Distal Splenorenal Shunt Versus Endoscopic Sclerotherapy for Long-term Management of Variceal Bleeding

Abstract

This paper reports the preliminary results of a prospective randomized trial comparing endoscopic variceal sclerosis and distal splenorenal shunt (DSRS) in the management of patients with cirrhosis and variceal bleeding. Seventy-one patients have been entered; 36 have received sclerosis and 35 DSRS. Randomization of the study population was stratified on Child's A/B (56%) and Child's C (44%). Sixty-one per cent had alcoholic and 39% non-alcoholic cirrhosis. No patients have been lost to follow-up, which currently stands at a median of 26 months. Rebleeding occurred significantly (p less than 0.05) more frequently in patients in the sclerosis group (19 of 36: 53%) compared to DSRS (1 of 35: 3%), but only 11 of 36 (31%) were not controlled by further sclerosis and failed that therapy. Patients in whom sclerosis failed underwent surgery. Survival was significantly (p less than 0.01) improved in the sclerosis group (+ surgery in 31%), with an 84% 2-year survival compared to a 59% 2-year survival in the DSRS group. Portal perfusion was significantly (p less than 0.05) better maintained in the sclerosis (95%) compared to the DSRS (53%) group. Galactose elimination capacity improved significantly (p less than 0.05) in 21 patients successfully managed by sclerosis at 1 year and was significantly (p less than 0.01) better maintained in the sclerosis compared to DSRS group. The authors conclude that endoscopic sclerosis: has a higher rebleeding rate than DSRS, with one third of patients failing therapy from rebleeding; allows significant improvement in liver function when successful; and gives significantly improved survival in the management of variceal bleeding when backed up by surgical therapy for patients with uncontrolled rebleeding.

Selective shunts for portal hypertension: Current role of a 21-year experience

“…Initial reports of good results appeared with this therapy in the 1970s and in the first years of the 1980s; prospective randomized controlled trials were begun to compare surgical treatment with sclerotherapy. 9,10 Results varied from one trial to another but showed that survival was similar with both forms of therapy, and better bleeding control was achieved with the surgical treatment. 11 At the beginning of 1980, pharmacotherapy in the form of ␤-blockers also appeared.…”

Zum Stellenwert der Sperr- und Shunt-operationen bei der Therapie der rezidi- vierenden Ösophagus- und/oder Magen· varizenblutung des Leberzirrhotikers

“…Zu ähnlichen Ergebnissen kam unsere Arbeits gruppe. die über einen Zeitraum von 10 Jahren 692 [38] Leberzirrhotiker mit rezidivierender Ösophagus-und/oder Magen varizenblutung behandelte [22,33] [20,24). Beide Shunts sind transplantationsfreundlich und schützen in Konkurrenz zu al len konservativen, endoskopischen, interventionellen und chirur gischen Verfahren am besten, sichersten und dauerhaftesten vor einer erneuten Blutung aus Ösophagus-und/oder Magenvarizen [20.…”

Endoscopic Esophageal Sclerotherapy: Long-Term Results of the Elective Procedure

“…However, the incidence and severity of encephalopathy were markedly diminished after DSRS [46]. The effectiveness of DSRS has been compared to EST in three studies [47][48][49] (table 10). Rebleeding rates have al ways been lower after DSRS than after EST (11.5 vs. 47.4%).…”