Long-term results after modified distal splenorenal shunt with expanded PTFE interposition.

Forty consecutive patients with esophagogastric varices underwent a modified distal splenorenal shunt with expanded polytetrafluoroethylene (PTFE) interposition and were followed up for 12 to 66 months (mean 44.7). The operations were urgent in 9, elective in 14, and prophylactic in 17 patients. There were 24 males and 16 females. Age ranged from 32 to 76 years with an average of 53.8. The causes of portal hypertension were liver cirrhosis in 32, chronic hepatitis in 4, idiopathic portal hypertension in 3, and primary biliary cirrhosis in 1. Twenty-six patients were in Child's class A, 6 in class B, and 8 in class C. The operative death rate within 1 month was 2.5% and the overall in-hospital mortality rate was 5%. The shunt patency rate was 97.2% at early and 100% at late examinations. Only one patient (2.5%) had upper gastrointestinal bleeding. Hepatic encephalopathy was seen in 8 (20.5%) of 39 surviving patients. Six patients died of liver failure and another six died from various causes during the follow-up period. Twenty-six patients (65%) are alive at present. The 1-, 3-, and 5-year cumulative survival rates were 87.4%, 73.3% and 48.8%, respectively. The current modified shunt can be carried out more safely and easily and yield a similar result to that with the original Warren shunt. In order to avoid hepatic encephalopathy and liver failure, however, it is not wise to persist in this procedure.     

The distal splenorenal shunt

Distal splenorenal shunt (DSRS) provides selective decompression of gastroesophageal varices, with maintenance of portal hypertension and prograde portal flow to the cirrhotic liver. Accurate patient evaluation is essential to select appropriate patients for DSRS. Variceal bleeding control is greater than 85% and is as effective as total portosystemic shunts. Maintenance of prograde portal flow is greater than 90% in nonalcoholic disease, but only 50% in alcoholic cirrhosis; the latter is improved by total splenopancreatic disconnection. Hepatic function is better maintained when portal flow is maintained. Encephalopathy is lower after DSRS than after total shunts. Survival is not significantly improved after DSRS in patients with alcoholic cirrhosis compared to outcome after total shunts. The survival in patients with nonalcoholic disease is significantly improved over that of alcoholics.     

The distal splenorenal shunt

Our initial use of the distal splenorenal shunt (DSRS) in 1973 was fostered by disappointment with the results of so-called total shunts. This selective shunt was, when anatomically feasible, our preferred therapy until 1980, when surgical referral was affected by enthusiasm for sclerotherapy. Our study of 71 DSRSs is uncontrolled because we could not recruit patients for a prospective randomized trial that involved either no treatment of operations that had proven faults. Our experience shows that operative risk (4%) and incidence of postshunt encephalopathy (6%) are low, that the rate of shunt occlusion is acceptable (10%), and that bleeding is as well controlled as with other shunts. Survival rates correlate with the cause of portal hypertension and with hepatic functional reserve. Analysis of the causes of death shows that the natural history of cirrhosis and coexistent disease are major determinants of prognosis.     

Modified splenorenal shunt with splenopancreatic disconnection

Distal splenorenal shunt with splenopancreatic disconnection is a difficult surgical procedure; therefore its use is not widespread. We present a modified technique that facilitates the procedure and also ensures maintenance of portal flow by adding gastric devascularization and gastric disconnection. Our results compare favorably with the standard distal splenorenal shunt.     

Hyperbilirubinemia following distal splenorenal shunt

To assess the incidence, pathogenesis, and associated morbidity and mortality of hyperbilirubinemia following the distal splenorenal shunt, hepatic hemodynamics, liver function, and clinical course were evaluated before and after this procedure in 78 cirrhotic patients. Individuals with a peak postoperative bilirubin level greater than 5 mg/dL had a higher preoperative bilirubin concentration, worse Child's score, longer hospital stay, and higher mortality than patients with a peak postoperative bilirubin level less than 5 mg/dL. Mean preoperative and postoperative hepatic portal perfusion and sinusoidal pressure were similar in both groups. When only patients with minimally elevated preoperative bilirubin levels (less than 2 mg/dL) were analyzed, 83% of individuals who developed postoperative hyperbilirubinemia (level, greater than 5 mg/dL) had a major alteration in hepatic hemodynamics as manifested by either complete portal vein thrombosis or a marked change in sinusoidal pressure (greater than 4 mm Hg). Although preoperative hepatic functional reserve is the major determinant of postoperative bilirubin concentration, alterations in hepatic hemodynamics secondary to the distal splenorenal shunt may also play a role.     

Haemodynamics after distal splenorenal shunt

Haemodynamic studies were made both preoperatively and 7--62 months after the operation in 17 cirrhotic patients subjected to distal splenorenal shunt. Patent shunt was demonstrated in all patients. Preoperatively all patients had hepatopetal portal flow. Postoperatively portography through percutaneous transhepatic portal vein cannulation demonstrated hepatopetal flow in nine patients and reversed flow in eight patients. Portal pressure was significantly decreased in both groups after the shunt (p less than 0.01). However, no differences in pre- and post-operative portal pressure were observed in the two patient groups. In patients with hepatopetal flow, minimal new collaterals without clear connection to gastroesophageal region could be demonstrated. Collateral formation in patients with reversed flow was more abandoned but, even in these cases, no connection to gastroesophageal region could be demonstrated. The results indicate that a continuous increase in liver resistance due to the progression of the liver disease is the main cause of changes in portal circulation.     

Acute necrotizing pancreatitis after distal splenorenal shunt

World Journal of Surgery - Two cases of fatal acute necrotizing pancreatitis shortly after distal splenorenal shunt are presented. Instrumental injury to the pancreas during operation may have...     

Selectivity of the distal splenorenal shunt.

The distal splenorenal shunt is less likely to provoke encephalopathy than conventional shunting procedures, and it may offer a survival advantage for certain cirrhotic individuals, presumably because of its selective nature. This study suggests that the distal splenorenal shunt, even with exceptional efforts to achieve portomesenteric-gastrosplenic (PM-GS) disconnection, is not nearly as selective as it originally was assumed to be. In 11 patients intraoperative pressure determinations showed a significant decrease in portal pressure after end-to-side distal splenorenal anastomosis and no restoration of portal pressure after PM-GS disconnection. Measurements of flow through the shunt were comparable to those reported for portacaval shunts, and shunt flow was not decreased significantly by PM-GS disconnection. Postoperative angiography showed some PM-GS collateral in 17 of 18 patients, and later angiographic studies showed a tendency for progressive collateral development and consequent loss of hepatopetal portal perfusion. The advantages of the distal splenorenal shunt must accrue from gradual, as opposed to abrupt, portal deprivation, rather than from lasting selectivity.     

Liver transplantation with renoportal anastomosis after distal splenorenal shunt

BACKGROUND: The distal splenorenal shunt (DSRS) is designed to maintain hepatopetal portal vein flow while decompressing gastroesophageal varices. However, over time, as the underlying liver disease progresses, the DSRS loses its selectivity. The most common method of addressing this issue during orthotopic liver transplantation is shunt ligation with or without splenectomy. Dismantling the shunt increases the complexity of the transplantation, and splenectomy may increase the risk of infection. HYPOTHESIS: Anastomosis of the donor portal vein to the left renal vein without dismantling the shunt is an effective method of portal vein reconstruction for patients with a patent DSRS. DESIGN: Retrospective analysis. SETTING: University-based teaching hospital, Miami, Fla. PATIENTS: Five liver transplant recipients with patent DSRS who received an orthotopic liver transplant between September 1996 and August 1999. INTERVENTIONS: The donor portal vein was anastomosed end-to-end to the left renal vein during liver transplantation. MAIN OUTCOME MEASURES: Perioperatve morbidity, portal vein flow by Doppler study, patient survival, and graft survival. RESULTS: In all patients, the graft liver reperfused promptly via flow through the left renal vein with adequate decompression of the bowel. Normal portal venous flow was demonstrated by intraoperative and postoperative Doppler ultrasound studies. At the mean follow-up of 16 months, 4 patients were alive with well-functioning grafts. CONCLUSIONS: This novel technique has the advantage of decreasing the complexity of the procedure, without requiring splenectomy, while securing adequate portal perfusion. Additionally, it can be applied without modifications in patients with portal vein thrombosis.     

Factors influencing survival after distal splenorenal shunt

Prospective study of 206 patients treated by distal splenorenal shunts for esophagogastric hemorrhage due to portal hypertension reveals a probability of survival at 6 years of 0.53. The actuarial analyses show a marked difference in survival between alcoholic patients (0.39) and non-alcoholics (0.68) during the same interval. In the latter group, those patients with stable liver disease had a probability of survival of 0.78.The leading causes of death for alcoholic patients were liver failure, liver cancer, and trauma. In the nonalcoholic group, there were two leading causes: liver failure and complications of arteriosclerosis.

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Resumen El estudio prospectivo de 206 pacientes tratados con shunt esplenorenal distal para hemorragia esofagogástrica debida a hipertensión portai demuestra una probabilidad de supervivencia a seis años de 0.53. Los análisis actuariales exhiben una marcada diferencia entre la supervivencia de los pacientes alcohólicos, 0.39, y la de los no alcohólicos, 0.68 en el mismo intervalo. Entre estos últimos, los no alcohólicos, aquellos pacientes con enfermedad hepática estable tuvieron una probabilidad de supervivencia de 0.78.Las causas principales de muerte en los pacientes alcohólicos fueron: falla hepática, cáncer hepático y trauma. En el grupo de los no alcohólicos hubo dos causas principales: falla hepática, y complicaciones de la arterioesclerosis. Los datos emanados de este estudio aportan amplia evidencia de que por lo menos para los pacientes cirróticos no alcohólicos con enfermedad hepática estable que han padecido hemorragia varicosa, el shunt espleno-renal distal provee la oportunidad óptima de supervivencia a largo plazo.

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Résumé L'étude prospective de 206 malades traités par anastomose spléno-rénale distale pour hémorragie par rupture de varices oesophagiennes dues à l'hypertension portale se solde par une probabilité de survie à 6 ans de 53%. Les analyses actuarielles montrent une différence marquée de la survie selon que les patients sont alcooliques (39%) ou ne sont pas alcooliques (68%), pour la même période de temps. Chez ces derniers les malades dont les fonctions hépatiques sont stables ont une chance de survie de 78%. Les causes principales de la mort chez les alcooliques sont: 1) la défaillance hépatique; 2) le cancer du foie; 3) le traumatisme. Chez les patients qui ne sont pas alcooliques la défaillance hépatique et les complications de l'artériosclérose sont les causes principales de décès.

     

The distal splenorenal shunt: An update

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

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Resumen El shunt espleno-renal distal (SERD) comprende dos principios básicos: primero, el control de la hemorragia varicosa, puede ser logrado por la descompresión selectiva del segmento gastroesofágico; y segundo, la función hepática puede ser mantenida mediante la preservación de la hipertensión portai y la perfusión venosa del hígado. El SERD, como portotipo del procedimiento para la descompresión varicosa selectiva, ha evolucionado a lo largo de 17 años desde su introducción en 1966. Una cuidadosa atención al detalle en la evaluación preoperatoria y en el manejo perioperatorio resulta en una menor morbilidad. La experiencia informada por 25 centros médicos ha demostrado una mortalidad global promedio de 9%, permeabilidad del shunt y control de la hemorragia > 90%, encefalopatía de 0–18% y supervivencia a 5 años de 50–60%. Los cirróticos no alcohólicos (70–80%) exhiben una supervivencia a 5 años significativamente superior (p<0.05) a la de los cirróticos alcohólicos (45%). Los seis estudios prospectivos y aleatorizados que comparan el SERD con los shunts portasistémicos totales han sido realizados primordialmente en cirróticos alcohólicos y no muestran una diferencia significativa en la supervivencia. La experiencia actual con esquistosomiasis y con trombosis de la vena porta indica que la descompresión selectiva es superior al shunt total. Estudios cuantitativos realizados antes y un ano después del SERD demuestran disminución en el tamaño del hígado, estabilización de la función del hepatocito y modificaciones diferentes en la hemodinamia: los cirróticos alcohólicos tienen un 60% de probabilidad de perder el flujo venoso portal, en tanto que los no alcohólicos mantienen la perfusión portal. La pérdida del flujo venoso portal se asocia con una respuesta hiperdinámica sistémica en aquellos pacientes con más pobre función hepatocítica. La desconexión esplenopancreática está siendo estudiada en la actualidad en un esfuerzo por mantener mejor la perfusión portal y, preservar el volumen del hígado. Nuestra conclusión es que el SERD ha logrado sus propósitos de prevención de la hemorragia varicosa recurrente al tiempo que preserva la función del hepatocito. Se están desarrollando modificaciones tanto en el manejo como en el procedimiento quirúrgico mismo, derivados de un mayor conocimiento de la patología y de las causas fondamentales de la hipertensión portal que lleva a la formación de várices esofágicas.

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Résumé L'anastomose spléno-rénale distale prototype de la décompression sélective des varices, a évolué depuis son début il y a 17 ans. L'attention apportée à l'appréciation des données cliniques et biologiques préopératoires ainsi qu'à la technique opératoire en ont diminué la morbidité.L'expérience rassemblée de 25 centres a montré que la mortalité opératoire était de 9%, que le taux de perméabilité de l'anastomose et du contrôle de hémorragie dépassait 90%, que la fréquence de l'encéphalopathie était comprise entre 0 et 18%, que la survie à 5 ans était de 50–60%. Le taux de survie à 5 ans est inférieur chez les malades atteints de cirrhose alcoolique (45%) que chez les sujets dont la cirrhose n'est pas d'origine alcoolique (70–80%).Six études prospectives faites au hasard comparant l'anastomose spléno-rénale distale aux anastomose portocaves totales pratiquées au cours des cirrhoses alcooliques permettent d'affirmer que la durée de la survie est alors identique. L'anastomose spléno-rénale distale est supérieure à l'anastomose portocave classique en cas de bilharziose ou de thrombose de la veine porte.L'étude quantitative pratiquée avant l'anastomose et un an après sa réalisation montre une diminution du volume du foie, la stabilisation de la fonction hépatocytaire et des modifications hémodynamiques variables: dans 70% des cas le flux portal est perdu chez le cirrhotique alcoolique alors qu'il est conservé lorsque l'alcool n'est pas en cause. La perte du flux portal s'accompagne d'une réponse hyperdynamique de la circulation chez ceux dont la fonction hépatocytaire est défaillante.La déconnecxion spléno-pancréatique pour essayer de maintenir la circulation portale et de préserver le volume du foie est en cours d'étude.En conclusion, l'anastomose spléno-rénale distale a atteint les buts qu'elle se proposait: prévenir la récidive de l'hémorragie et maintenir les fonctions hépatiques. Des modifications dans le traitement et la technique opératoire sont en cours grâce à la meilleure connaissance de la pathologie des causes sous-jacentes de l'hypertension portale à l'origine des varices hémorragiques.

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Supported by United States Public Health Service Grant, AM15736.     

Correction of hypersplenism following distal splenorenal shunt.

The effect of splenorenal shunt on hypersplenism was assessed in 47 patients with splenomegaly, 26 of whom had significant thrombocytopenia or leukopenia. Of 16 patients with thrombocytopenia, platelet count returned to normal in 15 (94%) following operation, an improvement which was statistically highly significant (P less than 0.001). Of 16 patients with leukopenia, leukocyte count returned to normal in 11 (69%), also a highly significant improvement (P less than 0.001). Dramatic relief of hypersplenism occurs in the majority of patients following splenorenal shunt. Thrombocytopenia is more consistently corrected than is leukopenia. The etiology of liver disease appeared not to be a factor, but leukopenia was corrected more consistently in alcoholic than in nonalcoholic patients, while there was no difference in the postoperative response of thrombocytopenia to the operation. Long-term follow-up in 26 patients demonstrated sustained improvement in 57% of patients with preoperative leukopenia and 78% of patients with thrombocytopenia. Since significant improvement in leukopenia and thrombocytopenia will occur following the distal splenorenal shunt, hypersplenism is not a contraindication to this procedure.     

Early variceal rebleeding after successful distal splenorenal shunt

Of 77 patients with repeated variceal hemorrhage who underwent distal splenorenal shunt, five (6.5%) developed rebleeding despite a patent splenorenal anastomosis. Three of the five patients died. Early variceal rebleeding usually indicates shunt thrombosis but may occur with a patent anastomosis. Anatomic or functional left renal vein and/or splenic vein hypertension producing incomplete variceal decompression is generally the cause. Ineffective separation of the main portal vein from the gastrosplenic venous plexus may coexist and further intensify variceal congestion. Urgent angiographic studies and direct shunt catheterization with measurement of splenic vein, left renal vein, and inferior vena cava pressures should be performed to plan appropriate therapy. A significant gradient between the splenic and renal veins is evidence of an unsatisfactory anastomosis and should be managed by balloon angioplasty or reoperation. High splenic and left renal vein pressures with a gradient of more than 10 mm Hg between the renal vein and the inferior vena cava indicate renal vein hypertension. Initial therapy should include serial injection sclerotherapy, as renal vein hypertension will usually resolve over time as additional collaterals develop. However, persistent or recurrent variceal hemorrhage may require total portal decompression to bypass the restrictive left renal vein segment.     

Hepatic tissue perfusion studies during distal splenorenal shunt

Hepatic tissue perfusion was measured by the krypton-85 clearance technique during surgery in four patients with bleeding esophageal varices before and immediately after Warren distal splenorenal shunt. No significant reduction in perfusion was found in any patient, thus confirming the concept that this type of portasystemic shunt maintains portal flow to the liver.     

Patency of infrainguinal polytetrafluoroethylene bypass grafts with distal interposition vein cuffs

Polytetrafluoroethylene (PTFE) prosthetic bypasses in the lower extremity have poor patency rates, particularly in limb salvage cases. Patency and limb salvage rates of PTFE bypasses supplemented by distal interposition vein cuffs were assessed in patients requiring revascularization for critical limb ischemia, in the absence of a suitable autologous saphenous vein. Between October 1993 and April 1996, 163 patients underwent 185 infrainguinal bypasses. Forty-three limbs in 42 patients (12 women, 30 men; mean age 67 years) did not have a suitable autologous saphenous vein (24%) and had femoropopliteal (20) and infrapopliteal (23) bypasses performed. Patients were examined prospectively at 3-month intervals during the first year and at 6-month intervals thereafter to determine graft patency and limb salvage. Postoperative anticoagulation with warfarin was used in 26 patients. Indications for operation included limb salvage in 41 extremities (21 rest pain/ulceration or gangrene, 20 rest pain alone), and disabling claudication in two. Patients were followed clinically for 2–30 months (mean 10 months). Cumulative 2-year life-table patencies for all grafts, femoropopliteal and infrapopliteal bypasses were 64%, 75% and 62%, respectively. Previous primary patencies at the authors' institution for PTFE bypasses without vein cuffs were 35%, 46% and 12% for the same categories. Cumulative life-table limb salvage for all PTFE/vein cuff bypasses in the present series was 76% compared with 37% in previous PTFE bypasses without vein cuffs. Adjunctive use of distal interposition vein cuffs improves prosthetic graft patency, while producing satisfactory limb salvage. Postoperative anticoagulation did not influence graft patency. PTFE/vein cuff for lower-extremity revascularization shows good 2-year patency and is an acceptable alternate conduit in patients with critical limb ischemia when autologous saphenous vein is absent.     

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

Summary In 50 consecutive patients portal blood flow was determined using computed liver perfusion scintigraphy preoperatively and at 6, 12, 24, 36, 48, 60, 72, and 84 months postoperatively between 1 January 1983 and 1 January 1990. All 25 subjects had undergone placement of a distal splenorenal shunt (DSRS) and 25, insertion of low-diameter PTFE mesocaval interposition shunt (LDMIS) between 15 January 1983 and 1 January 1988. Indications for shunt operation included recurrent variceal hemorrhage in spite of long-term endoscopic sclerotherapy, a Child-Pugh classification of A or B, a sonographically determined liver volume of between 1000 and 2500 ml, exclusion of the activity and progression of liver disease by biopsy and stenosis of the hepatic artery or coeliac trunk. DSRS was performed when the portal perfusion index (PPI) was >30% (normal values 56±5%) and LDMIS was carried out when the PPI was 10% to 30%. In all cases the underlying disease was liver cirrhosis of alcoholic (n = 34, 68%) or hepatic (n = 12, 24%) etiology. Five patients who underwent LDMIS had originally scheduled for DSRS at a PPI of >30%; because the DSRS would have been technically difficult due to severe chronic pancreatitis, a LDMIS was performed. One in-hospital death due to liver failure had occurred in each group by 1 January 1990. One patient in the DSRS group and two in the LDMIS group died later, and in each group one patient was lost to follow-up. In the DSRS group, no case of encephalopathy or rebleeding was encountered, and in the LDMIS group, one case each of encephalopathy (4%) and rebleeding (4%) were recorded. In the DSRS group, the PPI value showed a steady reduction from 38% (preoperatively) to 15% (after 7 years); the same tendency could be demonstrated in the LDMIS group from 24% to 0). The difference between the preoperative and late postoperative PPI values obtained for both shunt types was statistically significant. We concluded that a reduction in portal blood flow to the liver develops during the period following the surgical implantation of a selective or non-selective shunt. LDMIS maintains portal perfusion for at least 6 years post-surgery. Thus, LDMIS constitutes an excellent alternative in patients in whom the insertion of a Warren shunt is either not possible or not indicated due to an insufficient PPI value (<30%).