Distal splenorenal shunting for bleeding gastric varices

Abstract

In patients with bleeding gastric varices from causes other than splenic vein thrombosis, endoscopic sclerotherapy and ablative surgery have yielded poor results. Over a 3-year period starting in June 1989, a total of 30 distal splenorenal shunts were performed prospectively on 19 paediatric and 11 adult patients with bleeding gastric varices and good liver function. The mean (s.d.) age was 17(12) (range 6-50) years; there were 20 male and ten female patients of whom six had cirrhosis, four non-cirrhotic portal fibrosis and 20 portal vein thrombosis. Two patients died and two more had shunt thrombosis; all four were considered failures of treatment. Hypersplenism was present in 15 patients but reverted to normal in 13. In 26 patients the gastric varices disappeared. Concomitant oesophageal varices were present in 22 patients and showed marked regression, with no rebleeding over a mean (s.d.) follow-up of 21(10) (range 7-39) months. A distal splenorenal shunt was effective in controlling gastric variceal haemorrhage in 26 of 30 patients in whom liver function was well preserved.

The role of the transjugular intrahepatic portosystemic stent-shunt(TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations

“…Previous studies have used bovine thrombin which has the potential risk of prion transmission 8 9 although our experience with human thrombin has been promising so far. 20 Surgical shunts may be of value in patients with early liver disease [21][22][23] but have the disadvantage of high mortality in patients with advanced liver disease, particularly in the emergency setting. 24 Our findings show that TIPSS is equally effective in the prevention of rebleeding from gastric and oesophageal variceal haemorrhage.…”

Current Role of Surgery in Portal Hypertension

“…High-risk gastric varices, especially in patients with NCPH and Child's A cirrhosis are best addressed by a decompressive shunt surgery whenever feasible [74]. Although glue injections remain effective, surgery offers a one-time therapy with durable long-term outcome [71].…”

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.…”