The distal splenorenal shunt: An update

Abstract

The distal splenorenal shunt (DSRS), as the prototype for selective variceal decompression, has evolved over the 17 years since its introduction. Attention to detail in the preoperative assessment and perioperative management will minimize morbidity. Reported experience from over 25 centers has shown an average overall operative mortality rate of 9%, shunt patency and bleeding control rates in excess of 90%, encephalopathy in from 0 to 18% of cases, and a 5‐year survival rate between 50 and 60%. Non‐alcoholic cirrhotics (70–80%) have a significantly (p< 0.05) greater 5‐year survival rate than do alcoholic cirrhotics (45%). The 6 prospective randomized trials comparing DSRS to total portal systemic shunts have been conducted primarily in alcoholic cirrhotics; they show no significant difference in survival. Current experience in schistosomiasis and portal vein thrombosis shows selective variceal decompression to be superior to total shunt. Quantitative data prior to and 1 year after DSRS show a fall in liver volume, stabilization of hepatocyte function, and variable change in hemodynamics: alcoholic cirrhotics have a 70% chance of losing portal venous flow, while nonalcoholics maintain portal perfusion. Loss of portal venous flow is associated with a systemic hyperdynamic response in those with poorer hepatocyte function. Splenopancreatic disconnection is currently being studied in an attempt to maintain portal perfusion better and preserve liver volume. We conclude that the DSRS has achieved its pathophysiological goals of preventing recurrent variceal bleeding, while maintaining hepatocyte function. Modifications in management and the operative procedure are evolving from increased understanding of the pathology of the underlying causes of the portal hypertension leading to variceal bleeding.

Longterm follow up of transjugular intrahepatic portosystemic stent shunt (TIPSS) for the treatment of portal hypertension: results in 130 patients.

“…38 We found a relatively high 30 day mortality of 21 8% compared with some groups,22 however mortality has been consistently shown to depend on Childs grade at time of TIPSS and our higher percentage of Childs B and C patients (38.9% and 53-2% respectively) and higher numbers of emergency procedures (26.9%) would account for this. Our one and two year survival of 62-3% and 46.5% respectively are similar to the recently reported series from San Francisco.2' Longterm survival after TIPSS will depend on the underlying severity of liver disease and improved survival due to reduced rebleeding will be difficult to detect.…”

Surgical outcomes of distal splenorenal shunt or liver transplantation in treatment of schistosomal refractory variceal bleeding

“…Most published series was proved the therapeutic efficacy of DSRS with low recurrent variceal bleeding incidence (5%-8%), acceptable risk of hepatic encephalopathy (5%-15%) and excellent long-term survivals [133][134][135] . The improved surgical techniques in splenopancreatic disconnection and omental division significantly reduced postoperative encephalopathy risk and give good results in patients with schistosomal portal hypertension .…”

Der portale Kreislauf nach der Warrenschen Operation: Computertomographische Untersuchungen der portalen H�modynamik 5?11 Jahre nach distaler spleno-renaler Anastomose

“…[1,9], die behaupten, dab die Operation nach Warren die portale Leberperfusion nicht unver/indert beibehalten kann; die Warren-Operation wurde sogar einer lateralen porto-cavalen Anastomose gleichgestellt [1]. Grundlegend stimmen hingegen die Daten unserer Serie mit denen von Warren und seinen Mitarbeitern [7] fiberein, die in 30% der F/ille die Leberperfusion unver/indert vorfinden: in unserem Fall sind es 4 von 18 F/illen, also 22%. Die Tendenz zur Verminderung der Leberperfusion kann durch die Verminderung des Durchmessers der Vena portae objektiviert werden, der einen Durchschnittswert von 8,7 mm aufweist (die Pfortader wurde im CT in 16 der 18 F/ille, Tabelle 11.…”