Current status of the distal splenorenal shunt in China

Herein we report the results and current status of the distal splenorenal shunt (DSRS) in China. From June 1979 to June 1989, the DSRS was performed in 302 patients with esophagogastric varices. Among a group of 249 patients, 112 were in Child's class A, 97 were in class B, and 40 were in class C. The cause of portal hypertension was posthepatic cirrhosis in 217 patients, schistosomiasis in 28 patients, alcoholic cirrhosis in 3 patients, and biliary cirrhosis in 1 patient. Therapeutic selective shunts were performed in 200 patients with variceal bleeding, and 102 patients received prophylactic shunts. Emergency operations were performed in 10 patients. The original Warren shunt was performed in 264 patients, and various modifications in 38 patients. Simultaneous ligation of the splenic artery was performed in 202 patients. The overall operative mortality rate was 6%. A 3-month to 10-year follow-up demonstrated an 8% recurrent bleeding rate, a 1% incidence of encephalopathy, and a survival rate ranging from 72.3% to 100%. From the preliminary results obtained, we conclude that DSRS is effective and safe in the treatment of esophagogastric variceal bleeding. It can also be used as a prophylactic procedure in Child's class A and B patients.     

Surgical versus non-surgical treatment in patients with esophageal varices--a prospective randomized study]

In Japan, non-shunting procedures and selective shunt such as esophageal transection (ET), and distal splenorenal shunt (DSRS) have been widely performed. A prospective randomized trial was done to assess the effects of EIS and DSRS for treating patients with esophageal varices. Ninety-six Japanese with good liver function (Child A or B) and large esophageal varices were randomly assigned to one of three groups given different treatments; (EIS, n = 32), (ET, n = 32) and (DSRS, n = 32). Five patients (15.6%) of the DSRS group has to be excluded from this study, because of severe chronic pancreatitis. No patient died within 30 days of the treatments. The 5-year cumulative bleeding rates were 0%, 4.3% and 12.1% in the EIS, ET and DSRS groups, respectively, with no statistical significances. In no case in the three groups did the death occur because of variceal bleeding. Nineteen patients died mainly due to the underlying liver disease; 5 in the EIS, 5 in the ET and 9 in the DSRS group. There was no statistically significant difference in the survival rates among the three groups. We conclude that EIS is a satisfactory alternative to ET or DSRS for the management of patients with large esophageal varices.     

Selective variceal decompression in portal vein thrombosis

Thirty-two patients with congenital portal vein thrombosis have been managed for bleeding gastro-oesophageal varices. Fifteen had splenectomy and/or other therapy before referral: nine were managed by endoscopic sclerosis, four by devascularization and two by total shunt; six rebled. Seventeen had their spleen 'in situ' at referral and were evaluated for selective shunt: thirteen had distal splenorenal shunts (DSRS)--one transiently rebled despite a patent shunt and one had shunt thrombosis; four had no veins suitable for shunt, and were managed by splenectomy and devascularization, with two rebleeds. Detailed study of seven patients before, and 1 year after DSRS, showed a rise in platelet count, maintenance of hepatocyte function, portal perfusion, liver blood flow and liver size. The spleen showed a significant (P less than 0.025) reduction in size with trans-splenic decompression. We conclude that DSRS provides an excellent method for long-term control of bleeding in such patients, without alteration of liver function or haemodynamics. Patients managed by splenectomy and direct ablative procedures have a significantly (P less than 0.05) greater risk of rebleeding than patients receiving DSRS.     

Bleeding esophagogastric varices from extrahepatic portal hypertension: 40 years' experience with portal-systemic shunt

BACKGROUND: This article discusses the largest and longest experience reported to date of the use of portal-systemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT). STUDY DESIGN: Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93%); 166 were eligible for and received 10 or more years of regular followup (83%). RESULTS: The etiology of PVT was unknown in 65% of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15%), umbilical vein catheterization in 14 patients (7%), and peritonitis in 14 patients (7%). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76%), the portal vein and adjacent superior mesenteric vein in 10 patients (5%), and the portal and splenic veins in 56 patients (28%). Postoperative survival to leave the hospital was 100%. Actuarial 5-year, 10-year, and 15-year survival rates were 99%, 97%, and 95%, respectively. Five patients (2.5%), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97% of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected. CONCLUSION: PSS is the only consistently effective therapy for bleeding esophagogastric varices from PVT and extrahepatic portal hypertension, resulting in many years of survival, freedom from recurrent bleeding, normal liver function, and no encephalopathy.     

A randomized trial for the study of the elective surgical treatment of portal hypertension in mansonic schistosomiasis

From 1977 to 1983, 94 patients with esophageal varices and gastrointestinal bleeding secondary to mansonic schistosomiasis were entered into a prospective randomized trial comparing the three operations mainly used in Brazil: esophagogastric devascularization associated with splenectomy (EGDS, 32 patients), classical splenorenal shunt (SRS, 32 patients), and distal splenorenal shunt (DSRS, 30 patients). The randomization was interrupted because of a significant incidence of portosystemic encephalopathy (PSE) in the SRS group (26%), as compared to the DSRS (7%) and EGDS (0%) groups. The rate of rebleeding was the same in the three groups, but the rate of failure, as defined by the presence of technical problems, postoperative complications, or death, was significantly higher in the SRS group. This 2-year follow-up shows that SRS should be abandoned in hepatosplenic schistosomiasis and that a comparison between DSRS and EGDS with a longer follow-up is urgently needed.     

The changing spectrum of treatment for variceal bleeding.

OBJECTIVE: The objective of this study was to assess the impact of endoscopic therapy, liver transplantation, and transjugular intrahepatic portosystemic shunt (TIPS) on patient selection and outcome of surgical treatment for this complication of portal hypertension, as reflected in a single surgeon's 18-year experience with operations for variceal hemorrhage. SUMMARY BACKGROUND DATA: Definitive treatment of patients who bleed from portal hypertension has been progressively altered during the past 2 decades during which endoscopic therapy, liver transplantation, and TIPS have successively become available as alternative treatment options to operative portosystemic shunts and devascularization procedures. METHODS: Two hundred sixty-three consecutive patients who were surgically treated for portal hypertensive bleeding between 1978 and 1996 were reviewed retrospectively. Four Eras separated by the dates when endoscopic therapy (January 1981), liver transplantation (July 1985), and TIPS (January 1993) became available in our institution were analyzed. Throughout all four Eras, a selective operative approach, using the distal splenorenal shunt (DSRS), nonselective shunts, and esophagogastric devascularization, was taken. The most common indications for nonselective shunts and esophagogastric devascularization were medically intractable ascites and splanchnic venous thrombosis, respectively. Most other patients received a DSRS. RESULTS: The risk status (Child's class) of patients undergoing surgery progressively improved (p = 0.001) throughout the 4 Eras, whereas the need for emergency surgery declined (p = 0.002). The percentage of nonselective shunts performed decreased because better options to manage acute bleeding episodes (sclerotherapy, TIPS) and advanced liver disease complicated by ascites (liver transplantation, TIPS) became available (p = 0.009). In all Eras, the operative mortality rate was directly related to Child's class (A, 2.7%; B, 7.5%; and C, 26.1 %) (p = 0.001). As more good-risk patients underwent operations for variceal bleeding, the incidence of postoperative encephalopathy decreased (p = 0.015), and long-term survival improved (p = 0.012), especially since liver transplantation became available to salvage patients who developed hepatic failure after a prior surgical procedure. There were no differences between Eras with respect to rebleeding or shunt occlusion. Distal splenorenal shunts (p = 0.004) and nonselective shunts (p = 0.001) were more protective against rebleeding than was esophagogastric devascularization. CONCLUSIONS: The sequential introduction of endoscopic therapy, liver transplantation, and TIPS has resulted in better selection and improved results with respect to quality and length of survival for patients treated surgically for variceal bleeding. Despite these innovations, portosystemic shunts and esophagogastric devascularization remain important and effective options for selected patients with bleeding secondary to portal hypertension.     

Conversion of failed transjugular intrahepatic portosystemic shunt to distal splenorenal shunt in patients with Child A or B cirrhosis.

OBJECTIVE: The authors demonstrate the feasibility of converting failed transjugular intrahepatic portosystemic shunt (TIPS) to distal splenorenal shunt (DSRS) in patients with good hepatic reserve for long-term control of variceal bleeding. SUMMARY BACKGROUND DATA: TIPS is an effective method for decompressing the portal venous system and controlling bleeding from esophageal and gastric varices. TIPS insufficiency is, however, a common problem, and treatment alternatives in patients with an occluded TIPS are limited because most have already failed endoscopic therapy. METHODS: The records of five patients who underwent conversion from TIPS to DSRS because of TIPS failure or complication in the past 36 months were reviewed. RESULTS: Four patients had ethanol-induced cirrhosis and one patient had hepatitis C virus cirrhosis. Three patients were Child-Pugh class A and two were class B. All patients had excellent liver function, with galactose elimination capacities ranging from 388 to 540 mg/min (normal 500 +/- 100 mg/min). The patients had TIPS placed for acute (2) or sclerotherapy-resistant (3) variceal hemorrhage. All five TIPS stenosed 3 to 23 months after placement, with recurrent variceal hemorrhage and failed TIPS revision. One patient had stent migration to the superior mesenteric vein that was removed at the time of DSRS. All five patients underwent successful DSRS, and none have had recurrent hemorrhage 18 to 36 months after surgery. CONCLUSIONS: TIPS provides inadequate long-term therapy for some Child-Pugh A or B patients with recurrent variceal hemorrhage. TIPS failure in patients with good liver function can be salvaged by DSRS in many cases.     

Prophylactic distal splenorenal shunt for child's class A and B patients at high risk of bleeding

During recent 17 years, prophylactic distal splenorenal shunt was carried out on 29 patients. Patients were composed of 18 males and 11 females. Age ranged from 34 to 66 years with an average of 52.4. All patients had risky esophagogastric varices; varices larger than 5 mm in diameter and or varices with red color signs such as cherry red spots endoscopically. Underlying liver disease were cirrhosis of the liver in 27, chronic hepatitis in one, and idiopathic portal hypertension in one. Twenty-three patients were in Child's class A and six were in class B. Thirteen patients underwent the original Warren shunt but the remaining 16 had modified distal splenorenal shunts with expanded polytetrafluoroethylene interposition. Portal-azygos disconnection was routinely performed. One patients (3.4%) died of hepatic failure on the 6th postoperative day. Four patients (14.3%) developed hepatic encephalopathy of mild to moderate degree but no patients have suffered from variceal bleeding until now. The 5-, 10-, and 15-year survival rates were all 85.5 per cent. It is concluded that distal splenorenal shunt is a safe and reliable method to prevent variceal bleeding in a selected group of patients.     

Transabdominal Extensive Esophagogastric Devascularization with Gastroesophageal Stapling for Management of Noncirrhotic Portal Hypertension: Long-term Results

Outside Japan portosystemic shunts have been favored as the surgical procedure of choice for the management of portal hypertension of noncirrhotic etiology. Devascularization procedures have resulted in high rebleed rates probably owing to a limited extent of devascularization. We performed this study to assess the efficacy of our modification of Sugiura's procedure for long-term control of variceal bleeding in patients with noncirrhotic portal hypertension. Forty-six patients with extrahepatic portal venous obstruction (EHPVO) and 22 with noncirrhotic portal fibrosis (NCPF) were subjected to transabdominal extensive esophagogastric devascularization with esophageal or gastric stapled transection (modified Sugiura's procedure), 38 in an emergency situation and 30 electively. Follow-up endoscopies were performed every 6 months. Operative mortality, morbidity, variceal status, and causes of recurrent bleeding were evaluated. The postoperative mortality was 4%. Early procedure-related complications were seen in 6%, and esophageal strictures formed in 7 of 45 survivors undergoing esophageal transection (15%). Over a mean ± SD follow-up of 53 ± 34 months, 95% of patients were free of varices. Seven survivors (11%) had a rebleed, but only 5% were due to varices (two esophageal, one gastric). Six (9%) patients developed gastropathy. The 5-year survival was 88%. The modified Sugiura's procedure is safe and effective for long-term control of variceal bleeding especially in the emergency setting and in patients with anatomy unsuitable for shunt surgery or if surgical expertise for a shunt operation is not available.     

Distal splenorenal shunt: preferred treatment for recurrent variceal hemorrhage in the patient with well-compensated cirrhosis

HYPOTHESIS: Distal splenorenal shunt (DSRS) is a safe and effective treatment for patients with Child-Pugh class A and B cirrhosis with recurrent variceal hemorrhage after failed transjugular intrahepatic portosystemic shunt. DESIGN: Retrospective case review. SETTING: Hepatobiliary surgery and liver transplantation department in a tertiary referral medical center. PATIENTS: Between August 1, 1985, and May 1, 2005, 119 patients with Child-Pugh class A and B cirrhosis underwent DSRS for recurrent variceal hemorrhage. Of these, 17 (14.3%) had thrombosed or failing transjugular intrahepatic portosystemic shunt prior to DSRS. INTERVENTION: Distal splenorenal shunt for recurrent variceal hemorrhage after failure of conservative management. MAIN OUTCOME MEASURES: Morbidity, mortality, and subsequent liver transplantation rate. RESULTS: The overall perioperative morbidity rate was 31.5%. Thirteen patients (11.7%) developed encephalopathy and 6 (5.4%) had recurrent variceal hemorrhage. Other complications included portal vein thrombosis, pancreatitis, pancreatic pseudocyst, pneumonia, and wound infection. The 30-day operative mortality rate was 6.4% (n = 7). The 1-year survival rate was 85.9%. The incidence of DSRS for failed transjugular intrahepatic portosystemic shunt during the first 12 years of the study (1985-1997) was 11.1% (9/81). This proportion increased to 26.7% (8/30) during the second half of the study (1997-2005). During the 20-year period, 15 patients (13.5%) underwent liver transplantation a mean of 5.1 years after DSRS without an increase in morbidity or mortality after transplantation. CONCLUSIONS: Distal splenorenal shunt may be the preferred treatment for recurrent variceal hemorrhage in the patient with well-compensated cirrhosis. In addition, DSRS does not cause increased morbidity or mortality in subsequent liver transplantation.     

Bleeding esophagogastric varices from extrahepatic portal hypertension: 40 years’ experience with portal-systemic shunt

Background:

This article discusses the largest and longest experience reported to date of the use of portal-systemic shunt (PSS) to treat recurrent bleeding from esophagogastric varices caused by extrahepatic portal hypertension associated with portal vein thrombosis (PVT).

Study Design:

Two hundred consecutive children and adults with extrahepatic portal hypertension caused by PVT who were referred between 1958 and 1998 after recovering from at least two episodes of bleeding esophagogastric varices requiring blood transfusions were managed according to a well-defined and uniformly applied protocol. All but 14 of the 200 patients were eligible for and received 5 or more years of regular followup (93%); 166 were eligible for and received 10 or more years of regular followup (83%).

Results:

The etiology of PVT was unknown in 65% of patients. Identifiable causes of PVT were neonatal omphalitis in 30 patients (15%), umbilical vein catheterization in 14 patients (7%), and peritonitis in 14 patients (7%). The mean number of bleeding episodes before PSS was 5.4 (range 2 to 18). Liver biopsies showed normal morphology in all patients. The site of PVT was the portal vein alone in 134 patients (76%), the portal vein and adjacent superior mesenteric vein in 10 patients (5%), and the portal and splenic veins in 56 patients (28%). Postoperative survival to leave the hospital was 100%. Actuarial 5-year, 10-year, and 15-year survival rates were 99%, 97%, and 95%, respectively. Five patients (2.5%), all with central end-to-side splenorenal shunts, developed thrombosis of the PSS, and these were the only patients who had recurrent variceal bleeding. During 10 or more years of followup, 97% of the eligible patients were shown to have a patent shunt and were free of bleeding. No patient developed portal-systemic encephalopathy, liver function tests remained normal, liver biopsies in 100 patients showed normal architecture, hypersplenism was corrected.

Conclusion:

PSS is the only consistently effective therapy for bleeding esophagogastric varices from PVT and extrahepatic portal hypertension, resulting in many years of survival, freedom from recurrent bleeding, normal liver function, and no encephalopathy.     

Distal splenorenal shunt versus endoscopic sclerotherapy for long-term management of variceal bleeding. Preliminary report of a prospective, randomized trial.

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% non-alcoholic cirrhosis. No patients have been lost to follow-up, which currently stands at a median of 26 months. Rebleeding occurred significantly (p less than 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 less than 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 less than 0.05) better maintained in the sclerosis (95%) compared to the DSRS (53%) group. Galactose elimination capacity improved significantly (p less than 0.05) in 21 patients successfully managed by sclerosis at 1 year and was significantly (p less than 0.01) better maintained in the sclerosis compared to DSRS group. The authors conclude that endoscopic sclerosis: has a higher rebleeding rate than DSRS, with one third of patients failing therapy from rebleeding; allows significant improvement in liver function when successful; and gives significantly improved survival in the management of variceal bleeding when backed up by surgical therapy for patients with uncontrolled rebleeding.     

Results of non-decompression surgery for esophago-gastric varices--postoperative disappearance, recurrence, rebleeding rate of varices, and cumulative survival rate]

A total of 508 patients had an non-decompression surgery for esophago-gastric varices in our department, from September 1979 to December 1991. These patients consisted of 387 cases of transthoracic esophageal transection with para-esophagogastric devascularization, 40 cases of transabdominal esophageal transection, and 81 cases of Hassab procedure. The original diseases were cirrhosis in 432 patients, IPH in 35, extrahepatic-portal occlusion in 24, primary biliary cirrhosis in 6, Budd-Chiari syndrome in 4, and others in 7. Operative mortality rate was 5.3%. By thoracic approach, esophageal varices completely disappeared. Postoperative cumulative variceal recurrence and bleeding rates at 10 years were 12% and 7%, although recurrence occurred more often than not in cases with hepatocellular carcinoma (HCC). Cumulative survival rates at 5, 10 years were 69%, 46% in liver cirrhosis without HCC. Present study confirmed that our non-decompression surgery is effective in controlling esophagogastric varices in long term of periods.     

Modified distal splenorenal shunt with expanded polytetrafluoroethylene interposition

Two types of modified distal splenorenal shunt with expanded polytetrafluoroethylene (Gore-Tex; WL Gore & Associates Inc., Elkton, Md.) interposition were performed in 18 consecutive patients with esophageal or esophagogastric varices. There were 12 men and six women ranging in age from 32 to 76 years. The causes of portal hypertension were cirrhosis of the liver in 15 patients, chronic hepatitis in two, and idiopathic portal hypertension in one. In five patients the left gastric vein branched off from the splenic vein; bilateral gastric venous decompression was achieved by preserving the splenic vein. Porta-azygos disconnection was routinely performed by confirming repeated intraoperative direct splenoportography. The operations were elective in seven and were emergencies in five patients. Six patients underwent a prophylactic shunt; all patients had "red color signs" endoscopically, and three of them had concomitant hepatocellular carcinoma. Postoperative morbidity was minimal and there was no mortality. Shunt patency was confirmed angiographically in all patients 14 to 56 days after surgery. The varices disappeared or significantly improved in all patients. No patients had variceal bleeding postoperatively. Hepatic encephalopathy was transiently seen in one (the oldest) patient.     

The distal splenorenal shunt: an update on experience of 106 cases

This paper analyzes experience with 106 patients treated primarily with DSRS during a ten year period. Operative mortality was 5% of cases. Shunt patency was evaluated by postoperative angiography in 70 patients. A shunt thrombosis and a recanalization of the splenic vein were noted in a patient who had a Britton's operation resulting in a side-to-side shunt. In the other 31 cases, shunt patency was indirectly confirmed by the absence of varices at postoperative or long-term endoscopic examination. At postoperative check, esophageal varices had disappeared in only 19% of patients. However, this rose to 60% at long-term check-up. Ten patients bled from varices in the postoperative period (9%). During the follow-up period, no patient bled from varices, while five patients bled from gastroduodenal lesions (5%). During the postoperative period, 52% of cases had ascites. In the long-term, ascites developed in only 15% of cases and was well controlled by standard medical treatment. Analysis of the actuarial curve showed a 5-year survival rate of 63%. During the follow-up period, 17% of patients experienced at least one episode of acute encephalopathy. Chronic encephalopathy appeared in 14% of cases: ten patients suffered a mild form (10%) and four (4%) a moderate form. No patient had severe chronic encephalopathy. DSRS is effective as treatment of portal hypertension with a low long-term morbidity despite a more troublesome early postoperative period.     

小口径人工血管架桥门体分流联合贲门周围血管离断术治疗门静脉高压症上消化道出血

目的 探讨小口径人工血管(直径0.8 cm)门体静脉架桥联合贲门周围血管离断术在门静脉高压症(PHT)合并上消化道出血治疗中的应用价值.方法 对38例PHT合并上消化道出血患者采用小口径人工血管脾-腔架桥(14例)、肠-腔架桥(24例)联合贲门周围血管离断术治疗.结果 术后患者自由门静脉压力平均下降(6.6±1.2)cm H2O,手术前后肝功能相比差异无统计学意义(P>0.05).脾-腔架桥组术后外周血血小板和白细胞计数恢复正常(均P<0.05).手术死亡率为3%.术后并发症有发热4例,顽固性腹水和乳糜腹水各1例,肝性脑病1例,腹腔感染1例,应激性溃疡1例.除1例腹腔感染患者死亡外,其余经保守治疗后均痊愈.对35例进行了6个月至3年的随访,消化道出血复发2例,死亡2例,总有效率为89%.1年和3年人工血管通畅率分别为80%和75%.25例患者于术后6个月行纤维胃镜检查,食管胃底静脉曲张基本消失或减轻.结论 小口径人工血管架桥门体分流联合贲门周围血管离断术治疗PHT合并上消化道出血可明显降低门静脉压力,有效控制上消化道出血,肝性脑病发生率低.脾-腔架桥术可同时消除患者脾脏功能亢进.     

Esophageal transection may well be the approach of choice for patient with portal venous obstruction and esophageal varices

Thirty patients with esophageal varices, portal venous obstruction and a histologically proven normal liver underwent either one of 2 different types of surgery. Shunt surgery was performed on 20 patients: 9 had a mesocaval shunt, 3, a splenorenal shunt, 4, a left gastric venacaval shunt, and 4, a distal splenorenal shunt. Conversely, direct interruption was performed on the other 10 patients; 6 underwent an esophageal transection, and 4 underwent a resection of the proximal stomach. Re-hemorrhage occurred in 7 of the former 20 patients but not in any of the 10 on whom the direct interruption method was used. In 6 of these 7 patients who experienced rebleeding, subsequent direct interruption surgery led to control of the bleeding. One patient died of a variceal hemorrhage one month postoperatively. The total 10 year cumulative survival rate was 86.3 per cent. In the light of these findings, we believe that methods of direct interruption, such as esophageal transection, may well be the approach of choice for patients with esophageal varices caused by extrahepatic portal venous obstruction.     

The Usefulness of Distal Splenorenal Shunt in Children with Portal Hypertension for the Treatment of Severe Thrombocytopenia and Leukopenia

Background In the current era of transplantation and therapeutic endoscopy, the role of the distal splenorenal shunt (DSRS) for portal hypertension (PH) has diminished. We reviewed the outcome of the use of DSRS in children to determine the usefulness of this operation. Methods In the follow-up course for PH from 1987 to 2006, 15 patients who developed severe thrombocytopenia (platelet count < 50 × 10³/mm³) and/or leukopenia (WBC count < 3000/mm³) with normal liver function were referred for DSRS. Primary diagnosis was portal vein thrombosis (N = 10) and congenital hepatic fibrosis (N = 5). Platelet, WBC count, liver function test, and spleen size were checked before and after DSRS. Shunt patency was accessed postoperatively. Operative morbidity, mortality, and long-term outcomes were measured. Results Platelet count and WBC count increased in individual patients. Mean value of each count increased significantly after DSRS (p = 0.002, .004, respectively). Spleen size decreased significantly (N = 7, p = 0.018). Shunt patency rate was 100%. There was one postoperative complication and no postoperative mortality. Two patients developed portopulmonary hypertension. No patients underwent subsequent transplantation or endoscopic treatment for gastroesophageal varices after DSRS. Conclusions DSRS is an effective and reliable procedure for children with PH and is still useful for selected pediatric patients.     

Selective variceal decompression: current status.

Since its introduction into clinical practice in 1967, selective variceal decompression by means of a distal splenorenal shunt (DSRS) has become one of the more commonly performed portal-systemic shunting procedures in the treatment of variceal hemorrhage throughout the world. In addition to selective decompression of gastroesophageal varices, the DSRS provides the advantages of preservation of portal perfusion of the liver and maintenance of intestinal venous hypertension. Many large, uncontrolled series and the majority of controlled randomized studies have demonstrated a lower incidence of encephalopathy after the DSRS than after nonselective shunt procedures. A secondary advantage of the DSRS is that the hepatic hilum is avoided, thus making subsequent liver transplantation a less formidable procedure. None of the studies have shown an advantage to this shunt with respect to long-term survival in patients with alcoholic cirrhosis. However, some of the large, uncontrolled series have shown that survival is significantly improved in patients with non-alcoholic cirrhosis compared to nonselective shunt procedures in the same population. Controlled trials comparing the DSRS to endoscopic sclerotherapy have shown that chronic endoscopic variceal sclerosis is an appropriate initial therapy for most patients as long as shunt surgery is readily available if sclerotherapy fails.     

Esophageal transection may well be the approach of choice for patients with portal venous obstruction and esophageal varices

Thirty patients with esophageal varices, portal venous obstruction and a histologically proven normal liver underwent either one of 2 different types of surgery. Shunt surgery was performed on 20 patients: 9 had a mesocaval shunt, 3, a splenorenal shunt, 4, a left gastric venacaval shunt, and 4, a distal splenorenal shunt. Conversely, direct interruption was performed on the other 10 patients: 6 underwent an esophageal transection, and 4 underwent a resection of the proximal stomach. Re-hemorrhage occurred in 7 of the former 20 patients but not in any of the 10 on whom the direct interruption method was used. In 6 of these 7 patients who experienced rebleeding, subsequent direct interruption surgery led to control of the bleeding. One patient died of a variceal hemorrhage one month postoperatively. The total 10 year cumulative survival rate was 86.3 per cent. In the light of these findings, we believe that methods of direct interruption, such as esophageal transection, may well be the approach of choice for patients with esophageal varices caused by extrahepatic portal venous obstruction.