Distal Splenorenal Shunt Versus Endoscopic Sclerotherapy in the Prevention of Variceal Rebleeding First Stage of a Randomized, Controlled Trial

Abstract

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.

Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta-analysis

“…The rebleeding rate from portal hypertension has been found to range from 3% to 18% in patients treated with surgical shunts and followed-up for a mean period of 28 to 60 months. 30,31 In our meta-analysis, the combined rebleeding rate after TIPS was 19%, only slightly higher than those reported after surgical shunts; however, the mean follow-up periods after TIPS were much shorter, less than 20 months in all but 2 studies (25 and 32 months). 16,23 The rebleeding rate after TIPS is anticipated to increase with time because of a progressive increase in the rate of stent dysfunction (stenosis or occlusion) within at least the first 3 years.…”

“…This is not surprising, because TIPS is a portosystemic shunt; the incidence of encephalopathy in patients with distal splenorenal surgical shunts has been reported between 16% and 34% and in those with surgical portosystemic shunts above 40%. 30,31 There was no common trend for days of hospitalization; some reported that patients randomized to TIPS 13,15,16 spent more days in hospital, whereas others reported that patients randomized to ET 14,23,25 spent more days in hospital during follow-up. Patients randomized to ET had a mean of 3 to 4 sessions for varice eradication and a surveillance endoscopy every 3 to 6 months thereafter, whereas patients randomized to TIPS had many Doppler ultrasounds, at least 2 to 3 angiographies within the first year, and several stent interventions for asymptomatic or symptomatic stent dysfunction.…”

Portal hypertension and variceal bleeding: An AASLD single topic symposium

“…96,98,113,114,116,117 Data indicate Ն90% control of bleeding with all types of surgical shunt. Encephalopathy and liver failure rates are dependent on underlying liver disease and the loss or maintenance of portal perfusion.…”

“…Surgical shunts have received renewed interest in the 1990s because of their effectiveness in preventing rebleeding. 96,98,[109][110][111][112][113][114] Bleeding is controlled in 90% to 95% of patients. Data on surgical shunts in the 1990s indicate better outcomes than earlier reported series in the literature primarily because of better patient selection.…”

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

“…[7.22.25.34]. In fünf der sieben Studien war die Überlebenszeit bei beiden Modalitä ten gleich [25,[34][35][36][37], In zwei Studien der Emory-Gruppe aus At lanta (USA) wurde bei allen Sklerosierungsversagern, die in 30% der Fälle auftraten, eine Shuntoperation vorgenommen [22. 33].…”