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

Abstract

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)

Recent role of splenectomy in chronic hepatic disorders

“…Treatment strategies for esophagogastric varices have undergone significant changes in the past decades. Nonselective shunting procedures had been progressively abandoned owing to serious deterioration in quality of life due to devastating encephalopathy and hepatic failure 46–48 . As a result, selective distal splenorenal shunt, which preserves portal blood flow, has been more widely accepted as the definite surgical management in western countries, based on its lower incidence of post‐shunting encephalopathy and accelerated liver failure from reduced hepatic perfusion 46,47 .…”

“…As a result, selective distal splenorenal shunt, which preserves portal blood flow, has been more widely accepted as the definite surgical management in western countries, based on its lower incidence of post‐shunting encephalopathy and accelerated liver failure from reduced hepatic perfusion 46,47 . However it has subsequently been reported that the selectivity of distal sprenorenal shunting is lost with time because of new venous collaterals around the peripancreatic or gastrosplenic parts 48–51 . Surgical difficulties in freeing the huge splenic vein from the inflamed surrounding tissues have made surgeons reluctant to perform this surgery, especially in Japan 52 …”

Influência do grau de insuficiência hepática e do índice de congestão portal na recidiva hemorrágica de cirróticos submetidos a cirurgia de Teixeira-Warren

“…Nesse mesmo estudo (9) , em que se revisou retrospectivamente a recidiva hemorrágica nos pacientes Child A e B operados pela técnica de Teixeira-Warren, observou-se que a percentagem de ressangramento (56%) foi mais acentuada do que na literatura (3,8% -14%) (13,15,16,17,21,28) . Atribui-se esse índice ao elevado número de doentes Child B e de cirrose por álcool.…”

Decision-analysis of transjugular intrahepatic portosystemic shunt versus distal splenorenal shunt for portal hypertension

“…The pooled mortality for patients with Child' s class A cirrhosis undergoing DSRS was 2.9% in the first year and 12.0% in the second year of the model. 12,13 The pooled mortality for patients with Child' s class A cirrhosis undergoing TIPS was 5.7% in the first year and 10.9% in the second year of the model. 10,14,15,16 A sensitivity analysis was used to address the issue of the wide range of survival statistics.…”