Distal Splenorenal Shunt Group Research Articles

Splenic artery ligation and distal splenorenal shunt in schistosomiasis

Background A prospective study was carried out to evaluate the results of distal splenorenal shunt (DSRS) with or without splenic artery ligation (SAL) in patients with schistosomal portal hypertension. Materials and methods Thirty patients were divided into two groups: 15 were submitted to DSRS (Group I) and the other 15 were submitted to DSRS + SAL (Group II). They were observed for 24 months. Clinical and laboratory features were analyzed. Results There was neither mortality nor clinical manifestation of portosystemic encephalopathy in both groups. Recurrent hemorrhage and thrombosis incidence had no statistical difference. Although patients in Group II presented higher levels of postoperative pain and fever, spleen size reduction was higher than in Group I. White blood cells and platelets were increased in patients who underwent DSRS + SAL, even though there was no statistically significant difference between the groups. An increase in bilirubin was observed on the first postoperative day. Arterial blood ammonia and liver function were similar in both groups. Endoscopic control showed reduction in size of varices or their disappearance in 80 and 93% of patients from Groups I and II, respectively. Conclusions Although SAL associated with DSRS was responsible for increasing postoperative morbidity, it did not increase the incidence of shunt thrombosis and improved white blood cells and platelets count as well as reduced the spleen size. Therefore, the authors believe that SAL associated with DSRS is an effective treatment for schistosomal portal hypertension. Besides, it should be performed when a large spleen and hypersplenism are present.

Avaliação da anamastose espleno-renal distal, com e sem ligadura da artéria esplênica, para tratamento a hipertensão portal esquistossomática

OBJETIVO: Avaliar os resultados da derivação espleno-renal distal (DERD) com ligadura da artéria esplênica (LAE) em pacientes com hipertensão portal esquistossomótica e história de sangramento por varizes esôfago-gástricas. MÉTODO: Estudo prospectivo de trinta pacientes que foram divididos em dois grupos: 15 foram submetidos à DERD (Grupo I) e 15 foram submetidos à DERD associada à LAE (Grupo II). Os pacientes foram acompanhados por 24 meses, e estudados quanto à recorrência de hemorragia digestiva por ruptura de varizes, controle endoscópico das varizes e permeabilidade da anastomose através de ultra-sonografia e angiografia. RESULTADOS: Um paciente do Grupo I (6,67%) apresentou trombose da anastomose e recidiva hemorrágica em decorrência de varizes. No Grupo II, nenhum paciente, em dois anos de observação, desenvolveu trombose da anastomose e hemorragia digestiva. Não houve diferença estatisticamente significativa entre os grupos. Quanto à análise endoscópica após seis meses, houve redução do tamanho ou desaparecimento das varizes em 80% dos pacientes do Grupo I e em 93% daqueles do Grupo II. CONCLUSÕES: A derivação espleno-renal distal com ligadura da artéria esplênica não está associada a uma maior incidência de trombose da anastomose, de recidiva hemorrágica e nem modificou o tamanho das varizes esôfago-gástricas em comparação com a derivação espleno-renal distal isolada.

An evaluation of splenopancreatic disconnection as a modification of the distal splenorenal shunt, studied in nonalcoholic patients by sequential angiography.

To evaluate the validity and complications of modifying the distal splenorenal shunt (DSRS) by performing splenopancreatic disconnection (SPD), hemodynamic changes in the portal system were assessed by visceral angiography in 93 patients with nonalcoholic portal hypertension during early postoperative follow-up after DSRS. There were 40 patients who underwent DSRS alone and 53 who underwent DSRS plus SPD. Early follow-up angiography showed that portal vein perfusion was well maintained, and that the diameter of the portal vein had decreased significantly by the same degree in both groups. Hepatofugal collaterals for the shunt had developed to a greater extent in the DSRS group, while they were almost completely absent in the DSRS with SPD group. Nevertheless, partial portal vein thrombosis was not detected in the DSRS group, although it was seen in seven (13.2%) of the patients who underwent DSRS plus SPD, in whom the left proximal splenic vein was not visible. The proximal splenic vein was seen in significantly less of the DSRS with SPD patients (47.2%) than the DSRS group patients (85%). In conclusion, SPD more effectively prevented the early postoperative development of collateral pathways for the shunt compared with standard DSRS; however, the possible stagnation of blood flow in the left proximal splenic vein may predispose to a risk of partial portal vein thrombosis developing during the early postoperative period after DSRS with SPD.

Pre-Liver Transplant: Tips Versus Distal Splenorenal Shunt

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclero-therapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P=0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132±725 ml/min in the TIPS group compared with 1120±351ml/min in the DSRS group (P<0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P=0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intra0Perative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.

Distal splenorenal shunt versus 10-mm low-diameter mesocaval shunt for variceal hemorrhage

Portal hypertension surgery remains a good therapeutic choice for well selected patients with variceal bleeding. The distal splenorenal shunt (DSRS) has shown good long-term results and low-diameter shunts have emerged as an alternate choice. A prospective, controlled and not randomized study was designed to compare the DSRS (23 patients) and the low-diameter 10 mm ring reinforced PTFE mesocaval shunt (LDMCS) (22 patients) in low-risk electively operated patients (Child-Pugh A-B). The operation was selected according to the anatomical status of the veins. Both groups were comparable. No differences were observed regarding rebleeding, operative mortality and survival. Significative differences were observed regarding encephalopathy and shunt thrombosis (higher in the LDMCS). Postoperative angiography showed better maintenance of portal blood flow in the DSRS group. Both operations are adequate alternatives for the elective treatment of portal hypertension in low-risk patients. However, the DSRS has more advantages than the LDMCS.

A Comparison Of Treatment With Transjugular Intrahepatic Portosystemic Shunt Or Distal Splenorenal Shunt In The Management Of Variceal Bleeding Prior To Liver Transplantation

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclerotherapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P = 0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132 +/- 725 ml/min in the TIPS group compared with 1120 +/- 351 ml/min in the DSRS group (P < 0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P = 0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intraoperative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.

A Comparison Of Treatment With Transjugular Intrahepatic Portosystemic Shunt Or Distal Splenorenal Shunt In The Management Of Variceal Bleeding Prior To Liver Transplantation

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclerotherapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P = 0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132 +/- 725 ml/min in the TIPS group compared with 1120 +/- 351 ml/min in the DSRS group (P < 0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P = 0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intraoperative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.

Sclerotherapy vs. esophageal transection vs. distal splenorenal shunt for the clinical management of esophageal varices in patients with child class A and B liver function: A prospective randomized trial

Ninety-six patients with good liver function (Child class A or B) and esophageal varices were randomly assigned to one of three groups given different treatments: endoscopic injection sclerotherapy (n = 32), esophageal transection (n = 32) or distal splenorenal shunt (n = 32). Five patients (5.2%) had to be excluded from this study because severe chronic pancreatitis made separation of the distal splenic vein from the pancreatic bed difficult. Esophageal transection was performed for these patients. No deaths occurred during the 30 days of treatment. The 5-yr cumulative bleeding rates were 0%, 5.9% and 12.9% in the endoscopic injection sclerotherapy, esophageal transection and distal splenorenal shunt groups, respectively (no statistical significance). In no case in the three groups did death occur because of variceal bleeding. Sixteen patients died, mainly because of underlying liver disease; four were in the endoscopic injection sclerotherapy group, five were in the esophageal transection group and seven were in the distal splenorenal shunt group. No statistically significant difference in survival rate among the three groups was found. These results show that endoscopic injection sclerotherapy is a satisfactory alternative to esophageal transection or distal splenorenal shunt for the clinical management of patients with esophageal varices.

Investigation of the portal perfusion index after low diameter mesocaval interposition and distal splenorenal shunt — a prospective study

In 50 consecutive patients portal blood flow was determined using computed liver perfusion scintigraphy preoperatively and at 6, 12, 24, 36, 48, 60, 72, and 84 months postoperatively between 1 January 1983 and 1 January 1990. All 25 subjects had undergone placement of a distal splenorenal shunt (DSRS) and 25, insertion of low-diameter PTFE mesocaval interposition shunt (LDMIS) between 15 January 1983 and 1 January 1988. Indications for shunt operation included recurrent variceal hemorrhage in spite of long-term endoscopic sclerotherapy, a Child-Pugh classification of A or B, a sonographically determined liver volume of between 1000 and 2500 ml, exclusion of the activity and progression of liver disease by biopsy and stenosis of the hepatic artery or coeliac trunk. DSRS was performed when the portal perfusion index (PPI) was greater than 30% (normal values 56 +/- 5%) and LDMIS was carried out when the PPI was 10% to 30%. In all cases the underlying disease was liver cirrhosis of alcoholic (n = 34, 68%) or hepatic (n = 12, 24%) etiology. Five patients who underwent LDMIS had originally scheduled for DSRS at a PPI of greater than 30%; because the DSRS would have been technically difficult due to severe chronic pancreatitis, a LDMIS was performed. One in-hospital death due to liver failure had occurred in each group by 1 January 1990. One patient in the DSRS group and two in the LDMIS group died later, and in each group one patient was lost to follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Endoscopic Variceal Sclerosis Compared with Distal Splenorenal Shunt To Prevent Recurrent Variceal Bleeding in Cirrhosis

To define the roles of endoscopic variceal sclerosis and distal splenorenal shunt in the prevention of recurrent variceal bleeding in patients with cirrhosis. A prospective, randomized clinical trial with crossover for those failing therapy. The median follow-up was 61 months. A private, tertiary-referral university hospital. Seventy-two patients fulfilling inclusion criteria were drawn from a total of 420 patients treated during a 4.5-year interval. Endoscopic variceal sclerosis or distal splenorenal shunt. Survival was significantly (P = 0.02) improved in patients randomly assigned to receive sclerotherapy: 13 of these 37 (35%) patients failed sclerotherapy and required surgical rescue. A survival advantage (P = 0.01) was seen in patients with alcoholic cirrhosis who had this combined therapy; however, in patients with nonalcoholic cirrhosis, survival for those receiving sclerotherapy and surgical rescue was not significantly (P = 0.36) different from that of patients receiving distal splenorenal shunt. Control of variceal bleeding was significantly (P less than 0.001) better in the distal splenorenal shunt group (34 of 35 [97%] compared with 15 of 37 [41%] in the sclerotherapy group). Using death, uncontrolled rebleeding, or shunt thrombosis as the endpoints resulted in no significant difference between treatment groups. Hepatocyte function and portal perfusion were significantly better maintained in patients with alcoholic cirrhosis who were managed by sclerotherapy rather than shunt (P = 0.01 and P = 0.001, respectively). Endoscopic sclerotherapy with surgical rescue for uncontrolled bleeding is the optimum therapy for patients with alcoholic cirrhosis and variceal bleeding. Survival is similar in nonalcoholic patients treated with either distal splenorenal shunt or endoscopic sclerotherapy, but shunting provides better control of variceal bleeding.

Endoscopic sclerotherapy with portal-systemic shunt rescue

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% nonalcoholic cirrhosis. No patients have been lost to follow-up, which currently stands at a median of 26 months. Rebleeding occurred significantly (p &lt; 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 &lt; 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 &lt; 0.05) better maintained in the sclerosis (95%) compared to the DSRS (53%) group. Galactose elimination capacity improved significantly (p &lt; 0.05) in 21 patients successfully managed by sclerosis at 1 year and was significantly (p &lt; 0.01) better maintained in the sclerosis compared to DSRS group. The authors conclude that endoscopic sclerosis: (1) has a higher rebleeding rate than DSRS, with one third of patients failing therapy from rebleeding; (2) allows significant improvement in liver function when successful; and (3) gives significantly improved survival in the management of variceal bleeding when backed up by surgical therapy for patients with uncontrolled rebleeding. The authors report the results of a randomized comparison of emergency portacaval anastomosis (PCA) (32 patients) with endoscopic sclerotherapy (EST) (32 patients). Short-term survival was similar in the two groups, respectively (44% vs. 50%). The amount of blood transfusions required and the length of the hospital admissions were significantly less in the EST group (p &lt; 0.001). Recurrences of variceal hemorrhage, the number of transfusions required to treat them and the duration of hospital readmissions were all greater in the EST group (p &lt; 0.001). Almost half of the EST patients who were discharged from the hospital alive subsequently rebled and required surgical treatment. The authors conclude that EST is as effective as PCA in the acute treatment of bleeding, but that when EST fails, PCA may be effective management.