Splenopancreatic Disconnection Research Articles

Effect of selective decompression of portal vein by distal splenorenal shunt combined with splenopancreatic disconnection on glucose and amino acid metabolism in patients with cirrhosis

Effect of selective decompression of portal vein by distal splenorenal shunt combined with splenopancreatic disconnection on glucose and amino acid metabolism in patients with cirrhosis

New trends in surgical treatment for portal hypertension

A number of surgical procedures have been developed to manage esophageal varices. Broadly, these can be classified as shunting and non-shunting procedures. While total shunt effectively reduces the incidence of variceal bleeding, it is associated with a high risk of hepatic encephalopathy. The distal splenorenal shunt (DSRS), a selective shunt, was developed by Warren in 1967 to preserve portal blood flow through the liver while lowering variceal pressure. The hope was that both bleeding and hyperammonemia would be prevented. The DSRS effectively prevents rebleeding, but still carries a risk of hyperammonemia. We improved the DSRS procedure by additionally performing splenopancreatic disconnection (SPD, i.e. skeletonization of the splenic vein from the pancreas to its bifurcation at the splenic hilum) and gastric transection (GT, i.e. transection and anastomosis of the upper stomach with an autosuture instrument). An alternative to shunting was developed by Sugiura and Futagawa in 1973. Esophageal transection (ET) divides and reanastomoses the distal esophagus and devascularizes the distal esophagus and proximal stomach; splenectomy, selective vagotomy, and pyloroplasty are performed concomitantly. DSRS was more effective than ET in preventing recurrence of esophageal varices, but was associated with a higher incidence of hyperammonemia. The incidence of hyperammonemia in patients who underwent DSRS with SPD plus GT was significantly lower than that in patients who underwent DSRS alone or those who underwent DSRS with SPD. In conclusion, there are various surgical treatments for esophagogastric varices. Distal splenorenal shunt with SPD plus GT is considered an adequate treatment for patients with esophagogastric varices.

Gastrectomy in Combination with a Distal Splenorenal Shunt in a Patient with Gastric Cancer and Portal Hypertension: Report of a Case

We describe the case of a patient with gastric cancer complicated by portal hypertension due to liver cirrhosis. Endoscopy showed esophageal varices in the lower third of the esophagus and a superficially depressed lesion in the middle third of the stomach, while a biopsy suggested signet-ring cell carcinoma. Laboratory data showed pancytopenia, the indocyanine green fraction after 15 min was 29%, and the symptoms corresponded to the Child B criteria. A preoperative arteriogram revealed a remarkably dilated left gastric vein and the development of collateral pathways. We performed a distal subtotal gastrectomy with a reconstruction by the Billroth I method combined with a distal splenorenal shunt (DSRS) and a splenopancreatic disconnection (SPD). The endoscopic findings of the esophageal varices 15 months after surgery showed only a few white veins and the red color sign had disappeared. Now 7 years have passed since surgery, the risk of variceal hemorrhage has disappeared, and the patient is ambulatory and well. These results seems to be attributable to the long-term maintenance of the shunt selectivity and good portal hemodynamics. In patients with gastric cancer complicated with esophageal and/or gastric varices, it is recommended that DSRS with SPD be performed after a reconstruction using the Billroth I method.

Distal spenorenal shunt with splenopancreatic disconnection for portal hypertension in biliary atresia: T. Hasegawa, H. Tamada, Y. Fukui, et al. Pediatr Surg Int 15:92–96, (March), 1999

Distal spenorenal shunt with splenopancreatic disconnection for portal hypertension in biliary atresia: T. Hasegawa, H. Tamada, Y. Fukui, et al. Pediatr Surg Int 15:92–96, (March), 1999

Selective distal splenorenal shunt without requiring splenopancreatic disconnection with the use of the external iliac vein graft: A preliminary report

Distal splenorenal shunt (DSRS) with splenopancreatic disconnection (SPD) is an ideal operation for permanent control of variceal bleeding. However, it is a very complicated procedure, and DSRS without SPD has a functional disadvantage: It gradually loses its selectivity and portal blood flow. To overcome these conditions, we designed a new technique--modified DSRS, which is easy to perform and maintains long-term selectivity of the shunt. Modified DSRS was performed by using an external iliac vein graft without treating small pancreatic tributaries of the splenic vein. It was applied in 4 cases, and shunt patency and selectivity were examined by angiography during follow-up periods (6-76 months). Modified DSRS was technically more feasible and less complicated than DSRS with SPD. Every attempt was successful. There was no operative mortality, and all the patients were discharged from the hospital in good condition. The shunts were patent in all of them, and the selectivity of the shunt was maintained better in comparison to standard DSRS. Modified DSRS is a much easier and safer technique than standard DSRS. We consider this procedure to be the best method for surgical management of portal hypertension causing esophageal and gastric varices.

Selective distal splenorenal shunt without requiring splenopancreatic disconnection with the use of the external iliac vein graft: A preliminary report

Selective distal splenorenal shunt without requiring splenopancreatic disconnection with the use of the external iliac vein graft: A preliminary report

Distal splenorenal shunt with splenopancreatic disconnection for portal hypertension in biliary atresia.

This study evaluated the long-term effects of distal splenorenal shunt with splenopancreatic disconnection (DSRS-SPD) on portal hypertension (PH) in biliary atresia (BA) patients. Five patients with BA underwent DSRS-SPD at the age of 3.3 to 8.5 years. They had been free from jaundice after hepatic portoenterostomy (HPE); however, they gradually developed gastroesophageal varices and hypersplenism. Portal venous pressure after anastomosis was 37.2 +/- 6.1 cmH2O, as high as that before anastomosis (37.8 +/- 3.3 cmH2O). Postoperatively, liver function tests became worse within 2 weeks; however, they returned to preoperative levels within 1 month without any further treatment. No patient developed a significant encephalopathy throughout the observed period. During follow-up of 4 to 12 years, the shunt was patent in all patients. Spleen size decreased after operation. Abdominal-wall venous dilatation completely disappeared in two of four patients. The platelet counts gradually increased and were significantly higher 3 years (126.6 +/- 59.3 x 10(3)/mm3) after DSRS-SPD than preoperative values (66.0 +/- 24.2 x 10(3)/mm3). White blood cell counts showed no significant changes. No patient developed a gastrointestinal hemorrhage postoperatively, although three had had repeated hemorrhages before the operation. Two patients showed disappearance of varices endoscopically at 2 years and 7 months after DSRS-SPD, respectively, but had recurrent varices at 7 and 11 years, respectively. The endoscopic findings regarding varices 3 to 7 years after DSRS-SPD were as follows: decreased number (80%); decreased length (40%); improvement of form (20%); improvement of fundamental color (60%); disappearance of red-color sign (100%); disappearance of gastric varices (75%); and disappearance of acute gastric mucosal lesions (100%). Although one patient later underwent liver transplantation because of progression of liver cirrhosis, all five are doing well. From these results, DSRS-SPD may prove to be a safe and feasible procedure for intrahepatic PH after HPE for BA and may improve gastroesophageal varices and hypersplenism on long-term follow-up.

Afluência da veia esplênica e sua importância nas derivações esplenorrenais seletivas

Os autores realizaram estudo da afluência da veia esplênica utilizando 38 moldes de duodeno, estômago, pâncreas e baço, por meio da técnica de repleção e corrosão, com vinilite corado com azul da Prússia. Os afluentes encontrados foram: ramos pancreáticos em todas as peças, variando de 7 a 22 ramos, com média de 14,52 ± 3,53; a veia gástrica esquerda, em 36,84% das peças; a veia mesentérica inferior em 44,74% das peças; ramo gástrico (gástrica posterior), proveniente do fundo gástrico, em 57,89% das peças, e ramos pancreáticos, provenientes da cauda do pâncreas e desembocando em ramos segmentares da veia esplênica, em 65,79% das peças. Os ramos pancreáticos variaram em número de um a quatro, com média de 1,64 ± 0,95. Os autores concluem que o conhecimento dos afluentes da veia esplênica seria importante na realização das derivações esplenorrenais distais, quando associadas à desconexão esplenopancreática.

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.

Should the distal splenorenal shunt be combined with gastric disconnection and transection?

Background: This study was aimed at evaluating advantages of distal splenorenal shunt (DSRS) with splenopancreatic and gastric disconnection (DSRS-SPGD) over DSRS with splenopancreatic disconnection (DSRS-SPD) and standard DSRS (S-DSRS). Methods: DSRS-SPGD, DSRS-SPD, and S-DSRS were performed on 62, 7, and 55 patients, respectively, from 1970 to 1992. Comparison was performed in the following aspects: (1) long-term results in ratio of rebleeding, survival rate, and quality of life and (2) portal hemodynamics evaluated by preoperative and postoperative angiography. Portal blood flow was assessed by the ratio of the diameter of portal vein (PV) to superior mesenteric vein (SMV), and shunt selectivity was evaluated by selectivity grade.Results: Incidence of rebleeding was significantly lower in patients who underwent DSRS-SPGD than in those who underwent S-DSRS (p< 0.05). Grade 0 and I performance status was better in patients who underwent DSRS-SPGD. Accumulated survival ratio for 5 and 7 years was 78.3% and 70.5% in patients who underwent DSRS-SPGD, 59.7% and 44.1% in patients who underwent S-DSRS, and 75% and 75% in patients who underwent DSRS-SPD. Hemodynamic evaluation showed significantly lower PV/SMV ratio and degree of change in PV/SMV ratio of patients who underwent S-DSRS and DSRS-SPD. Many patients who underwent S-DSRS and DSRS-SPD exhibited loss of shunt selectivity at grades II and III. In contrast, patients who underwent DSRS-SPGD maintained satisfactory PV/SMV ratio and selectivity grade.Conclusions: DSRS-SPGD clearly showed advantages in decrease of rebleeding and improvement of quality of life resulting from maintenance of shunt selectivity and portal blood flow.

Evaluation of long-term follow-up after distal splenorenal shunt with splenopancreatic disconnection

Evaluation of long-term follow-up after distal splenorenal shunt with splenopancreatic disconnection

The effect of splenomegaly on splanchnic hemodynamics in nonalcoholic cirrhosis after distal splenorenal shunt and splenopancreatic disconnection

We investigated the effect of splenomegaly on portal hemodynamics during and after distal splenorenal shunt with splenopancreatic disconnection in 27 patients with nonalcoholic cirrhosis (13 with and 14 without splenic enlargement). Data were obtained by Doppler flowmetry, electromagnetic flowmetry and computed tomographical scanning. The splenomegaly group had a significantly higher preoperative splenic and portal blood flow than the nonsplenomegaly group. In both groups, postoperative portal venous pressure did not fall; portal blood flow significantly decreased while splenic volume was reduced, despite the lack of significant changes in splenic venous blood flow. There was a greater reduction of portal blood flow with previous splenomegaly than with normal-sized spleens, and this was not related to the degree of reduction in liver volume. In the splenomegaly group, the increase of splenic blood flow was only present during the early postoperative period. In conclusion, distal splenorenal shunt with splenopancreatic disconnection influenced portal hemodynamics differently in nonalcoholic cirrhotic patients with and without splenomegaly. (Hepatology 1994;20:342–348.)

The effect of splenomegaly on splanchnic hemodynamics in nonalcoholic cirrhosis after distal splenorenal shunt and splenopancreatic disconnection

We investigated the effect of splenomegaly on portal hemodynamics during and after distal splenorenal shunt with splenopancreatic disconnection in 27 patients with nonalcoholic cirrhosis (13 with and 14 without splenic enlargement). Data were obtained by Doppler flowmetry, electromagnetic flowmetry and computed tomographical scanning. The splenomegaly group had a significantly higher preoperative splenic and portal blood flow than the nonsplenomegaly group. In both groups, postoperative portal venous pressure did not fall; portal blood flow significantly decreased while splenic volume was reduced, despite the lack of significant changes in splenic venous blood flow. There was a greater reduction of portal blood flow with previous splenomegaly than with normal-sized spleens, and this was not related to the degree of reduction in liver volume. In the splenomegaly group, the increase of splenic blood flow was only present during the early postoperative period. In conclusion, distal splenorenal shunt with splenopancreatic disconnection influenced portal hemodynamics differently in nonalcoholic cirrhotic patients with and without splenomegaly.

Use of distal splenorenal shunt in children referred for liver transplant evaluation

Variceal bleeding remains a common cause of morbidity for children with both intrahepatic and extrahepatic portal hypertension. Occasionally, patients referred for liver transplant evaluation have significant variceal bleeding, despite adequate synthetic liver function. During a 7-year period, 322 children were referred for liver transplant evaluation. Six underwent distal splenorenal shunt surgery after evaluation. There were four boys and two girls. The average age was 11 ± 4 years, and the average weight was 39 ± 15 kg. The etiology of variceal bleeding was intrahepatic portal hypertension in five (1 biliary atresia, 2 chronic hepatitis, 2 congenital hepatic fibrosis) and extrahepatic portal vein thrombosis in one. Two patients had no previous attempts at sclerotherapy (one because of an abnormality in platelet function, the other because of extensive gastric varices), and four had multiple previous sclerotherapy treatments. No patient had preoperative encephalopathy. Three cases were Child's class A, and three were Child's class B. Preoperative evaluation of the portasystemic system was performed with magnetic resonance (MR) imaging or splenoportography. All patients underwent a distal splenorenal shunt procedure, four of whom also had splenopancreatic disconnection. One patient required 100 mL of blood replacement, and five required no blood. The average length of hospital stay was 9.8 ± 2.2 days. Postoperative complications were minimal. All patients are alive, without recurrent gastrointestinal bleeding or encephalopathy, and they have patent shunts, which was confirmed by MR or Doppler ultrasound at a mean of 25 ± 20 months after shunt surgery. Children who have significant cirrhosis, portal hypertension, recurrent variceal bleeding refractory to sclerotherapy, and adequate synthetic function can be effectively treated with a distal splenorenal shunt. While the choice between liver transplantation of shunting may be difficult, use of the distal splenorenal shunt does not preclude future liver transplantation for such children.

Shunt surgery and beta-blockers

The distal splenorenal shunt (DSRS) operation was designed to obviate some of the major problems associated with previous forms of portal decompressive surgery (development of hepatic encephalopathy and deterioration of liver function due to reduced liver perfusion). It was proposed that this could be achieved by selectively decompressing the gastroesophageal varices while maintaining mesentericoportal blood flow to the liver (1). Unfortunately, subsequent investigations failed to confirm the expectations for DSRS: the clinical results were not clearly better than those obtained with standard shunt surgery, which could be due to a progressive loss of due to the opening of large collaterals between the mesenterico-portal bed and the low pressure territory created by the DSRS (2-4). This collateralisation, which is especially marked in patients with alcoholic cirrhosis (5), often results in a reversal of portal blood flow (6). Therefore, in many of these patients the results of longterm follow-up of DSRS were similar to those with a sideto-side shunt (6). Recent studies by Dr Henderson have shown that loss of selectivity can be prevented in part by splenopancreatic disconnection (7); however, this makes an already difficult procedure even more complex. In part because of these inconveniences, and also because of the advent of new, effective therapies (such as endoscopic sclerotherapy, beta-blockers and variceal banding ligation), this procedure is now used much less than it was 10 years ago_ Nevertheless, the results of DSRS in patients with non-alcoholic cirrhosis and relatively preserved liver function are good enough to justify the use of this operation in selected patients (2,7,8). This is well demonstrated by studies comparing therapeutic DSRS with endoscopic sclerotherapy. These studies indicate that both treatments are non-significantly different

Factors predicting chronic hepatic encephalopathy after distal splenorenal shunt: a multivariate analysis of clinical and hemodynamic variables.

This study was aimed at evaluating several factors that promote chronic hepatic encephalopathy by multivariate analysis of data for patients with cirrhosis with good or moderate liver function submitted to distal splenorenal shunts. The study group comprised 131 patients: 55 had alcoholic and 76 nonalcoholic cirrhosis. Seventy patients were in Child's class A and 61 in class B. Cerebral function was assessed by a complete neurologic examination. Angiography with venous phase was performed before and within 1 month after the shunt operation. In 84 cases the original Warren technique was used and in 20 cases a Britton's modified procedure was used. Twenty-seven patients had distal splenorenal shunts with a splenopancreatic disconnection. Statistical analysis was performed by two multivariate analyses based on stepwise selection. Thirty-nine patients died during a follow-up period of 51 +/- 32 months. Chronic encephalopathy occurred in 18 patients (14%). According to the multivariate analysis of the preoperative prognostic factors, only age (p = 0.0001) and albumin values (p = 0.0002) were independent predictive risk factors for chronic encephalopathy. In the multivariate analysis concerning the hemodynamic consequences of the selective shunts, independent risk factors promoting chronic encephalopathy were postoperative portal perfusion (p = 0.0001), postshunt portal pressure (p = 0.001), and surgical disconnection (p = 0.0064). Our study has shown that chronic encephalopathy after selective shunt surgery is promoted by both clinical and hemodynamic factors. A better selection of the candidates for shunt surgery and prevention of the development of portal malcirculation by accurate surgical disconnection should further decrease the risk of chronic encephalopathy.

Surgical treatment of complications of portal hypertension

This review defines the role of non-transplant surgery in portal hypertension. Surgical options for patients with portal hypertensive bleedings include portacaval shunt emergently and distal splenorenal shunt with splenopancreatic disconnection electively. There is currently renewed interest for calibrated portacaval H-grafts. Early results show a low encephalopathy rate and a good control of bleeding.

Should both schistosomal and nonschistosomal variceal bleeders be disconnected?

Splenopancreatic disconnection (SPD) was conceived and implemented as a technical addition to distal splenorenal shunt (DSRS) to maintain its selectivity and preserve portal perfusion. The proposed hemodynamic and metabolic stability of hepatocytes after DSRS-SPD should improve survival. In this nonrandomized study, 145 consecutive (Child A/B) variceal bleeders were electively subjected to selective shunt with DSRS in 93 and DSRS-SPD in 52 patients. The 2 groups were similar before surgery with a mean follow up of 24 +/- 12 (DSRS) and 27 +/- 14 (DSRS-SPD) months. DSRS-SPD had an operative mortality of 3.8%. Postoperative pancreatitis occurred in 7.7% after DSRS-SPD and 3.2% after DSRS alone, with schistosomal hepatic fibrosis representing 86% of morbid cases. Shunt patency was high and recurrent variceal hemorrhage was low in both groups. Clinical encephalopathy was significantly reduced after DSRS-SPD (p less than 0.05). The addition of SPD significantly reduced both the incidence of chronic hyperbilirubinemia in the schistosomal patients (p less than 0.05) and the difference between the changes in total serum bilirubin in all patients (p = 0.001). Portal perfusion was preserved after DSRS-SPD in all of the angiographically-studied patients. The overall survival was 84% after DSRS and 88% after DSRS-SPD. The schistosomal patients showed an incidence of 95% and 96% survival after DSRS and DSRS-SPD, respectively. DSRS-SPD was able to improve survival (92%) better than DSRS (77%) among well-matched nonschistosomal patients. These data show: (1) DSRS-SPD still has low operative mortality and a high patency rate with a low incidence of recurrent variceal hemorrhage, (2) DSRS-SPD maintains portal perfusion, achieves better survival, and reduces the incidence of encephalopathy, especially in patients with nonalcoholic cirrhosis and mixed liver disease, (3) in the schistosomal population, DSRS-SPD reduces the incidence of chronic hyperbilirubinemia but increases the risk of postoperative pancreatitis.

Selective variceal decompression and its role relative to other therapies

Seventy patients, selected from 265 patients with proved variceal bleeding, underwent a distal splenorenal shunt (DSRS) procedure with or without splenopancreatic disconnection (SPD). Alcoholic cirrhosis was the cause of portal hypertension in 57% of the patients. The operative mortality was 13% (Child's classes A and B 2%, class C 66%). Despite fewer varices in all of the patients, variceal rebleeding and death occurred in one patient (2%). Late portal perfusion was observed in 91% of the patients, with worsening in 23%, compared with the preoperative study. Persistent hepatocyte necrosis and incomplete SPD were the most significant prognostic factors for decreased perfusion (presence and absence of necrosis, 38% and 12%, respectively; DSRS and DSRS with SPD, 43% and 12%, respectively). SPD also decreased ongoing hepatocyte damage. Post-shunt encephalopathy was clinically evident in 7% of the patients, but after electroencephalographic evaluation, it increased to 24.6%. Significant factors in its development included decreased portal perfusion (62% versus 14%), active hepatitis (48% versus 17%), and incomplete SPD (43% versus 14%). The higher late liver-related mortality was associated with a lack of or decreased portal perfusion and the absence of SPD.

The selective shunt for variceal bleeding: A personal perspective

It has been proved that selective decompression of esophageal varices can occur by way of the left gastric venous route or the transsplenic route. The left gastric venacaval shunt functions well over a long postoperative period, if the shunt is technically satisfactory; however, the distal splenorenal shunt (DSRS) can be problematic. Unless the proximal and distal portions of the splenic vein are both entirely isolated from the pancreas, blood flow will be diverted from the portal vein to the distal splenic vein, where the pressure has been lowered by the shunt. This portal malcirculation may lead to portal thrombosis or stenosis on occasion. To prevent this adverse effect, complete isolation of the splenic vein (splenopancreatic disconnection) is necessary. Extensive gastric disconnection is irrelevant in this regard. Although the conventional DSRS has been viewed with disfavor, we must realize that splenopancreatic disconnection makes the DSRS a satisfactory technique. The clinical evidence and theoretic basis of the selective shunt for esophageal varices are described herein.