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

Hepatic schistosomiasis

Praziquantel is the treatment of choice for schistosomiasis because of its efficacy, ease of administration, limited side effects, and low cost. Praziquantel has been so effective that alternative therapies are increasingly difficult to obtain, and the development of novel medications has been limited. The possibility of praziquantel resistance is a grave concern. Low cure rates for praziquantel have been reported in several countries, but despite widespread use, no significant loss of efficacy has occurred to date. The primary goal of antischistosomal therapy is parasite eradication, which reduces the likelihood of chronic complications, including advanced hepatic fibrosis. Mild to moderate hepatic fibrosis results from the immune response to schistosome eggs deposited in the portal venules and reverses with successful treatment. Most individuals clear schistosomiasis with a single course of therapy. Repeat doses cure the majority of patients in whom eradication does not occur after the initial dose. A secondary goal of therapy for patients with persistent or recurrent infection is egg burden reduction, which also reduces the risk of hepatic fibrosis and lowers community spread. Community eradication programs in highly endemic regions use periodic retreatment to limit chronic schistosomiasis' morbidity. Advanced liver fibrosis and portal hypertension due to chronic schistosomiasis are irreversible. Variceal bleeding is the primary cause of death in hepatic schistosomiasis. The bleeding risk is best reduced through use of beta-blocker prophylaxis or endoscopic banding or sclerotherapy. Surgical management of varices, including splenectomy with esophagogastric devascularization or selective shunts such as the distal splenorenal, is effective in patients with recalcitrant bleeding. Because hepatic synthetic function is normal in patients with schistosomiasis, procedures that reduce portal pressures may lower hepatic perfusion and cause hepatic impairment. The risk of encephalopathy after shunt surgery is higher in patients with schistosomiasis than in those with cirrhosis. For these reasons, nonselective shunt surgery such as the proximal splenorenal or the transjugular intrahepatic portosystemic shunt should not be performed in patients with advanced hepatic schistosomiasis.

Recent role of splenectomy in chronic hepatic disorders

For years splenectomy in hepatic disorders has been indicated only for the treatment of gastro-esophageal varices. However, with recent advances in medical and surgical treatments for chronic hepatic disorders, the use of splenectomy has been greatly expanded, such that splenectomy is used for reversing hypersplenism, for applying interferon treatment for hepatitis C, for treating hyperdynamic portal circulation associated with intractable ascites, and for controlling portal pressure during small grafts in living donor liver transplantation. Such experiences have shown the importance of portal hemodynamics, even in cirrhotic livers. Recent advances in surgical techniques have enabled surgeons to perform splenectomy more safely and less invasively, but the procedure still has considerable clinical outcomes. Splenectomy in hepatic disorders may become a more common procedure with expanded indications. However, it should also be noted that the long-term effects of splenectomy, in terms of improved hematological or hepatic function, is still not guaranteed. Moreover, the impact of splenectomy on immunologic status remains unclear and needs to be elucidated in both experimental and clinical settings.

Afluência da veia esplênica e sua importância nas derivações esplenorrenais seletivas

Os autores realizaram estudo da afluência da veia esplênica utilizando 38 moldes de duodeno, estômago, pâncreas e baço, por meio da técnica de repleção e corrosão, com vinilite corado com azul da Prússia. Os afluentes encontrados foram: ramos pancreáticos em todas as peças, variando de 7 a 22 ramos, com média de 14,52 ± 3,53; a veia gástrica esquerda, em 36,84% das peças; a veia mesentérica inferior em 44,74% das peças; ramo gástrico (gástrica posterior), proveniente do fundo gástrico, em 57,89% das peças, e ramos pancreáticos, provenientes da cauda do pâncreas e desembocando em ramos segmentares da veia esplênica, em 65,79% das peças. Os ramos pancreáticos variaram em número de um a quatro, com média de 1,64 ± 0,95. Os autores concluem que o conhecimento dos afluentes da veia esplênica seria importante na realização das derivações esplenorrenais distais, quando associadas à desconexão esplenopancreática.

Red cell survival in patients with nonalcoholic liver cirrhosis before and after distal splenorenal shunt

We previously reported severe hemolysis in one patient immediately after distal splenorenal shunt (DSRS). The purpose of the present study was to evaluate changes in red cell survival after DSRS. In ten patients with nonalcoholic cirrhosis in whom DSRS was performed for esophageal varices, red cell survival and splenic quantitative hemodynamic studies were performed before and after DSRS. The splenic venous blood flow per unit volume (flow/volume ratio) was calculated. The red cell survival was significantly (P < 0.05) shortened after DSRS; the apparent half-life survival time (T 1/2) before and after DSRS was 24.6 +/- 5.9 (mean +/- SD) and 16.3 +/- 8.5 days, respectively. After DSRS, the spleen volume was significantly (P < 0.05) decreased, whereas the splenic venous blood flow was slightly increased. The spleen flow/volume ratio was significantly (P < 0.05) increased after DSRS. There was a significant and negative correlation (r = -0.684, P < 0.05) between the postoperative percentage change in T 1/2 and the spleen flow/volume ratio. These findings suggest that the red cell survival period is significantly decreased, after DSRS in patients with nonalcoholic cirrhosis, and that the increased splenic blood flow per unit spleen volume after DSRS may play an important role in the hemolytic reaction in the spleen after this procedure.

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.

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.

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.

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.