Distal splenorenal shunt vs. portal-systemic shunt: Current status of a controlled trial

Abstract

A prospective controlled comparison of portal-systemic (PSS) and distal splenorenal shunts (DSRS) in cirrhotic patients who had survived hemorrhage from esophagogastric varices was undertaken 5 yr ago at five hospitals by the Boston-New Haven Collaborative Liver Group. The clinical and endoscopic criteria for massive hemorrhage were satisfied in 155 patients. Thirty-four patients were excluded, primarily because of uncontrolled hemorrhage. Thirty-four were rejected because the were poor operative risks and 21 because they did not satisfy criteria. Thirteen patients refused to participate; the remaining 53 were randomized; 29 to receive PSS and 24, DSRS. The two groups were similar in clinical, laboratory, and manometric characteristics. The DSRS group was older and tended to have had more previous hemorrhages. Followup ranged from 1 to 56 months (mean 21). After PSS, which was performed by 10 different surgeons, 6 patients died during the hospital admission (21%) compared to 2 after DSRS (12%). There were 6 late deaths in the PSS group and 4 in the DSRS group. Portal-systemic encephalopathy occurred in 5 of the 23 survivors of PSS (23%), and in 6 of the 19 who survived DSRS (32%. Two patients in the PSS group bled (9%), 1 after thrombosis and 1 after stenosis of the shunt. Three patients in the DSRS group bled (16%) and all had thrombosis of the shunt. PSS was associated with an unexplained but inordinately high operative mortality. Although the DSRS was accomplished with an acceptably low operative mortality, it was associated with frequent portal-systemic encephalopathy, shunt occlusion, and recurrent hemorrhage. Similar incidences of portal-systemic encephalopathy, shunt occlusion, and recurrent hemorrhage were observed in the PSS group. More patients and longer followup are necessary to determine which of these portal decompressive procedures is superior.

Prognostic Value of Child-Turcotte Criteria in Medically Treated Cirrhosis

“…The patients were included in the placebo-treated group (260 patients) of a controlled clinical trial of prednisone (10 to 15 mg daily) versus placebo in cirrhosis (14).…”

Distal splenorenal vs. portal-systemic shunts after hemorrhage from varices: A randomized controlled trial

“…A preliminary report of a randomized study which compared DSRS with mesocaval and mesorenal shunts was published in 1976 by Galambos, Warren and their colleagues, and appeared to confirm the beneficial effects of the DSRS (7)(8)(9). Our preliminary report, published in 1981, suggested that although the PCA and DSRS could be performed with similar operative mortality and resulted in similar reductions in recurrent hemorrhage and in similar long-term survival, the prevalence of PSE was not decreased by DSRS (10). Four additional, controlled comparisons of DSRS and PSS have since been reported with conflicting results…”

Evolução das varizes esofagogástricas após anastomose esplenorrenal proximal versus esplenorrenal distal

“…26 Thomas (1994) demonstrou que, após três anos da cirurgia, houve desaparecimento das varizes no estômago e no esôfago, demonstrando que essa técnica foi eficaz no controle do sangramento. 27 Entretanto, alguns estudos mostram que a ERD associa-se a maior incidência de encefalopatia e ressangramento do que as anastomoses porto-cava calibradas, 26 enquanto outros trabalhos não demonstraram essa relação em uma comparação entre as mesmas técnicas.…”

“…26 Thomas (1994) demonstrou que, após três anos da cirurgia, houve desaparecimento das varizes no estômago e no esôfago, demonstrando que essa técnica foi eficaz no controle do sangramento. 27 Entretanto, alguns estudos mostram que a ERD associa-se a maior incidência de encefalopatia e ressangramento do que as anastomoses porto-cava calibradas, 26 enquanto outros trabalhos não demonstraram essa relação em uma comparação entre as mesmas técnicas. 5,28 Na comparação entre os dois procedimentos, demonstrou-se que, em um acompanhamento a longo prazo de pacientes com esquistossomose submetidos a tratamento com três diferentes abordagens, a encefalopatia por disfunção hepática e a mortalidade foram significativamente maiores na ERP quando comparada à ERD, tornando esse procedimento proibitivo em pacientes com esquistossomose.…”