic approach.

Percutaneous transluminal angioplasty of an occluded distal splenorenal shunt

A distal splenorenal (Warren) shunt was performed on a 39-year-old female with bleeding esophageal varices secondary to portal hypertension and cirrhosis. On the twelfth postoperative day, however, she rebled, and angiography revealed that the shunt was occluded. Using a percutaneous approach, successful balloon angioplasty and recanalization was performed. The patient did well and was discharged without further bleeding. Percutaneous transluminal angioplasty (PTA) appears to be effective in dilating occluded splenorenal shunts, obviating a second surgical procedure in high-risk patients.

Long-term effects of distal splenorenal shunt on hepatic hemodynamics and liver function in patients with cirrhosis: importance of reversal of portal blood flow

We studied 23 patients with cirrhosis who had undergone retroperitoneal distal splenorenal shunt without portal-azygos disconnection more than 2 yr earlier. We investigated the suitability of the Doppler technique (ultrasound + Doppler) to assess the patency and blood flow direction through the portal vein and the distal splenorenal shunt and its correlation with the continuous thermal dilution technique. The study also assessed the influence of the distal splenorenal shunt and time after surgery on portal perfusion and liver function. Ultrasound + Doppler distal splenorenal shunt thrombosis in two patients; however, none was confirmed by continuous thermal dilution. Ultrasound + Doppler flowmetry was possible in 19 patients (83%) (mean, 1.58 +/- 0.53 L/min). Distal splenorenal shunt continuous thermal dilution measurements were performed in all patients (100%), (mean, 1.65 +/- 0.5 L/min). Good correlation was seen between them (r = 0.66). Ultrasound + Doppler of the portal vein showed a hepatopetal flow in 16 patients (69.9%). Hepatic blood flow was significantly higher in patients with hepatopetal flow (p = 0.003). Hepatic clearance and intrinsic hepatic clearance of indocyanine green were significantly lower in patients with hepatofugal flow. Patients with hepatofugal flow had a higher incidence of chronic encephalopathy. None of the patients with a follow-up of less than 4 yr exhibited hepatofugal flow, whereas 7 of the 16 patients with a longer follow-up had hepatofugal flow (43.7%). The difference was statistically significant (p = 0.04). This study suggests that ultrasound + Doppler sonography may provide useful data in the evaluation of the patency and blood flow direction through the portal vein and the distal splenorenal shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

Postprandial augmentation of portal hepatic inflow after prosthetic H-graft portacaval shunt

Encephalopathy after portasystemic shunting generally occurs after eating. After partial portal decompression, encephalopathy is uncommon, presumably because of associated portal hemodynamics. However, after partial shunting, the changes in portal venous hemodynamics that occur with eating are unknown. With this in mind, 11 nonencephalopathic adults were studied more than 1 year after 8-mm H-graft portacaval shunt (PCS). The studies utilized color flow duplex ultrasound to determine the changes in portal vein (PV) and inferior vena cava blood flow that occur with eating a standardized meal. Following H-graft PCS, there is increased blood flow in the inferior vena cava after eating, particularly cephalad to the H-graft PCS, implying increased flow through the prosthetic shunt. Eating also increases hepatopedal blood flow in the PV distal to the H-graft PCS. Postprandial increases in hepatopedal portal blood flow may play an important role in avoiding encephalopathy after H-graft PCS.

Sclerotherapy vs. esophageal transection vs. distal splenorenal shunt for the clinical management of esophageal varices in patients with child class A and B liver function: a prospective randomized trial

Ninety-six patients with good liver function (Child class A or B) and esophageal varices were randomly assigned to one of three groups given different treatments: endoscopic injection sclerotherapy (n = 32), esophageal transection (n = 32) or distal splenorenal shunt (n = 32). Five patients (5.2%) had to be excluded from this study because severe chronic pancreatitis made separation of the distal splenic vein from the pancreatic bed difficult. Esophageal transection was performed for these patients. No deaths occurred during the 30 days of treatment. The 5-yr cumulative bleeding rates were 0%, 5.9% and 12.9% in the endoscopic injection sclerotherapy, esophageal transection and distal splenorenal shunt groups, respectively (no statistical significance). In no case in the three groups did death occur because of variceal bleeding. Sixteen patients died, mainly because of underlying liver disease; four were in the endoscopic injection sclerotherapy group, five were in the esophageal transection group and seven were in the distal splenorenal shunt group. No statistically significant difference in survival rate among the three groups was found. These results show that endoscopic injection sclerotherapy is a satisfactory alternative to esophageal transection or distal splenorenal shunt for the clinical management of patients with esophageal varices.

Investigation of the portal perfusion index after low diameter mesocaval interposition and distal splenorenal shunt--a prospective study

In 50 consecutive patients portal blood flow was determined using computed liver perfusion scintigraphy preoperatively and at 6, 12, 24, 36, 48, 60, 72, and 84 months postoperatively between 1 January 1983 and 1 January 1990. All 25 subjects had undergone placement of a distal splenorenal shunt (DSRS) and 25, insertion of low-diameter PTFE mesocaval interposition shunt (LDMIS) between 15 January 1983 and 1 January 1988. Indications for shunt operation included recurrent variceal hemorrhage in spite of long-term endoscopic sclerotherapy, a Child-Pugh classification of A or B, a sonographically determined liver volume of between 1000 and 2500 ml, exclusion of the activity and progression of liver disease by biopsy and stenosis of the hepatic artery or coeliac trunk. DSRS was performed when the portal perfusion index (PPI) was greater than 30% (normal values 56 +/- 5%) and LDMIS was carried out when the PPI was 10% to 30%. In all cases the underlying disease was liver cirrhosis of alcoholic (n = 34, 68%) or hepatic (n = 12, 24%) etiology. Five patients who underwent LDMIS had originally scheduled for DSRS at a PPI of greater than 30%; because the DSRS would have been technically difficult due to severe chronic pancreatitis, a LDMIS was performed. One in-hospital death due to liver failure had occurred in each group by 1 January 1990. One patient in the DSRS group and two in the LDMIS group died later, and in each group one patient was lost to follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical emergencies in liver disease

In this chapter the surgical management of bleeding oesophageal varices, ruptured hepatocellular carcinoma and fulminant liver failure have been discussed. Bleeding oesophageal varices can usually be successfully treated with vasopressin, balloon tamponade and injection sclerotherapy. Emergency surgery should be considered if two courses of injection sclerotherapy have failed to achieve haemostasis. Stapled oesophageal transection and portosystemic shunting are currently the two most popular procedures. The former is associated with a lower morbidity and mortality as well as a lower incidence of subsequent encephalopathy. Ruptured hepatocellular carcinomas are usually associated with liver cirrhosis and impaired liver function. Selective coeliac axis cannulation followed by embolization of the hepatic artery branches supplying the tumour is an effective method of achieving haemostasis and is associated with a lower morbidity and mortality than emergency hepatic artery ligation or liver resection. If haemostasis is achieved by embolization the patient may subsequently be assessed for an elective resection of the tumour. Fulminant liver failure may be managed by supportive medical therapy or orthotopic liver transplantation. Patients whose liver failure is graded as mild (grade I) should be treated by medical therapy, whereas those with severe liver damage (grades III and IV) should be assessed for transplantation. Accurate monitoring of the patient's clinical progress and prognostic indicators are vital in deciding whether conservative treatment should be continued or liver transplantation performed.

The management of variceal bleeding

Variceal bleeding has a high mortality, as the majority of patients have cirrhosis, with hepatic coma, renal failure, ascites and clotting deficiencies as complicating factors. Bleeding varices must therefore be treated as an emergency. Resuscitation, endoscopic diagnosis and haemostasis are the cornerstones of treatment. Once bleeding varices have been identified, attempts to stop the bleeding must be made at once as this will lessen the chances of hepatic failure developing. Endoscopic sclerotherapy at the time of diagnosis is the best available treatment at present, although profusely bleeding varices can be difficult to see and inject. In these circumstances the passage of a Sengstaken tube should stop the bleeding, allowing later sclerotherapy to be successful. If rebleeding recurs and cannot be controlled, oesophageal transection with a stapling gun may be life-saving, although the varices may later recur and long-term endoscopic follow-up will be necessary. Portacaval shunting and the distal splenorenal shunt involve arduous surgery and are followed by a significant incidence of hepatic encephalopathy; they should be reserved for those few cases when simpler measures have failed, although shunts do lead to permanent decompression of the portal system. The acute variceal bleed may also be dealt with pharmacologically. Vasopressin, used in combination with nitroglycerin to lessen the harmful side-effects, is cheaper and as effective as terlipressin or somatostatin and its synthetic analogue octreotide. Several courses of injection sclerotherapy will be required to eliminate oesophageal varices. Thereafter, long-term follow-up will be necessary to deal with any recurrence. The place of non-selective beta-blockers is still contentious, but they do reduce portal pressure and may lessen the chance of rebleeding. There is also a growing role for hepatic transplantation, which not only eliminates the varices but also restores liver function to normal and greatly reduces the risk of subsequent hepatoma development.

Current concepts in the pathophysiology and treatment of portal hypertension and variceal hemorrhage

Recent studies have demonstrated that increased resistance to portal inflow is not solely responsible for the development of portal hypertension. Increased splanchnic flow has been attributed to a combination of factors, including elevated circulating levels of vasodilators and diminished sensitivity of the splanchnic vasculature to endogenous vasoconstrictors. In selected animal models of portal hypertension, increased splanchnic flow accounts for approximately 40% of the observed elevations in total portal venous pressure. Improved understanding of the pathophysiologic factors responsible for the development of portal hypertension has led to pharmacologic efforts to decrease portal pressure. Current limitations include lack of drug selectivity and specificity and inability to predict and monitor patient responses. Primary treatment options include selective portosystemic shunts, endoscopic sclerotherapy (ES), and orthotopic liver transplantation. ES is more effective in preventing recurrent variceal hemorrhage than medical treatment but is less effective than shunt surgery. In selected studies, ES better maintains hepatic function and may prolong survival compared to primary shunt surgery. ES failures occur in nearly 33% of patients, but "salvage shunts" in these patients appear to be reasonably safe and quite effective in preventing recurrent hemorrhage. Selective shunts are favored because they appear to confer a better quality of life (but not improved longevity) than conventional shunts. Liver transplantation is preferred for patients with end-stage liver disease in whom the predicted mortality of conventional surgery outweighs the survival benefit.

Should both schistosomal and nonschistosomal variceal bleeders be disconnected?

Splenopancreatic disconnection (SPD) was conceived and implemented as a technical addition to distal splenorenal shunt (DSRS) to maintain its selectivity and preserve portal perfusion. The proposed hemodynamic and metabolic stability of hepatocytes after DSRS-SPD should improve survival. In this nonrandomized study, 145 consecutive (Child A/B) variceal bleeders were electively subjected to selective shunt with DSRS in 93 and DSRS-SPD in 52 patients. The 2 groups were similar before surgery with a mean follow up of 24 +/- 12 (DSRS) and 27 +/- 14 (DSRS-SPD) months. DSRS-SPD had an operative mortality of 3.8%. Postoperative pancreatitis occurred in 7.7% after DSRS-SPD and 3.2% after DSRS alone, with schistosomal hepatic fibrosis representing 86% of morbid cases. Shunt patency was high and recurrent variceal hemorrhage was low in both groups. Clinical encephalopathy was significantly reduced after DSRS-SPD (p less than 0.05). The addition of SPD significantly reduced both the incidence of chronic hyperbilirubinemia in the schistosomal patients (p less than 0.05) and the difference between the changes in total serum bilirubin in all patients (p = 0.001). Portal perfusion was preserved after DSRS-SPD in all of the angiographically-studied patients. The overall survival was 84% after DSRS and 88% after DSRS-SPD. The schistosomal patients showed an incidence of 95% and 96% survival after DSRS and DSRS-SPD, respectively. DSRS-SPD was able to improve survival (92%) better than DSRS (77%) among well-matched nonschistosomal patients. These data show: (1) DSRS-SPD still has low operative mortality and a high patency rate with a low incidence of recurrent variceal hemorrhage, (2) DSRS-SPD maintains portal perfusion, achieves better survival, and reduces the incidence of encephalopathy, especially in patients with nonalcoholic cirrhosis and mixed liver disease, (3) in the schistosomal population, DSRS-SPD reduces the incidence of chronic hyperbilirubinemia but increases the risk of postoperative pancreatitis.

The role of continued drinking in loss of portal perfusion after distal splenorenal shunt

Fifty percent of patients with alcoholic cirrhosis who undergo distal splenorenal shunting for variceal bleeding lose portal perfusion within 1 year. Although it was previously considered that this loss of portal flow was irrevocable, the present study shows that with resolution of alcoholic hepatitis, portal perfusion can be restored. A 34-year-old patient with alcoholic liver disease and a distal splenorenal shunt lost portal perfusion 1 year after the operation. He had continued to drink alcohol and had high sinusoidal pressure. Following forced abstinence over the next 2 years, his sinusoidal pressure fell, liver volume decreased, results of liver biopsy improved, and portal perfusion was restored. Shunt patency was documented, and the same collaterals from the portal vein to the shunt could still be visualized as had been seen when portal flow was absent. Restoration of portal perfusion was attributed to decreased intrahepatic resistance secondary to abstinence from alcohol. A return to drinking in the next 9 months led to alcoholic hepatitis and once again loss of portal perfusion. This study places emphasis on increased intrahepatic resistance rather than the development of portal-to-shunt collaterals as important in the loss of portal flow in such patients.

The endoscopic and surgical management of portal hypertension in children: analysis of 123 cases

Since 1973, 178 children with portal hypertension (PH) have been seen at Instituto da Criança of the University of São Paulo Medical School. Fifty-five of these children were excluded from this analysis for various reasons, including no treatment required, death before treatment, or incomplete data. From the remaining 123 children with esophageal varices, only 96 (76.1%) of them had at least one episode of upper gastrointestinal hemorrhage. Eighty-eight children were submitted to injection sclerotherapy; 26 treated prophylactically, and 62 for treatment of previous bleeding. Eleven (42.3%) children from the prophylactic group bled from esophageal varices during the treatment. They were all successfully managed thereafter. Satisfactory results were achieved in 53 (85.4%) children in the therapeutic group. Twenty-eight (45.1%) children had at least one episode of bleeding after beginning of sclerotherapy, 19 of whom eventually had successful control of the variceal bleeding. From 1973 to 1984, distal splenorenal shunt (DSS) was the procedure of choice for the treatment of bleeding esophageal varices. Forty-two children have undergone DSS during this period. Only one child was shunted prophylactically. Since 1985, injection sclerotherapy has been the first choice for the treatment and only seven children with sclerotherapy failure have since been treated by DSS. Characteristically these children had very similar splenoportographic pattern with huge esophageal and gastric varices and deviation of portal vein blood flow toward the left gastric vein.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective study of a prosthetic H-graft portacaval shunt

This study was undertaken to prospectively evaluate the 8-mm Gore-Tex interposition H-graft portacaval shunt. Thirty-six high-risk patients at the University of South Florida-affiliated hospitals received small-diameter shunts because of bleeding esophagogastric varices over a recent 2-year period. Portal vein and portal vein-inferior vena cava gradients were significantly reduced after shunting. These pressure changes were manifested clinically by the absence of variceal rebleeding and improvement of ascites; in addition, the incidence of encephalopathy was low. The 8-mm graft maintained hepatopedal flow in 67% of the patients, but reversal of flow did not result in complications commonly associated with poor portal perfusion. Graft thrombosis occurred in four (11%) patients. All grafts were successfully revised, three by operative revision and one by an interventional radiologist. Operative mortality was low (11%), and morbidity was unusual. The small-diameter H-graft portacaval shunt is a safe and effective method of treatment for bleeding esophagogastric varices.

Surgical treatment of severe postshunt hepatic encephalopathy

Hepatic encephalopathy is a major complication of portal-systemic shunts with an incidence ranging up to 52%. A small fraction of these patients are refractory to medical therapy. Shunt ligation and colonic procedures are the main surgical approaches. The goal of the latter is to diminish the colonic absorption of nitrogenous substances which are involved in the pathophysiology of hepatic encephalopathy. Six patients, whose average age was 55.7 +/- 2.6 years, were operated for severe postshunt encephalopathy requiring 4.3 +/- 0.9 admissions for a total duration of 76 +/- 26 days over 1-11 years. One patient had undergone a splenoral shunt and 5 had a portacaval shunt. One ligation of the shunt and 5 colon exclusions were performed. The average postoperative hospital stay was 21.5 +/- 3.9 days. The mean follow-up was 47 +/- 20 months. The patient with the shunt ligation remains free of encephalopathy 94 months after the procedure and has not bled from his esophageal varices. Among the 5 colon exclusion patients, there were 1 death and 3 complications. Three patients were completely relieved of their hepatic encephalopathy. One of those 3 died of a subarachnoid hemorrhage 28 months after the surgery. The fourth still needs medication to control a persistent, although improved, encephalopathy that required 2 further hospitalizations. Colon exclusion is a useful intervention in very selected cases. It has a lower operative mortality than total colectomy and the advantage over shunt ligation of not reestablishing hypertension in the portal system.

Selective shunt versus nonshunt surgery for management of both schistosomal and nonschistosomal variceal bleeders

This clinical study included 219 (Child A/B) consecutive variceal bleeders. Electively 123 had distal splenorenal shunt (DSRS) and 96 had splenectomy with gastroesophageal devascularization (S&GD). Liver pathology was documented in 73% of patients, with schistosomal fibrosis in 41% and nonalcoholic cirrhosis or mixed pattern (fibrosis and cirrhosis) in 59%. The surgical groups were similar before operation, with a mean follow-up of 82 +/- 13 and 78 +/- 18 months, respectively (range, 60 to 120 months). The two pathologic populations were also similar before each and both procedures. The operative mortality rates were low, with incidences of 3.3% (DSRS) and 3.1% (S&GD). Rebleeding occurred significantly (p less than 0.05) more frequently after S&GD (27%) compared to DSRS (5.7%). Sclerotherapy salvaged 65% of S&GD rebleeders. Encephalopathy developed significantly (p less than 0.05) more after DSRS (18.7%) compared to S&GD (7.3%), with no significant difference among the current survivors. The difference in overall rebleeding and encephalopathy rates between both procedures was statistically related to patients with cirrhosis and mixed lesions (p less than 0.05). Distal splenorenal shunt significantly reduced the endoscopic variceal size more than S&GD (p less than 0.05). Prograde portal perfusion was documented in 94% of patients in each group, with a variable distinct pattern of portaprival collaterals in 91% (DSRS) and 65% (S&GD). The total population cumulative survival was similar with 80% for DSRS and 79% for S&GD (plus sclerosis in 23%), with hepatic cell failure the cause of death in 46% and 50%, respectively. However, in the schistosomal patients, survival was better improved after DSRS (90%) compared to S&GD (75%), with no difference among the cirrhotic and mixed group (DSRS 73%, S&GD 72%). In conclusion (1) both DSRS and S&GD have low operative mortality rates, (2) DSRS is superior to S&GD in the schistosomal patients, and (3) S&GD backed by endosclerosis for rebleeding is a good surgical alternative to selective shunt in the nonalcoholic cirrhotic and mixed population.

The selective shunt for variceal bleeding: a personal perspective

It has been proved that selective decompression of esophageal varices can occur by way of the left gastric venous route or the transsplenic route. The left gastric venacaval shunt functions well over a long postoperative period, if the shunt is technically satisfactory; however, the distal splenorenal shunt (DSRS) can be problematic. Unless the proximal and distal portions of the splenic vein are both entirely isolated from the pancreas, blood flow will be diverted from the portal vein to the distal splenic vein, where the pressure has been lowered by the shunt. This portal malcirculation may lead to portal thrombosis or stenosis on occasion. To prevent this adverse effect, complete isolation of the splenic vein (splenopancreatic disconnection) is necessary. Extensive gastric disconnection is irrelevant in this regard. Although the conventional DSRS has been viewed with disfavor, we must realize that splenopancreatic disconnection makes the DSRS a satisfactory technique. The clinical evidence and theoretic basis of the selective shunt for esophageal varices are described herein.

Selective variceal decompression and its role relative to other therapies

Seventy patients, selected from 265 patients with proved variceal bleeding, underwent a distal splenorenal shunt (DSRS) procedure with or without splenopancreatic disconnection (SPD). Alcoholic cirrhosis was the cause of portal hypertension in 57% of the patients. The operative mortality was 13% (Child's classes A and B 2%, class C 66%). Despite fewer varices in all of the patients, variceal rebleeding and death occurred in one patient (2%). Late portal perfusion was observed in 91% of the patients, with worsening in 23%, compared with the preoperative study. Persistent hepatocyte necrosis and incomplete SPD were the most significant prognostic factors for decreased perfusion (presence and absence of necrosis, 38% and 12%, respectively; DSRS and DSRS with SPD, 43% and 12%, respectively). SPD also decreased ongoing hepatocyte damage. Post-shunt encephalopathy was clinically evident in 7% of the patients, but after electroencephalographic evaluation, it increased to 24.6%. Significant factors in its development included decreased portal perfusion (62% versus 14%), active hepatitis (48% versus 17%), and incomplete SPD (43% versus 14%). The higher late liver-related mortality was associated with a lack of or decreased portal perfusion and the absence of SPD.

Selective shunt in schistosomiasis in Egypt

A joint study of the selective shunt in schistosomiasis was conducted in Egypt by the Mansoura University and Emory liver research teams. One hundred seventy patients with biopsy-proven hepatic schistosomiasis and a history of variceal bleeding were included in the study. The findings indicate that this procedure is safe and effective in the treatment of this patient population.

Current status of the distal splenorenal shunt in China

Herein we report the results and current status of the distal splenorenal shunt (DSRS) in China. From June 1979 to June 1989, the DSRS was performed in 302 patients with esophagogastric varices. Among a group of 249 patients, 112 were in Child's class A, 97 were in class B, and 40 were in class C. The cause of portal hypertension was posthepatic cirrhosis in 217 patients, schistosomiasis in 28 patients, alcoholic cirrhosis in 3 patients, and biliary cirrhosis in 1 patient. Therapeutic selective shunts were performed in 200 patients with variceal bleeding, and 102 patients received prophylactic shunts. Emergency operations were performed in 10 patients. The original Warren shunt was performed in 264 patients, and various modifications in 38 patients. Simultaneous ligation of the splenic artery was performed in 202 patients. The overall operative mortality rate was 6%. A 3-month to 10-year follow-up demonstrated an 8% recurrent bleeding rate, a 1% incidence of encephalopathy, and a survival rate ranging from 72.3% to 100%. From the preliminary results obtained, we conclude that DSRS is effective and safe in the treatment of esophagogastric variceal bleeding. It can also be used as a prophylactic procedure in Child's class A and B patients.

Surgical rescue for failures of cirrhotic sclerotherapy

Bleeding from gastroesophageal varices remains the most devastating complication of the portal hypertensive syndrome. Endoscopic sclerotherapy has emerged as the best initial treatment for bleeding varices because surgery is obviated and survival may be improved. However, sclerotherapy will fail and surgical rescue will be required in at least a third of patients. There are two viable surgical rescue procedures: shunt surgery and liver transplantation. This paper summarizes the available data and concludes that there is a role for both procedures.

Improved survival after prophylactic portal nondecompression surgery for esophageal varices: a randomized clinical trial. Cooperative Study Group of Portal Hypertension of Japan

To evaluate prophylactic surgery for esophageal varices, a prospective randomized controlled trial was begun in 1980 by the Japanese Research Society for Portal Hypertension. Methods of operation included selective shunts and nonshunting interruption procedures. One hundred and twelve Japanese patients, in whom endoscopic findings suggested risk of bleeding but who had no bleeding episode, were randomly allocated to the operated group of 60 patients or nonoperated group of 52 patients. Nine patients with idiopathic portal hypertension, histologically proven noncirrhotic disease, which all fell in the operated group, were excluded from the study and the remaining 103 patients (51 operated and 52 nonoperated) were analyzed. Long-term follow-up of patients for a median of 49 mo with a maximum of 73 mo showed a total of 11 (22%) deaths, including 2 operative deaths, in the operated group compared with 23 (49%) deaths in the nonoperated group. The cumulative survival rate at 5 yr in the operated group was 72%, which was significantly higher than the 45% of the nonoperated group (p less than 0.05). The cumulative variceal bleeding rate at 5 yr was 7% in the operated group, which was significantly lower than that of the nonoperated group of 46% (p less than 0.001). It was concluded that portal nondecompression surgery was effective in preventing the variceal bleeding and in improving survival.

Role of the distal splenorenal shunt in management of variceal bleeding in Latin America

In the early 1970s, we began to perform selective shunts on a regular basis for the treatment of portal hypertension. In a 15-year period, 177 patients (155 with liver cirrhosis) were treated with 3 kinds of selective shunts: the Warren shunt (128 patients) the end-to-end splenorenal shunt (29 patients), and the splenocaval shunt (20 patients). One hundred sixty-seven of the procedures were elective. Operative mortality was 14%, and survival for the Child's class A group was 75% at 1 year, 69% at 5 years, and 65% at 15 years. Incapacitating encephalopathy was observed in 7% of the patients, rebleeding in 6%, and shunt thrombosis in 6%. Postoperative portal vein alterations included reduced venous diameter (13%) and thrombosis (21%). Experience with the Warren shunt in schistosomiasis, a disease in which normal liver function is the rule in Latin American countries, is discussed. We believe that, when feasible, the selective shunts are the treatment of choice for portal hypertension in Latin American countries.

Current strategy for esophageal varices in Japan

Management of bleeding esophageal varices in Japan includes tamponade, sclerotherapy, devascularization, and shunt procedures. Sclerotherapy is the most widely used treatment in both acute and chronic management. The Japanese Research Society for Sclerotherapy of Esophageal Varices monitors and surveys this treatment method at 152 institutions. Extensive devascularization operations now include a thoracotomy less frequently than previously, and they have a 6.6% rebleeding rate in elective patients. Shunt operations are applied in 20% of cases of bleeding esophageal varices in Japan. Effective medical and surgical treatments have led to changes in management strategy and to diversity in treatment during the last decade. The timing of treatment, the nature of the disease, the patient's liver function, and the distribution of collaterals should all be considered in selecting treatment.

Definitive therapy for variceal bleeding: a personal view

Definitive therapy for variceal hemorrhage has evolved during the past half century. Only completely decompressing shunts (nonselective shunts) were available before 1967. Additional options now include selective shunts, devascularization procedures, endoscopic sclerotherapy, pharmacotherapy, and hepatic transplantation. Although drug treatment is experimental at the present time, the remaining therapeutic options are applicable to various subgroups of patients and in certain clinical settings. At the University of Nebraska, patients with variceal bleeding are first grouped based on their candidacy for transplantation. Transplantation candidates with advanced (Child's class C) or symptomatic liver disease undergo transplantation as soon as possible. Future transplantation candidates with stable, asymptomatic liver disease undergo either long-term sclerotherapy or a distal splenorenal shunt if sclerotherapy fails or if they have poor access to tertiary medical care. These patients are carefully monitored so that they can undergo transplantation before they become high-operative risks. Patients who are not candidates for transplantation receive chronic variceal sclerotherapy as initial therapy so long as shunt surgery is readily available if sclerotherapy fails. When surgery is indicated, the distal splenorenal shunt is preferred to nonselective shunts because several controlled and uncontrolled series have demonstrated a lower frequency of encephalopathy after selective variceal decompression.

The Emory perspective of the distal splenorenal shunt in 1990

The distal splenorenal shunt (DSRS) has been extensively studied at Emory University over the past 18 years to define its role in the management of variceal bleeding. DSRS has been applied broadly in many different patient groups and has been evaluated in prospective randomized trials; thus, a considerable amount of data has accrued on the metabolic and hemodynamic consequences of selective variceal decompression. Its current role is defined as primary therapy for variceal bleeding in patients with portal vein thrombosis and good-risk patients with nonalcoholic cirrhosis. As a therapy for patients whose bleeding is not controlled by sclerotherapy, it should be used as the shunt procedure of choice, but patient evaluation must focus on the choice between DSRS and liver transplantation.

Selective shunts: the Johannesburg experience

My personal 15-year experience with 141 selective shunts (127 elective, 14 emergency) for portal hypertension is reported. Alcoholic cirrhosis comprised 54% of elective operations, and of the nonalcoholic patients, 22% were cirrhotic and 24% were noncirrhotic. Adequate and, if necessary, prolonged (mean 6 weeks) in-hospital preparation resulted in Hospital mortality and long-term actuarial survival were better in nonalcoholics compared with alcoholics, but there was no significant difference between cirrhotic nonalcoholics and alcoholics. Variceal rebleeding was rare (4% of Warren procedures) and, when present, was usually related to shunt failure. Gastric fundal variceal rebleeding did not occur in 44 patients undergoing splenopancreatic disconnection. Postoperative encephalopathy occurred in 13% of patients; however, it did not occur at all in noncirrhotic patients. Prograde portal venous perfusion was preserved in 77% of patients. Fifteen alternate selective operations to the Warren shunt were performed, usually because of antecedent splenectomy. Shunt failure and variceal rebleeding occurred more frequently with these more vulnerable shunts, but 66% had a satisfactory outcome. Selective shunts have produced highly satisfactory results in appropriately selected patients.

The interposition mesocaval shunt

The interposition mesocaval C-shunt is an excellent alternative for the management of bleeding esophageal varices. The comparable operative mortality, long-term survival, and minimal operative time and blood loss make it the emergency shunt of choice. The C-shunt modification has improved long-term patency and ease of operation. The interposition mesocaval shunt also is increasing in importance as the best portosystemic shunt in those patients who may eventually require liver transplantation.

The portacaval shunt. Is it still indicated?

This article has attempted to question whether the more recently introduced methods of treating the patient with variceal hemorrhage have resulted in higher salvage rates and a better quality of life. Data concerning other types of central shunts, selective shunting, nonshunt operations, hepatic transplantation, sclerotherapy, and pharmacologic manipulation have all been critically reviewed. It seems clear that, although some of these modalities are roughly equivalent to portacaval shunting, others are inappropriate. This is especially so in the majority of patients with portal hypertension in the United States whose cirrhotic etiology is based on alcohol addiction. Additionally, a large, one-institution series of side-to-side portacaval shunts has been presented that yielded good results. It is hoped that this presentation has succeeded, at a minimum, in causing the reader to question the basis of treatment for variceal hemorrhage and, at a maximum, in convincing him or her to retain the portacaval shunt as a mainstay in treating the hemorrhagic complications of portal hypertension.

The distal splenorenal shunt

Distal splenorenal shunt (DSRS) provides selective decompression of gastroesophageal varices, with maintenance of portal hypertension and prograde portal flow to the cirrhotic liver. Accurate patient evaluation is essential to select appropriate patients for DSRS. Variceal bleeding control is greater than 85% and is as effective as total portosystemic shunts. Maintenance of prograde portal flow is greater than 90% in nonalcoholic disease, but only 50% in alcoholic cirrhosis; the latter is improved by total splenopancreatic disconnection. Hepatic function is better maintained when portal flow is maintained. Encephalopathy is lower after DSRS than after total shunts. Survival is not significantly improved after DSRS in patients with alcoholic cirrhosis compared to outcome after total shunts. The survival in patients with nonalcoholic disease is significantly improved over that of alcoholics.

Distal splenorenal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding. First stage of a randomized, controlled trial

In 1984 we started a prospective controlled trial comparing endoscopic sclerotherapy (ES) with the distal splenorenal shunt (DSRS) in the elective treatment of variceal hemorrhage in cirrhotic patients. The study population included 40 patients with cirrhosis and portal hypertension referred to our department from October 1984 to March 1988. These patients were drawn from a pool of 173 patients who underwent either elective surgery or endoscopic sclerotherapy during this time. Patients were assigned to one of the two groups according to a random-number table: 20 to DSRS and 20 to ES. During the postoperative period, no DSRS patient died, while one ES patient died of uncontrolled hemorrhage. One DSRS patient had mild recurrent variceal hemorrhage despite an angiographically patent DSRS. Four ES patients suffered at least one episode of gastrointestinal bleeding: two from varices and two from esophageal ulcerations. Five ES patients developed transitory dysphagia. Long-term follow-up was complete in all patients. Two-year survival rates for shunt (95%) and ES (90%) groups were similar. One DSRS patient rebled from duodenal ulcer, while three ES patients had recurrent bleeding from esophagogastric sources (two from varices and one from hypertensive gastropathy). One DSRS and two ES patients have evolved a mild chronic encephalopathy; four DSRS and two ES patients suffered at least one episode of acute encephalopathy. Two ES patients had esophageal stenoses, which were successfully dilated. Preliminary data from this trial seem to indicate that DSRS, in a subgroup of patients with good liver function and a correct portal-azygos disconnection, more effectively prevents variceal rebleeding than ES. However no significant difference in the survival of the two treatment groups was noted.

Early hemodynamic changes following selective distal splenorenal shunt for portal hypertension: comparison of surgical techniques

Ninety patients with cirrhosis undergoing elective distal splenorenal shunt (DSRS) for variceal bleeding between January, 1977 and September, 1988 comprised the study group. In 63 cases, the original technique of Warren was used and, in 15, the modified Britton procedure was employed. Twelve patients had a DSRS plus splenopancreatic disconnection. Thirty-four had alcoholic cirrhosis and 56 had nonalcoholic cirrhosis. Intraoperative portal pressure remained high after the shunt (29.4 cm H2O) even if its initial value was probably decreased by the loss of the splenic flow. Splenic pressure was reduced to 21 cm H2O. The hepatic artery diameter enlarged even after selective shunt (from 6.5 to 7.1 mm). The persistence of a high portal pressure allowed for the preservation of hepatopedal portal flow in 87% of cases. Disconnection between the high-pressure mesenteric area and the low-pressure splenic area seemed to be ideal in only 17% of cases. Fifty-five percent of cases had the early development of minimal or moderate portomesenteric gastrosplenic (PM-GS) collateral pathways. In 33%, the PM-GS collaterals were generally abundant and often allowed visualization of the splenic and caval veins during the venous phase of the superior mesenteric arteriograms. In this group, portal flow was generally highly reduced and even abolished. The incidence of portal thrombosis was 11%. Early angiographic checks after DSRS did not show a different hemodynamic behavior between alcoholics and nonalcoholics. Splenopancreatic disconnection seems to prevent the development of collaterals and the loss of portal perfusion after shunt surgery.

Development of chronic hepatocerebral degeneration eight years after a distal splenorenal (Warren) shunt

It is well known that chronic encephalopathy may be a major complication after the establishment of a surgical portal caval shunt for an episode of variceal haemorrhage. In an effort to minimise this problem Warren and colleagues developed the distal splenorenal shunt where the portal and mesenteric blood flow to the liver was left intact. It is now recognised, however, that the longterm incidence of encephalopathy may be no different with this type of shunt compared with conventional surgical portal systemic shunts. Acquired chronic hepatocerebral degeneration has not been reported after such a selective shunt. A patient with primary biliary cirrhosis is reported who developed the clinical features of this syndrome eight years after a successful distal splenorenal shunt.

A prognostic evaluation of endoscopic intravariceal injection sclerotherapy for esophageal varices

Eighty cases of endoscopic injection sclerotherapy for esophageal varices were retrospectively studied to evaluate their prognoses. These cases were evaluated in terms of post-therapeutic bleeding, survival rates and causes of death. Post-therapeutic bleeding occurred in 50% of the emergency cases (26 cases), 25% of the elective cases (16 cases) and 23.7% of the prophylactic cases (38 cases). The frequency of post-therapeutic bleeding was significantly lower in cases with variceal obliteration than in cases without obliteration. An evaluation of the survival rates by the Kaplan-Meier method revealed that poor prognostic factors in sclerotherapy cases were emergency cases, Child's C group, post-therapeutic cases with unsuccessfully obliterated varices, and cases with post-therapeutic bleeding. Concerning early death within 7 days after sclerotherapy, 4 emergency cases died from initial variceal bleeding despite sclerotherapy. Three of these 4 were hepatocellular carcinoma cases, and all 3 cases had tumor thrombi of the portal vein. We recommend prophylactic sclerotherapy from the standpoint of the prognosis after sclerotherapy. However, in the bleeding cases of hepatocellular carcinoma in Child's C group complicated by tumor thrombi of the portal vein, overly enthusiastic application of the therapy should be avoided.

Improved results with selective distal splenorenal shunt in a highly selected patient population. A prospective study

In a 5-year period 299 patients were admitted to the Heinz-Kalk Hospital with bleeding esophageal varices. Patients with acute bleeding were treated with endoscopic sclerotherapy. Sessions were performed as many times as needed for each individual case. One hundred seventy-eight patients in Child-Pugh class C were excluded from surgical treatment; the remaining 121 patients (Child AB) were selected using the following criteria: liver volume (ultrasound) between 1000 to 2500 ml, portal perfusion (sequential scintigraphy) more than 30%, no activity or progression of liver disease proved by biopsy, no stenosis of the hepatic arteries, and suitable anatomy to perform the Warren shunt. Only 32 patients fulfilled these criteria. In seven of these cases the shunt was technically impossible to perform. Operative mortality rate was 8% and the late mortality rate was 12%. No history of rebleeding, encephalopathy, and/or shunt thrombosis was recorded. Five-year survival rate, according to the method of Kaplan-Meier was 75%. We conclude that the Warren shunt is the treatment of choice for elective management of bleeding esophageal varices. The postoperative results can be improved with strict selection using the above criteria. The preoperative use of sclerotherapy has a positive influence. Prophylactic management to prevent encephalopathy is also recommended.

Esophageal transection may well be the approach of choice for patient with portal venous obstruction and esophageal varices

Thirty patients with esophageal varices, portal venous obstruction and a histologically proven normal liver underwent either one of 2 different types of surgery. Shunt surgery was performed on 20 patients: 9 had a mesocaval shunt, 3, a splenorenal shunt, 4, a left gastric venacaval shunt, and 4, a distal splenorenal shunt. Conversely, direct interruption was performed on the other 10 patients; 6 underwent an esophageal transection, and 4 underwent a resection of the proximal stomach. Re-hemorrhage occurred in 7 of the former 20 patients but not in any of the 10 on whom the direct interruption method was used. In 6 of these 7 patients who experienced rebleeding, subsequent direct interruption surgery led to control of the bleeding. One patient died of a variceal hemorrhage one month postoperatively. The total 10 year cumulative survival rate was 86.3 per cent. In the light of these findings, we believe that methods of direct interruption, such as esophageal transection, may well be the approach of choice for patients with esophageal varices caused by extrahepatic portal venous obstruction.

Portal hypertension

Portal hypertension is a frequent syndrome characterized by a chronic increase in portal venous pressure and by the formation of portal-systemic collaterals. Its main consequence is massive bleeding from ruptured esophageal and gastric varices. Bleeding is promoted by increased portal and variceal pressure, and is favored by dilatation of the varices. The evaluation of the portal hypertensive patient should include the assessment of portal vein patency by ultrasonography, endoscopic evaluation of the presence, size, and extent of esophageal varices, and hemodynamic studies with measurements of portal pressure and of portal-collateral blood flow. The preferred techniques are hepatic vein catheterization and measurement of azygos blood flow. Endoscopic measurements of variceal pressure and estimations of portal blood velocity by the Doppler technique have recently been introduced, but are still research procedures. Acute variceal hemorrhage should be treated under intensive care. Specific therapy to arrest variceal bleeding includes balloon tamponade, vasopressin, somatostatin, sclerotherapy, and emergency surgery. Treatment of portal hypertension is aimed at preventing variceal hemorrhage and bleeding-related deaths. Pharmacologic prophylaxis is based on the use of drugs that cause a sustained reduction in portal pressure; most studies have used propranolol. Surgery and endoscopic sclerotherapy can also be used to prevent rebleeding.

Change in hepatic function, hemodynamics, and morphology after liver transplant. Physiological effect of therapy

Orthotopic liver transplantation (OLT) has become standard therapy for patients with acute hepatic necrosis and end-stage liver disease. This study measured change in hepatic function (galactose elimination capacity [GEC]), liver blood flow (low dose galactose clearance: flow), hepatic volume (CT scan; volume) and morphology after OLT. The aim was to measure the physiologic response after OLT and compare this response with that after selective shunt (SS) and sclerotherapy (ES) to determine which patients should receive specific therapy. Between January 1987 and November 1988, 37 patients underwent OLT. Operative mortality was 18%, which was similar to that of SS in Child's C cirrhotics. GEC and volume were less in transplant patients than in cirrhotics treated with SS or ES. GEC, flow, and volume normalized after OLT; GEC was preserved after ES and SS, but volume decreased. Three preoperative patterns were observed that can aid in selection of OLT candidates. Patients with chronic cirrhosis (chronic active hepatitis; cryptogenic) need OLT when GEC is less than or equal to 225 mg/min and volume is less than or equal to 50% normal. Patients with Budd-Chiari Syndrome require OLT if cirrhosis has evolved. Patients with sclerosing cholangitis and primary biliary cirrhosis qualify for transplants when complications of the portal hypertensive syndrome develop. The studies can also direct therapy for ES failures. Selective shunt is indicated in those patients with stable disease whose GEC is greater than or equal to 300 mg/min and liver volume is greater than 75% normal; OLT is indicated for cirrhotics with GEC that is less than 225 mg/min and liver volume that is less than 50% predicted normal.

Partial portal decompression for variceal hemorrhage

To test the hypothesis that partial portal decompression in the treatment of variceal hemorrhage will diminish subsequent encephalopathy, 50 consecutive patients were studied after construction of a small-stoma (10 to 12 mm) side-to-side portacaval shunt, with the goal of a postoperative portacaval pressure gradient of 10 mm Hg. During follow-up averaging 26 months, six patients (12 percent) died. Four patients (8 percent) had episodes of rebleeding, only one from varices. All patients had patent shunts at subsequent angiography or ultrasonography. Despite consistent (100 percent) postoperative reversal or stagnation of portal flow on duplex scan, encephalopathy on clinical and psychometric grounds was observed in only three patients (6 percent). This study suggests that small-stoma portacaval shunt can be performed with reliably low rates of rebleeding and encephalopathy. That encephalopathy was rare despite loss of hepatic portal perfusion incriminates other factors besides portal flow in the genesis of postshunt hepatic failure.

The surgeon's role in the management of portal hypertension

Patients with portal hypertension are referred to surgeons for several reasons. These include the management of continued active variceal bleeding; therapy after a variceal bleed to prevent further recurrent bleeds; consideration for prophylactic surgical therapy to prevent the first variceal bleed; or, rarely, an unusual cause of portal hypertension which may require some specific surgical therapy. Injection sclerotherapy is the most widely used treatment for both acute variceal bleeding and long-term management after a variceal bleed. Unfortunately it has probably been overused in the past. The need to identify the failures of sclerotherapy early and to treat them by other forms of major surgery is emphasized. The selective distal splenorenal shunt is the most widely used portosystemic shunt today, particularly in nonalcoholic cirrhotic patients. The standard portacaval shunt is still used for the management of acute variceal bleeding as well as for long-term management, particularly in alcoholic cirrhotic patients. For acute variceal bleeding the surgical alternative to sclerotherapy or shunting is simple staple-gun esophageal transection, whereas in long-term management the main alternative is an extensive devascularization and transection operation. Liver transplantation is the only therapy that cures both the portal hypertension and the underlying liver disease. All patients with cirrhosis and portal hypertension should be assessed as potential liver transplant recipients. If they are candidates for transplantation, sclerotherapy should be used to treat bleeding varices whenever possible, as this will interfere least with a subsequent liver transplant.

Schistosomal versus nonschistosomal variceal bleeders. Do they respond differently to selective shunt (DSRS)?

The distal splenorenal shunt (DSRS) was performed in 125 consecutive variceal bleeders. To date, no patients have been lost to follow-up (mean of 79 +/- 20 months). Liver pathology was documented in 85 patients: 45 patients had schistosomal hepatic fibrosis, 17 had nonalcoholic cirrhosis, and 23 had mixed pattern (hepatic fibrosis and cirrhosis). The preoperative data base for these three groups was matched (p greater than 0.05), with a mean follow-up of 79 +/- 20, 70 +/- 14, and 77 +/- 22 months for each population, respectively. The results showed low operative mortality (4.8%), high cumulative patency rate (94.8%) and low recurrent variceal hemorrhage (5.6%). The biochemical data showed significant increase in serum bilirubin (p less than 0.001) and aspartate transaminase (AST) (p less than 0.05) in the nonschistosomal patients. Chronic hyperbilirubinemia was found in 33% of the schistosomal group. Prograde portal perfusion was detected in 94% of the patients, with development of collaterals in 91%. The angiographic pattern of these collaterals was 50% pancreatic, 45% gastric, and 26% colosplenic. Patients with mixed liver disease had a high incidence of Grade III portal perfusion (57%) and more common pancreatic and gastric collaterals (71%). The cumulative survival for all patients was 74.1%, with hepatic cell failure being the leading cause of death (13 patients, 50% of all deaths). The schistosomal patients had a 91.6% incidence, whereas the cirrhotic and mixed groups had survival rates of 75.6% and 65.2%, respectively. Also, of a 15% total incidence of encephalopathy, 4.4% was related to the schistosomal patients, 23.5% to the cirrhotics, and 21.7% to the mixed population. Statistically, the survival rate was significantly better (p less than 0.05) and encephalopathy was significantly lower (p less than 0.05) in the schistosomal population. In conclusion, this data shows that: 1) DSRS has a high patency rate and a low variceal hemorrhage recurrence rate; 2) it maintains some degree of portal perfusion in patients with different nonalcoholic liver diseases, despite development of collaterals; and 3) the schistosomal patients have a better survival rate, with a low incidence of encephalopathy after DSRS, compared with the cirrhotic and mixed populations.

Liver resection for hepatocellular carcinoma: results from 150 consecutive patients

During the past 6 years, 150 consecutive hepatic resections were performed for hepatocellular carcinoma on 129 male and 21 female patients. Their ages ranged from 17 years to 78 years, with an average of 57.0 years. All but two patients had an underlying parenchymal disease of the liver; 131 had liver cirrhosis, 16 chronic hepatitis, and one liver fibrosis. The operations performed were extended right lobectomy in 10 cases, right lobectomy in 13, left lobectomy in 5, left lateral segmentectomy in 11, other segmentectomies in 31, and partial wedge resection in 80 instances. The operative and in-hospital mortality rates were 6.0% and 12.0% respectively. In the 122 patients with curative resection, the 1-, 3- and 5-year survival rates were 75.2%, 49.0% and 30.0% respectively. The 1- and 3-year survival rates were 14.3% and 7.1% in the 28 patients with palliative resection. The tumor size and Child's classification generally reflected the survival rate.

Doppler echography for hemodynamic studies of the azygos vein

Using a convex array transducer, the advantages and shortcomings of transesophageal real-time two-dimensional Doppler echography (TE2DD) were assessed in a study of the vessels around the esophagus and the stomach in 67 adult patients with (n = 56) or without (n = 11) liver cirrhosis. In most cases, all but the upper- and lowermost margins of the azygos vein could be visualized. The more caudally the portion located, the smaller its diameter and flow velocity became. The average number of intercostal veins visualized by TE2DD was 4 per person. The observable esophagogastric varices seemed to be limited to deeply located ones around the esophagogastric junction. In five patients who had undergone distal splenorenal shunt, splenic venous flow, or shunt flow could be seen from the stomach over a length of about 5 cm. The azygos venous flow in cirrhotic patients was significantly greater than that of patients without cirrhosis. TE2DD appears to be very useful for evaluating flow in the cephalad collateral veins and other vessels around the esophagus and the stomach.

Appraisal of distal splenorenal shunt in the treatment of esophageal varices: an analysis of prophylactic, emergency, and elective shunts

From June, 1969 to February, 1987, distal splenorenal shunt was carried out on 78 patients with esophagogastric varices. The operations were urgent in 9, elective in 40, and prophylactic in 29 patients. There were 52 males and 26 females. Age ranged from 16 to 76 years with an average of 53 years. Thirty-seven patients were alcoholics. Hepatitis B surface antigen was positive in only 15.5%. The causes of portal hypertension were cirrhosis of the liver in 67, chronic hepatitis in 5, idiopathic portal hypertension in 4, primary biliary cirrhosis in 1, and fatty liver in 1 patient. Fifty-two patients were in Child's class A, 18 in class B, and 8 in class C. Emergency shunts were performed only when conservative therapy had failed to stop variceal bleeding. Prophylactic operations were done in patients having Child's class A or class B liver disease and risky varices, in varices larger than 5 mm in diameter and/or varices with red color signs such as cherry red spots. Forty-two patients underwent the original Warren shunt, but the remaining 36 had modified distal splenorenal shunt with expanded polytetrafluoroethylene interposition. The operative mortality rates were 11.1% in the emergency group, 2.5% in the elective group, and 3.4% in the prophylactic group. The overall operative and hospital death rates were 3.8% and 7.7%, respectively. The patency rate was 94.1% and the incidence of rebleeding from esophageal varices was 3.8%. Hepatic encephalopathy, although mild to moderate in degree, was observed in 14.7% of 75 patients excluding 3 operative deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of a prior portasystemic shunt on subsequent liver transplantation

Fifteen patients who had a prior portasystemic shunt underwent orthotopic liver transplantation. Shunt types were portacaval in six patients, H-graft mesocaval in six, distal splenorenal in two, and proximal splenorenal in one. Mean blood loss and hospital stay were highest in the portacaval group. Retransplants (two patients) and deaths (two patients) also were limited to this group. In this report, technical considerations, advantages, and disadvantages of the various shunt types are described. Management of patients with late stages of portal hypertension must include estimation of the effects of a portasystemic shunt on subsequent liver transplantation. It is concluded that portacaval shunts should be avoided in patients who may be considered for transplantation. Distal splenorenal shunts are best performed in younger patients with intractable variceal bleeding who are not expected to require transplantation in the near future. A mesocaval H-graft is the shunt of choice in patients who are current liver transplant candidates.

Amino acid imbalance following portal diversion in the rat. The relevance of nutrition and of hepatic function

End-to-end portacaval transposition has previously been shown to produce less hepatocellular dysfunction than end-to-side portacaval shunt in the rat. Liver weight is also significantly reduced after portacaval shunt compared to portacaval transposition and these differences are not abolished by pair-feeding. Histological evidence of CNS damage is also reduced in transposed rats compared to shunted animals. This study examines the amino acid and hormone changes in these models. The characteristic amino acid changes of chronic liver disease (decreased branched-chain and elevated aromatic amino acids) are reproduced in portacaval shunt rats, but not in portacaval transposition. The differences between these groups in the branched-chain amino acids, but not those in the aromatic amino acids, are reduced by pair-feeding. Insulin and glucagon are elevated to a similar extent in both groups. These findings add further support to a role for peripheral amino acid imbalance in the pathogenesis of portal-systemic encephalopathy. Normal liver function, maintained by replacement of portal inflow with systemic blood, appears to minimize both CNS damage and amino acid changes.

Liver transplantation in the treatment of bleeding esophageal varices

From March 1980 to July 1987, 1000 patients with various end-stage liver diseases received orthotopic liver transplants. Of the 1000 patients, three hundred two had definite histories of bleeding from esophageal varices before transplantation. There were 287 patients with nonalcoholic liver diseases and 15 patients with alcoholic cirrhosis. All patients had very poor liver function, which was the main indication for liver transplantation. One- through 5-year actuarial survival rates of the 302 patients were 79%, 74%, 71%, 71%, and 71%, respectively. These survival rates are far better than those obtained with other available modes of treatment for bleeding varices when liver disease is advanced. Long-term sclerotherapy is the treatment of primary choice for bleeding varices. Patients in whom sclerotherapy fails should be considered for liver transplantation unless clear contraindications exist.

Distal splenorenal shunt: standard procedure for elective and emergency treatment of bleeding esophageal varices

The distal splenorenal shunt has been advocated for patients with bleeding esophageal varices because it is a selective shunt which decompresses the varices while preserving hepatic flow. The procedure appeared sound physiologically and since 1976, the distal splenorenal shunt has been our procedure of choice for both emergency and elective situations. Our series of 43 patients included 6 patients in Child's class A, 18 in Child's class B, and 19 in Child's class C. The operative mortality rate was 4.7 percent (2 of 43 patients) and there were 34 long-term survivors (79 percent). Use of modern cardiovascular techniques is an essential facet of the surgeon's technical ability to achieve low morbidity and mortality rates. In the present series, the average blood loss was 440 ml and the average operative time, 2 1/2 hours. The distal splenorenal shunt can be performed for emergency and elective therapy of bleeding esophageal varices with a low incidence of complications and death and excellent long-term quality of life.

Improved quality of life after distal splenorenal shunt. A prospective comparison with side-to-side portacaval shunt

The distal splenorenal shunt (DSRS) was compared with the side-to-side portacaval shunt (PCS) in 93 prospectively matched patients with portal hypertension. After 38 months mean follow-up the two shunts had a different incidence of acute encephalopathy (22% in PCS group and 33% in DSRS group) and chronic encephalopathy (35% in PCS group and 17% in DSRS group), but the difference was not statistically significant. However, the only cases of severe and disabling chronic encephalopathy arose after PCS (p = 0.049). Actuarial curves of chronic encephalopathy showed that the maximum rate of encephalopathy (18%) in the DSRS group was reached 27 months after shunt surgery, whereas this value was reached and passed in PCS group only 4 months after shunt. Chronic encephalopathy occurred for a total duration of 20.1 months after PCS and only 11.1 months afer DSRS (p = 0.003) and occupied 46.3% of the follow-p of PCS patients, as contrasted to 18.7% of the follow-up of DSRS patients (p = 0.0001). DSRS is associated with a lower global incidence of chronic HE without severe forms and provides a better quality of life than does a nonselective shunt.

Morphological and hemodynamic changes in the portal venous system after distal splenorenal shunt: an ultrasound and pulsed Doppler study

We investigated a group of patients who underwent distal splenorenal shunt using high-resolution real-time equipment and a duplex scanner with the aims: (i) to evaluate the rate of visualization of shunt; (ii) to assess change in size in the portal vein, and (iii) to characterize the flow pattern in the splenic vein and to study flow direction and velocity in the portal vein, thus adding new data on the efficacy of this operation in maintaining hepatic perfusion. Real-time ultrasonography was performed in 29 patients before surgery, after 7 to 30 days and after 4 to 12 months. Direct visualization of the shunt was achieved in 53.5% of the patients. Mean caliber of the portal vein significantly decreased after the operation: preoperative = 1.52 +/- 0.32; after 7 to 30 days = 1.32 +/- 0.16 (p less than 0.001), and after 4 to 12 months = 0.99 +/- 0.19 (p less than 0.001). The overall postoperative incidence of portal thrombosis was 22.2%. Thirteen of these patients also underwent a postoperative (4 to 36 months) pulsed Doppler investigation. Flow towards anastomosis was demonstrated in the splenic vein in 11 patients, and in 7 cases, typical caval pulsatility was observed. Decreased hepatopetal flow in the portal vein was found in 10 of 13 patients. In two patients, no flow was detectable and in the other the flow was hepatofugal. On the basis of our data, we can affirm that pulsed Doppler investigation may provide useful data for the evaluation of shunt patency and preservation of a decreased portal hepatic perfusion in the majority of patients.

Selective distal splenorenal shunt versus side-to-side portacaval shunt. Clinical results of a prospective, controlled study

A prospective, controlled study comparing the clinical results of the selective distal splenorenal shunt procedure and the side-to-side portacaval shunt procedure was undertaken in 1980. Ninety-three cirrhotic patients with previous episodes of bleeding from esophageal varices underwent a distal splenorenal shunt procedure (47 patients). The operative mortality rate was 2 percent in both groups. The intraoperative decrease of portal hypertension after the portacaval shunt procedure was higher than after the distal splenorenal shunt procedure (p less than 0.05), and in those with patent shunts, there was a 0 percent incidence of early variceal rebleeding after the portacaval shunt procedure compared with a 9 percent incidence after the distal splenorenal shunt procedure (p less than 0.05). Both shunts, however, had similarly satisfactory results in preventing long-term variceal rebleeding (portacaval shunt 2 percent and distal splenorenal shunt 0 percent). Postoperative ascites was more common after the distal splenorenal shunt procedure (58 percent versus 24 percent; p less than 0.01). Analysis of actuarial survival curves showed no difference between the two procedures. The incidences of long-term episodes of chronic encephalopathy were not statistically different after both procedures. The only three instances of severe encephalopathy occurred in patients with the portacaval shunt (p less than 0.05). The distal splenorenal shunt also seemed to have a less negative effect on postoperative liver function than the portacaval shunt. These data suggest that the selective shunt should be viewed as a first choice strategy in the treatment of portal hypertension.