Distal splenorenal shunt: role, indications, and utility in the era of liver transplantation

HYPOTHESIS: The distal splenorenal shunt (DSRS) continues to play an important role in the management of recurrent variceal bleeding with minimal negative impact on subsequent orthotopic liver transplantation (OLT). DESIGN: Case-control study. SETTING: Hepatobiliary surgery and liver transplantation unit in a tertiary referral medical center. PATIENTS: From August 1, 1985, through October 31, 1997, a single team of surgeons performed 81 DSRS procedures for recurrent variceal hemorrhage. Eleven patients undergoing OLT subsequent to DSRS were compared with a group of 274 patients undergoing OLT without any previous shunt during the same period. MAIN OUTCOME MEASURES: Operative time, use of blood products, length of hospital stay, perioperative complications, and survival rates. RESULTS: Operative (30-day) mortality for DSRS was 6% (n = 5). From follow-up information available for 74 patients, the 1- and 5-year survival rates were 86.4% (n = 64) and 74.3% (n = 55), respectively. Recurrent variceal bleeding and hepatic encephalopathy occurred in 5 (6.8%) and 11 patients (14.9%), respectively, after DSRS. In 9 patients, DSRS was used as salvage for failed transjugular intrahepatic portosystemic shunt. CONCLUSIONS: Distal splenorenal shunt is a safe, durable, and effective treatment for controlling recurrent variceal hemorrhage in patients with acceptable operative risk and good liver function. It does not compromise future liver transplantation and can considerably delay the time until transplantation is required. Given the early occlusion rate and need for constant surveillance, transjugular intrahepatic portosystemic shunting should be reserved for patients with Child C classification cirrhosis with chronic hemorrhage or intractable ascites or as an emergency procedure for patients with uncontrollable bleeding using endoscopic therapy.     

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.     

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 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.     

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.     

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.     

Liver transplantation for variceal hemorrhage

At the present time, liver transplantation must be considered among the treatment options for patients with variceal hemorrhage. For a significant percentage of variceal bleeders throughout the world, however, transplantation is not a viable option either because the patient is not an appropriate transplant candidate or because of the etiology of the patient's portal hypertension. Sclerotherapy and portosystemic shunts remain the mainstay of therapy for these patients. The survival rates with liver transplantation are superior to those reported for other therapies for variceal hemorrhage in patients who have moderate or severe liver disease in addition to variceal hemorrhage. Child's C patients whose variceal hemorrhage is controlled medically should be evaluated for transplantation and receive chronic sclerotherapy while they wait on the transplant list. If the variceal hemorrhage cannot be controlled medically in a transplant candidate, then the patient should undergo an emergency shunt procedure. The shunt of choice is a large-bore H-graft mesocaval or mesorenal shunt. This shunt effectively controls the acute hemorrhage, is relatively simple to perform, does not adversely impact on the subsequent liver transplant, and can simply be ligated after the transplant is completed. Patients who experience variceal hemorrhage as the only manifestation of their liver disease should be treated initially with endoscopic sclerotherapy. For that small group of patients who are either not candidates for sclerotherapy or who rebleed despite sclerotherapy, the choice of shunt or transplantation is presently a difficult one, because both therapies provide excellent results in this group of patients. The choice of therapy should be made on an individual basis and only after consultation with both transplant and shunt surgeons. If a shunt is chosen, we prefer the DSRS because it maintains hepatic portal perfusion in many patients and does not require dissection of the porta hepatis. The management of patients with a prior portosystemic shunt at the time of transplantation depends on the type of shunt and the duration of time between the shunt and the transplant. Shunts not involving the hepatic hilum have little adverse impact on the performance of the transplant. There are insufficient data to assess accurately the effect of a prior portacaval shunt on the transplant. However, our clinical experience and that of other transplant groups indicate that the transplantation of these patients is technically more difficult than that of patients with shunts not involving the hilum. With the availability of other shunting procedures that do not involve extensive dissection of the hepatic hilum, there is little role for either end-to-side or side-to-side portacaval shunts in patients who are potential liver transplant candidates.(ABSTRACT TRUNCATED AT 400 WORDS)     

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.     

Recent advances in the management of variceal bleeding

A prospective randomized trial of selective distal splenorenal shunt (DSRS) versus H-graft interposition total shunt at Emory Hospital in 1971 showed DSRS to be superior to a total shunt in shunt patency, prevention of variceal bleeding, preserving hepatic cell function, preserving the quality of life and patient survival. These results were particularly evident in the non-alcoholic patients. In the alcoholic patients, there was a greater loss of hepatic portal perfusion. In a later phase of the study, it was found that pancreatic veins formed a pathway of collaterals to the shunt, that is a so-called pancreatic siphon. In order to prevent loss of portal and pancreatic flow through the siphon, a total spleno-pancreatic disconnection was developed, whereby the hormone diversion is expected to be diminished.     

Long-term Efficacy of Distal Splenorenal Shunt with Splenopancreatic and Gastric Disconnection for Esophagogastric Varices in Patients with Idiopathic Portal Hypertension

Idiopathic portal hypertension (IPH) requires invasive measures to prevent rupture and bleeding of esophagogastric varices. However, the long-term results of shunt surgery for IPH have not been reported. In particular, the pros and cons of surgery that preserves the spleen and its long-term hematologic effects have not been described. The records of 15 patients who underwent distal splenorenal shunt with splenopancreatic and gastric disconnection (DSRS with SPGD) for IPH between 1983 and 1998 was reviewed retrospectively. One patient died within 3 years of surgery, for a 3-year survival rate of 93%; the 10-year survival rate was 64%. Three patients (18%) suffered rebleeding from esophagogastric varices. The white blood cell and platelet counts were higher 3–5 years and 7–13 years postoperatively compared with preoperative values. Four of five patients who underwent postoperative computed tomography had a smaller spleen postoperatively. DSRS with SPGD provides long-term hemostasis for esophagogastric variceal bleeding in IPH and alleviates hypersplenism. DSRS with SPGD is an effective treatment for patients with IPH in whom long-term survival is expected.     

Distal splenorenal shunt with splenopancreatic disconnection. A 4-year assessment

The aims of distal splenorenal shunt with splenopancreatic disconnection (DSRS-SPD) were to improve maintenance of portal flow and prevent siphoning of hepatotrophic factors from the pancreas, as occurs after standard DSRS. The main patient population targeted for improvement were alcoholic cirrhotics, who have poorer survival than nonalcoholic cirrhotics and greater loss of portal flow (60%) after standard DSRS. Seventy-eight patients had DSRS-SPD during the study period 1983 to 1987: thirty-two patients were Child's A, 25 were Child's B, and 21 were Child's C. The 35 patients with alcoholic cirrhosis were a significantly poorer risk group by Child's class and galactose elimination capacity (GEC) than the 39 patients with nonalcoholic cirrhosis. Four patients had portal vein thrombosis. At 4-year follow-up, portal perfusion is maintained in 84% alcoholic and 90% nonalcoholic patients, with hepatic and systemic hemodynamics showing identical patterns for both groups. Hepatic function measured by GEC was maintained in alcoholic patients (290 +/- 68 mg/min to 303 +/- 74 mg/min) and nonalcoholics patients (342 +/- 92 to 320 +/- 118 mg/min). Gastric variceal rebleeding occurred in 10 patients--4 early (less than 2 months) and 6 late (18 to 54 months), leading to operation in 4 and transhepatic embolization in 4 patients: 2 of these patients died from this complication. Survival data show an operative mortality rate of 6.4% and overall mortality rate of 30%, with no significant difference between alcoholic and nonalcoholic cirrhotics. DSRS-SPD has significantly improved maintenance of portal perfusion and survival in patients with alcoholic cirrhosis requiring selective shunt for variceal bleeding when compared to standard DSRS. In this population DSRS-SPD is the operation of choice. In patients with nonalcoholic cirrhosis, the current data have not shown DSRS-SPD to have advantage over standard DSRS.     

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.     

Selective shunt in the management of variceal bleeding in the era of liver transplantation.

This study reports the Emory experience with 147 distal splenorenal shunts (DSRS) and 110 orthotopic liver transplants (OLT) between January 1987 and December 1991. The purpose was to clarify which patients with variceal bleeding should be treated by DSRS versus OLT. Distal splenorenal shunts were selected for patients with adequate or good liver function. Orthotopic liver transplant was offered to patients with end-stage liver disease who fulfilled other selection criteria. The DSRS group comprised 71 Child's A, 70 Child's B, and 6 Child's C patients. The mean galactose elimination capacity for all DSRS patients was 330 +/- 98 mg/minute, which was significantly (p less than 0.01) above the galactose elimination capacity of 237 +/- 82 mg/minute in the OLT group. Survival analysis for the DSRS group showed 91% 1-year and 77% 3-year survival, which was better than the 74% 1-year and 60% 3-year survivals in the OLT group. Variceal bleeding as a major component of end-stage disease leading to OLT had significantly (p less than 0.05) poorer survival (50%) at 1 year compared with patients without variceal bleeding (80%). Hepatic function was maintained after DSRS, as measured by serum albumin and prothrombin time, but galactose elimination capacity decreased significantly (p less than 0.05) to 298 +/- 97 mg/minute. Quality of life, measured by a self-assessment questionnaire, was not significantly different in the DSRS and OLT groups. Hospital charges were significantly higher for OLT (median, $113,733) compared with DSRS ($32,674). These data support a role for selective shunt in the management of patients with variceal bleeding who require surgery and have good hepatic function. Transplantation should be reserved for patients with end-stage liver disease. A thorough evaluation, including tests of liver function, help in selection of the most appropriate therapeutic approach.     

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.     

Comparison between selective distal splenorenal shunt and small diameter H-graft portosystemic shunt

Although most commonly performed portal decompressive procedures control bleeding effectively, postoperative morbidity and mortality remains a serious problem in these patients. Both distal splenorenal shunts (DSRS) and small-diameter portacaval H-grafts (PCHG) are reported to produce decreased rates of postoperative encephalopathy. We prospectively evaluated 69 patients in whom 27 PCHG and 45 DSRS were performed over a seven-year interval. There were no significant preoperative differences between these groups. Operative mortality was 12.9% overall. DSRS was associated with decreased intraoperative blood transfusions and operative time. Postoperatively, DSRS was associated with significantly less encephalopathy, other postoperative complications, and ascites. Recurrent variceal bleeding was seen in three patients treated with PCHG and two patients with DSRS. We conclude that both DSRS and PCHG are effective in preventing recurrent variceal bleeding, but DSRS remains our procedure of choice because of its decreased rates of postoperative complications.     

Management of variceal bleeding in patients with noncirrhotic portal vein thrombosis.

Since 1971, 70 patients have been seen at Emory University Hospital with gastroesophageal varices secondary to extrahepatic portal vein thrombosis (PVT). Thirty-seven of these patients had had prior major operative therapy. In only three patients (8%) was shunt surgery successful, and there was a high incidence of rebleeding, other morbidity, and mortality. Of especial note are the serious consequences of simple splenectomy; splenomegaly and thrombycytopenia should rarely, if ever, be used as indication for splenectomy in portal hypertension. In 1977, the use of selective distal splenorenal shunt (DSRS) was begun at Emory in this population and a selective shunt has been possible in 24 of 29 patients (83%) who had had no prior operative therapy. Results have been excellent with a greater than 90% patency rate, long-term portal perfusion in all, no encephalopathy, and late rebleeding in one patient. Quantitative studies at 3-6 years show stability of liver function, significant decrease in spleen size, and rise in platelet count. However, long-term follow-up (greater than 15 years) is required in PVT patients before definitive assessment can be obtained. A specific problem of the PVT patient is late shunt stenosis which requires close observation; dilatation of the shunt was performed in six of the 24 patients with a patent shunt. Poor results with non-shunt operative procedures in PVT were again documented. The proper role of endoscopic variceal sclerotherapy is not yet clear, but appears to be an excellent addition to the therapeutic options. In conclusion, for patients with a patent splenic vein, initial therapy should be a selective shunt; for patients without a patent splenic venous system, endoscopic sclerotherapy is the procedure of choice.     

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

BACKGROUND: 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. METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.     

Distal splenorenal shunt for management of variceal bleeding in patients with schistosomal hepatic fibrosis.

The distal splenorenal shunt was performed in 60 patients with schistosomal hepatic fibrosis in whom no evidence of cirrhosis was documented by preoperative needle and operative wedge biopsy. No patients have been lost to follow-up with a median of 37 months (range: 17-86). The results showed low operative mortality (1.7%), high patency rate (92.5%), and low recurrent variceal hemorrhage (6.7%). Thrombosed shunts were treated either by refashioning the shunt (1 patient) or splenectomy and gastric devascularization (2 patients). Initial hyperbilirubinemia and reduction in serum albumin were found in the early postoperative period, with persistent hyperbilirubinemia in 32% of the patients. The 5-year survival was 88%, with liver disease related mortality in only three patients. Clinical encephalopathy was detected in three patients (5.1%); only one of them was incapacitated. These data showed that: selective shunt (distal splenorenal shunt, DSRS) is an effective surgical procedure in the treatment of schistosomal variceal bleeding, shunt thrombosis is rare and can possible be corrected if detected early, schistosomal patients have a better survival and a lower incidence of encephalopathy after DSRS than that reported in cirrhotics, and liver biopsy should be performed for proper assessment of the schistosomal population especially in the geographic areas where the schistosoma parasite and viral hepatitis are endemic.     

Recent advances in the management of variceal bleeding

A prospective randomized trial of selective distal splenorenal shunt (DSRS)versus H-graft interposition total shunt at Emory Hospital in 1971 showed DSRS to be superior to a total shunt in shunt patency, prevention of variceal bleeding, preserving hepatic cell function, preserving the quality of life and patient survival. These results were particularly evident in the non-alcoholic patients. In the alcoholic patients, there was a greater loss of hepatic portal perfusion. In a later phase of the study, it was found that pancreatic veins formed a pathway of collaterals to the shunt, that is a socalled pancreatic siphon. In order to prevent loss of portal and pancreatic flow through the siphon, a total spleno-pancreatic disconnection was developed, whereby the hormone diversion is expected to be diminished. This report is the gist of a paper read by W. D. W. at the 85th Annual Meeting of the Japanese Surgical Society, Sendai, Japan, 1985     

Selective and nonselective shunts for variceal bleeding. A prospective study of 103 patients

Based on the experience reported herein, the following conclusions have been made: (1) Although nonoperative means, including sclerotherapy, have an important role in the management of bleeding varices, they are not definitive means of treating recurrent variceal hemorrhage. (2) Because of the maintenance of hepatopetal flow and splanchnic venous hypertension, a selective shunt is associated with a lower incidence of encephalopathy and provides a better quality of life than does a nonselective shunt. Thus, an elective distal splenorenal shunt is the elective operation of choice for recurrent variceal hemorrhage. (3) Nonselective shunts can be performed with similar expectation of patient survival as selective shunts, but because of increased encephalopathy, should be reserved for emergency operations, in cases of unsuitable venous anatomy, and in those patients with intractable ascites. (4) A well-conceived elective shunt procedure can be performed with low operative mortality and long-term patency, results in significant survival, and is still considered the "gold standard" for treatment of variceal bleeding.